^Cti 


AN     INDEX     OF 

DIFFERENTIAL    DIAGNOSIS 

OF     MAIN     SYMPTOMS 


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Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/indexofdifferent1912fren 


AN    INDEX    OF 

Differential  Diagnosis 
of  main  symptoms 


BY    VARIOUS    WRITERS 


HERBERT    FRENCH,    M.A.,  M.D.  Oxon,  F.R.C.P.  Lond. 

Assistant   PJiysiciaii   to   Gicy's   Hospital 


WITH     SIXTEEN     COLOURED     PLATES 
AND     OVER     TWO     HUNDRED     ILLUSTRATIONS     IN     THE     TEXT 


1^10. 


WILLIAM     WOOD     AND     COMPANY 
MDCCCCXII 


JOHN     WRIGHT     AND     SONS    LTD. 
PRINTERS     AND     PUBLISHERS.     BRISTOL 


PREFACE 

This  book  is  a  treatise  on  the  application  of  differential  diagnosis 
to  all  the  main  signs  and  symptoms  of  disease.  It  aims  at  being  of 
practical  utility  to  medical  men  whenever  difficulty  arises  in  deciding 
the  precise  cause  of  any  particular  symptom  of  which  a  patient  may 
complain.  It  covers  the  whole  ground  of  medicine,  surgery, 
gynaecology,  ophthalmology,  dermatology,  and  neurology. 

Whatever  the  disease  from  which  a  patient  is  suffering,  the  import- 
ance of  diagnosing  it  as  early  as  possible  can  hardly  be  over-rated. 
The  present  volume  deals  with  diagnosis  from  a  standpoint  which  is 
different  from  that  of  most  text -books,  having  been  written  in  response 
to  requests  for  an  Index  of  Diagnosis  as  a  companion  to  the  pub- 
lishers' Index  of  Treatment,  issued  in  1907.  The  book  is  an  index  in 
the  sense  that  its  articles  on  the  various  symptoms  are  arranged  in 
alphabetical  order  ;  at  the  same  time  it  is  a  work  upon  differential 
diagnosis  in  that  it  discusses  the  methods  of  distinguishing  between 
the  various  diseases  in  which  each  individual  symptom  may  be 
observed.  Whilst  the  bod\'  of  the  book  thus  deals  with  symptoms, 
the  general  index  at  the  end  gathers  these  together  under  the  headings 
of  the  ^•arious  diseases  in  which  they  occur. 

The  Editor  lays  particular  stress  upon  the  importance  of  using 
these  two  parts  of  the  book  together.  Unless  reference  is  made  freely 
to  the  general  index,  the  reader  may  miss  a  number  of  the  places 
in  which  is  discussed  the  diagnosis  of  the  disease  with  which  he  has 
to  deal  ;  for  while  each  symptom  is  considered  but  once,  each  disease 
is  likely  to  come  up  for  discussion  under  the  heading  of  each  of  its 
more  important  symptoms. 

The  guiding  principle  throughout  has  been  to  suppose  that  a 
particular  symptom  attracts  special  notice  in  a  given  case,  and  that 
the  diagnosis  has  to  be  established  by  differentiating  between  the 
various  diseases  to  which  this  symptom  may  be  due.  One  of  many 
difficulties  arising  during  the  construction  of  the  work  was  that  of 
deciding  where  to  draw  the  line  as  regards  symptoms  themselves. 
The  exclusion  of  many  borderline  headings  such  as  "  Dullness  at  the 
base  of  one  lung,"  "  Inability  to  breathe  through  the  nose,"  and 
various  signs  such  as  Romberg's,  Stellwag's,  von  Graefe's,  and  so 
forth,   may   perhaps   seem   arbitrary  ;     but   reference   to   the   minor 


vi  PREFACE 

sjTnptoms  and  physical  signs  which  have  not  been  thought  suffi- 
ciently important  to  merit  separate  articles  will  be  found  in  the 
general  index  at  the  end  of  the  volume. 

Treatment,  pathology,  and  prognosis  are  not  dealt  with  except  in 
so  far  as  they  may  bear  upon  differential  diagnosis — the  emplo5''ment 
of  salic3"lates,  for  instance,  in  distinguishing  acute  rheumatic  from 
other  forms  of  arthritis  ;  the  use  of  the  microscope  in  distinguishing 
malignant  neoplasms  from  inflammatory  or  other  tumours ;  the 
value  of  the  lapse  of  time  in  distinguishing  between  tuberculous  and 
meningococcal  meningitis. 

Coloured  plates  and  other  illustrations  ha\"e  been  introduced  freely 
wherever  it  was  thought  they  might  be  helpful  in  diagnosis.  Most  of 
them  are  original,  but  a  few  are  reproduced  from  other  sources, 
and  thanks  are  due  to  the  authors  and  publishers  who  have  kindly 
lent  them. 

So  far  as  the  Editor  is  aware,  although  there  exist  indices  of 
s^-mptoms,  and  medical  works  in  which  various  maladies  are  discussed 
in  alphabetical  order,  the  present  Index  of  Differential  Diagnosis  of 
Main  S5^mptoms  is  unique  in  medical  literature.  It  rests  with  the 
medical  profession  to  decide  whether  it  strikes  the  mark  at  which  it 
aims.  There  must  be  room  for  improvement  in  many  respects, 
notwithstanding  the  great  amount  of  time  and  labour  that  have 
been  bestowed  upon  it. 

However  this  ma}-  be,  the  work  undoubtedl}^  owes  much  of  what 
value  it  possesses  to  the  suggestions  and  kindty  help  of  the  manj' 
contributors  who  have  assisted  in  its  making  ;  and  to  the  prac- 
titioners and  the  authorities  of  various  institutions  ^^■ho  have 
generously  lent  the  material  lor  many  of  the  illustrations.  Indeed, 
it  is  difficult  to  see  how  the  book  could  have  been  produced  in  its 
present  completeness  wthout  their  willing  collaboration  :  they  are 
enumerated  elsewhere,  and  to  all  of  them  the  Editor  tenders  his 
sincere  thanks. 

Criticisms  and  suggestions  are  invited,  and  will  be  received  with 
gratitude  by  the  Editor, 

Herbert    French. 

62,  Wimpole  Sired,  London,  W. 
MarcJi^  1912. 


LIST     OF     CONTRIBUTORS 

William  Cecil  Bosanquet,  m.a.,  m.d.  Oxon.,  e.r.c.p.  ;  Physician  to  Out- 
Patients,  Charing  Cross  Hospital  ;  Assistant  Physician,  Brompton  Hos- 
pital for  Consumption  and   Diseases  of  the  Chest. 

E.  Farouhar  Buzzard,  m.a.,  m.d.,  b.ch.  Oxon.,  f.r.c.p.  ;  Physician  to  Out- 
Patients  at  St.  Thomas'  Hospital  and  at  the  National  Hospital  for  the 
Paralysed  and  Epileptic,  Queen  Square  ;  Consulting  Neurologist  to  the 
Royal  Free  Hospital  and  to  the  Hospital  for  Diseases  of  the  Throat, 
Golden  Square. 

Percy  John  Cammidge,  m.d.  Lond.,  d.p.h.  Camb. 

Herbert  L.  Eason,  m.d.,  m.s.  Lond.;  Senior  Ophthalmic  Surgeon,  Guy's 
Hospital. 

John  W.  H.  Eyre,  m.d.,  m.s.  Durh.,  d.p.h.  Camb.;  Director  of  the  Bacterio- 
logical Department,  Guy's  Hospital  ;  Lecturer  on  Bacteriology  to  the 
Medical  School  and  Dental  School,  Guy's  Hospital. 

Herbert  Morley  Fletcher,  m.a.,  m.d.  Camb.,  f.r.c.p.  ;  Physician  in  charge 
of  Out-Patients,  and  of  Diseases  of  Children  Department,  St.  Bartholomew's 
Hospital  ;    Physician,  East  London  Hospital  for  Children. 

Herbert  French,  m.a.,  m.d.  Oxon.,  f.r.c.p.  ;  Assistant  Physician,  Guy's 
Hospital. 

Archibald  Edwd.  Garrod,  m.a.,  m.d.  Oxon.,  f.r.c.p.,  f.r.s.  ;  Physician,  with 
charge  of  Out-Patients  to,  and  Lecturer  on  Chemical  Pathology  at,  St. 
Bartholomew's  Hospital  ;  Physician  to  the  Hospital  for  Sick  Children, 
Great  Ormond  Street. 

George  Ernest  Gask,  f.r.c.s.  ;  Assistant  Surgeon,  St.  Bartholomew's 
Hospital  ;  Demonstrator  of  Operative  and  Practical  Surgery,  St.  Bar- 
tholomew's Hospital  Medical  School. 

Hastings  Gilford,  f.r.c.s.,  ;  Consulting  Surgeon,  Reading  Dispensary  and 
Kingwood  Sanatorium. 

Arthur  Frederick  Hertz,  m.a.,  m.d.  Oxon.,  f.r.c.p.  ;  Assistant  Physician 
and  Physician  for  Nervous  Diseases  and  to  the  Electrical  Department, 
Guy's  Hospital. 

Robert  Hutchison,  m.d.,  cm.  Edin.,  f.r.c.p.  ;  Physician  to  the  London 
Hospital,  and  Assistant  Physician  to  the  Hospital  for  Sick  Children,  Great 
Ormond  Street. 

Arthur  John  Jex-Blake,  m.a.,  m.b.,  b.ch.  Oxon,  m.r.c.p.  ;  A.ssistant  Physician, 
St.  George's  Hospital  ;  Assistant  Physician,  Brompton  Hospital  for  Con- 
sumption. 

Sir  Malcolm  Morris,  k.c.v.o.,  f.r.c.s.  Edin.  ;  Consulting  Surgeon,  Skin 
Department  at  St.  Mary's  Hospital  ;  Surgeon,  Skin  Department,  Seamen's 
Hospital. 

Robert  P.  Rowlands,  m.b.,  m.s.  Lond.,  f.r.c.s.  ;  Assistant  Surgeon  and 
Surgeon  in  charge  of  the  Orthopaedic  Department,  Guy's  Hospital ;  Demon- 
strator of  Operative  Surgery  and  Surgical  Pathology,  Guy's  Hospital 
Medical  School,  oj>         ^  i:' 


LIST     OF     CONTRIBUTORS 


James  E.  H.  Sawyer,  m.a.,  m.d.,  b.ch.  Oxon.  ;  Assistant  Physician,  General 
Hospital,  Birmingham. 

Frederick  John  Smith,  m.a.,  m.d.  Oxon.,  f.r.c.p.,  f  r.c.s.  ;  Physician,  London 
Hospital  ;  Consulting  Physician  to  the  City  of  London  Dispensary  and 
to  the  National  Orthopaedic  Hospital. 

Thomas  George  Stevens,  m.d.,  b.s.  Lond.,  m.r.c.p.,  f.r.c.s.  ;  Physician, 
Hospital  for  Women,  Soho  Square  ;  Physician  to  Out-Patients,  Queen 
Charlotte's  Hospital  ;  Obstetric  Physician,  Surrey  Dispensary ;  Obstetric 
Tutor,  St.  Mary's  Hospital  Medical  School. 

Russell  H.  Jocelyn  Swan,  m.b.,  m.s.  Lond.,  f.r.c.s.  ;  Surgeon,  Cancer 
Hospital,  Brompton. 

Frederick  Taylor,  m.d.  Lond.,  f.r.c.p.  ;  Consulting  Physician,  Guy's  Hospital, 
and  Evelina  Hospital  for  Sick  Children ;  Physician,  Seamen's  Hospital, 
Greenwich. 

Philip  Turner,  b.sc,  m.b.,  m.s.  Lond.,  f.r.c.s.  ;  Assistant  Surgeon,  Guy's 
Hospital  ;  Demonstrator  of  Operative  Surgery,  Guy's  Hospital. 

William  Hale  White,  m.d.  Lond.,  m.d.  Dub.,  f.r.c.p.;  Senior  Phj'sician  and 
Lecturer  on  Medicine,  Guy's  Hospital. 


The  book  owes  much  to  all  its  contributors,  and  in  addition  the  Publishers 
wish  to  acknowledge  the  courtesy  and  valuable  assistance  they  have  received 
from  the  following  medical  authorities,  practitioners,  publishers,  and  others  in 
various  ways  : — 

Dr.  A.  J.  Jex-Blake,  Dr.  W.  J.  H.  Pinniger,  and  Dr.  A.  Rendle  Short,  for 
help  and  suggestions  which  have  lightened  the  labour  of  passing  the  sheets 
through  the  press,  and  constructing  the  General  Index. 

The  Authorities  at  St.  Bartholomew's,  St.  George's,  and  Guy's  Hospitals,  a.nd 
the  Bristol  Royal  Infirmary,  for  many  illustrations,  negatives,  and  drawings  ; 
Sir  Dyce  Duckworth,  Dr.  Garrod,  and  the  Royal  Society  of  Medicine  for 
Plate  IX  ;  Dr.  A.  C.  Jordan  and  Mr.  Hugh  Walsham  for  valuable  skiagrams  ; 
Dr.  D.  S.  Davies,  M.O.H.  Bristol,  for  photographs  of  eruptive  fevers  ; 
Dr.  Armauer  Hansen,  Inspector  General  of  Leprosy  in  Norway,  for  Figs.  124, 
140  ;  Dr.  Boycott  and  Dr.  Haldane  for  negatives  of  the  ova  of  Ankylostomum 
duodenale ;  Dr.  Adams,  of  the  Clinical  Research  Association,  London,  for  great 
pains  in  furnishing  material  and  assistance  in  drawing  Plates  II  and  XII. 
Mr.  C.  F.  Walters,  of  Clifton,  kindly  gave  some  of  the  coloured  sketches  for 
Plates  V  and  VI.  Mr.  H.  A.  Wilson  they  have  to  thank  for  permission  to 
reproduce  his  drawing  of  Bilharzia  hcsmatobia,  and  Mr.  Pillischer,  of  New  Bond 
Street,  for  the  fine  specimen  of  the  head  of  a  Tcsnia  solium  which  appears 
in  Fig.  150. 

They  are  specially  indebted  to  Dr.  Farquhar  Buzzard  for  the  series  of  photo- 
graphs illustrating  facies  in  disease,  and  for  several  original  carefully  worked- 
out  diagrams  ;  and  to  Professor  Rutherford  Morison,  Sir  Malcolm  Morris,  Dr. 
Llewellyn  Jones,  and  others  for  permission  to  use  various  illustrations  from 
works  written  by  them.  They  also  have  to  thank  Messrs.  Bailliere,  Tindall  and 
Cox,  Cassell  &  Co.,  Macmillan  &  Co.,  Rebman,  and  the  Editors  of  the  Medical 
Annual,  Allbutt  and  Rolleston's  System  of  Medicine,  The  Journal  of  Hygiene, 
The  Quarterly  Journal  of  Medicine,  Guy's  Hospital  Reports,  and  others,  for 
sinailar  permission,  which  has,  they  believe,  been  acknowledged  in  the  text  in 
each  case. 

The  volume  has  been  fortunate  in  having  at  its  service  the  artistic  and 
technical  ability  of  Mr.  A.  W.  Head  for  the  drawings  of  the  fundus  oculi,  and 
of  Messrs.  Shiells  and  Ford  for  many  of  the  other  coloured  illustrations, 


LIST      OF      ILLUSTRATIONS 


COLOURED      PLATES 


PLATE 

I.- 

II.- 

III.- 

IV.- 

V.  I 

VI.  J 

VII.  I 

VIII.  J 

IX.- 

X.- 

XI.- 

XII.- 
XIII.- 
XIV.- 

XV.- 
XVI.- 


-Renal  tube  casts  ..... 

-Red  and  white  blood  corpuscles 

-Symmetrical  gangrene  of  the  fingers  in  Raynaud's  disease 
-Gangrene  of  the  foot         ..... 

Bladder  appearances  seen  through  the  cystoscope 

Ophthalmoscopic  appearances         .... 

-Intestinal  sand,  true  and  false      .... 
-Pityriasis  rubra  ..... 

-Diagram    showing    the    radicular    sensory    areas    of    the 
human  body  ..... 

-Bacteria  and  blood  parasites  .  .  -  . 

-Popliteal  aneurysm  .  .  .  .  . 

-Cirsoid  aneurysm  .  -  . 

-Early  stages  of  carcinoma  of  the  tongue 
-Varicose  abdominal  veins  .... 


Facing  page 


281 

284 

308 

310 

.    461 

.    463 

,    652 

658 

663 

,  696 

.    762 

.    764 

814 

,    824 

ILLUSTRATIONS      IN      THE      TEXT 


13- 
I4-- 
I5-- 
16.- 
17- 
18. 
19. 


26.- 
27. 
28. 
29.- 


-The  hand  of  tetany  ..... 

-Pseudo-leukaemia  infantum  (von  Jaksch's  disease) 

-My.xcedema  :    the  same  patient  as  (4)   prior  to  the  attack 

-Myxoedema  :    the  characteristic  facies 

-Myxcedema  :    characteristic  hands 

-Echinococcal  booklets         .  .  .  .  - 

-Infantile  paralysis  of  the  left  shoulder  and  upper  arm 
-Tooth's  peroneal  type  of  neuro-muscular  dystrophy  (early) 
-Tooth's  peroneal  type  of  neuro-muscular  dystrophy  (later) 
-Primary  syphilitic  sore  on  lower  lip  - 

-Cancrum  oris  ...... 

-Amceba  histolylica  and  Amceba  coli         -  -  - 

-Ova  of  Bilharzia  hfematobia  .... 

-.•Vnkylostomum  duodenale  .... 

-Ankylostomum  duodenale,   ova  at  different  stages 
-Ankylostomum  duodenale,   two-cell  stage  of  developing  ovum 
-Spectral  absorption   band :    oxyhaemoglobin 
-Spectral  absorption  band  :    reduced  haemoglobin 
-Spectral  absorption  band  :    carboxyha?moglobm 
-Spectral  absorption  band  :    haematin  in  alkaline  solution 
-Spectral  absorption  band :    acid  heematin 
-Spectral  absorption  band :    methaemoglobin 
-Spectral  absorption  band :    urobilin 
-Diagram  of  bruits  of  mitral  stenosis 
-Diagram  of  heart  to  explain  Flint's  murmur 
-Charcot-Leyden  crj'stals  -  -  -     .         - 

-Skiagram  showing  mottled  lung  apices  produced  by  phthisis 
-Cheyne-Stokes'  breathing  .... 

-Claw-foot 


3 

42 

43 

43 

43 

57 

70 

71 

71 

86 

SS 

91 

93 

94 

94 

94 

95 

95 

95 

95 

95 

95 

95 

108 

109 

117 

120 

124 

126 


LIST     OF    ILLUSTRATIONS 


FIG-  PAGE 

30. — Syringomyelic  claw-hand                ......  ^^7 

31. — Clubbed  fingers  due  to  congenital  pulmonary  stenosis                 -             -  129 

32. — Habitual  constipation        .......  j^j 

33. — Dyschezia                -              ---....  142 

34. — Normal  large  intestine       .----.-  143 

35. — Post-dysenteric  atony  and  paresis  of  the  colon      -              -              .             .  144 

36. — Constipation  due  to  lead  poisoning            .....  j^^ 

37- — Constipation  with  niuco-membranous  colitis         -              .              .              .  145 

38. — Skiagram  :    obstruction  due  to  carcinoma  coli     ....  146 

39. — Skiagram  :    ptosis  of  caecum  and  transverse  colon              -              -              .  147 

40. — Colon  in  a  case  of  Hirschsprung's  disease               ....  148 

41. — Visceroptosis            ........  14^ 

42. — .\thetosis                   --......  1^4 

43. — Volkm arm's  ischa;nuc  paralysis      ......  166 

44. — Dupuytren's  contracture    ...--..  167 

45. — Cicatricial  contracture  after  a  burn           -              -              -              -              -  168 

46. — Curschmann's  spirals  from  asthmatic  sputum        ....  lyq 

47. — -Osteitis  deformans  in  a  man         ......  182 

48. — Osteitis  deformans  in  a  woman    -.--..  182 

49. — Myopathic  lordosis               .......  183 

50. — Morbus  caeruleus                  ._.--..  184 

51. — Cystin.  crystals         -             -              -              -              -              -              -             -  187 

52. — Politzer's  acoumeter  -  -  -  -  -  -  .188 

53. — Tuning  fork,  with  foot  for  testiug  hearing             ....  189 

54. — Galton's  whistle                    .......  jSg 

55. — Cyrtometric  tracing  of  rickety  chest         .....  192 

56. — Cyrtometric  tracing  of  normal  adult  chest           ....  ig2 

57. — Cyrtometric  tracing  of  pigeon  chest         -              ■              -             -              -  192 

58. — C}Ttometric  tracing  of  fibrosis  of  lung    ....              -  192 

59. — CjTtometric  tracing  of  emphysematous  chest      ....  152 

60. — Diagram  of  homonymous  double  images               -              -             -             -  199 

61. — Diagram  of  crossed  double  images             .....  igg 

62. — Transillumination  of  the  antrum                 .....  205 

63. — Dwarfism  :    extinct  rickets              ......  212 

64. — Dwarfism :    achondroplasia             -             -              -              -             -             -  213 

65. — Dwarfism :    osteogenesis  imperfecta            .              .              -             .             .  213 

66. — Dwarfism :    anangioplastic  infantilism       -             -             -             -             -  215 

67. — Dwarfism  :    cretinism          .......  216 

68. — Dwarfism:    mongolism       ........  217 

69. — Dwarfism :    ateleiosis          -  .          -             -             -             -             -             -  217 

70. — Dwarfism  :    progeria            .......  218 

71. — ^Tooth-plate  impacted  in  the  larynx           .....  223 

72. — Obstruction  to  superior  vena  cava  by  an  aortic  aneurysm           -             -  234 

73. — Obstruction  to  superior  vena  cava  by  an  aortic  aneurysm              -              -  235 

74. — Skiagram  of  a  large  saccular  aneurysm  of  the  aorta         -              -              -  236 

75. — Meningocele  projecting  into  the  face  from  base  of  skull                  •              -  254 

76. — Myxoedema              -             -                  ......  258 

77. — ^The  same  patient  as  76  prior  to  the  disease        ....  258 

78.— Congenital  syphilis:    prominent  forehead  and  depressed  nasal  bridge      -  259 

79. — Congenital  syphOis  :    notched  teeth  and  sore  angle  of  mouth        -              -  259 

80. — Congenital  syphilis :    Hutchinsonian  notched  teeth            -              -              -  260 

81. — Myopathic  facies  :    the  loose  pout             .....  260 

82. — Myopathic  facies  :    the  transverse  smile                 ....  260 

83. — Myasthenic  facies  :    the  appearance  of  fatigue    ....  261 

84. — Myasthenic  facies  :    the  nasal  smile,  one-sided    -             -             .             .  261 

85. — Exophthalmic  goitre           .......  261 

86. — Paralysis  agitans                  .......  262 

87. — Tabetic  facies          ........  262 

88. — .\cromegaly  :    facies  and  hands     ---...  263 

89. — .Achondroplasia        ..--....  263 

90. — Mongolian  idiot  in  infancy            ......  264 

91. — Mongolian  idiot,  older        .......  264 

92. — Sarcinae  ventriculi                •              -                           ■              -              -              -  267 

93. — Favus          .-....-..  271 

94. — Cholesterin  crystals             -             -             -             -             -             ■             -  281 

95. — Raynaud's  disease  :    stage  of  local  asphyxia          ....  283 

96. — Raynaud's  disease  :    recurrent  necrosis  of  the  fingers      -              -              -  284 

97.— Skiagram  of  calculus  in  dropped  left  kidney         ....  309 


LIST     OF     ILLUSTRATIONS 


VU:.  PAGE 

g8. — Skiagram  of  coinpositc  vesical  calculus     -----  312 

99. — Skiagram  of  lobar  pneumonic  consolidation  of  left  lung                -              -  321 

100. — Skiagram  of  hydatid  cyst  of  the  thorax  -              -              -              ■•              -  323 

loi. — Hemianopsia:    diagram  showing  optic  nerves  and  tracts            -              -  334 

102. — Hemianopsia  :    diagram  showing  optic  nerves  and  tracts            -              -  334 

103. — -Hemianopsia:    diagram  showing  optic  nerves  and  tracts            -              -  335 

104. — Hemianopsia  :    diagram  showing  optic  nerves  and  tracts            -              -  335 

105. — Skiagram  :    bismuth  shadow  of  a  dropped  dilated  stomach            -              -  353 

106. — Chart  :    pyrexia  and  rapid  pulse  of  rheumatoid  arthritis               -              -  377 

107. — -Acute  rheumatoid  arthritis              ..-.--  378 

108. — Skiagram  :    severe  rheumatoid  arthritis,  showing  ulnar  deflection           -  379 

109. — Heberden's  nodosities          -------  380 

no. — Skiagram:    rheumatoid  arthritis,  transparency  of  ends  of  bones               -  381 

III. — -Henoch's  purpura                .-..---  382 

112. — -Chronic  gout  :    urate  of  sodium  deposits               .              -              -              .  382 

113. — Skiagram:    chronic  gout,  showing  sodium  urate  deposits              -              -  383 

114. — Pads  over  finger-joints        -------  385 

115. — Skiagram  of  the  pads  in  (114)        ---.--  385 

116. — Charcot's  disease  of  the  knee-joint             .              .              -              .              .  387 

117. — ^The  hands  in  pulmonary  osteo-arthropathy           -              -              -              -  369 

118. — Pulmonary    osteo-arthropathy        -..-.-  390 

119. — Hodgkin's  disease                 -              -              -              -              -              ■              -  4i7 

120. — Still's  disease           --------  418 

121. — Macular  S3'philides               .......  425 

122. — Hirschsprung's  disease  :    idiopathic  dilatation  of  colon    -              •              ■  432 

123. — Tubular  mucous  cast  of  large  intestine                   .              -              .              .  ^^^ 

124. — Nodular  leprosy  in  a  Norwegian                .....  451 

125. — Girl  suffering  from  hypernephroma            -              ...              -  453 

126. — Girl  suffering  from  h3'pernephroma            -              -              ■              -              -  454 

127. — Milroy's  or  Meige's  disease             -              -              ■    ,          -              -              -  45^ 

128. — Angioneurotic  oe.dema  of  eyelids   -              -              .              ...  458 

129. — Bilateral  hereditary  trophoedema  of  the  legs         ....  460 

130. — Crystals  of  calcium  oxalate             -              -              ....  470 

131. — Skiagram :    aneurysm  of  innominate  artery           •              -              -              -  483 

132. — Segmental  areas  of  head  and  neck  and  their  maximal  points                 -  497 

133. — Segmental  areas  of  head  and  neck  and  their  maximal  points                  ■  497 

134. — Segmental  areas  of  head  and  neck  and  their  maximal  points                  -  497 

135. — Segmental  areas  of  head  and  neck  and  their  maximal  points                 -  497 

136. — Paralysis  of  the  right  side  of  the  face       -              -              -              -              -  534 

137. — Post-paralytic  contracture  of  left  side  of  face      -              -              -              -  535 

138. — Same  patient  as  (137)  closing  her  eyes     -----  535 

139. — Same  patient  as  (137)   smiling       ------  535 

140. — Bilateral    facial    palsy         -------  535 

141. — -Hemiatrophy  of  left  side  of  face  (early  stage)     -              -              -              -  537 

142. — Brown-Sequard  paralysis                 -              -              -              -              -              -  54© 

143. — Diagram  of  lumbo-sacral  plexus  and  its  branches             -              -              -  544 

144. — Paresis  of  the  arms  in  lepra  maculo-ansesthetica                -              -              -  551 

145. — Diagram  of  the  cervico-brachial  plexus  and  its  branches               -              -  553 

146. — Diagram  of  sensor}^  localization  in  the  spinal  cord             -              -              -  566 

147. — Diagram  of  localization  of  reflex  centres  in  the  spinal  cord            -              -  566 

148. — Head  of  Ta3nia  solium         ....---  568 

149. — ^Head  of  Tasnia  solium,  semi-diagrammatic            _              .              -              -  568 

150. — Head  of  Ta3nia  mediocanellata       ------  568 

151. — Head  of  Bothriocephalus  latus       ------  568 

152. — Ovum  of  Ta3nia  solium       -------  569 

153. — Ovum  of  Ascaris  lumbricoides        ------  569 

154. — Ovum  of  Trichocephalus  dispar     ------  570 

155. — Triple  phosphate  crystals                ......  573 

156. — Paralysis  of  left  third  ner\-e  :    face  at  rest              .              -              -              -  589 

157. — Paralysis  of  left  third  nerve  :    patient  looking  to  right  -              -              -  5'89 

158. — Paralysis  of  third  and  seventh  nerves  :    face  at  rest         -              -              -  589 

159. — Effort  to  show  teeth   and  close  eyes  in   case   158            -              -             -  5'89 

160. — Smallpox  ;    confluent  arid  discrete  varieties,  2   views  (stereoscopic)       _  -  606 

161. — Septic  dermatitis  wrongly  diagnosed  as  smallpox,  2  views  (stereoscopic)  6o'8 

162. — Temperature  chart  :    typhoid  fever           -              -              -              -              -  61:1 

163. — Temperature  chart  :    Malta   fever               .              .              -              -              -  /6i-2 

164. — Temperature  chart  :    malignant    endocarditis        -              -              -              -  613 

165. — Temperature  chart  :    pyasmia         -              -              -              -              -              -  6^:3 


LIST     OF    ILLUSTRATIONS 


FIG. 

i66. 
i67.- 
i68.- 
169. 
170. 
171. 
172. 
173- 
174- 
I75- 
176.- 
177.- 
178.- 
179.- 
180.- 
181.- 
182.- 
183.- 
184.- 
185.- 
186.- 
187.- 


190.- 
191.- 
192.- 

I93-- 
194.- 

I95-- 
196.- 
197.- 
198.- 
199.- 
200.- 
201.- 
202.- 
203.- 
204.- 
205.- 
206.- 
207.- 
208.- 
^09.- 
^10.- 
jii.- 

212.- 

213.- 


-Temperature  chart  :    facial  erysipelas        _  .  .  .  . 

-Temperature  chart  :    pernicious  anaemia  .  .  .  . 

-Temperature  chart  :    Hodgkin's  disease  .  .  .  . 

-Temperature  chart  :    sarcoma  of  the  neck  and  mediastinum 
-Diagram  of  malformations  of  rectum        .  -  -  -  . 

-Diagram  of  malformations  of  rectum       .  .  -  -  - 

-Diagram  of  malformations  of  rectum        -  .  .  .  - 

-Diagram  of  malformations  of  rectum       .  -  -  -  . 

-Diagram  of  the  distribution  of  sensory  nerves  in  the  skin 
-Peripheral  neuritis  :    glove  and  stocking   anaesthesia 
-Division  of  ulnar  nerve  at  wrist — area  of  impaired  sensation 
-Sensory  paths  in  the  peripheral  nerves  and  spinal  cord 
-Loss  of  sensibility  from  comminuted  fracture  of  sacrum 
-Loss  of  sensibility  from  dorsal  myelitis     -  .  -  -  . 

-Loss  of  sensibility  from  fracture-dislocation  of  cervical  spine     - 
-Brown-Sequard    paralysis  ...... 

-Loss  of  sensibility  in  syringomyelia  .  .  .  .  . 

-Loss  of  sensibility  in  early  tabes  dorsalis  .  .  .  . 

-Loss  of  sensibility  from  thrombosis  of  posterior  inferior  cerebellar  artery 
-Diagram  of  left  cerebral  hemisphere,  with  speech  centres 
-Splenic  anaemia       ...--- 
-Elastic  fibres  from   sputum  .... 

-Temperature  chart  :    lobar    pneumonia     - 

-Plan   of  regions  of  the  abdomen 

-Idiopathic  dilatation  of  the  stomach 

-Idiopathic  dilatation  of  the  bladder 

-Skiagram  :    chronic  periostitis  of  the  ulna 

-Skiagram  :    tuberculous  dactylitis 

-Skiagram  :    cancellous  exostosis  of  the  femur 

-Skiagram  :    enchondroma  of  fifth  metacarpal  bone 

-Skiagram  :     periosteal   sarcoma   of   tibia 

-Skiagram :    myeloid  sarcoma  of  radius     - 

-Skiagram  :    myeloid  sarcoma  of  radius 

-Skiagram :    myeloid  sarcoma  of  radius     - 

-Diagram  of  the  cutaneous  nerve  supply  of  the  scalp 

-MoUuscum   fibrosum — early   stage 

-Segmental  areas  of  the  scalp        .... 

-Segmental  areas  of  the  scalp         .... 

-Area  of  referred  spinal  pain  and  tenderness 

-Graphic  record  of  movements  in  intention  tremor 

-Graphic  record  of  movements  in  ataxy     - 

-Perforating  ulcer  of  foot 

-Diagram    of    gummatous    ulcer 

-Diagram   of   tuberculous   ulcer 

-Diagram  of  epitheliomatous  ulcer 

-Diagram   of  rodent   ulcer 

-L'ric  acid  crystals 

-Smallpox  :    showing  distribution  of  the  eruption 


PAGE 

614 

616 

617' 

617 

637 

637 

637 

637 
659 
660 
661 
662 
663 
663 
663 
664 
66=; 
665 
666 
683 
694 
701 
702 
723 
728 
730 
751 
752 
753 
754 
754 
755 
756 
756 
781 
782 
783 
783 
788 

799 
799 
809 
811 
811 
811 
811 
816 
833 


INDEX     OF 

DIFFERENTIAL    DIAGNOSIS 

OF     MAIN     SYMPTOMS 


ACCENTUATION  OF  HEART  SOUNDS. — It  often  happens  that,  without 
there  being  any  cardiac  bruit,  one  or  other  of  the  heart  sounds  is  much  louder 
than  it  ought  to  be.  Such  accentuation  generally  has  important  chnical  sig- 
nificance. Roughly  speaking,  it  is  the  first  sound  that  is  likely  to  be  either 
accentuated  or  prolonged  at  the  impulse  ;  whilst  in  the  second  right,  or  second 
and  third  left  intercostal  spaces  close  to  the  sternum,  it  is  the  second  sound  that 
is  likely  to  be  accentuated  rather  than  the  first.  It  is  very  unusual  to  find  the 
first  sound  accentuated  at  the  base  or  the  second  sound  at  the  impulse,  unless 
there  is  at  the  same  time  still  greater  accentuation  of  the  first  sound  at  the 
impulse,  and  of  the  second  sound  at  the  base  respectively.  Hence  the  three 
conditions  under  which  accentuation  of  a  cardiac  sound  becomes  chnically 
important  are  :  (i)  When  the  second  sound  is  unduly  loud  in  the  second  right 
intercostal  space  close  to  the  sternum  ;  (2)  When  there  is  an  accentuation  of  the 
second  sound  with  maximum  intensity  in  the  second  or  third  left  intercostal  space- 
close  to  the  sternum  ;  (3)  When  there  is  accentuation  of  the  first  sound  with 
maximum  intensity  at  or  near  the  impulse. 

Accentuation  of  the  second  sound  with  maximum  intensity  in  the  second 
right  intercostal  space  close  to  the  sternum  nearly  always  indicates  that 
the  systemic  blood-pressure  is  above  the  normal.  The  latter  can  only  be 
determined  with  certainty  by  actual  measurement  of  the  systemic  blood-pressure 
instrumentally.  The  causes  of  the  increase  will  probably  be  one  or  other  of  the 
following  : — 

Age. — Even  healthy  patients  over  forty  begin  to  show  a  slight  but  definite 
increase  of  Blood-pressure  {q.v.)  as  the  years  go  on.  In  people  over 
fifty,  therefore,  the  aortic  second  sound  begins  to  get  relatively  louder  than 
the  first. 

Arteriosclerosis  or  granular  kidney.  These  can  be  discussed  together,  because 
it  is  extremely  difficult  to  tell  where  the  one  ends  and  the  other  begins.  In 
both  there  is  cardiac  hypertrophy,  increase  in  the  blood-pressure,  prolongation 
of  the  first  sound  at  the  impulse,  and  possibly  a  blowing  systolic  bruit  there,  a 
ringing  or  clanging  aortic  second  sound  which  may  ultimately  change  into  the 
diastohc  puff  of  sHght  aortic  regurgitation,  albuminuria,  a  tendency  to  heart 
failure  as  time  goes  on,  with  all  its  concomitant  symptoms,  and  albuminuric 
retinitis.  It  is  sometimes  stated  that  the  accentuation  of  the  aortic  second  sound 
is  due  to  local  atheroma  ;  but  this  is  inaccurate,  for  atheroma  by  itself,  though 
it  may  easily  produce  an  aortic  systolic  bruit,  does  not  accentuate  the  second 
sound  ;  and  when  in  the  second  right  intercostal  space  there  is  a  .soft  systolic 

D  I 


ACCENTUATION     OF    HEART    SOUNDS 


bruit  replacing  the  first  sound,  and  a  clanging  second  sound,  the  former  indi- 
cates atheroma  of  the  aortic  valves,  and  the  latter  arteriosclerosis.  These  two 
absolutely  distinct  vascular  lesions  often  coincide  in  the  same  patient,  atheroma 
affecting  the  aorta,  and  the  coronary  and  cerebral  arteries,  whilst  arteriosclerosis 
affects  the  middle-sized  arteries,  especially  of  the  splanchnic  area.  There  is 
often  extensive  visceral  arteriosclerosis  when  the  radial  artery  does  not  feel 
abnormal  to  the  fingers. 

Accentuation  of  the  second  sound  with  maximum  intensity  in  the  second 
or  third  left  intercostal  space  close  to  the  sternum,  generally  spoken  of  as 
accentuation  of  the  pulmonary  second  sound,  indicates  a  higher  pressure  than 
there  should  be  in  the  pulmonary  circulation,  except  in  children,  in  whom  it  is 
not  uncommon  to  find  the  pulmonary  second  sound  normally  much  louder 
than  the  aortic.  The  most  important  cause  of  pathological  accentuation  of 
the  pulmonary  second  sound  is  disease  of  the  mitral  valve  ;  it  occurs  more 
markedly  with  mitral  stenosis  than  with  mitral  regurgitation.  It  may  sometimes 
be  a  marked  feature  of  the  latter,  whether  due  to  organic  changes  in  the  naitral 
valve  itself,  or  secondary  to  dilatation  ot  the  otherwise  normal  orifice  as  the 
result  of  heart  failure  from  aortic  disease,  myocardial  degeneration,  arterio- 
sclerosis, or  granular  kidney.  Sometimes,  instead  of  accentuation  of  the 
pulmonary  second  sound,  the  latter  may  be  reduplicated  ;  the  significance  of  its 
reduphcation  is  identical  with  that  of  its  accentuation,  the  probable  reason  for 
the  reduplication  being  that  when  the  pressure  in  the  pulmonary  circulation  is 
relatively  very  much  above  the  normal,  the  pulmonary  semilunar  valves  close 
sooner  than  the  aortic,  the  first  part  of  the  reduplicated  second  sound  being  due 
to  closure  of  the  pulmonary  valves,  whilst  its  second  part  is  due  to  closure  of 
the  aortic  valves. 

The  cause  of  an  accentuated  or  reduplicated  pulmonary  second  sound  will 
generally  be  obvious  if  the  other  cardiac  physical  signs  are  observed  carefully  ; 
one  way  in  which  it  may  have  particular  significance  is  in  distinguishing 
between  old  and  recent  changes  in  the  mitral  valves  ;  when,  for  instance, 
a  systolic  and  mid-diastolic  bruit  at  the  impulse  are  due  to  recent  endocarditis 
which  may  possibly  clear  up,  there  is  very  much  less  accentuation  of  the 
pulmonary  second  sound  than  there  would  be  if  the  same  bruits  were  due  to 
mitral  stenosis  and  regurgitation  due  to  old  fibrotic  changes.  The  greater  the 
accentuation  of  the  pulmonary  second  sound,  the  greater  the  mitral  leakage 
or  obstruction. 

Accentuation  ot  the  first  sound  at  the  impulse  may  have  one  or  other  of  two 
entirely'  dift'erent  characters  ;  it  may  be  an  accentuation  of  very  short  duration, 
difficult  to  describe  in  words,  though  obvious  enough  when  heard,  and  often 
spoken  of  as  a  "  slapping  "  first  sound  at  the  impulse  :  this  is  one  of  the  most 
characteristic  physical  signs  in  many  cases  of  mitral  stenosis.  It  may  occur 
when  there  is  neither  a  presystolic  nor  a  mid-diastolic  bruit,  though  even  when 
there  is  a  bruit  the  slapping  character  of  the  first  sound  is  still  to  be  distinguished. 
When  there  is  failure  of  compensation  in  a  mitral  case,  the  driving  power  of  the 
heart  may  become  so  feeble  that  bruits  are  no  longer  audible,  and  the  heart's 
action  is  quite  irregular  ;  in  such  cases,  the  occurrence  of  this  slapping  character 
of  the  first  sound,  clearly  audible  here  and  there  in  an  otherwise  tumbling 
rhythm,  is  highly  suggestive  of  mitral  stenosis. 

The  second  variety  of  accentuation  of  the  first  sound  at  the  impulse  consists 
in  its  being  very  much  longer  than  it  ought  to  be — a  marked  prolongation  of  the 
first  sound  as  distinct  from  there  being  any  bruit.  This  prolongation  is  obvious 
enough  when  heard.  It  indicates  that  there  is  considerable  hypertrophy  of  the 
left  ventricle,  and  therefore,  in  the  absence  of  bruits,  nearly  always  points  to  a 
high  blood-pressure  such  as  results  from  either  arteriosclerosis,  granular  kidney, 


ACCOUCHEUR'S    HAND 


or  the  two  combined  ;  it  is  repeatedly  met  with  in  cases  in  which  there  is 
accentuation  of  the  aortic  second  sound  at  the  same  time.  In  a  person  of 
middle  age  or  over,  in  whom  there  is  a  prolonged  first  sound  at  the  impulse 
— sometimes  spoken  of  as  a  "  lumpy  "  first  sound — and  a  clanging  aortic 
second  sound,  with  or  without  Albuminuria  [q-v.],  a  diagnosis  of  arterio- 
sclerosi  or  of  granular  kidney  is  very  probably  correct,  and  instrumental 
determination  of  the  blood -pressure  will  generally  show  that  it  has  risen 
from  the  normal  120-150  mm.  Hg  to  something  between  200  and  300  mm. 
Hg,  or  even  more. 

It  is  noteworthv  that  transient  accentuation  of  the  first  sound  at  the  impulse 
mav  occur  in  nervous  young  patients  examined  while  their  hearts  are  acting 
rapidlv ;  it  vanishes  in  a  few  minutes  when  the  patient  becomes  less  nervous 
and  the  heart  slower.  The  phenomenon  is  common  in  connection  with  life 
insurance  examinations.  Herbert  French. 

ACCOUCHEUR'S  HAND. — Accoucheur's  hand  is  seen  most  characteristically 
in  tetany  {Fig.  1),  though  it  may  also  occur  in  a  few  cases  of  other  spasmodic 
neuro-muscular  affections  such  as 
athetosis.  In  a  typical  case,  the 
attitude  of  the  fingers  is  almost 
pathognomonic.  There  is  full  ex- 
tension of  all  the  fingers  and  of 
the  thumb  at  the  interphalangeal 
joints,  the  four  fingers  are  adducted 
firmly  towards  the  middle  finger,  so 
as  to  form  a  cone,  they  are  semi- 
flexed at  the   metacarpo-phalangeal 

joints,    and    the    thumb    is     strongly  ^,V    i._The  hand  of  tetany. 

adducted  and   opposed  to  the  cone 

of    which   the    middle    finger  forms  the   apex,    or  else    into    the    palm    of    the 

hand. 

The  spasmodic  muscular  contraction  seldom  ceases  here,  but  generally  affects 
the  rest  of  the  arm  also,  the  wrist  being  strongly  flexed  and  abducted 
towards  the  ulnar  side.  The  elbow  is  flexed  to  a  right  angle,  and  the  arm 
inwardly  rotated  and  adducted  so  as  to  lie  in  contact  with  the  trunk.  The 
aft'ection  is  symmetrical.  The  feet  and  ankles  are  apt  to  show  similar 
spasmodic  contractions,  the  ankle  being  fully  plantar-flexed,  the  toes  and 
the  distal  half  of  the  feet  being  inwardly  rotated,  the  knees  rigidly  extended, 
and  generally  the  thighs  also.  The  contractions  may  be  limited  to  the 
hands  and  feet — the  so-called  carpo-pedal  spasm — especially  in  the  tetany 
of  young  children  suffering  from  rickets,  or  from  gastro-intestinal  disorder 
such  as  diarrhoea. 

WTien  adults  are  affected,  the  symptoms  spread  from  the  limbs  to  the 
trunk,  the  whole  body  being  kept  rigidly  extended,  the  paroxysms  lasting 
from  a  few  minutes  to  many  hours,  and  recurring  for  days,  weeks,  or  even 
months.  So  far  as  the  tetany  itself  is  concerned,  recovery  is  invariable, 
though  the  patient  may  sometimes  succumb  to  the  associated  malady,  tetany 
itself  generally  being  not  a  primary  disease  but  a  comphcation  of  gastric 
ulcer,  gastrectasis,  colitis,  intestinal  fermentation  or  putrefaction,  thyroidectomy 
or  pregnancy.      The  diagnosis  is  seldom  difficult. 

One  remarkable  feature  of  the  case  is,  that  in  the  intervals  between  the 
spasms,  if  the  upper  arm  is  firmly  grasped  between  the  observer's  two  hands, 
and  the  pressure  maintained,  the  hand  and  wrist  may  be  forthwith  sent  into 
the  typical  spasm,  a  sign  described  as  Trousseau's.  Herbert  French. 


ACETONURIA 


ACETONURIA. — This  term  denotes  the  occurrence  of  acetone  in  the  urine  in 
amounts  to  be  detected  b}'  ordinary  chnical  tests.  In  practice  the  laboratory 
method  of  distilHng  a  quantity  of  urine  to  get  a  concentrated  solution  of  any 
acetone  that  may  be  present  takes  too  long,  and  yet  without  distillation  it  is 
difficult  to  apply  the  iodoform  tests  for  acetone.  An  easier  and  more  usefuLplan 
is  Legal's  nitroprusside  test,  or  Rothera's  modification  of  it.  Legal's  test 
consists  in  taking  5  cc.  of  urine  in  a  test-tube,  adding  a  few  drops  of  liquor  sodae, 
then  a  few  drops  of  fresh  nitroprusside  solution  made  by  dissolving  a  crj-stal  or 
two  of  this  salt  in  ordinary  water,  and  finally  acidifying  with  strong  acetic 
acid.  The  liquor  sodse  causes  no  change  of  colour,  or  at  most  an  opalescence 
from  the  precipitation  of  phosphates  ;  the  sodium  nitroprusside  produces  a  red 
or  reddish-brown  colour  in  almost  all  urines  owing  to  the  presence  of  creatinine  ; 
if  the  red  colour  is  due  to  creatinine  only,  it  is  discharged  on  adding  acetic 
acid,  whereas  the  latter  in  the  case  of  acetone  deepens  the  red  into  a  rich 
burgundy  that  is  unmistakable. 

Rothera's  modification  of  this  test  consists  in  adding  a  few  drops  of  fresh 
nitroprusside  solution  to  5  cc.  of  urine,  hquor  ammoniae  till  the  mixture  is 
decidedly  alkaline,  and  then  ammonium  sulphate  crystals  in  excess  ;  as  the 
solution  becomes  saturated  with  the  latter,  a  colour  like  that  of  potassium 
permanganate  develops  if  acetone  is  present,  the  maximum  being  reached  in 
about  fifteen  minutes. 

Acetone  is  often  associated  with  diacetic  acid,  oxybutyric  acid,  and  amido- 
oxybutyric  acid  ;  the  detection  of  these,  however,  affords  no  clinical  information 
that  is  not  afforded  by  the  acetone  alone,  so  that  it  generally  suffices  to  test 
for  the  latter,  and  possibly  for  diacetic  acid  also.  The  tests  for  the  butj^ric 
acids  are  difficult.  When  these  substances  are  being  produced,  the  patient  is 
said  to  be  suffering  from  acidosis,  the  result  of  unnatural  metabolism.  Aceton- 
uria  is  indeed  the  chief  practical  evidence  of  acidosis.  It  occurs  in  the  most 
extreme  degree  in  certain  cases  of  diabetes  mellitus  ;  indeed,  from  the  point  of 
view  of  prognosis  all  cases  of  glycosuria  may  be  divided  broadly  into  two  classes, 
namely,  those  with,  and  those  without,  acetonuria.  The  same  patient  may, 
of  course,  be  passing  acetone  in  his  urine  at  one  time  and  not  at  another  ;  the 
prognosis  is  always  graver,  however,  when  acetone  is  present,  for  it  is  the  acidosis 
that  causes  the  serious  results  of  diabetes  and  glycosuria.  A  patient  without 
acetonuria  is  in  no  immediate  danger  of  coma,  whereas,  when  acetone  is  present 
as  well  as  sugar,  coma  may  supervene  at  any  time.  Broadly  speaking,  once 
glycosuria  has  been  diagnosed,  it  is  more  important  to  test  the  urine  for  acetone 
from  time  to  time  than  it  is  for  sugar,  and  that  treatment  which  reduces  the 
acetone  to  a  minimum  is,  generally  speaking,  doing  most  good,  whatever 
quantities  of  sugar  may  be  passed. 

Acetonuria  may  occur,  however,  without  any  glycosuria,  and  it  is  important 
to  remember  that  even  a  healthy  person  who  is  starved  of  carbohydrate  food 
is  apt  to  pass  acetone  and  diacetic  acid  in  the  urine.  This  explains  why  it  is 
that  acetonuria  occurs  in  such  conditions  as  gastric  ulcer  ;  gastric  carcinoma  ; 
gastrectasis  ;  oesophageal  stenosis  ;  intestinal  obstruction  ;  cachexia,  whether 
tuberculous,  malignant,  syphiliti:  or  malarial  ;  in  cases  of  persistent  vomiting 
of  pregnancy  ;  uraemia  ;  severe  migraine  ;  infantile  diarrhoea  and  vomiting  ; 
and  probably  in  many  other  conditions  in  which  there  is  either  actual  or  virtual 
starvation.  The  same  applies  to  surgical  operations  under  anaesthetics — the 
patient  is  often  starved  beforehand,  and  may  then  be  persistently  sick  after- 
wards ;  almost  all  patients  who  have  been  under  a  general  anaesthetic  for  any 
ength  of  time  have  acetonuria,  and  in  some  the  acidosis  increases  instead  of 
being  transient,  this  being  to  a  large  extent  the  pathology  of  so-called  delayed 
chloroform  poisoning. 


ALBUMINURIA 


The  chief  importance  of  acetonuria  therefore  from  a  diagnostic  point  of  view 
Ues,  not  so  much  in  distinguishing  one  disease  from  another,  as  in  detecting 
the  existence  of  acidosis.  The  importance  of  this  from  the  point  of  view  of 
prophylaxis  and  treatment  will  be  obvious  when  it  is  remembered  that  acidosis 
does  not  occur  until  the  liver  and  tissues  have  lost  their  glycogen,  and  that 
glycogen  storage  depends  largely  upon  the  ingestion  of  carbohydrates  either 
by  the  mouth,  the  rectum,  or  hypodermically.  Herbert  French. 

ACIDOSIS. — (See  Acetonuria.) 

ACROPARffiSTHESIA.^(See  Sensation,   Abnormalities  of.) 

ALBUMINURIA. — This  term  is  used  to  denote  the  passage  in  the  urine  of 
proteid  that  is  coagulable  on  boiling.  More  than  one  substance  is  included  in 
the  word  albumin  in  this  sense,  and  there  are  varying  proportions  of  serum 
albumin  and  serum  globulin  in  different  cases.  So  variable  may  be  the  relative 
amounts  of  these,  not  only  in  different  diseases,  but  also  in  different  cases  of  the 
same  disease,  and  in  the  same  patient  at  different  times,  that  there  is  little  useful 
clinical  information  to  be  obtained  by  dealing  with  the  albumin  and  the  globulin 
separately,  at  any  rate  so  far  as  present  knowledge  goes.  Nucleo-proteid  or 
nucleo-albumin  {q.v.)  comes  in  quite  a  different  category. 

Although  a  large  number  of  different  tests  for  albumin  have  been  devised  and 
advocated,  for  clinical  purposes  there  is  little  need  to  trouble  about  more  than 
the  two  common  ones,  namely  the  acetic  acid  and  boiling,  and  the  cold  nitric  acid 
tests.  It  is  true  that  each  of  these  has  fallacies  ;  but  the  latter  are  not  common 
to  both,  and  therefore,  if  there  is  any  doubt  in  the  interpretation  of  one  of  the 
two  tests,  it  can  readily  be  confirmed  or  otherwise  by  the  other.  It  is  alleged 
that  more  delicate  tests  exist,  but  there  is  such  a  thing  as  too  great  delicacy  in 
a  clinical  method.  One  does  not  want  to  find  albumin  in  minute  traces  where 
it  does  not  matter ;  and  it  seldom  matters  until  its  amount  is  sufficient  to  give 
both  the  common  tests. 

The  Acetic  Acid  and  Boiling  Test — A  test-tube  three  parts  full  of  urine  — cleared 
if  need  be  by  filtration — is  held  by  its  lower  end,  whilst  its  upper  part  is  carefully 
heated  to  boiling  point.  It  is  best  not  to  add  any  acetic  acid  before  boiling 
unless  the  specimen  is  distinctly  alkaline,  in  which  case  it  may  be  just  acidulated 
with  a  drop  of  acetic  acid.  After  boiling,  the  tube  should  be  held  in  a  good 
surface-light  against  a  dark  background,  such  as  the  sleeve  of  one's  coat  ;  any 
opalescence  will  be  obvious  at  once,  and  there  ma}^  be  a  dense  white  cloud. 
Except  in  very  rare  cases  of  Bence- Jones'  albumosuria  (p.  21),  this  cloud  will 
be  due  to  one  or  more  of  three  things,  namely,  calcium  and  magnesium  phosphate, 
calcium  carbonate,  or  coagulated  albumin.  One,  two,  or  more  drops  of  acetic 
acid  solution  (B.P.)  are  now  added  ;  if  the  cloud  disappears  entirely,  quickly, 
and  at  once,  it  was  due  to  earthy  phosphates,  and  no  albumin  is  present ;  if  it 
disappears  entirely  but  with  brisk  effervescence,  the  latter  is  due  to  calcium 
carbonates  amongst  the  phosphates,  and  no  albumin  is  present  ;  if,  on  the  other 
hand,  the  cloud  clears  up  but  partially,  or  remains  unaltered,  or  actually  increases 
and  becomes  more  fiocculent,  albumin  is  almost  certain!}'  present.  There  is 
only  one  serious  fallacy  remaining,  and  that  is  in  regard  to  nucleo-proteid  ;  this 
is  precipitated  by  acetic  acid,  and  it  is  possible  for  a  cloud  of  phosphates  to  be 
cleared  up  by  the  latter  and  yet  for  a  faint  cloud  of  nucleo-proteid  to  come  down 
in  the  place  of  the  phosphates  in  such  a  way  as  to  suggest  that  the  original 
cloud  was  not  wholly  soluble  in  the  acid,  and  therefore  that  albumin  is  present 
when  it  is  not.  There  are  three  ways  of  obviating  this  source  of  fallacy  :  the 
first  is  to  add  a  single  drop  of  dilute  non-fuming  nitric  acid  to  the  suspicious 


ALBUMINURIA 


cloud  that  remains  after  the  addition  of  acetic  acid  ;  if  it  is  due  to  albumin  it 
will  persist  or  even  increase,  whilst  if  it  is  due  to  nucleo-proteid  the  nitric  acid 
will  disperse  it  ;  the  second  is  to  perform  the  cold  nitric  acid  test  for  albumin 
as  described  below — nucleo-proteid  will  not  give  a  definite  localized  white  ring 
with  it  ;  and  thirdly,  a  control  test  maj-  be  done,  acetic  acid  being  added  to 
another  specimen  of  the  urine  without  boiling,  and  the  cloud  due  to  any 
nucleo-proteid  present  compared  with  the  cloud  in  the  acidulated  and  boiled 
specimen. 

Heller's  Cold  Nitric  Acid  Test — About  an  inch  and  a  half  of  urine  is  poured 
into  a  test-tube,  the  latter  is  held  much  inclined,  and  colourless  nitric  acid  is 
allowed  to  flow  gently  down  the  side,  until  about  one-third  as  much  as  the  urine 
has  been  added.  The  nitric  acid  is  heavier  than  urine  and  goes  to  the  bottom  ; 
if  albumin  is  present  a  white  ring  forms  at  the  junction  of  the  two  fluids.  Some 
prefer  to  pour  the  nitric  acid  into  the  test  tube  first  and  then  to  add  the  urine 
carefully  with  a  pipette.  It  is  important  not  to  shake  the  tube,  or  the  nitric 
acid  and  urine  will  mix,  and  there  will  be  no  definite  line  of  junction  between 
them.  Fuming  nitric  acid  must  be  avoided,  because  the  nitrous  oxide  fumes 
cause  decomposition  of  the  urea,  and  the  resultant  bubbles  mix  the  fluids  ; 
sometimes  there  is  bubbling  even  when  the  nitric  acid  is  colourless,  in  which  case 
this  is  due  to  CO^  set  free  from  carbonates.  The  test  is  very  delicate  ;  if  any 
large  quantity  of  albumin  is  present,  the  ring  appears  at  once ;  if  there  is  only  a 
trace,  the  white  ring  may  not  appear  for  a  little,  and  the  tube  should  be  set  aside 
and  looked  at  again  in  a  few  minutes.  Broadh-  speaking,  it  takes  three 
minutes  for  it  to  develop  when  the  amount  of  albumin  is  i  part  in  30.000. 
This  test  is  open  to  more  fallacies,  however,  than  the  acetic  acid  and  boiling 
test,  so  that  the  nitric  acid  test  should  not  be  trusted  to  alone,  unless  it  is 
negative.  In  concentrated  urines  it  is  common  to  get  a  dark-brown,  reddish- 
brown,  or  violet-brown  ring  of  colour  at  the  junction  ;  this  is  nothing  to  do 
with  albumin  ;  it  is  general!}-  most  marked  in  cases  of  Indicaxuria  [q-v.). 
White  rings,  more  or  less  like  that  due  to  albumin,  may  also  be  due  to  any 
of  the  following  : — 

1.  Resin. — If  the  patient  is  taking  copaiba  resin,  or  other  similar  drug,  enough 
of  the  resin  may  be  excreted  in  the  urine  to  form  a  difl'use  white  cloud  above  the 
nitric  acid.  This  source  of  fallacj-  is  best  avoided  by  bearing  it  in  mind,  and 
checking  the  nitric  acid  test  by  the  heat  test  ;  this  latter  safeguard  applies  to 
all  cases  of  suspected  albuminuria. 

2.  Albumoses. — These  generally  occur  in  association  with  albumin  ;  should 
the}'  occur  alone,  the  ring  will  disappear  with  warming,  to  reappear  with  cool- 
ing, and  there  will  be  no  cloud  with  the  heat  test. 

3.  Bence-Jones'  Albiimose. — This  occurs  without  albumin,  gives  a  ring  with 
nitric  acid  that  disappears  on  warming,  to  reappear  on  cooling  ;  with  the  heat 
test,  a  dense  cloud  appears  about  60-  C,  to  disappear  on  further  heating  to 
boiling-point. 

4.  Nucleo-albumin. — The  ring  with  this  is  not  in  contact  with  the  nitric  acid, 
but  higher  up,  and  diffuse  ;  it  may  be  a  real  difficulty  in  diagnosis  from  albu- 
min, for  it  is  also  precipitated  by  acetic  acid,  and  may  therefore  give  a  cloudi- 
ness with  the  boiling  test  (see  above). 

5.  Urates. — These  may  form  a  cloud  near  the  nitric  acid  if  the  urine  is  very 
concentrated  ;  the  cloud  will  disappear  on  gentle  warming,  to  reappear  on 
cooling,  so  that  it  may  also  be  mistaken  for  albumose  ;  the  fallacy  may 
be  avoided  by  diluting  the  urine  with  plain  water  before  the  nitric  acid  test 
is  employed. 

6.  Urea  nitrate. — If  the  urine  contains  a  large  percentage  of  urea,  a  crystalline 
deposit  of  urea  nitrate  may  form  at  the  junction  ;  as  a  rule,  the  crystalline  nature 


'^. 

«     * 


^'ig--  c. 


FLA  TE     I. 

RENAL       TUBE       CASTS 


&    c 


^ig-  E. 


i^4-.   D. 


^r 


^ 


'^ 


<a» 


^ " 


^'g-   F. 


y 


/ 


^!g.  G. 


i^'>--   H. 


A.   Hyaline  casts.     B.  Waxy  casts      C.  Hyaline  cast  containing  small  crystals  of  calcium  oxalate. 
D.   Blood'casts.     E.  A  leucocyte  cast.     F.  Epithelial  casts.     G.  Granular  casts.     H.  Fatty  casts. 


INDEX     OF     DIAG.NOSIS 


ALBUMINURIA  7 


of  the  ring  is  obvious  on  inspection  ;  but  in  case  of  doubt  the  urine  should  be 
diluted  and  the  test  repeated. 

It  does  not  matter  which  test  is  most  relied  upon  when  the  result  is 
negative  ;  but  before  the  positive  deduction  that  a  urine  contains  albumin  is 
drawn,  both  the  acetic  acid  and  boiling,  and  the  cold  nitric. acid  tests,  should 
be  positive. 

In  arriving  at  a  diagnosis  of  the  precise  cause  of  albuminuria  in  any  given  case, 
it  is  essential  that  a  microscopical  examination  of  the  centrifugalized  deposit  from 
the  urine  should  be  made.  Whatever  else  may  be  found,  the  first  question  to  be 
answered  is  :  Are  renal  tube-casts  present,  as  well  as  albumin,  or  not  ?  All 
cases  of  albuminuria  may  be  divided  into  two  main  groups,  namely  :  (I.)  Cases 
with   renal  tube-casts  ;     (II.)   Cases  without  renal  tube-casts. 

Renal  Tube-casts. — When  one  speaks  of  renal  tube-casts  in  this  respect, 
however,  one  has  to  bear  in  mind  the  fact  that  modern  methods  of  centrifugalizing 
with  electrically-driven  machinery  have  reached  so  high  a  degree  of  perfection, 
that  hardly  anything  that  a  given  specimen  of  urine  contains  escapes  detection  ; 
technique  has  become  almost  too  perfect ;  for  when  clinical  methods  become  too 
delicate  they  begin  to  lose  some  of  their  clinical  value.  The  result,  in  connection 
with  casts,  is  that  even  in  a  great  many  normal  urines  an  occasional  renal 
tube-cast  and  an  occasional  red  blood  corpuscle  are  found ;  therefore  when  one 
speaks  of  cases  of  "  albuminuria  with  tube-casts,"  one  means  "  with  enough 
renal  tube-casts  to  be  pathological."  The  observer  learns  from  previous 
experience  to  know  when  the  "  occasional  "  tube-cast  is  inside  or  outside  the 
normal  limits.  More  than  one  examination  may  be  required,  and  the  urine 
should  be  as  fresh  as  possible,  for  casts  disintegrate  on  standing,  especially  in 
hot  weather  and  in  alkaline  urines. 

Renal  tube-casts  are  of  various  sorts  {Plate  I),  and  a  certain  amount  of  help 
can  be  derived  from  a  knowledge  of  the  particular  kinds  of  casts  present  in  a 
given  case.  Their  matrix  or  foundation  is  a  structureless  material  whose  origin 
is  obscure,  though  thought  to  be  due  to  some  kind  of  proteid  coagulation.  Some- 
times the  casts  consist  of  this  structureless  matrix  only,  and  according  as  they 
are  then  less  or  more  highly  retractile,  they  are  spoken  of  as  hyaline  casts  or  waxy 
casts  respectively.  The  hyaline  form  is  commoner  than  the  waxy,  but  neither  is 
characteristic  of  any  particular  disease.  Embedded  in  the  hyaline  matrix  there 
may  be  various  substances  or  structures ;  and  according  to  the  main  features 
of  the  embedded  substances,  the  casts  receive  different  descriptive  names.  If 
renal  epithelial  cells  predominate,  the  cast  is  called  an  epithelial  cast  ;  if  leucocytes 
or  pus  corpuscles,  a  leucocytic  cast  ;  if  red  blood  corpuscles,  a  blood  cast  ;  if 
bacteria,  bacterial  casts  ;  if  fat  globules,  probably  derived  from  degenerated 
renal  cells  or  leucocytes,  fatty  casts  ;  if  non-fatty  granular  debris,  granular  casts. 
It  is  not  at  all  uncommon  to  find  a  long  cast  which  in  one  part  is  simply  hyaline, 
at  one  end  is  granular,  and  at  the  other  epithelial — a  mixed  cast.  Upon  the 
whole  one  may  say  that  the  hyaline  cast  occurs  in  all  forms  of  nephritic  conditions, 
whether  acute  or  chronic ;  that  epithelial  and  leucocytic  casts  indicate  active 
catarrh ;  that  granular  casts  tend  to  occur  along  with  epithelial  casts,  but  that 
when  they  occur  alone  or  in  association  with  hyaline  casts,  they  are  evidence  of 
at  least  less  acute  mischief  than  are  epithelial  casts,  whilst  fatty  casts  come 
between  the  two.  Blood  casts  may  occur  in  almost  any  variety  of  renal 
haemorrhage,  and  by  themselves  they  are  not  evidence  of  inflammation, 
though  in  association  with  other  casts  they  indicate  very  acute  inflammatory 
changes. 


ALBUMINURIA 


I. — Albuminuria  with  Renal  Tube-Casts. 

When  it  has  been  decided  that  there  ai'e  a  pathological  number  of  renal  tube 
casts  as  well  as  aibumin  in  the  urine,  it  is  almost  certain  that  there  is  an  inflam- 
mator\^  lesion  of  the  kidney.  The  next  step  in  the  diagnosis  is  to  decide  by 
microscopical  examination  whether  pus  is  present  also  ;  in  other  words,  the 
cases  may  be  subdivided  into  two  main  sub-groups,  namely  :  {A)  Albuminuria 
zi'ith  renal  tube-casts  without  obvious  pus  ;  and  {B)  Albuminuria  it'ith  renal  tube 
casts  and  obvious  pits.  There  are,  of  course,  a  few  border-line  cases  in  which 
leucocytes  are  present  in  excess,  and  yet  not  in  sufficient  numbers  to  constitute 
pus.  There  will  generally  be  other  points  about  such  a  case  that  will  lead  one 
to  decide  whether  it  comes  rather  in  the  pyuric  or  in  the  apyuric  group.  The 
differential  diagnosis  of  the  former  is  discussed  under  Pyuria,  so  that  it  only 
remains  here  to  discuss  : — 

(A)  The  di-fferential  diagnosis  of  albuminuria  with  tube-casts  without  obvious  pus. 
The  causes  of  this  condition  may  be  classified  as  follows  : — 

1.  The  various  forms   of  Bright's  Disease  : — 
ia)  A  primars'  acute  nephritis. 

ib)  An  acute  exacerbation  upon  an  underhung  chronic  nephritis, 
(c)   Chronic  nephritis  of  young  people  : — 

(i).  Arising  out  of  a  known  attack  of  acute  nephritis. 

(ii).  Arising  without  any  known  previous  attack  of  acute  nephritis. 

(iii).  Chronic  nephritis  of  old  people — cirrhosis  of  the  kidneys. 

iv).  Arteriosclerosis. 

(v).  Cvstic  disease  of  the  kidneys. 

2.  Nephritis  of  Pregnancy. 

3.  Chronic  Ascending  Nephritis,  leading  to  scarred  contracted  kidneys,  the 
result  of  : — ■ 

[a).   Obstruction  to  outflow  bj-  : — 
(i).  Urethral  stenosis. 
(ii).  Enlarged  prostate, 
(iii).  Displacement  of  the  womb. 

(iv).  Fibromyoma,  ovarian  cyst,  or  other  pelvic  tumour. 
(v).  Pregnancies. 

(vi).  Undue  mobility  of  the  kidney  and  kinking  of  the  ureter, 
(vii).  Rarities,  such  as  abdominal  aneuiy^sm  obstructing  a  ureter. 
<[b).   Irritation  ascending  from  the  pelvis  of  the  kidney,  the  result  especially 
of  calculus,  but  also  sometimes  of  chronic  tuberculous  lesions. 

4.  Lardaceous   Disease  of   the  Kidneys. 

5.  Infarction  of  the  Kidneys,  especially  when  the  result  of  embolism  in  cases 
of  fungating  endocarditis  ;   but  also  due  to  thrombosis,  as  in  some  blood  diseases. 

6.  Thrombosis  of  the  inferior  vena  cava  involving  the  renal  veins. 

7.  New  Growth  of  the  Kidney,  some  cases. 

In  man}^  instances  the  diagnosis  soon  becomes  obvious,  but  in  some  there  may 
be  great  difficulty.  The  1r\vo  following  cases  may  serve  to  indicate  how  such 
difficulties  may  arise  : 

A  patient  of  middle  age,  who  had  not  been  strong  for  a  long  time,  began  to 
suffer  from  oedema  of  the  ankles,  which  rapidly  increased  and  spread  to  her 
back,  genital  organs,  thighs,  and  legs.  She  did  not  see  a  doctor  at  once  ;  but 
within  a  few  days  her  abdomen  began  to  swell,  and  she  began  to  pass  very 
little  water,  and  what  she  did  pass  was  the  colour  of  blood.  Upon  examina- 
tion the  urine  had  a  specific  gravity  of  1030,  and  was  loaded  with  albumin  and 
blood  ;  whilst  microscopically  there  was  an  abundance  of  red  corpuscles,  renal 


ALBUMINURIA 


epithelial  cells,  leucocytes,  and  epithelial,  fatty,  granular,  and  blood  casts, 
without  pus,  crystals,  or  bacteria.  It  seemed  almost  obvious  that  she  must  be 
suffering  from  acute  Bright's  disease  ;  but  there  was  no  oedema  of  the  eyelids, 
and  there  was  definite  enlargement  of  the  left  supraclavicular  lymphatic  gland  ; 
the  discovery  of  the  latter  led  to  a  very  careful  examination  for  malignant 
disease  ;  and  a  latent  and  quite  unsuspected  carcinoma  of  the  rectum  was  dis- 
covered. The  diagnosis  was  carcinoma  recti,  secondary  deposits  in  the  retro- 
peritoneal glands,  obstruction  and  thrombosis  of  the  inferior  vena  cava  and  of 
the  renal  veins,  with  consequent  albuminuria,  haematuria,  and  renal  tube-casts 
from  asphyxial  nephritis,  simulating  acute  Bright's  disease. 

Another  case  was  that  of  a  girl  of  i6,  who  began  to  suffer  from  increasing 
anaemia,  shortness  of  breath,  oedema  of  her  ankles  and  face,  and  slight  pyrexia. 
The  heart  seemed  to  be  a  little  enlarged,  and  there  were  soft  systolic  bruits  that 
were  regarded  as  secondary  to  the  anaemia.  The  urine  contained  blood  and 
albumin,  with  renal  epithelial  cells  and  tube-casts  in  abundance.  Ascites 
developed,  with  increasing  general  oedema  ;  there  were  also  retinal  hcemor- 
rhages  and  neuro-retinitis.  The  diagnosis  of  acute  nephritis,  however,  was 
onl}?-  in  small  degree  correct  ;  for  she  was  really  suffering  from  malignant 
endocarditis  of  a  subacute  type,  the  nephritis  being  due  to  infected  emboli 
of  the  kidney  producing  inflammatory  changes  around  multiple  renal  infarcts. 

These  two  cases  will  serve  to  show  how  it  may  be  impossible  to  arrive  at  a 
correct  diagnosis  except  by  a  thorough  examination  of  all  the  svstems,  by  watch- 
ing the  case  carefulh',  and  by  repeating  the  full  systemic  examination  at  intervals. 
We  wiU  now  deal  with  the  main  headings  in  the  above  table  in  their  reversed 
order. 

If  there  is  New  Growth  in  a  kidney  the  number  of  renal  tube-casts  is  likely  to 
be  small  ;  sooner  or  later  a  microscopic  fragment  of  new  growth  will  probably 
be  detected  in  the  centrifugalized  urinary  deposit.  Albuminuria  will  not  be 
extreme  unless  the  renal  veins  and  the  inferior  vena  cava  become  involved,  the 
same  applying  also  to  the  oedema  of  the  legs  and  trunk  ;  haematuria  is  likely  to 
occur  at  intervals,  the  attacks  being  separated  by  many  weeks  sometimes,  and 
being  relatively  painless  ;  there  may  be  an  increasing  renal  tumour  ;  cystoscopic 
examination  may  show  the  blood-stained  urine  (see  Plate  V,  Fig.  A)  to  be  coming 
from  one  ureter  only  ;  and  finally,  when  suspicion  of  new  growth  has  been 
aroused,  laparotomy  may  be  indicated  and  the  diagnosis  thereby  confirmed. 

Thrombosis  of  the  Renal  Veins  and  Inferior  Vena  Cava  has  been  referred  to 
above,  as  a  condition  that  ma^'  simulate  acute  nephritis.  Points  to  lay  stress  on 
in  arriving  at  the  diagnosis  are  :  (i)  To  make  a  ver}^  careful  and  systematic 
examination,  including  that  of  rectum  and  vagina,  in  order  not  to  miss  anything, 
such  as  some  latent  growth  whose  secondary  deposits  are  obstructing  the 
veins  ;  (2)  To  enquire  carefully  into  the  history — a  great  many  cases  of  inferior 
venacaval  thrombosis  are  due  to  extension  upwards  from  iliac  or  saphenous 
clots,  in  which  case  there  will  nearly  always  have  been  swelling  of  one  leg 
only  to  start  with,  followed  later  by  extension  to  the  back  and  to  the  other  leg  ; 

(3)  To  note  that  although  the  oedema  of  the  legs  and  back  may  be  extreme, 
there  is  a  definite  upper  level  to  it,  and  no  swelling  of  the  eyelids  or  scalp  ;    and 

(4)  To  note  that  if  there  are  any  distended  or  varicose  veins  upon  the  abdoininal 
wall  (see  Veins,  Varicose  Abdominal,  Plate  XVI),  the  blood-current  in  them 
has  become  reversed — to  being  from  below  upwards  instead  of  from  above 
downwards . 

Infarction  of  the  Kidneys  may  be  either  embolic  or  thrombotic.  By  far  the 
commonest  cause  of  embolic  renal  infarction  is  infected  or  fungating  endocarditis. 
Each  embolus  gives  rise  to  the  sudden  appearance  of  blood  in  the  urine  which 
may  have  contained  none  previously,  or  to  a  sudden  marked  increase  in  any 


ALBUMINURIA 


existent  hsematuria  ;  there  may  or  may  not  have  been  a  sudden  pain  in  the 
back  at  the  same  time.  Around  each  infarct  there  develops  acute  nephritis,  so 
that  in  some  cases  all  the  characters  of  the  latter  malady  may  be  superposed 
upon  those  of  the  fungating  endocarditis.  If  the  patient  is  already  known  to 
have  heart  disease,  the  diagnosis  is  easy  enough  ;  the  difficulties  arise  in  cases 
in  which,  notwithstanding  the  fungating  endocarditis,  there  is  no  bruit.  If 
fungating  endocarditis  is  suspected,  the  points  that  confirm  the  diagnosis  are  : 
pyrexia,  which  may  be  of  any  type — though  absence  of  pyrexia  does  not  exclude 
the  disease  ;  enlargement  of  the  spleen  ;  cutaneous,  retinal,  or  other  haemor- 
rhages ;  progressive  anaemia  ;  definite  cardiac  bruits,  especially  if  the  latter 
at  any  time  undergo  any  radical  change  in  their  character,  such  as  becoming 
musical  instead  of  blowing,  or  vice  versa  ;  optic  neuritis  ;  and  multiple  embolism, 
for  instance,  in  the  brain,  spleen,  or  a  peripheral  artery.  There  is  no  marked 
leucocytosis  as  a  rule.  Venous  blood  may  be  cultivated  bacteriologically  as 
a  means  of  confirming  the  diagnosis. 

Thrombotic  infarcts  are  less  severe  in  their  effects  ;  they  may  produce  no 
hsematuria  at  all,  and  the  albuminuria  may  be  slight,  and  unaccompanied  by 
tube-casts.  They  generally  arise  in  cachectic  conditions,  or  in  blood  diseases 
such  as  leukaemia  or  pernicious  anaemia,  in  which  cases  the  diagnosis  will  be 
arrived  at  on  other  grounds,  and  albuminuria  will  not  be  the  prominent  feature 
of  the  case. 

Lardaceous  Disease  of  the  Kidneys  used  to  be  common  enough  in  the  days- 
of  septic  surgery,  but  it  is  decidedly  uncommon  now.  It  is  a  risky  diagnosis  to 
make,  therefore,  unless  there  is  some  obvious  cause  for  it,  such  as  long-standing 
suppuration  in  association  with  a  spinal,  hip-joint,  or  empyema  sinus,  bronchi- 
ectasis, phthisis  with  cavitation,  or  the  like  ;  or  else  clear  evidence  of  tertiary 
syphilis  of  the  viscera  with  cachexia.  There  is  nothing  characteristic  about  the 
urine,  although  statements  are  made  to  the  contrary.  In  the  earlier  stages 
there  may  be  but  a  trace  of  albumin  in  an  otherwise  normal  urine  ;  later,  the 
albumin  increases,  and  it  may  reach  very  large  amounts,  such  as  20  parts  per 
1000,  casts  being  very  few  in  proportion,  the  total  amount  of  urine  increased, 
its  colour  pale,  and  its  specific  gravity  low — 1005  to  1012  ;  later  still,  possibly 
as  the  result  of  a  superposed  nephritis,  the  amount  of  urine  falls  until  only  a 
few  ounces  may  be  passed  each  day,  of  high  colour  and  specific  gravity  1020 
to  1035,  loaded  with  albumin,  and  now  containing  hyaline,  waxy,  granular,  fatty, 
and  epithelial  casts.  Lardaceous  casts  may  or  may  not  occur,  but  they  are 
not  diagnostic,  for  they  have  also  been  found  in  cases  of  nephritis  without 
lardaceous  disease,  hj'aline  degeneration  of  the  renal  tissue  being  not  uncommon 
in  cases  of  chronic  nephritis.  Indeed,  the  diagnosis  of  lardaceous  kidney  resolves- 
itself  into  one  of  guesswork  in  a  case  in  which  there  has  been  prolonged  suppura- 
tion or  severe  syphilis  to  give  rise  to  it,  and  in  which  there  maj'  be  smooth  firm 
enlargement  of  the  liver,  moderate  enlargement  of  the  spleen,  and  more  or  less- 
severe  diarrhoea,  to  indicate  corresponding  lardaceous  change  in  the  other  organs 
that  are  generally  affected  at  the  same  time  as  the  kidneys. 

Chronic  Ascending  Nephritis  arises  from  precisely  the  same  causes  as  acute- 
ascending  nephritis  or  surgical  kidney,  and  probably  results  from  recurrent  focal 
inflammations  which  heal,  each  leaving  behind  a  smaller  or  larger  scar  ;  with 
the  result  that,  in  the  course  of  months  or  years,  the  kidneys  are  converted  into 
a  mass  of  irregular  fibrotic  scars,  which  together  produce  the  same  local  and 
general  changes  and  effects  as  are  to  be  found  in  cases  of  ordinarj'  red  granular 
contracted  kidney. 

This  is  not  always  kept  clearly  in  mind.  At  first  sight  it  might  seem  that 
there  could  be  little  connection  between  prolapsus  uteri  and  cerebral  haemor- 
rhage ;    but  the  latter  may  be  due  to  the  former,  by  the  following  sequence  of 


ALBUMINURIA 


events — the  displacement  of  the  womb  and  bladder  sometimes  produces  a  bend 
or  kink  in  the  ureters  a  short  distance  above  their  vesical  ends  ;  this  obstruction, 
persisting  for  years,  tends  to  produce  chronic  ascending  nephritis  ;  the  fibrotic 
changes  in  the  kidneys  that  result  from  this  may  lead  to  thickening  of  arterioles, 
high  blood -pressure,  and  hypertrophied  heart,  with  tendency  to  apoplexy,  just 
as  other  forms  of  granular  kidney  do.  It  is  true  that  this  sequence  of  events  is 
not  very  common  ;  but  this  is  because  prolapse  of  the  uterus,  fortunately,  is  not 
generally  left  untreated  when  it  is  of  sufficient  degree  to  cause  the  ureteral 
obstruction  referred  to  above.  Nevertheless,  it  is  important  to  bear  in  mind 
that  any  cause  of  prolonged  obstruction  to  the  urine  outflow  may  cause  granular 
kidney  with  albuminuria,  without  pus,  but  with  casts,  in  a  pale  and  abundant 
urine  of  low  specific  gravity. 

The  diagnosis  will  generally  be  obvious  when  the  obstruction  is  due  to  urethral 
stricture  ;  it  is  more  apt  to  be  overlooked  in  other  cases,  though  if  one  bears  in 
mind  the  kind  of  causes  mentioned  in  the  list  above,  the  methods  of  diagnosis 
will  generally  be  obvious.  One  would  only  mention  in  particular,  that  uterine 
tumours  or  displacements  are  a  very  common  cause  for  slight  albuminuria  and 
a  few  renal  tube-casts  in  women  ;  and  that  in  men  of  sixty  and  over,  enlarge- 
ment of  the  prostate  causes  a  precisely  similar  condition  long  before  there  is  any 
definite  pyuria. 

Pregnancy  Nephritis  is  sometimes  spoken  of  as  though  it  were  an  altogether 
different  thing  to  nephritis  of  the  Bright's  disease  ty^pe  in  general.  I  do  not 
subscribe  to  this  view.  I  hold  that  Bright's  disease  has  man}-  different  causes 
and  manv  different  types.  It  may  be  due  to  scarlet  fever,  in  which  case  it  is 
very  possibly  streptococcal  ;  it  may  be  due  to  pneumonia  or  empyema,  in  which 
cases  it  may  be  pneumococcal  ;  it  may  be  due  to  various  other  micro-organisms  ; 
it  occurs  in  some  cases  of  cholera,  and  in  severe  secondary  syphilis  ;  it  may  be 
due  to  chemical  substances,  such  as  turpentine,  cantharides,  or  oxalic  acid  ;  it 
very  often  seems  to  come  on  from  no  known  cause  at  all,  though  in  such  cases 
there  must  be  a  microbial  or  other  cause  that  is  not  discovered  ;  it  m-ay  be 
due  to  pregnancy,  in  which  case  it  is  ascribed  to  unknown  toxins. 

In  all  these  cases,  the  types  of  reaction  on  the  part  of  the  kidney  are  similar, 
and  one  can  only  regard  pregnancy  nephritis  as  a  variety'  of  non-suppurative 
nephritis  in  general.  Very  likely  it  is  only  a  matter  of  degree  whether  it  is  non- 
suppurative or  merges  into  the  t^'pe  in  which  there  is  pyuria  as  well  as  albumin- 
uria— pyelitis  of  pregnancy.  Pregnane}-  may  cause  a  primary  acute  nephritis, 
which  may  recover  either  completely,  or  but  partially  and  persist  as  chronic 
nephritis  ;  or  maj^  seem  to  recover,  when  in  reality  it  is  merely  latent,  or  even 
slowly  and  insidiously  progressive  ;  it  may  produce  what  seems  to  be  a  primary 
acute  nephritis  which  is  really  but  an  exacerbation  superposed  upon  a  chronic 
nephritis  that  has  been  unsuspected  ;  and  very  possibly  it  may  produce  nephritic 
changes  which  are  not  associated  with  definite  symptoms  at  the  time,  but 
which  ultimately  result  in  what  is  spoken  of  as  chronic  interstitial  nephritis. 
When,  therefore,  albuminuria  with  renal  tube-casts,  but  without  pyuria,  occurs 
during  pregnancy,  it  matters  little  what  name  is  given  to  the  condition,  pro- 
vided it  is  realized  that  just  the  same  difficulties  offer  themselves  here  as  in 
Bright's  disease  in  general,  in  arriving  at  a  conclusion  as  to  whether  the  renal 
lesion  is  acute,  chronic,  or  acute  on  chronic. 

Various  forms  of  Bright's  Disease. — Of  all  these,  the  hardest  to  diagnose  with 
certainty  is  primary  acute  nephritis  in  the  adult.  The  majority  of  adult  cases  that 
are  labelled  acute  Bright's  disease  are  really  suffering,  not  from  primary  acute 
nephritis,  but  from  an  acute  exacerbation  upon  the  top  of  already  existent  but 
possibly  latent  chronic  nephritis.  The  difficulty  is  to  arrive  at  the  diagnosis 
between  these  two,  particularly  since  many  of  the  points  mentioned  in  text- 


ALBUMINURIA 


books  as  occurring  in  acute  nephritis  are  really  due,  not  to  the  acute  attack, 
but  to  the  subacute  or  chronic  renal  lesion  which  has,  until  then,  been  unsuspected. 

The  best  examples  of  primary  acute  nephritis  are  to  be  seen  in  cases  that  are 
already  under  observation  for  some  other  disease,  notably  scarlet  fever  or  lobar 
pneumonia.  Sometimes  the  onset  of  the  nephritis  is  indicated  bj-  general  oedema, 
especially  of  the  eyelids  and  face,  ankles,  genital  organs,  and  loins  ;  but  it  cannot 
be  too  strongly  insisted  upon  that  oedema  is  not  essential,  man}-  cases  of  acute 
nephritis  having  no  oedema  at  all,  especially  if  the  patient  is  ahead}-  in  bed  when 
the  kidne}-  inflammation  begins,  as  in  scarlatina  cases.  If  the  urine  were  not 
examined,  the  renal  lesion  would  often  escape  recognition  altogether  ;  and  there 
can  be  no  doubt  that  many  cases  of  primary  acute  nephritis  do  escape  recognition 
in  this  way,  coming  under  observation  later,  when  they  present  symptoms  of 
chronic  nephritis,  or  an  acute  exacerbation  on  chronic  nephritis. 

The  essential  point  in  the  diagnosis  is  urine  examination.  According  to  the 
severity  of  the  nephritis  there  will  be  more  or  less  diminution  in  its  total  dail}^ 
quantity  ;  it  is  common  for  less  than  20  oz.  to  be  passed  in  the  twenty-four 
hours,  and  often  the  amount  falls  to  10  oz.,  5  oz.,  or  even  to  none  at  all  for  a 
whQe.  The  specific  gravity  is  raised  to  1025,  1030,  or  even  to  1035,  but  rarely 
to  1040.  The  reaction  is  generally  acid  at  first,  but  it  soon  becomes  alkaline 
on  standing.  The  colour  is  extremely  variable,  according  as  little  or  much 
blood  is  present ;  sometimes  it  is  almost  normal  or  merely  that  of  a  concen- 
trated urine ;  more  often  there  is  some  tinging  with  blood,  varying  from 
bright  red  to  brownish,  brown,  brown-black,  or  to  that  peculiar  blackish  tint 
which  is  described  as  smoky.  There  is  a  general  cloudiness  of  the  specimen, 
and  on  standing,  it  deposits  a  heavj^  sediment  which  often  has  a  dark  brownish 
tint,  owing  to  the  phosphates  carrying  the  blood  pigment  down  with  them. 
Microscopically,  the  centrifugalized  deposit  consists  partly  of  amorphous  debris 
due  to  earthy  phosphates,  and  to  the  disintegration  of  cells  and  tube-casts  ;  and 
one  expects  to  find  an  abundance  of  red  corpuscles,  renal  epithelial  cells,  variable 
numbers  of  epitheUal,  fatty,  granular,  hyaline,  and  blood-casts,  an  excess  of 
leucocytes,  an  occasional  crj^stal  of  calcium  oxalate  or  uric  acid,  and  irregular 
granular  masses  which  are  not  definiteh-  tube-casts.  It  is  noteworthy,  how- 
ever, that  in  the  very  acute  stages  there  may  be  no  tube-casts,  though  shed 
renal  epithelial  cells  are  abundant  ;  in  such  a  case,  tube-casts  will  show  them- 
selves in  a  few  daj'S. 

It  is  important  that  each  specimen  should  be  examined  as  fresh  as  possible, 
owing  to  the  tendency'  to  alkaline  reaction  and  disintegration  of  casts  and  cells 
on  standing.  In  addition  to  red  corpuscles  there  is  often  a  considerable  amount 
of  free  haemoglobin  ;  the  tincture  of  guaiacum  test  will  be  positive,  and  the 
spectroscope  will  show  the  bands  of  oxyhaemoglobin  or  of  methaemoglobin. 
Coagulable  proteid  is  generally  present  in  abundance,  the  proportions  of  globulin 
and  albumin  varying  greatly,  but  together  amounting  to  anything  between 
2  and  20  parts  per  thousand — often  about  15  parts  per  thousand  at  first,  rapidly 
dropping  to  less  after  the  first  few  days  of  treatment,  until  at  the  end  of  from 
a  fortnight  to  a  month  it  ma}'  be  i  part  per  thousand  or  less,  or  even  absent 
altogether.  In  a  few  cases,  however,  there  is  vpry  little  coagulable  proteid  but 
an  abundance  of  albumose,  so  that  the  boiling  test  gives  but  a  faint  cloud,  whilst 
the  nitric  acid  test  j-ields  a  dense  white  ring,  soluble  on  warming,  to  reappear 
on  cooling.  There  is  generall}'  an  excess  of  nucleoproteid  also.  The  urea, 
chlorides,  and  phosphates  all  fall  below  the  normal  totals,  though  their  per- 
centages may  be  increased  if  the  urine  is  very  concentrated. 

With  this  condition  of  urine  there  will  be  little  doubt  as  to  the  presence 
of  acute  nephritis  ;  the  only  question  being  whether  it  is  primary,  or  whether 
it  is  an  exacerbation  upon  chronic  nephritis.       The  former  is  probable  if  it  is 


ALBUMINURIA  13 


known  that  the  urine  was  free  from  albumin  up  to  the  time  of  the  attack,  if 
the  patient  is  known  to  have  suffered  recently  from  scarlet  fever,  pneumonia, 
diphtheria,  secondary  syphilis,  or  some  other  similar  fever  ;  if  the  heart  is  of 
normal  size  and  its  sounds  natural,  the  blood-pressure  natural,  and  the  retina: 
healthy.  It  may  be  that  the  patient  himself  may  have  been  exposed  to  scarla- 
tinal infection,  and  without  having  had  the  rash,  may  develop  nephritis  ;  the 
association  of  peeling  of  the  skin,  or  recent  sore  throat  with  enlarged  glands 
in  the  neck,  or  otitis  media,  might  suggest  the  diagnosis  in  these  mild  cases  of 
scarlatina,  though  sometimes  acute  nephritis  in  a  child  may  be  the  sole 
evidence  of  the  disease.  The  course  of  the  malady  will  also  assist  the  diagnosis  ; 
the  albuminuria  of  primary  acute  nephritis  may  clear  up  entirely  in  from  a 
fortnight  to  six  weeks,  though  in  unfavourable  cases  it  persists,  and  chronic 
nephritis  develops  out  of  the  acute.  If,  on  the  other  hand,  it  is  found  that,  in 
a  case  of  apparently  recent  acute  nephritis,  with  general  oedema,  haematuria,  and 
the  other  urinary  changes  described  above,  there  is  cardiac  hypertrophy,  with  a 
prolonged  lumpy  first  sound  at  the  impulse,  a  ringing  aortic  second  sound,  a 
blood-pressure  of  more  than  150  mm.  Hg,  and  possibly  albuminuric  retinitis,  the 
probability  is  that  the  acute  nephritis  is  not  primary,  but  an  acute  exacerbation 
of  an  unsuspected  chronic  nephritis.  There  is  often  a  history  of  former  scarlet 
fever  or  of  syphilis  in  such  cases  ;  the  patients  may  be  of  any  age,  from  child- 
hood to  past  middle  life.  If  the  patient  survives,  one  or  other  of  two  conditions 
usually  results  :  either  the  albuminuria,  the  scanty  urine,  and  the  tube-casts 
persist,  whilst  the  patient  remains  waterlogged  until  the  end  comes  in  a  few 
weeks  or  months,  or  else  the  acute  exacerbation  subsides  and  the  clinical 
characters  of  chronic  nephritis  remain.  Some  of  these,  but  by  no  means 
all  of  them,  are  examples  of  primary  acute  nephritis,  persisting  and  becoming 
chronic. 

It  must,  however,  always  be  very  difficult,  and  indeed  almost  a  matter  of 
opinion  in  many  cases,  to  decide  whether  a  patient  is  suffering  from  a  chronic 
nephritis  which  is  the  result  of  a  primary  acute  nephritis  that  has  not  cleared  up, 
or  from  a  chronic  nephritis  which  was  present  but  unrecognized  before  an  acute 
exacerbation  drew  attention  to  it  ;  but  my  own  view  is  that  many  cases  in 
which  young  adults  seem  to  develop  acute  nephritis  from  no  more  definite  cause 
than  exposure  to  damp  or  cold,  are  really  examples  of  acute  on  chronic,  and  not 
of  primary  acute,  Bright's  disease.  The  albuminuria  in  these  cases  does  not 
clear  up,  and  it  is  a  mistake  to  restrict  the  diet  or  the  daily  occupation  after  the 
acute  exacerbation  has  subsided.  In  spite  of  the  persistence  of  albuminuria, 
these  patients  do  best  if  they  are  given  iron  and  allowed  to  go  about  their  ordinary 
avocations  ;  they  have  diseased  kidneys,  and  they  will  not  live  many  years, 
but  there  is  no  need  to  adopt  treatment  which  constantly  reminds  them  of  the 
fact.  As  the  acute  exacerbation  subsides  in  these  cases,  the  amount  of  urine 
rises  rapidly  to  60  or  70  oz.  or  more  per  diem,  and  remains  increased  even  after 
all  oedema  has  passed  away  ;  the  specific  gravity  falls  to  1012,  loio,  or  1008  ; 
the  albumin  persists  to  the  extent  of  anything  between  0-5  and  8  parts  per 
thousand  ;  blood  is  absent,  though  an  occasional  red  corpuscle  may  be  seen 
under  the  microscope  ;  and  there  are  moderate  numbers  of  hyaline,  granular, 
or  even  fatty  casts,  with  an  occasional  renal  epithelial  cell. 

It  not  infrequently  happens  that  a  young  patient  suffering  from  chronic  nephritis 
comes  under  observation  for  shortness  of  breath,  palpitations,  anaemia,  or  for 
inflammation  of  one  or  other  of  the  serous  membranes,  without  ever  having 
had  any  symptoms  of  acute  nephritis  at  all.  The  kidneys  that  would  be  found 
in  such  cases  differ  from  the  granular  contracted  kidneys  of  older  people  in  that 
they  are  pale  instead  of  red.  They  are  pale  granular  contracted  kidneys,  preciselj^ 
similar  to  those  which  may  result  from  a  long  antecedent  acute  nephritis  that 


14  ALBUMINURIA 


has  not  entirely  cleared  up.  When  they  develop  without  any  known  preceding 
attack  of  acute  nephritis,  they  have  been  referred  to  as  Rose-Bradford  kidneys. 
It  is  by  no  means  impossible  that  they  are  really  the  result  of  a  preceding  acute 
nephritis  which  escaped  recognition,  because  there  was  no  oedema  to  attract 
attention  to  the  need  for  urine  examination.  The  patient  may  be  of  any  age, 
though  generally  between  five  and  thirty-five.  There  may  be  no  sign  of  any- 
thing wrong  until  acute  uraemia,  with  convulsions,  leads  to  rapid  death.  On 
the  other  hand,  in  a  typical  case,  in  addition  to  the  urine  changes  mentioned 
above,  one  expects  to  find  some  of  the  following  symptoms  or  signs  :  a 
great  increase  in  the  size  of  the  left  ventricle,  as  evidenced  by  displacement 
of  the  impulse  downwards  and  outwards  into  the  sixth  left  intercostal  space 
below  or  outside  the  left  nipple,  with  increase  of  the  precordial  impairment 
of  resonance  outwards  to  the  left  without  corresponding  increase  upwards  or 
to  the  right  ;  a  ringing  exaggerated  second  sound  in  the  second  right  inter- 
costal space  close  to  the  sternum,  and  a  prolongation  of  the  first  sound  at  the 
impulse,  or  its  replacement  by  a  more  or  less  localized  blowing  systolic  bruit  ; 
more  or  less  anaemia,  sometimes  very  considerable  and  of  the  chlorotic  type  ; 
a  maximum  systolic  blood-pressure,  of  175  mm.  Hg  or  more,  sometimes  over 
300  mm.  Hg,  even  when  the  pulse  feels  comparatively  soft  to  the  finger  ; 
albuminuric  retinitis  ;  a  tendency  to  haemorrhages,  especially  to  epistaxis  ; 
headache  ;  insomnia  ;  breathlessness  on  exertion  ;  and  inability  to  work  with 
the  usual  energy,  either  mentally  or  physically. 

The  chronic  nephritis  of  old  people  is  diagnosed  more  often  than  it  exists,  if  one 
understands  by  it  the  disease  associated  with  small  red  granular  contracted 
kidneys.  On  the  other  hand,  the  kidneys  of  most  old  people  exhibit  a  certain 
amount  of  interstitial  fibrosis,  with  occasional  retention  cysts  and  some  granu- 
larity of  the  surface  when  the  capsules  are  stripped  off,  without  there  being  any 
material  diminution  in  their  size.  Where  senile  changes  that  are  almost  normal 
end  and  chronic  interstitial  nephritis  begins,  is  difficult  to  determine.  The 
same  applies  to  arteriosclerosis  and  the  renal  changes  associated  with  this  arterial 
degeneration.  Some  regard  arteriosclerosis  and  chronic  interstitial  nephritis  as 
essentially  different  maladies  ;  others  regard  the  arterial  secondary  to  the 
renal  changes  ;  others  hold  that  arteriosclerosis  leads  to  a  variety  of  red  granular 
kidney  that  is  not  the  same  as  the  red  granular  contracted  kidney  of  chronic 
interstitial  nephritis  ;  whilst  others  again  favour  what  seems  a  likely  view, 
namely,  that  arteriosclerosis  and  sclerosis  of  the  kidneys  both  have  a  common 
cause,  and  that  it  is  more  or  less  of  an  accident  whether  the  patient,  on  post- 
mortem examination,  presents  more  arterial  than  renal  changes,  or  about  the 
same  degree  of  both.  During  life  the  differential  diagnosis  between  them  is 
sometimes  impossible.  In  either  case  there  will  be  a  hypertrophied  left  ventricle, 
a  loud  lumpy  first  sound,  or  a  blowing  systolic  bruit  at  the  impulse,  a  markedly 
accentuated  aortic  second  sound,  a  systolic  blood-pressure  somewhere  between 
150  and  320  mm.  Hg,  with  a  tendency  to  shortness  of  breath;  giddiness, 
especially  on  sudden  change  of  posture  ;  singing  in  the  ears  ;  difficulty  in  con- 
centration of  mind  ;  and  very  possibly  cardiac  symptoms,  varying  from  a  mere 
consciousness  of  the  existence  of  the  heart,  to  precordial  pain  of  varying 
severity,  or  even  extreme  heart-failure,  with  oedema  of  the  lips,  ascites,  nutmeg 
liver,  orthopnoea,  and  pulmonary  congestion.  In  the  latter  case  the  great 
difficulty  will  be  to  decide  whether  the  heart  failure  is  due  to  primary  renal 
or  arterial,  primary  cardiac,  or  to  primary  pulmonary  disease,  and  the  only 
sure  methods  of  deciding  that  there  is  a  renal  lesion  are,  first,  the  discovery 
of  more  than  an  occasional  granular  and  hyaline  tube-cast  in  the  urine  ;  and 
secondly,  the  detection  of  albuminuric  retinal  changes.  Sometimes  inflammation 
of  one  of  the  serous   membranes   is    the   first  symptom  :    subacute  or  chronic 


ALBUMINURIA  15 


peritonitis  with  ascites  ;  pericarditis  ;  or  pleuritic  effusion.  On  the  other  hand, 
the  patient  may  seem  to  have  been  in  robust  health  until  the  nature  of  the  case 
is  suggested  by  a  sudden  apoplectic  seizure  due  to  cerebral  haemorrhage,  followed 
by  hemiparesis  or  aphasia. 

In  yet  another  group  of  cases  the  malady  is  discovered  accidentally  as  the 
result  of  examination  for  life  insurance.  It  is  not  very  uncommon  to  find 
glycosuria  as  well  as  albuminuria,  the  sugar  occurring  in  a  urine  of  normal 
specific  gravity,  without  any  associated  acetone  or  diacetic  acid.  The  degree 
of  albuminuria  is  very  variable  indeed  ;  when  there  are  signs  of  cardiac  failure, 
there  may  be  oliguria,  with  much  albumin  and  not  a  very  large  number  of  casts  ; 
when  there  is  no  heart  failure,  there  is  generally  polyuria,  the  patient  having 
to  rise  several  times  in  the  night,  passing  from  60  to  120  oz.  of  urine  in  twenty- 
four  hours.  It  is  pale,  of  specific  gravity  1008  to  1012,  often  containing  only  a 
trace  of  albumin,  and  even  that  not  constantly  ;  there  are  intermediate  cases  in 
which  the  amount  of  albumin  varies  from  o'25  to  4  or  5  parts  per  thousand. 
Upon  the  whole  one  may  say  that,  if  the  increased  albuminuria  due  to  heart 
failure  on  the  one  hand,  or  to  a  super-added  acute  attack  of  nephritis  on  the 
other,  can  be  excluded,  the  more  the  disease  approaches  the  type  of  red  granular 
contracted  kidney,  the  more  likely  is  the  albumin  to  be  small  in  amount  and 
intermittent  ;  whilst  the  more  the  disease  approaches  in  type  to  arterio- 
sclerosis with  renal  changes  on  the  one  hand,  or  to  pale  granular  contracted 
kidneys  on  the  other  the  greater  will  be  the  amount  of  albumin,  if  anj^  is 
present.  There  will  be  tube-casts,  chiefly  granular  and  hyaline,  most  numerous 
with  pale  granular  contracted  kidneys,  fewest  with  arteriosclerosis,  and  inter- 
mediate in  numbers  with  red  granular  contracted  kidneys.  It  need  scarcely 
be  added  that  the  absence  of  albuminuria  does  not  exclude  arteriosclerosis  ; 
but  we  are  here  dealing  only  with  cases  in  which  albuminuria  occurs. 

Cystic  Disease  of  the  Kidneys  is  found  in  three  entirely  different  types  of 
patients,  namely,  "(i)  the  newly  born,  (2)  the  young,  and  (3)  the  elderly.  In  the 
newly  born,  the  main  symptom  is  abdominal  distention,  which  may  be  so  extreme 
as  to  have  caused  difficulty  in  delivery  ;  the  bilateral  cystic  tumours  can  be  felt, 
and  the  diagnosis  in  extreme  cases  is  by  no  means  difficult.  Minor  cases  escape 
detection  at  birth,  and  it  may  be  that  several  years  have  elapsed  before  the 
diagnosis  is  arrived  at,  as  the  result  of  finding  bilateral  uneven  renal  tumours 
associated  with  the  passage  of  abundant  pale  urine  of  low  specific  gravity  con- 
taining traces  of  albumin,  a  few  granular  and  hyaline  tube-casts,  and  an  occasional 
red  corpuscle.  Sometimes,  a  sudden  and  severe  attack  of  haematuria  is  the  first 
symptom  in  the  case.  The  discovery  of  bilateral  irregular  renal  tumours  is  the 
clinching  point  in  the  diagnosis.  In  at  least  one  case  they  were  so  large  as  to 
meet  in  the  middle  line,  so  that  a  loop  of  intestine,  having  passed  in  between 
and  behind  them,  could  not  get  out  again,  and  the  patient  came  under  observation 
for  acute  intestinal  obstruction.  The  third  type  of  cystic  disease  of  the  kidneys, 
which  occurs  in  old  persons,  is  but  a  variety  of  chronic  interstitial  nephritis 
in  which  the  agglomeration  of  retention  cysts  has  reached  an  extreme  degree  ; 
the  enlargement  of  the  kidneys  in  these  cases  is  very  much  less  than  in 
young  persons,  where  the  lesion  is  probably  congenital ;  and  the  symptoms  and 
urinary  changes  are  precisely  similar  to  those  that  may  occur  in  cases  of  red 
granular  contracted  kidneys  already  described. 

[B)  Albuminuria  with  renal  tube  casts  and  with  pus. — When  pus  is  present  in 
the  urine,  along  with  albumin  and  renal  tube-casts,  the  differential  diagnosis 
resolves  itself  into  that  of  pyuria  that  is  partly  or  wholly  of  renal  origin  (see 
Pyuria).  It  only  remains  to  add  :  first,  that  it  is  by  no  means  sufficient  to 
rely  upon  the  naked-eye  characters  of   the   urine,  or   upon   chemical   tests,    in 


1 6  ALBUMINURIA 


excluding  minor  degrees  of  pA^uria  ;  microscopical  examination  of  the  centri- 
fugalized  deposit  is  essential,  especially  in  the  detection  of  acute  pj^elitis  and 
pyelonephritis,  the  result  of  coli-bacilluria  in  children,  pregnant  women,  and 
others  ;  secondly,  that  the  amount  of  albumin  actually  due  to  pus  itself  is 
small,  so  that  if  there  is  any  measurable  quantity  of  albumin  present  it 
indicates  that  the  kidneys  are  themselves  affected,  this  being  further  confirmed 
when  casts  are  also  found  ;  and  thirdly,  that  blood,  like  pus,  is  in  itself 
responsible  for  relatively  little  albumin,  so  that  when  there  is  considerable 
albuminuria  associated  with  blood,  there  is  strong  ground  for  believing  that  the 
albumin  is  by  no  means  all  due  to  the  blood.  The  presence  or  absence  of  ver\- 
small  quantities  of  blood  does  not  assist  the  differential  diagnosis  of  the  cause 
of  albuminuria  so  much  as  might  be  expected  ;  the  occurrence  of  much  blood 
with  much  albumin  and  man}' renal  cells  and  tube-casts  indicates  acute  nephritis, 
but  by  itself  does  not  decide  between  primary  acute  nephritis,  acute  exacerba- 
tion of  a  chronic  nephritis,  or  the  effects  of  embolic  infarction  in  cases  of 
malignant  endocarditis.  Renal  growths,  calculus,  or  tuberculosis  may  all  cause 
haematuria  and  pyuria  with  albuminuria,  and  a  variable  number  of  granular, 
hyaline,  fatty,  epithelial,  leucocyte,  or  blood  casts  ;  and  occasionally,  when 
the  amount  of  pus  is  small,  it  may  be  difficult  to  distinguish  between  these  and 
acute  nephritis.     Their  differential  diagnosis  is  discussed  under  H.i;jiaturia. 

II. — Albuminuria    without    Tube-Casts. 

Turning  now  to  the  question  of  the  occurrence  of  albuminuria  without  renal 
tube-casts,  one  would  first  emphasize  the  fact  that  more  than  one  microscopical 
examination  may  sometimes  be  required,  for  if  the  urine  is  alkaUne,  or  has 
stood  for  any  length  of  time,  casts,  originally  present,  may  have  become 
unrecognizable  ;  besides  which,  even  with  definite  nephritis,  there  may  be  very 
few  casts  at  one  time,  many  at  another.  This  apphes  particularly  to  the  ver\' 
acute  cases  on  the  one  hand  and  the  very  chronic  on  the  other.  Assuming, 
however,  that  no  cast,  or  not  more  than  a  very  occasional  cast,  is  found,  the 
chief  conclusion  that  can  generally  be  drawn  is,  that  the  albuminuria  is  not 
in.dicative  of  organic  renal  disease. 

The  cases  may  then  be  subdivided  into  :  (i)  Those  in  which  the  urine  presents 
some  other  definite  abnormality  besides  albuminuria,  especially  (a)  p5ruria, 
ib)  haematuria,  (c)  hsemoglobinuria.  or  [d)  glycosuria  ;  (2)  Those  in  which,  were 
the  albumin  removed,  the  urine  would  be  normal. 

1.  These  cases  need  not  be  further  discussed  here  ;  the  differential  diagnosis 
will  be  found  under  Pyuria,  H-5;maturia,  H.^moglobinuria,  and  Glycosuria 
respectively. 

2.  These  are  clinically  of  importance,  in  that,  until  the  absence  of  casts  has 
been  determined,  the  absence  of  organic  renal  changes  cannot  be  concluded. 
Even  when  casts  are  absent,  a  trace  or  a  small  amount  of  albumin  may  be  the 
first  evidence  in  elderh-  persons  of  enlargement  of  the  prostate,  chronic  inter- 
stitial nephritis,  or  arteriosclerosis  ;  or  in  younger  persons  of  chronic  ascending 
nephritis,  the  result  of  such  things  as  former  gonorrhoea,  repeated  pregnancies, 
uterine  prolapse  or  other  displacement,  chronic  vesical  catarrh,  or  urethral 
stricture.  The  chronic  effects  on  the  kidneys  of  interference  with  the  urine  out- 
flow are  apt  to  be  overlooked,  though  if  they  are  borne  in  mind  they  are  generally 
easy  of  diagnosis. 

The  following  are  a  number  of  other  conditions  which  may  cause  sUght  degrees 
of  albuminuria  without  tube-casts,  but  which  are  obvious,  or  else  diagnosed  by 
other  si.gns  that  are  discussed  elsewhere  :  burns,  scalds,  chronic  alcoholism, 
cirrhosis  of  the  liver,  diabetes  meUitus,  exophthalmic  goitre,  gout,  lead-poisoning, 
mumps,    secondary    syphilis,    morphinism,     mercuriali.sm,    vasomotor    neuroses 


ALBUMINURIA  17 


such  as  Raynaud's  disease  or  angeioneurotic  oedema,  obstruction  to  the  vena 
cava  interior  by  thrombosis  or  by  external  tumours,  the  pressure  of  considerable 
ascites,  ovarian  cysts  or  solid  tumours,  pernicious  anaemia,  Hodgkin's  disease  or 
lymphadenoma,  lymphosarcoma,  lymphatic  or  splenomeduUary  leukaemia, 
splenic  anaemia,  pemphigus,  phosphorus  poisoning,  chronic  arsenical  poisoning, 
pregnancy,  severe  anaemia  the  result  of  syphilitic,  malarial,  malignant,  tuber- 
culous, or  phthisical  cachexia,  ankylostomiasis,  or  infection  with  other  parasites 
such  as  Bothriocephalus  latus  or  Trichina  spiralis. 

There  remain  three  other  groups  of  conditions  in  which  albuminuria  and  its 
differential  diagnosis  are  often  important,  and  these  are  :  (i)  Febrile  conditions  ; 
(:)  Heart-failure  conditions  ;  and  (3)  So-called  "  physiological  "  albuminuria  of 
young  males. 

I.  Febrile  Conditions. — In  nearly  every  fever  there  is  some  cloudy  swelling 
of  the  parenchyma  of  various  viscera,  especially  the  kidneys  ;  consequently 
most  fevers  may  sometimes  be  associated  with  albuminuria,  and,  broadly  speaking, 
the  higher  the  patient's  temperature,  the  greater  is  the  liability  to  it.  The 
amount  of  albumin  present  is  generally  not  great.  We  need  not  enumerate  all 
the  various  fevers  in  this  connexion,  nor  discuss  the  causes  of  Hyperpyrexia 
iq.v.).  Suffice  it  to  say  that  albuminuria  is  relatively  common  in  scarlatina, 
diphtheria,  variola,  erysipelas,  pyrexial  phthisis,  cholera,  dysentery,  Weil's 
disease,  severe  malaria,  and  yellow  fever ;  not  so  common  in  lobar  pneu- 
monia, bronchopneumonia,  typhoid  fever,  and  empyema  ;  and  relatively 
uncommon  in  other  febrile  conditions,  such  as  acute  rheumatism,  influenza, 
meningitis,  measles,  German  measles,  follicular  tonsillitis,  and  so  on.  The 
albuminuria  may,  of  course,  be  already  present  in  a  person  who  develops 
an  intercurrent  fever  ;  the  diagnosis  then  depends  upon  considerations  men- 
tioned above. 

If,  on  the  other  hand,  the  albuminuria  is  known  to  have  developed  coin- 
cidently  with  the  febrile  illness,  the  chief  point  to  decide  will  be  whether 
it  indicates  actual  nephritis  or  not.  Many  consider  there  is  an  essential 
difference  between  "  febrile  albuminuria  "  and  actual  nephritis.  This  may  or 
may  not  be  so,  but  it  is  extremely  difficult  to  be  sure  of  the  distinction  clinically. 
It  may  be  urged  that — to  take  scarlet  fever  as  an  example — the  albuminuria  of 
the  first  few  days  is  "  febrile,"  whilst  that  of  the  second  or  third  week  is 
"  nephritic."  As  a  matter  of  fact,  in  not  a  few  cases  in  which  death  has  occurred 
in  the  first  week,  the  "  febrile  "  albuminuria  has  been  associated  with  large 
mottled  acute  nephritic  kidneys,  even  when  there  has  been  no  oedema,  no 
haematuria,  and  no  very  large  numbers  of  renal  tube-casts.  Probably  there 
are  all  degrees  of  acute  nephritis,  from  very  slight  and  transient,  to  very 
severe  and  possibly  fatal ;  and  it  is  a  mistake  to  try  and  make  a  distinction 
in  kind.  The  great  majority  of  cases  of  albuminuria  during  fever  recover 
completely  ;  some  seem  to  recover,  but  come  under  observation  years  later 
with  pale  granular  contracted  kidneys  ;  others  die  during  the  acute  attack. 
The  degree  of  albuminuria  is  not  a  direct  measure  of  the  renal  changes 
unless  the  amount  of  albumin  is  large  ;  a  small  amount  of  albumin  does  not 
necessarily  indicate  trivial  nephritis.  Absence  of  oedema  is  the  rule.  Micro- 
scopical examination  of  the  centrifugalized  urinary  deposit  is  essential  :  the 
more  the  renal  epithelial  cells,  red  corpuscles,  leucocytes,  and  various  renal 
tube-casts,  the  more  conclusively  can  some  degree  of  actual  nephritis  be 
diagnosed. 

When  doubt  lies  between  scarlatina  and  measles  or  German  measles,  or  betweeij 
diphtheria  and  other  forms  of  sore  throat,  the  existence  of  albuminuria  some- 
times assists  in  arriving  at  the  diagnosis  of  scarlatina  in  the  one  case  or  of  diph- 
theria in  the  other. 

D  2 


ALBUMINURIA 


In  pneumonia,  albuminuria  has  become  much  less  frequent  since  blistering 
with  cantharides  has  gone  out  of  fashion  in  treating  this  disease. 

2.  Heart-failure  Conditions — The  right  side  of  the  heart  may  fail  owing  to 
many  different  causes,  which  may  be  arranged  under  four  main  headings,  as 
follows  :  [a)  Valvular  disease  ;  [b)  Obstructive  lung  affections  ;  (c)  Myocardial 
affections ;  {d)  Granular  kidneys  and  other  high  blood-pressure  conditions. 
Each  of  these  main  headings  has  many  sub-headings  which  need  not  be  repeated 
in  detail  (see  (Edema).  Any  one  of  them  may  result  in  albuminuria,  though 
the  amount  of  the  latter  is  extremely  variable,  some  cases  of  severe  heart  failure 
exhibiting  no  albuminuria  at  all,  whilst  others  may  have  as  much  as  lo  parts 
per  looo,  or  more. 

The  first  step  in  the  differential  diagnosis  is  to  exclude  primary  renal  conditions 
by  negative  microscopical  examination  of  the  centrifugalized  urine  deposit  for 
casts,  examination  of  the  retinae,  and  exact  determination  of  the  blood-pressure. 
Curiously,  even  with  feeble  irregular  pulses,  such  as  are  found  in  panting  cases 
of  mitral  stenosis,  the  blood-pressure  is  considerably  higher  than  normal,  doubt- 
less owing  to  partial  asphyxia  ;  so  that  merely  finding  a  systolic  blood-pressure 
of  150  or  160  mm.  Hg  is  no  proof  of  granular  kidney  or  arteriosclerosis  ;  some- 
times, however,  the  reading  is  as  high  as  200,  250,  300,  or  even  320  mna.  Hg,  and 
then  the  diagnosis  of  one  or  other  of  the  latter  is  almost  certain. 

If  renal  and  arteriosclerotic  conditions  can  be  excluded,  the  diagnosis  lies 
between  the  other  three  main  groups.  The  cardiac  bruits,  the  history  of  grow- 
ing pains,  chorea,  and  acute  rheumatism,  the  youth  of  the  patient,  the  family 
history  of  heart  disease  or  rheumatic  fever,  the  association  of  other  rheuraatic 
affections,  such  as  recurrent  tonsillitis,  subcutaneous  nodules,  or  erythema,  will 
often  serve  to  point  to  primary  valvular  disease  and  its  nature  ;  in  older  patients, 
especially  in  men  between  forty  and  fifty,  there  may  be  aortic  disease  and  a 
history  of  syphilis  and  not  of  acute  rheumatism.  In  severe  heart  failure  in 
children  under  puberty,  the  result  of  mechanical  difficulty  with  the  circula- 
tion, an  adherent  pericardium  is  generally  found,  and  clinically,  the  heart  is  large 
out  of  proportion  to  the  general  physical  signs. 

When  there  is  a  definite  history  of  recurrent  winter  cough  in  an  elderly  person, 
with  a  hyper-resonant  and  over-expanded  chest,  the  likelihood  of  emphysema  and 
bronchitis  will  at  once  suggest  itself.  Similarly  fibroid  lung,  or  fibroid  lung  and 
bronchiectasis,  as  a  cause  of  heart  failure  and  albuminuria,  only  needs  mentioning, 
the  diagnosis  generally  being  obvious  from  the  physical  signs,  the  clubbed 
fingers,  and,  in  the  bronchiectatic  cases,  the  abundant  intermittent,  and  fre- 
quently foul,  expectoration. 

Myocardial  affections,  such  as  fibroid,  fatty,  or  primary  alcoholic  heart,  are 
generally  diagnosed  by  guessing  at  them  when  other  causes  of  heart  failure  can 
be  excluded.  The  patients  are  generally  middle-aged,  with  precordial  pain 
and  even  angina  pectoris  occupying  a  prominent  position  amongst  their  cardiac 
symptoms  ;  there  may  or  may  not  be  a  high  blood-pressure,  the  albuminuria  is 
not  associated  with  renal  tube-casts,  there  is  often  no  cardiac  bruit,  or  at  most 
a  more  or  less  localized  blowing  systolic  bruit  at  the  impulse  ;  at  the  same  time 
the  heart  is  clearly  enlarged,  and  it  may  be  beating  rapidly  and  irregularly  ; 
there  may  be  a  history  of  syphilis  or  of  chronic  alcoholism  ;  the  patient  may  be 
very  stout  in  the  fatty,  though  generally  not  so  in  the  fibroid,  cases.  There 
may  be  a  history,  either  of  an  extremely  sedentary  life  upon  the  one  hand,  or 
of  over-use  of  the  heart  by  strenuous  hard  physical  work — as  a  blacksmith,  an 
athlete,  and  so  forth — on  the  other.  Needless  to  say,  the  exact  nature  of  the 
cardiac  lesion  remains  obscure  or  uncertain  in  many  of  these  cases,  many  a 
patient  who  really  has  mitral  stenosis  being  regarded  during  life  as  suffering 
rom  chronic  bronchitis  and  emphysema,  and  so  on. 


ALBUMINURIA  19 


3.  "Physiological"  Albuminuria. — Finally,  we  come  to  that  large  group  of 
cases  of  albuminuria  in  apparently  healthy  males  and  females  between  the 
ages  of  fifteen  and  thirty.  The  condition  was  unknown  until  medical  examina- 
tions at  schools  or  for  life  insurance,  for  the  army,  navy,  and  civil  services 
became  common  ;  and  it  has  received  a  large  number  of  different  names,  of 
which  the  following  are  some  :  "accidental,"  "essential,"  ''postural,"  "cyclic," 
"  orthostatic,"  "  intermittent,"  "  physiological,"  "  functional,"  "  orthotic  " 
albuminuria,  Pavy's  disease,  albuminuria  "  of  adolescence  "  or  "  of  puberty." 
It  derives  its  chief  importance  from  the  fact  that  young  males  who  suffer  from 
it  are  looked  at  askance  by  the  older  examiners  for  life  insurance  or  for  the 
"services,"  and  are  very  liable  to  be  rejected  altogether.  The  reason  for  this 
was  the  fear  that  they  were  sufferers  from  some  form  of  nephritis.  A  precisely 
similar  condition  occurs  in  perfectly  healthy  females  of  a  similar  age,  but  its 
occurrence  in  the  female  sex  is  detected  less  often  than  it  is  in  males,  because 
one  has  less  frequent  occasion  to  examine  the  urines  of  healthy  girls  than  is 
the  case  with  boys  and  youths. 

Collier  and  others  have  thrown  much  light  upon  the  nature  of  the  affection  by 
their  investigations  upon  the  urines  of  rowing  men.  It  is  found  that  the  urine 
voided  just  before  a  boat-race  being  free  from  albumin,  that  voided  immediately 
afterwards  is  generally  loaded  with  it.  A  few  hours  later  this  albuminuria  is 
gone  again.  Now  university  oarsmen  are,  upon  the  whole,  long  lived,  hence 
this  recurrent  albuminuria  cannot  matter  in  them  ;  and  the  same  applies  to 
the  albuminuria  of  many  adolescents.  A  prominent  feature  of  such  a  case  is, 
that  the  urine  first  voided  in  the  morning  is  quite  normal,  whilst  that  passed 
later  in  the  day  may  contain  anything  from  a  trace  to  five  parts  per  thousand  of 
albumin  ;  the  more  the  youth  has  exerted  himself  physically  by  walking  or 
otherwise,  and  the  more  he  has  exposed  himself  to  cold,  for  instance,  during  a 
train  journey  to  the  city  on  a  winter's  day,  or  in  a  cold  bath,  and  so  on,  the 
greater  is  the  liability  to  this  unimportant  but  possibly  alarming  albuminuria. 
Some  youths  are  so  liable  to  it  that  they  may  pass  albumin  for  days  together 
before  an  interval  of  freedom  from  it  occurs.  Sometimes  they  appear  to  be  in 
robust  health,  sometimes  they  look  a  little  pale,  as  though  they  had  been  over- 
working at  an  indoor  occupation  ;  they  may  be  nervous,  but  often  they  are 
not.  A  natural  nocturnal  emission  is  supposed  to  predispose  to  albuminuria 
next  day.  The  point  is  that  these  individuals  have  to  be  differentiated  from 
sufferers  from  Bright's  disease.  The  method  of  diagnosis  is  as  follows  :  a 
complete  routine  examination  is  carried  out,  and  no  obvious  affection  of  the 
heart  or  other  viscera  can  be  detected  ;  the  blood-pressure  is  normal  ;  the 
albumin  having  been  discovered,  the  patient  is  directed  to  supply  a  series  of 
samples,  at  intervals  of  a  few  days,  and  preferably  passed  immediately  after  rising 
in  the  morning.  If  all  samples  contain  albumin,  it  will  be  very  difficult  to 
exclude  organic  disease  ;  if  some  contain  albumin  in  abundance,  however,  and 
others  none  at  all,  the  presumption  will  be  that  it  is  "  functional  ;  "  before 
being  finally  satisfied,  however,  it  is  important  that  a  careful  microscopical 
examination  of  the  centrifugalized  deposit  from  a  specimen  containing 
albumin  should  be  made,  no  casts  or  other  abnormal  constituents  being  found. 
The  administration  of  calcium  chloride  greatly  diminishes  the  tendency  to  this 
form  of  albuminuria.  In  an  adolescent  male  who  has  no  symptoms,  albumin- 
uria discovered  accidentally,  present  after  exertion  or  after  exposure  to  cold, 
but  absent  after  rest  in  bed,  and  when  present  not  associated  with  renal 
tube-casts  or  with  signs  of  arterial,  cardiac,  or  other  diseases  that  should  be 
detected  by  physical  examination,  is  almost  certainly  a  "  physiological  " 
albuminuria  which  needs  no  treatment  and  is  not  indicative  of  any  underlying 
disease.  Herbert  French. 


ALBUMOSURIA 


ALBUMOSURIA. — The  occurrence  of  albumose  in  the  urine  used  to  be  termed 
peptonuria.  For  clinical  purposes  it  may  be  subdivided  under  two  main 
headings,  namely,  (i)  Ordinary  Albumosuria,  which  is  not  ver}''  uncommon,  but 
is  of  little  clinical  importance  ;  and  (2)  Bence-Jones'  Albumosuria,  which  is  rare, 
but  is  clinically  important. 

Ordinary  Albumosuria  is  seldom'  recognized  because  the  albumose  generally 
occurs  along  with  albumin,  and  it  cannot  be  recognized  until  this  albumin  has 
been  removed  bj"  acidulating  with  acetic  acid,  boiling  thoroughly,  and  filtering. 
Albumose  maj^  be  recognized  in  the  filtrate  bj-  the  fact  that  with  Heller's  nitric 
acid  test  it  gives  a  cloud  which  disappears  on  warming,  to  reappear  on  cooling  ; 
and  its  presence  may  be  confirmed  by  the  violet-red  colour  it  gives  with  the 
biuret  test,  which  consists  in  adding  excess  of  caustic  soda  to  a  drop  of  dilute 
copper  sulphate  solution,  adding  this  mixture  in  drops  to  the  urine,  from  which 
all  albumin  has  been  removed,  and  warming.  Another  test  for  albumose  is 
Hofmeister's,  which  consists  in  acidulating  the  urine  with  acetic  acid,  and  then 
adding  phosphotungstic  acid ;  albumoses  give  a  milky  cloud  with  the  latter. 
The  deutero-albumose  that  gives  these  tests  occurs  in  the  urine  under  a  great 
variety  of  circumstances  ;  apparently  the  one  essential  factor  is  cell  destruction 
within  the  body.  It  wiU  suffice  to  mention  some  of  the  many  diseases  in  which 
it  has  been  found  : — 

(a).  "  Febrile  "  Albumosuria  :  in  severe  cases  of  infective  fevers,  such  as 
t^^phoid  fever,  scarlet  fever,  small-pox,  measles,  acute  rheumatism,  lobar  pneu- 
monia. 

(b).  "Pyogenic"  Albumosuria:  in  empyema,  phthisis  with  cavitation,  bron- 
chiectasis, appendicular  abscess,  pyosalpinx,  subdiaphragmatic  or  hepatic 
abscess,  suppurating  gall-bladder,  suppurative  periostitis,  arthritis  or  osteo- 
mj'elitis,  gangrene  of  the  lung,  gangrene  of  the  leg,  breaking-down  cancer,  acute 
peritonitis. 

(c).  "Hepatogenous  "  Albumosuria:  in  cancer  of  the  liver,  cirrhosis,  catarrhal 
jaundice,  phosphorus  poisoning,  acute  yellow  atiophy,  infective  cholangitis, 
suppurative  p^'lephlebitis. 

(d).  "Alimentary  "  Albumosuria  :  in  cases  of  gastric  or  duodenal  ulcer,  car- 
cinoma of  the  colon  or  stomach,  ulcerative  colitis,  tuberculous  ulceration  of  the 
bowel,  acute  and  chronic  d\•senter3^ 

(e).  "  Hcsmatogenous  "  Albumosuria:  in  spleno-meduUarj^  or  lymphatic 
leukaemia,  scurvy,  purpuric  conditions,  and  as  the  result  of  internal  hasmato- 
mata,  such  as  pelvic  haematocele. 

(/).  "Albuminuric"  Albumosuria:  many  cases  of  acute  nephritis,  S5'p)hilitic 
albuminuria,  cardiac  and  other  forms  of  albuminuria,  are  associated  with  albu- 
mosuria. There  is  some  doubt,  however,  as  to  whether  the  chemical  reagents 
employed  do  not  themselves  convert  some  of  the  albumin  into  albumose  during 
the  course  of  the  qualitative  analysis. 

(g).  Albumosuria  due  to  ttnclassified  causes  :  such  as  pregnancy,  especially 
if  the  foetus  has  died,  though  sometimes  even  without  this. 

The  amount  of  albumose  present  in  any  of  the  above  conditions  is  seldom 
large,  and  diagnostically  it  has  little  if  any  significance  except  when  it  occurs 
apart  from  albumin.  Even  then,  its  main  importance  lies  in  the  necessity  of 
not  mistaking  it  for  albumin.  This  error  would  only  arise  with  the  nitric  acid 
test,  for  albumose  does  not  form  a  cloud  on  boiling  with  acetic  acid.  It  is  urged 
by  some,  that  the  presence  of  albumosuria  in  an  appendicitis  case  points  to 
abscess  rather  than  to  simple  inflammation  ;  that  in  a  pleuritic  case  it  points  to 
emp3^ema  rather  than  to  serous  effusion  ;  that  in  a  meningitic  case  it  points  to 
the  suppurative  or  epidemic  cerebrospinal  forms  rather  than  the  tuberculous  ;  and 
so  on  ;    but  it  is  very  doubtful  if  the  symptom  can  carry  so  much  weight  as  this 


ALLOCHEIRIA 


In  a  given  case  the  presence  of  ordinary  albumosuria  points  to  a  graver  prognosis 
upon  the  whole  than  if  no  albumose  were  present,  but  it  is  not  particularly  help- 
ful in  differential  diagnosis. 

Bence-Jones'  Albumosuria,  on  the  other  hand,  though  rare,  is  clinically  im- 
portant. The  nature  of  the  proteid  present  is  still  undecided,  and  certainly  is 
not  ordinary  albumose.  Its  most  striking  characteristic  appears  when  the  urine 
is  warmed  after  acidulation  with  acetic  acid  to  prevent  precipitation  of 
phosphates  :  long  before  the  urine  boils,  a  dense  milky  precipitate  appears, 
suggesting  at  first  sight  either  phosphates  or  coagulated  albumin  ;  it  attracts 
attention  at  once,  from  the  fact  that  on  further  warming  it  begins  to  clear  up 
again,  and  after  boiling  it  almost  or  completely  goes.  It  will  be  realized  that  the 
precipitate  cannot  be  albumin  or  phosphates,  for  not  only  would  neither  of  these 
clear  up  at  boiling-point  in  this  way,  but  also  the  acidulation  of  the  urine  has 
been  sufficient  to  prevent  phosphates  from  coming  down,  whilst  the  temperature 
at  which  the  dense  sticky  precipitate  appears  (about  60°  C.)  is  far  lower  than 
that  at  which  albumin  coagulates.  If  any  albumin  is  present  at  the  same  time, 
the  clearing  at  boiling-point  will  be  but  partial  ;  the  albumin  should  then  be 
removed  bj'  boiling  and  filtration,  when  nitric  acid  added  to  the  filtrate  will  give 
a  white  ring  which  redissolves  on  warming,  to  reappear  on  cooling,  like  that  of 
albumose. 

This  Bence-Jones'  proteid,  when  it  occurs  at  all,  is  generally  present  in  very 
much  larger  amounts  than  ordinary  albumose  ever  is,  so  that  it  is  seldom  over- 
looked unless  it  is  mistaken  for  albumin.  It  may  amount  to  anything  between 
I  and  20  parts  per  thousand,  or  more.  It  may  be  present  on  some  days  and 
not  on  others.  It  indicates,  almost  with  certainty,  that  there  is  some  affection 
of  the  bone-marrow  ;  it  might  be  due,  for  instance,  to  secondary  deposits  of 
malignant  disease  in  bones,  or  to  leukemia  ;  but  in  the  great  majority  of  cases 
it  has  occurred  in  connection  with  multiple  myelomata — Kahler's  disease  or 
myelopathic  albumosuria  of  Bradshaw.  Unless  there  is  other  evidence  to  the 
contrary,  the  occurrence  of  abundance  of  Bence-Jones'  proteid  in  the  urine 
indicates  multiple  tumours  of  the  bone-marrow.  Herbert  French. 

ALKAPTONURIA.— (See  Urine,    Abnormal  Coloration   of.) 

ALLOCHEIRIA — Literally  means  "other  handness."  It  sometimes  happens 
that  when  a  patient  is  touched  upon,  say,  the  back  of  his  right  foot,  and  is  then 
asked  where  he  has  been  touched,  he  says,  "  Upon  the  back  of  my  left  foot." 
This  reference  of  sensations  to  exactly  corresponding  parts  of  the  limbs  or  body 
on  the  wrong  side  is  known  as  allocheiria. 

Experiments  have  shown  that  complete  allocheiria  results  from  transverse 
hemisection  of  the  spinal  cord.  It  seems  that  sensory  impulses  travel  much 
the  more  readily  up  their  own  side  of  the  cord,  but  can  also  pass  by  the  opposite 
side  if  necessary  ;  when  they  are  compelled  to  do  so,  the  brain  interprets  them 
as  coming  from  that  side  of  the  body  which  usually  sends  impulses  up  this 
particular  side  of  the  cord.  When  a  patient  exhibits  allocheiria,  therefore, 
it  generally  indicates  that  there  is  a  lesion  affecting  one  side  of  the  spinal  cord,  or 
the  upward  extensions  of  the  tracts  which  convey  sensory  impulses  from  the  cord 
to  the  brain,  more  than  the  other.  It  is  necessarily  a  rare  symptom.  It  might 
result  from  a  stab  or  a  bullet  wound  damaging  the  cord  unilaterally  ;  or  from 
a  gumma  or  neoplasm  of  the  spinal  meninges  ;  it  may  be  functional  ;  rarely 
it  may  result  from  the  cord  becoming  compressed  more  on  one  side  than  on  the 
other  by  spinal  caries,  a  new  growth,  callus,  or  a  fracture- dislocation  ;  and 
occasionally  it  may  be  noticed  when  there  is  a  cord  disease  which,  though  usually 
bilateral,  happens  to  have  advanced  more  rapidly  on  one  side  than  upon  the 


ALLOCHEIRIA 


other^  as  in  exceptional  cases  of  disseminated  sclerosiSj  locomotor  ataxy,  or 
softening  from  sj-philitic  endarteritis  and  thrombosis. 

It  is  clear  that,  except  in  functional  cases,  allocheiria  will  seldom  if  ever  be 
the  only,  or  even  the  chief,  symptom  in  the  case  ;  paresis,  pain,  or  some  other 
symptom  will  certainly  be  present  also,  and  will  afford  greater  assistance  in  the 
diagnosis  than  will  the  allocheiria  itself.  Herbert  French- 

ALOPECIA.— (See  Baldness.) 

AMAUROSIS. — (See  Vision,  Defects  of.) 

AMBLYOPIA. — (See  Vision,  Defects  of.) 

AMENORRHCEA- — The  time  at  which  menstruation  first  appears  is  very 
variable  within  certain  limits,  being  influenced  very  largely  by  climatic  and 
racial  pecuharities  ;  in  this  country,  about  the  age  of  fourteen  years  may  be 
taken  as  the  average.  When  the  menstrual  flow  has  not  become  established 
it  is  usual  to  speak  of  primary  amenorrhcea,  whilst  cessation  of  the  flow  after 
it  has  once  been  regularly  established  is  known  as  secondary  amenorrhcea. 
From  a  perusal  of  the  table  of  the  causes  of  amenoirhoea  (page  23),  it  will  be 
seen  at  once  that  some  of  them  must  of  necessity  give  rise  to  primary 
amenorrhcea,  whilst  others  more  commonly  produce  the  secondary  variety. 

In  the  investigation  of  cases,  therefore,  it  is  important  to  ascertain  first 
whether  the  condition  is  primary  or  secondary,  and  next  whether  it  is  real  or 
only  apparent. 

The  latter  condition,  more  strict^  known  as  cryptomenorrhoea,  implies  that 
the  menstrual  flow  takes  place,  but  is  unable  to  escape  externally  because  there 
is  some  closure  of  a  part  of  the  genital  canal.  The  congenital  form  of  crj^pto- 
menorrhoea  is  the  only  variety  at  all  commonly  met  with,  acquired  closure  of 
a  part  of  the  genital  canal  being  an  exceedingly  rare  condition.  Stenoses  of 
the  vagina  are  not  uncommonly  produced  as  a  result  of  injur}^  and  infection  ; 
but  a  small  sinus  is  usually  left  which  suf&ces  for  the  escape  of  the  menstrual 
fluid.  We  are  commonly  led  to  suspect  cryptomenorrhoea  when  the  patient 
volunteers  the  statement  that  she  has  pelvic  pain,  headache,  and  possibly 
vomiting,  of  monthly  occurrence,  in  fact,  the  usual  menstrual  molimina  un- 
accompanied by  any  visible  flow.  A  physical  examination  should  be  made  at 
once  in  such  a  case,  including  abdominal  palpation,  inspection  of  the  vulva, 
and  a  recto-abdominal  bimanual  examination.  The  common  form  is  that  in 
which  the  hymen  is  imperforate,  a  condition  not  always  self-evident  on  inspection, 
The  complete  examination  in  such  a  case  will  reveal  a  fluctuating  swelling 
reaching  from  the  vulva  to  the  pelvic  brim,  above  which  the  uterus  can  often 
be  palpated  and  moved  about.  It  is  further  of  considerable  importance  to 
make  out  whether  the  uterus  and  Fallopian  tubes  are  distended  with  menstrual 
products  along  with  the  distended  vagina,  for  in  the  presence  of  haemato- 
salpinges  the  treatment  is  considerably  modified.  Abdominal  section  is  required 
in  such  a  case  to  avoid  rupture  of  the  tubes  when  the  vagina  collapses  after 
incision  of  the  hymen.  Distention  of  the  vagina  or  haematocolpos  is  complete 
in  this  case,  but  may  be  partial  where  the  lower  part  of  the  vagina  is  absent, 
and  then  is  more  than  likely  to  be  accompanied  by  distention  of  the  uterus 
(haematometra)  and  ha;matosalpinx. 

Complete  absence  of  the  vagina  can  only  be  inferred  from  a  physica 
examination,  when  the  distended  organ  appears  to  be  only  the  uterus. 
Although  a  secondary  phenomenon,  acquired  cryptomenorrhoea  produces  the 
same    symptoms    and    requires   the    same   kind    of   investigation   as  the   con- 


AMENORRHCEA 


23 


genital  cases.  It  must  not  be  forgotten  that  acquired  closure  of  the  vagina 
following  the  vaginitis  of  specific  fevers  may  occur  in  infancy,  and  will 
then,  of  course,  produce  primary  amenorrhoea. 


CAUSES    OF    APPARENT    AMENORRHCEA. 


COXGENITAL. 

Imperforate  hymen 

Imperforate  vagina 

Absence  of  the  vagina 

Imperforate  cervix 

Double  uterus  with  retention 

Hasmatocolpos 

Haematometra 

Hematosalpinx 


Acquired. 
Closure  of  the  vagina  : 

Due  to  specific  fevers 

Due  to  injury 
Closure  of  the  cervix  : 

Due  to  injury 

Following  operations 


CAUSES    OF    REAL    A:MEX0RRHCEA. 


Physiological 
Before  puberty 
After  the  menopause 
During  pregnancy 
During  lactation 


Pathological. 

Generative  System  : 

Absence  of  essential  organs 
Infantile  uterus 
Small  adult  type  of  uterus 
Deficient  ovarian  activity 
Destruction  of  both  ovaries  : 

By  double  ovarian  growths 

By  pelvic  inflammation 
Superinvolution  of  the  uterus 
Circulatory  System  : 
Chlorosis 
Anaemia 
Leucocythaemia 
Hodgkin's  disease 
Wasting  diseases  : 

Malignant  growths 

Tubercle 

Prolonged  suppuration 

Diabetes 
Late  stages  of  nephritis 
Late  stage  of  some  forms  of  heart  disease 
Late  stage  of  cirrhosis  of  the  liver 
Nervous  system  : 
Imbecility 
Cretinism 

Various  forms  of  insanity 
Cold  just  before  or  during  menstruation 
Suggestion — fear  of  pregnancy 
Anorexia  nervosa 
Altered  internal  secretion'^  : 
Myxoedema 
Exophthalmic  goitre 
Addison's  disease 
Acromegaly 
Obesity 

Change  of  habits 
Toxic  : 

After  specific  fevers 
Chronic    poisoning    by 

morphia,  alcohol 

Note: — Real  amenorrhoea  maybe  (i)  prirr.arywith  delayed  onset;    {2)  primary  and  permanent 

(3)  secondary. 


lead,    mercury, 


In  considering  the  diagnosis  of  the  causes  of  real  amenorrhoea,  the  primary 
and  secondary  forms  afford  us  an  important  clue  to  the  possible  causation. 
Suppose,  for  instance,  that  menstruation  has  once  been  regularly  estabhshed, 
it  is  clear  that  there  cannot  be  any  serious  congenital  anomaly  of  the  generative 


24  AMENORRHCEA 


system  ;  the  uterus  and  ovaries  must  at  least  be  present  and  functional.  We 
then  must  make  a  systematic  examination  of  the  generative,  circulatory, 
nervous,  and  ductless  gland  systems,  in  order  to  lea.rn  by  a  process  of  exclusion 
which  group  of  causes  we  have  to  deal  with.  If,  however,  the  amenorrho2a 
is  primary  and  real,  that  is,  the  patient  has  no  molimina,  our  examination 
must  first  be  directed  towards  finding  out  whether  the  essential  organs,  namely, 
uterus  and  ovaries,  are  present,  and  are  normal  in  size  and  shape  as  far  as  a 
bimanual  examination  can  ascertain.  If  necessary,  an  anaesthetic  may  be  given 
for  this  purpose,  for  it  is  often  a  matter  of  considerable  difficulty  to  decide  the 
question.  If  the  fact  of  absence  of  the  essential  organs  can  be  estabhshed,  we 
are  clearly  justified  in  considering  the  amenorrhoea  to  be  permanent,  and  the 
patient  or  her  friends  should  be  told  of  this. 

Apart  from  congenital  anomalies,  it  is  somewhat  remarkable  how  few  lesions 
of  the  generative  organs  there  are  which  produce  amenorrhoea.  Only  those 
diseases  which  completely  destroy  both  ovaries  or  render  the  uterus  functionless 
can  cause  amenorrhoea,  and  under  this  heading  we  find  only  double  ovarian 
growths,  the  late  stages  of  pelvic  inflammation  (salpingo-oophoritis)  and  super- 
involution  of  the  uterus.  A  tumour  destroying  one  ovary  as  a  rule  has  no 
effect  on  menstruation  at  all,  provided  the  other  is  present  and  functionally 
perfect.  It  is  possible  for  one  ovary  only  to  be  functional  ;  for  instance,  that  on 
the  same  side  as  the  undeveloped  half  of  a  unicornuate  uterus  may  be  quite 
atrophic  and  functionless.  The  presence  of  two  tumours  in  the  abdomen 
symmetrically  arranged  with  regard  to  the  uterus  will  sometimes  permit  of  the 
diagnosis  of  double  ovarian  destruction,  but  quite  commonly  one  tumour  is 
much  larger  than  the  other,  and  the  double  nature  of  the  lesion  cannot  be 
established  until  the  abdomen  is  opened.  Superinvolution  of  the  uterus  is  not 
difficult  to  recognize  when  we  remember  that  it  always  follows  pregnancy,  and 
the  small  size  of  the  uterus  can  be  readily  made  out  by  bimanual  examination 
and  the  passage  of  the  uterine  sound.  The  organ  sometimes  only  measures  i  ^ 
inches  by  the  sound.  It  must  not  be  forgotten  that  even  in  these  cases  the 
primary  lesion  may  be  an  ovarian  atrophy,  but  very  little  is  known  on  this 
point.  The  term  "  deficient  ovarian  activity  "  is  a  time-honoured  one,  and 
must  be  taken  to  mean  the  absence  of  the  internal  secretion  of  the  ovary.  It 
is  obvious  that  this  condition  cannot  be  diagnosed  by  any  physical  exami- 
nation, and  its  presence  can  only  be  inferred  when  absolutely  no  other  lesion 
of  any  system  can  be  found  to  account  for  amenorrhoea,  either  primary  or 
secondary. 

It  is  impossible  in  the  space  at  our  disposal  to  draw  up  any  detailed 
method  by  which  the  various  diseases  under  the  circulatory,  nervous,  etc., 
systems,  can  be  diagnosed  ;  these  come  naturally  within  the  province 
of  general  medical  diagnosis.  It  is,  however,  not  out  of  place  here  to 
note  that  amenorrhoea  caused  by  general  diseases,  unconnected  with  the 
generative  system,  depends  upon:  (i)  Alterations  in  the  blood  itself;  (2) 
Alterations  in  blood-pressure  ;  (3)  Altered  relation  of  the  nerve  impulses  which 
form  part  of  the  stimulus  for  menstruation  ;  (4)  Altered  relations  between  the 
internal  secretions  of  the  ovary  and  the  thyroid  glands  on  the  one  hand,  opposed 
to  the  suprarenal  and  pituitary  glands  on  the  other.  Finally,  with  regard  to 
pregnancy,  which  is  the  commonest  of  all  causes  of  secondary  amenorrhoea. 
it  may  be  formulated  as  an  axiom  that  an  otherwise  healthy  woman  who  has 
had  perfectly  regular  menstruation  is  probably  pregnant  if  she  has  a  period  of 
absolute  amenorrhoea.  Nevertheless,  the  presence  of  pregnancy  must  never 
be  assumed  without  a  most  careful  consideration  of  the  history,  combined  with 
a  complete  physical  examination.  The  diagnosis  of  pregnancy  must  always 
be    made    upon    a    complex    of    symptoms    rather    than    upon    any   one  ;     the 


AMNESIA  25 


combination  of  amenorrhoea,  secretion  to  be  squeezed  from  the  breasts, 
morning  sickness,  vaginal  discoloration,  and  an  abdominal  tumour,  can 
only  mean  pregnancy  in  the  vast  majorit}'  of  cases.  The  addition  of  foetal 
movements  and  the  fcetal  heart  are  only  required  to  make  the  diagnosis 
absolute.  7".  C.   Stevens 

AMNESIA. —  Loss  of  memory.  Memory  is  one  of  the  higher  lunctions  of 
the  brain,  and  presents  wide  variations  in  its  degree  of  development  in  different 
individuals.  The  physiological  range  being  so  extensive,  it  is  almost  impossible 
to  say  whether  an  apparently  poor  memory  is  pathological  or  not,  when  the 
condition  is  of  long  standing  and  stationary.  Slight  degrees  of  impairment  of 
memory  are  of  interest  to  the  psychologist,  but  to  the  majority  of  medical  men 
the  loss  must  be  of  considerable  extent  or  of  pecuUar  character  before  it  assumes 
a  position  of  diagnostic  importance. 

In  the  analysis  of  any  mental  disease,  the  condition  of  the  memory  must  be 
submitted  to  test.  In  some  forms  of  excitement  there  may  appear  to  be  an 
exaltation  of  memory  (hypermnesia)  ;  events  are  recalled  and  magnified  in 
importance,  which,  in  normal  states,  would  never  have  reached  the  surface 
of  conscious  memory.  In  all  forms  of  dementia,  on  the  other  hand,  memory 
becomes  impoverished  (hypomnesia),  and  may  eventually  fail  altogether 
(amnesia).  Reference  can  be  made  to  only  a  few  states  in  which  the  condition 
of  memory  may  be  of  service  in  diagnosis. 

Dementia. — In  all  forms  of  dementia — senile,  general  paralytic,  toxic,  etc. — 
memory  is  impaired,  and  it  is  the  rule  to  find  that  recent  events  are  lost 
before  those  belonging  to  distant  years.  Even  when  memory  is  obhterated 
almost  completely,  a  few  isolated  events  in  the  past  may  be  recalled  distinctly 
without  their  surroundings,  and  may  take  a  prominent  place  in  the  patient's 
personality.  These  traits  are  generally  recognized  in  connection  with  senility, 
but  are  also  to  be  found,  when  looked  for,  in  other  demented  states. 

Epilepsy. — Amnesia  is  an  important  feature  of  the  epileptic  seizure.  In 
the  majority  of  epileptics,  no  memory  is  preserved  of  the  convulsion,  although 
events  immediately  preceding  it  may  be  clearly  retained,  as  well  as  those  which 
follow  the  return  of  consciousness.  In  other  cases  the  amnesia  may  cover 
a  period  preceding  the  attack  (retrograde  amnesia),  while  in  others,  actions 
are  performed  after  the  attacks,  in  an  apparently  conscious  state,  which  the 
patient  is  quite  unable  to  recall  later  on.  To  this  phenomenon  may  be  appUed 
the  term  antegrade  amnesia  in  association  with  post-epileptic  automatism. 
From  the  diagnostic  point  of  view,  epileptic  amnesia  is  often  of  importance  in 
connection  with  medico-legal  questions  and  criminology.  In  addition  to 
temporary  lapses  of  memory,  the  majority  of  epileptics  suffer  from  the  progressive 
hypomnesia  common  to  all  forms  of  dementia.  It  is  one  of  the  first  signs  of 
their  intellectual  deterioration. 

Trauma. — Severe  falls  or  blows  on  the  head  are  not  infrequently  the  cause 
of  complete  amnesia,  and  the  latter  may  cover  not  only  a  period  of  unconscious- 
ness, but  also  a  period  preceding  or  following  it,  or  both.  As  in  cases  of  epilepsy, 
the  amnesia  may  be  retrograde,  anterograde,  or  antero-retrograde. 

Korsakow' s  Syndrome. — This  condition,  generally  the  result  of  alcoholism, 
is  characterized  by  hypomnesia,  disorientation,  and  pseudo-reminiscences.  The 
patient  loses  memory  for  recent  events,  has  no  appreciation  of  time  or  place, 
talks  freely  and  often  plausibly  about  events  which  have  never  occurred,  and 
yet  may  retain  a  very  natural  attitude  of  mind  towards  his  surroundings. 
So  natural  may  be  his  manner  of  talking  and  his  behaviour,  that  the  above- 
mentioned  mental  deficiencies  may  escape  notice  unless  the  medical  man  applies 
himself  to  their  discovery. 


26  AMNESIA 


Toxcsmia. — In  many  infective  diseases,  such  as  enteric  fever,  the  return  of 
health  may  reveal  a  state  of  amnesia  covering  a  considerable  part  of  the  patient's 
illness,  and  this  blank,  the  result  of  intoxication  of  the  higher  cerebral  centres, 
may  be  permanent. 

Hysteria. — Amnesia  is  probably  quite  complete  in  connection  with  some 
forms  of  hysterical  "  fits."  The  patient  in  the  interval  between  attacks  has  no 
recollection  of  the  latter,  although  they  are  not  associated  with  loss  of  conscious- 
ness. This  fact  underUes  the  theory  which  assumes  a  double  consciousness  ; 
the  person  in  one  state  of  consciousness  has  no  memory  for  events  which  occur 
in  the  other.  E.  Farquhar  Buzzard. 

ANEMIA. — Ansmia  is  a  general  and  inexact  term,  which  may  include  one 
or  more,  or  even  all,  of  several  different  changes  in  the  blood,  but  of  which  the 
main  criterion  from  a  clinical  point  of  view  is  diminution  in  the  amount  of 
haemoglobin  contained  in  a  given  volume,  usually  but  not  invariably  associated 
with  a  diminution  in  the  total  number  of  red  corpuscles  per  c.mm.  of  blood. 
The  leucocytes  may  vary  or  not  without  changes  in  them  being  essentially 
related  to  anaemia,  though  their  behaviour  affords  a  means  of  diagnosing 
some  forms  of  anaemia  from  others.  Various  terms  have  been  used  to  denote 
different  ways  in  which  the  blood  may  depart  from  the  normal,  and  these  may 
be  defined  shortly,  though  they  seldom  become  important  from  a  clinical 
point  of  view. 

OligocythcBmia  or  hypocythcBmia.  both  signify  a  diminution  of  the  number  of 
red  corpuscles  below  the  normal  per  c.mm.  of  blood — ^5,000,000  in  a  man, 
4,500,000  in  a  woman.  OligcBmia  means  a  diminished  total  amount  of  blood  in 
the  body  ;  hydrcBwiia,  an  increased  percentage  of  water  in  the  blood  ;  poly- 
plasmia, an  increase  in  the  volume  of  the  plasma  of  the  blood  such  as  is 
supposed  to  occur  in  chlorosis  ;  oligochromannia,  a  diminution  in  the  amount 
of  haemoglobin  per  c.mm.  of  blood. 

For  purposes  of  comparison  of  one  case  with  another,  one  speaks  of  the  red 
corpuscles  and  of  the  haemoglobin  as  being  normally  100  per  cent  in  health. 
It  is  possible  for  an  anaemia  to  be  such  that  the  hsemoglobin  is  greatly  diminished 
without  a  corresponding  diminution  in  the  red  corpuscles  ;  it  is  also  possible 
for  the  haemoglobin  and  the  red  corpuscles  each  to  be  diminished  in  equal 
proportions  ;  and  thirdly,  it  is  possible  for  both  the  haemoglobin  and  the  red 
corpuscles  to  be  diminished,  but  for  the  haemoglobin  to  be  relatively  less 
diminished  than  are  the  red  cells.  The  red  corpuscles  contain  relatively  less 
haemoglobin  than  they  ought  to  in  the  first  variety  of  anaemia,  which  is  probably 
the  commonest  of  all  ;  in  the  second  group,  although  there  is  anaemia,  each  red 
corpuscle  contains  its  full  quantity  of  hemoglobin  ;  whilst  in  the  third  group, 
although  there  is  anaemia,  each  corpuscle  contains  more  haemoglobin  than  it 
normally  should.  As  a  means  of  expressing  these  facts  shortly,  one  speaks  of 
the  colour  index  :  this  is  the  ratio  of  the  haemoglobin  to  the  red  corpuscles  ; 
if  the  red  corpuscles  and  haemoglobin  are  each  100  per  cent  of  normal,  the  colour 
index  is  j-{J-|},  or  i.  If  the  haemoglobin  were  diminished  to  40  per  cent  of  normal, 
whilst  the  red  corpuscles  were  only  diminished  to  80  per  cent  of  normal,  the 
colour  index  would  be  i^,  or  0-5 — the  chlorotic  type,  in  which  the  index  is  less 
than  I.  If  the  haemoglobin  and  the  red  corpuscles  were  both  diminished  to 
50  per  cent  of  normal,  there  would  be  anaemia  with  a  normal  colour  index  of 
^-,  or  I.  If  the  haemoglobin  were  diminished  to  30  per  cent  of  normal,  whilst 
the  red  corpuscles  were  diminished  to  20  per  cent  of  normal,  the  colour  index 
would  be  if}},  or  1-5 — that  is  to  say,  greater  than  i,  a  condition  which  is  spoken 
of  as  the  pernicious  type  of  colour  index,  because  it  is  almost  pathognomic 
of  pernicious  anaemia. 


ANEMIA  27 


Pallor  may  or  may  not  be  an  indication  of  anaemia.  There  are  many  persons 
who  look  almost  white,  and  yet  whose  blood  is  not  in  an  abnormal  condition. 
Pallor  is  normal  in  night-workers  and  in  those  who  work  underground.  Even 
in  some  daylight  workers,  the  distribution  of  the  cutaneous  capillaries  seems  to 
be  such  that  the  superficial  skin  has  little,  if  any,  of  the  normal  colour  of  blood, 
and  yet  the  individuals  are  not  anaemic  in  the  sense  of  having  any  diminution 
of  the  haemoglobin  or  the  red  corpuscles.  It  is  important  not  to  mistake  mere 
pallor  for  anaemia  ;  this  error  is  to  be  avoided  by  means  of  a  blood-count,  which 
in  all  cases  should  include  the  estimation  of  the  percentage  of  haemoglobin,  and 
of  the  total  number  of  red  corpuscles  per  c.mm.  ;  and  inmost  cases  should  also 
include  a  determination  of  the  number  of  leucocytes  per  c.mm.,  a  differential 
leucocyte  count  and  an  examination  of  the  characters  of  the  red  corpuscles  in 
stained  bloodfilms. 

Corpuscles  are  best  counted  by  means  of  the  Thoma-Zeiss  or  Thoma-Leitz  hcemo- 
cytometer  ;  hjeraoglobin  is  most  accurately  measured  by  the  Haldane-Gowers  h^mo- 
giobinometer  ;  and  blood  lilms  are  best  fixed  and  stained  simultaneously  bj'  means  of 
Jenner's  stain,  or,  when  hsematozoa  are  to  be  looked  for,  by  Leishman's  stain.  Ful 
directions  as  to  the  use  of  these  instruments  and  stains  are  generally  issued  with  them, 
or  one  of  the  many  small  handbooks  on  laboratory  methods  may  be  referred  to. 

TRUE    ANEMIAS. 

Having  definitely  proved  that  the  patient  is  suffering  from  real  anaemia,  that 
is  to  say  from  a  diminution  in  the  percentage  of  haemoglobin,  and  probably  from 
a  diminution  in  the  red  corpuscles  also,  the  next  step  in  the  diagnosis  is  to 
determine  what  is  the  nature  of  the  anaemia.  Attempts  are  sometimes  made  to 
fit  all  cases  of  anaemia  into  one  or  other  of  two  main  groups,  labelled  primary 
and  secondary  respectively  ;  but  this  is  not  really  very  helpful  clinically.  In 
many  cases  the  nature  of  the  anaemia  is  obvious  at  once — it  may  be  second- 
ary to  post-partum  haemorrhage  or  other  blood  loss,  or  the  later  stages  of 
phthisis,  syphilis,  cancer,  or  nialarial  cachexia,  and  so  on — the  diagnosis  being 
arrived  at  directly  without  any  difficulty.  Sometimes,  however,  even  though 
anaemia  is  really  du'e  to  a  cause  which  in  some  patients  is  obvious,  it  is  not  obvious 
in  the  patient  with  whom  one  happens  to  be  dealing  at  the  moment,  and  then 
the  diagnosis  has  to  be  arrived  at  by  a  process  of  exclusion.  One  need  but 
mention  as  examples,  perhaps,  the  difficulties  that  arise  sometimes  in  diagnosing 
between  fungating  infective  endocarditis,  gastric  carcinoma,  and  pernicious 
anaemia ;  or  between  anaemia  due  to  blood-loss  and  blood-loss  due  to  anaemia. 
In  arriving  at  the  diagnosis,  it  is  important  in  the  first  instance  to  exclude  those 
conditions  in  which  the  blood  picture  is  itself  positive. 

A  division  of  all  cases  of  anaemia  into  {A)  AncBinias  with  a  positive  blood 
picture  ;  and  {B)  Ancemias  with  an  indeterminate  or  negative  blood  picture,  is 
probably  more  helpful  clinically  than  any  other  classification.  The  only  anaemias 
in  which  the  blood  picture  can  be  described  as  itself  positive — that  is  to  say 
in  which  the  diagnosis  is  indicated  directly  by  the  results  of  blood  examina- 
tion— are  {a)  pernicious  anaemia,  {b)  spleno-meduUary  leukaemia,  (c)  lymphatic 
leukaemia,  {d)  mixed  varieties  of  leukaemia,  (e)  parasitic  anaemia,  associated 
with  eosinophilia,  and  (/)  pprasitic  anaemia  associated  with  parasites  in  the 
blood. 

Blood  changes  common  to  all  severe  ansemiaSo — In  any  severe  anaemia,  whether 
it  is  of  that  definite  variety  known  as  pernicious  anaemia  or  not,  there  are  certain 
blood  changes  which  are  almost  always  to  be  found,  which  are  not  characteristic 
of  any  one  variety  of  anaemia,  but  which,  seeing  that  pernicious  anaemia  in  its 
later  stages  is  probably  the  profoundest  of  all  the  anaemias,  are  perhaps  better 
seen  in  it  than  in  any  other  disease.     These  are  : — • 


28  A  X.EM  I A 

(a).  A  ver^,-  great  diminution  in  the  number  of  red  corpuscles,  down  even  to 
so  low  a  figure  as  600,000  per  cmm. 

(fc).  Great  variation  in  the  shapes  of  the  red  corpuscles  seen  in  blood  films — 
poikiloc],-tosis  ;  poikiloc\-tes  {Plate  II,  Fig.  E),  always  retain  a  smooth,  curved 
outUne.  but  instead  of  being  flat  circular  discs,  hke  normal  corpuscles,  they  may 
be  oval  or  pear-  or  hour-glass-shaped,  and  so  on.  It  is  important  not  to  mistake 
crenated  corpuscles  [Plate  II,  Fig.  D),  or  red  cells  that  have  become  polygonal 
by  reason  of  mutual  moulding  when  fixed  in  too  close  apposition  with  one 
another  (Plate  II,  Fig.   C),  for  poikilocytes. 

(c).  Alterations  in  the  sizes  of  the  corpuscles.  In  normal  blood  the  red  cells 
are  almost  aU  of  the  same  diameter,  about  7  yu  ;  in  any  se\-ere  anaemia  they  may 
vary  considerably  in  size,  many  being  much  smaller  than  normal — microcytes 
{Plate  II,  Fig.  B)  ;  some  larger  than  normal — macrocytes  or  megalocytes  [Plate 
II,  Fig.  B). 

(d).  The  presence  of  nucleated  red  corpuscles,  formally  none  are  present  in 
the  blood  even  in  infancy  ;  in  any  severe  anaemia  they  may  appear  in  varying 
numbers,  and  according  to  their  sizes  they  are  termed  microhlasts,  normoblasts, 
megaloblasts,  or  gigantoblasts  [Plate  II,  Fig.  F) — the  latter  containing  more 
than  one  nucleus,  the  others  only  one.  It  has  sometimes  been  stated  that  the 
greater  the  number  of  nucleated  corpuscles,  the  less  favourable  the  prognosis  ; 
but  this  is  not  necessarily- the  case,  except  in  so  far  that  it  is  unusual  for  nucleated 
forms  to  appear  until  a  severe  stage  of  the  anaemia  is  reached. 

Xone  of  the  above  changes,  one  must  repeat,  are  diagnostic  of  anj-  particular 
variety  of  severe  anaemia,  though  the}-  are  perhaps  most  marked  in  the  later 
stages  of  pernicious  anaemia. 

The    Differextial   Leucocyte    Count. 

I. — Normal  Varieties  of  White  Corpuscles. — It  often  happens  that  variations 
in  the  relative  proportions  of  the  difierent  leucocj-tes  in  the  blood  afford  means 
of  differential  diagnosis.  Before  changes  from  the  normal  can  be  understood, 
it  is  necessary-  to  say  a  word  or  two  about  the  normal  varieties  of  white  cells  ; 
these  number  an\-thing  from  5,000  to  10,000  per  cmm.,  the  total  changing 
considerably  at  different  times  of  the  day.  ^^TLen  films  are  made  it  is  found 
that  four  easily  distinguishable  varieties  are  to  be  seen.  These  have  received 
very  different  names  at  the  hands  of  different  observers,  but  they  are  so  distinct 
that  names  hardly  matter,  and  the}-  might  be  termed  quite  well  t\-pes  A,  B,  C, 
and  D  respectively.  If,  hoM-ever,  one  has  to  choose  between  the  different  names 
that  have  been  given  to  them,  the  following  may  perhaps  be  selected  as  the 
most  frequently  employed  : — (i)  Small  lymphocytes  ;  (2)  Large  lymphocytes  ; 
(3)  Polymorphonuclear  cells  ;  (4)  Coarsely  granular  eosinophile  corpuscles. 

1.  The  small  lymphocytes  [Plate  II.  Fig.  H)  stain  blue  with  Jenner's  stain, 
both  as  to  nucleus  and  protoplasm.  The  nucleus  is  round,  and  the  protoplasm 
is  relatively  small  in  amount  and  free  from  granules. 

2.  The  large  lymphocytes,  or  hyaline  corpuscles  {Plate  II,  Fig.  J),  stain  blue, 
both  as  to  nucleus  and  protoplasm.  The  nucleus  is  more  or  less  kidney-shaped, 
and  the  protoplasm  relatively  large  in  amount  and  free  from  granules. 

3.  The  polymorphonuclear  cells  {Plate  II,  Fig.  K)  stain  blue  as  to  the  multi- 
lobed  nucleus,  red  as  to  the  relatively  abundant  protoplasm,  which  under  the 
high  power  is  seen  to  be  speckled  with  %en.-  fine  red  granules. 

4.  The  coarsely  granular  eosinophile  corpuscles  {Plate  II,  Fig.  L)  stain  blue 
as  to  the  multi-lobed  nuclei,  red  as  to  the  protoplasm,  the  amount  of  which 
is  approximately  the  same  as  in  the  polymorpho-nuclear  cells,  but  differs  from 
the  latter  in  that  it  is  studded  with  very  striking  large  eosinophile  granules. 

The  onlv  difi&cultv  that  arises  in  making  a  differential  leucocvte  count  in 


PLA  TE     II. 

RED       AND       WHITE       BLOOD       CORPUSCLES 

As  seen  under  ihe  :j'.,th-inch   nil-ininier.sion   lens 


A,  Normal  red  corpuscles  ;  B,  Megalocytes  and  microcytes ;  0,  Normal  red  corpuscles  made 
angular  b}'  imperfect  fixation;  D,  Crenated  red  corpuscles;  E,  Poikilocytes ;  F,  Nucleated  red  cor- 
puscles, (i)  Normoblasts,  (2)  Megaloblasts,  (3)  Gigantoblasts ;  G,  Punctate  basophilia  and  poly- 
chromasia ;  H,  Small  lymphocytes;  I,  Indeterminate  lymphocyte;  J,  Large  hyaline  lymphocyte; 
K,  Polymorphonuclear  corpuscle;  L,  Coarsely  granular  eosinophile  corpuscle;  M,  Myelocyte; 
N,    Eosinophile  myelocyte;    O,    Basophile  corpuscle. 


Cflpyiight 

INDEX     OF      DIAGNOSIS 


/.  R.  Ford,  del. 


AN  MM  I A  29 


normal  blood  is  that  whereas  the  small  lymphocytes  usually  become  fixed  in 
such  a  way  as  to  cover  relatively  small  areas,  so  that  the  cells  seem  to  consist 
mainly  of  nucleus,  at  other  times  they  spread  out  ilatter  over  larger  areas,  and 
then  the  rounded  nucleus  seems  to  be  surrounded  by  much  protoplasm  {Plate  II 
Fig.  I).  When  the  small  lymphocyte  becomes  flattened  out  in  this  way,  it 
is  apt  to  be  called  either  a  large  lymphocyte  by  those  who  do  not  insist  upon 
the  reniform  nucleus  of  the  latter,  or  a  transitional  lymphocyte  by  other  observers. 
There  is  no  deduction  of  particular  clinical  value  to  be  obtained  by  distin- 
guishing these  cells  from  small  lymphocytes  ;  it  is  better  that  they  should  be 
grouped  with  the  small  lymphocytes  for  chnical  purposes  at  any  rate,  only 
undoubted  large  hyaline  cells  with  reniform  nucleus  being  included  in  the  group 
of  large  h'mphocytes  or  hyaline  corpuscles. 

The  relative  proportions  of  these  cells  differ  according  as  the  individual  is 
a  child  or  a  grown-up  person  ;  for  an  adult  one  may  say  that,  roughly  speaking, 
out  of  100  leucocytes  about — 

25  will  be   small  lymphocytes 

S  will  be  large  hyaline  lymphocytes 
65  will  be  polymorphonuclear  cells,  and 
2  will  be  coarsely  granular  eosinophile  corpuscles. 
100 

In  children,  the  tendency  is  for  the  small  lymphocytes  to  be  relatively  more 
numerous  in  health,  and  still  more  so  in  any  illness — up  to  40  per  cent  or  even 
more — whilst  the  polymorphonuclear   cells  are  correspondingly  diminished. 

Some  observers  prefer  to  represent  the  different  varieties  of  white  corpuscles 
not  as  percentages  but  as  total  numbers  per  c.mm.  of  blood  ;  but  this  has  not 
yet  become   a  widely  extended   custom. 

II.  Abnormal  Varieties  of  White  Corpuscles. — It  remains  to  add  that,  whereas 
the  above  are  the  only  kinds  of  white  corpuscles  seen  in  the  blood  during  health, 
in  certain  diseases  the  following  abnormal  white  cells  may  be  met  with  : — 

Myelocytes. — These  are  large  corpuscles  [Plate  II,  Fig.  M),  comparable  in  size 
to  the  polymorphonuclear  cells,  but  differing  from  the  latter  in  having  either  a 
perfectly  round,  an  oval,  or  possibly  a  shghtly  kidney-shaped  nucleus  rather  than 
a  multilobed  one.  There  are  all  gradations  of  these  cells,  and  at  the  two  extremes 
it  is  difficult  to  differentiate  some  from  large  lymphocytes  and  others  from 
polymorphonuclear  cells.  They  are  to  be  distinguished  from  the  latter  by  the 
roundness  of  the  nucleus,  and  from  large  lymphocytes  by  the  granularity  of  the 
protoplasm.  The  granules  in  question  are  sometimes  stained  brightly  with 
eosin — eosinophile  myelocytes  {Plate  II,  Fig.  N),  distinguishable  at  once  from  the 
ordinary  eosinophile  corpuscles  by  their  nuclei  being  nearly  spherical  ;  more 
often,  however,  the  granules  stain  blue,  or  some  colour  between  blue  and  red — 
ordinary  or  neutrophile  myelocytes.  No  useful  clinical  information  can,  so  far  as 
is  at  present  known,  be  obtained  by  laying  any  particular  stress  upon  these 
differences  in  the  staining  reactions  of  different  myelocytes,  so  that  these  cells 
are  usually  counted  together  simply  as  myelocytes.  There  is  only  one  condition 
in  which  they  are  very  numerous,  and  that  is  spleno-meduUary  leukaemia  •  but 
they  may  occur  in  small  num.bers  in  various  other  affections  also,  particularly 
in  lymphadenoma,  Hodgkin's  disease,  pernicious  anaemia,  and  aplastic  ansemia. 

Basophile  Corpuscles  {Plate  II,  Fig.  0). — These  are  much  smaller  than  myelo- 
cytes, their  size  being  comparable  i-ather  to  that  of  small  lymphocytes  ;  they 
differ  from  the  latter,  however,  in  that  the  protoplasm,  instead  of  being 
homogeneous,  contains  small  numbers — from  2  or  3  to  perhaps  20  or  more — 
of  very  large  granules  which  stain  deep  blue  with  Jenner's  stain.  They  are 
unmistakeable.      No    definite   clinical    deductions    can    be   drawn   from   their 


30  ANEMIA 


presence  beyond  the  fact  that,  if  there  are  more  than  i  or  2  per  1,000,  the  blood 
is  abnormal.  They  may  be  present  in  manj^  different  varieties  of  anaemia, 
but  they  are  not  characteristic  of  any  ;  thej'  seldom  amount  to  more  than 
2  or  3  per  cent,  and  often  to  no  raore  than  0-5  per  cent,  even  in  disease. 

Punctate  Basophilia. 

There  are  certain  conditions,  particularly  pernicious  ansemia  in  its  later  stages, 
leukaemia,  and  lead  poisoning,  in  which  the  red  corpuscles,  instead  of  staining 
uniformly  pink  with  the  eosin  of  Jenner's  stain,  present  large  numbers  of  very 
small  blue  specks  or  granules  in  their  protoplasm  {Plate  II,  Fig.  G),  a  condition 
known  as  punctate  basophilia.  In  a  case  of  doubt,  when  pernicious  anamia 
has  been  excluded  by  there  being  a  low  colour  index,  and  when  leukaemia  is 
contraindicated  by  the  fact  that  there  is  a  normal  leucoc5'te  count,  the  presence 
of  extensive  punctate  basophilia  sometimes  affords  confirmative  evidence  of 
plumbism. 

(J).— AX.EMIAS    WITH    POSITIVE    BLOOD    PICTURES. 

We  may  now  pass  on  to  consider  the  commoner  varieties  of  anaemia,  deahng 
first  with  anaemias  with  positive  blood  pictures. 

Pernicious  Anaemia  is  a  disease  of  insidious  onset  in  adults,  the  main  s^Tiiptoms 
being  progressive  loss  of  muscle-power  and  increasing  pallor,  with  loss  of  weight, 
but  with  relatively  less  loss  of  body  volume.  A  large  number  of  other  symptoms 
may  be  associated  with  these,  or  no  others  may  be  present.  The  diagnosis  is 
seldom  made  until  a  relatively  late  stage  of  the  malady  has  been  reached,  by 
which  time  there  is  a  great  diminution  in  the  haemoglobin,  down  perhaps  to  30 
per  cent  of  normal  or  less,  and  a  still  greater  diminution  of  the  red  corpuscles 
down  perhaps  to  25  per  cent,  20  per  cent,  or  even  10  per  cent  of  normal ;  con- 
sequently the  colour  index  is  high,  and  this  is  the  pathognomonic  sign  of  the 
disease.  There  is  no  leucocytosis,  but  rather  leucopenia  {q.v.)  ;  the  differential 
leucocyte  count  shows  a  relative  increase  in  the  small  leucoc^-tes,  a  corresponding 
diminution  in  the  poh-morphonuclear  cells,  normal  numbers  of  eosinophile 
corpuscles  and  large  lymphocytes,  occasional  basophile  corpuscles,  and  one  or 
two  myelocytes.  Blood  films  also  show  all  the  changes  described  above  as 
common  to  the  severe  anaemias  with  a  particularly  large  relative  number 
of  megalocytes.  When  these  blood  changes  are  all  present  there  can  be  httle 
or  no  doubt  about  the  diagnosis,  and  therefore  Ave  need  not  enter  here  into  all 
the  other  SA^mptoms  that  maj^  be  presented  by  the  patient.  It  is  important 
to  remember,  however,  that  there  is  one  group  of  the  cases  in  which  nerve 
symptoms  predominate  long  before  the  anaemia  is  pronounced.  The  diagnosis  of 
pernicious  anaemia  cannot  be  made  without  a  blood-count,  and  it  can  be  made 
absolutely  with  one  ;  only  one  word  of  warning  is  required,  and  that  is  that  the 
colour  index  is  not  continuously  high  in  every  case  of  pernicious  anaemia,  so  that 
perhaps  several  blood-counts  may  be  required  at  intervals.  It  should  also  be 
noted  that  the  power  of  temporary  recuperation  is  considerable,  and  when  the 
patient's  condition  improves  the  blood  ma}?  return  partly  or  whoUj^  to  normal ; 
and  during  this  remission  of  the  disease  the  colour  index,  instead  of  remaining 
greater  than  i,  becomes  i  or  less  than  i. 

It  is  on  this  account  that  pernicious  anaemia  in  its  earher  stages  is  exceedingly 
difficult  to  detect,  and  indeed  at  present  it  is  generally  mistaken  for  something 
else  until  the  anaemia  has  reached  such  a  stage  as  to  be  obvious. 

There  are  certain  cases  of  very  severe  anaemia  which  some  would  include 
under  the  heading  of  pernicious  anaemia,  although  the  colour  index  is  persistently 
less  than  i.     It  is  more  useful,  however,  from  a  clinical  point  of  view  to  leave 


AN.^MIA  31 


these  cases  unlabelled,  or  at  any  rate  not  to  call  them  pernicious  anaemia,  which 
has  so  characteristic  a  blood  picture.  One  variety  has  recently  become  separated 
from  the  rest  under  the  title  of  aplastic  ancemia,  the  chief  characters  of  which 
are  a  profound,  progressive,  and  ultimately  fatal  anaemia  for  which  no  cause 
can  be  found,  which  seems  in  many  respects  to  simulate  pernicious  anaemia, 
but  which  is  persistently  associated  with  a  low  instead  of  a  high  colour  index. 

Spleno-medullary  Leukaemia. — In  the  earlier  stages  of  this  disease  there  is 
no  anjemia  at  all,  though  later  diminution  both  in  the  haemoglobin  and  in  the 
red  corpuscles  may  be  profound.  The  essential  point  in  the  diagnosis  is  the 
occurrence  of  a  very  great  increase  of  the  total  number  of  leucocytes,  not  at  all 
uncommonly  up  to  such  a  figure  as  200,000,  and  sometimes  up  to  600,000  or 
even  1,000,000  per  c.mm.  of  blood.  There  is  only  one  other  condition  which 
can  produce  so  extreme  an  increase  in  the  total  nvimber  of  leucocytes,  and  that 
is  lyiiipJiatic  leukcsmia.  The  two  are  immediately  distinguishable  from  one 
another  by  the  differential  leucocyte  count,  the  characteristic  point  about  which, 
in  spleno-medullary  leukaemia,  is  the  large  number  of  myelocytes  present.  These 
may  amount  to  30,  to  even  50  per  cent,  or  more,  of  all  the  corpuscles  present, 
with  the  consequence  that  there  is  a  relative  but  not  an  absolute  diminution  in 
the  other  varieties  of  white  cells.  Occasionally  basophile  cells  are  seen  ;  but 
whatever  may  be  the  proportion  of  these  or  other  leucocytes,  the  main  point  in 
the  diagnosis  is  the  large  relative  number  of  myelocytes,  in  association  with 
an  enormous  increase  in  the  total  leucocyte  count.  When  anaemia  ultimately 
ensues  it  is  of  the  chlorotic  type ;  that  is  to  say,  the  haemoglobin  falls  before,  and 
to  a  greater  extent  than,  the  red  corpuscles.  The  disease  generally  lasts  from 
one  to  three  j^ears  before  ending  fatally,  and  in  the  later  stages  all  the  blood- 
changes  characteristic  of  severe  ana;mia  may  be  found.  Clinically,  the  other 
main  feature  of  the  complaint  is  the  enormous  enlargement  of  the  spleen,  which 
here  reaches  dimensions  bigger  than  in  any  other  disease,  the  viscus  often 
extending  right  across  the  middle  line  to  the  right  iliac  fossa  or  down  into  the 
pelvis.  It  is  noteworthy  that  in  patients  treated  with  the  ;i;-rays  the  spleen 
verj^  often  becomes  greatly  reduced  in  size,  and  the  blood  picture  may  return 
nearly  to  normal,  though  it  seldom  if  ever  happens,  even  when  the  number  of 
leucocytes  per  c.mm.  has  reached  the  normal,  that  there  is  an  absence  of 
myelocytes  in  the  differential  leucocyte  count.  Notwithstanding  this  apparent 
improvement  in  the  blood  and  in  the  spleen,  the  length  of  time  the  patient 
survives  does  not  seem  to  be  increased.  The  splenic  enlargement  is  not  associated 
with  enlargement  of  the  lymphatic  glands. 

Lymphatic  Leukaemia. — There  is  no  age  at  which  any  form  of  leukaemia  may 
not  occur  ;  but  upon  the  whole,  the  spleno-medullary  form  rather  affects  adults 
than  children,  whereas  the  lymphatic  form  affects  children  rather  than  adults. 
Its  course  is  usually  rapid  and  invariably  fatal,  death  resulting,  as  a  rule,  within 
three  or  four  months  from  the  first  definite  symptoms.  Anaemia  is  much  more 
rapid  in  its  development  in  the  lymphatic  than  in  the  spleno-medullary  form. 
The  first  symptoms  may  be  either  those  of  anaemia,  or  the  development  of 
obvious  lymphatic  glandular  enlargements  in  the  neck,  axillae,  and  groins,  or 
the  occurrence  of  purpura,  epistaxis  or  other  forms  of  haemorrhage,  or  in  certain 
cases  a  complete  change  in  the  child's  temperament  in  the  direction  particularly 
of  excessive  irritability  of  temper,  with  loss  of  appetite  and  obvious  and  progres- 
sive illness.  There  are  cases  in  which  there  is  no  glandular  enlargement  at  all, 
and  in  which  the  diagnosis  would  not  be  at  all  obvious  without  a  blood-count. 
More  often  there  is  the  general  enlargement- of  the  lymphatic  glands,  visceral 
and  peripheral,  sometimes  associated  with  similar  increase  in  the  size  of  other 
glands,  particularly  the  salivary  and  lachrymal,  and  upon  examination 
the   spleen   is   nearly  always   palpable  and  sometimes  decidedly  large,  though 


32  ANEMIA 


seldom  so  big  as  it  is  in  the  spleno-medullary  form  of  the  disease.  Serous 
inflammations  are  common,  and  there  is  apt  to  be  pyrexia,  just  as  there  is  in 
other  severe  ansemias,  especially  in  spleno-medullary  leukaemia,  Hodgkin's 
disease,  and  pernicious  anemia.  The  diagnosis  is  at  once  afforded  by  the  blood- 
count  in  the  great  majority  of  cases.  There  is  a  varying  degree  of  increase  in 
the  total  number  of  leucocytes  per  c.mm.  of  blood,  sometimes  reaching  no 
higher  than  20,000  or  30,000,  more  often  80,000  to  100,000,  and  sometimes,  but 
more  rarely,  to  much  higher  figures,  such  as  200,000,  600,000,  800,000  or  even 
1,500,000  per  c.mm.  Whatever  the  total  number  of  leucocytes,  however,  the 
most  striking  feature  in  these  cases  is  the  enormous  relative  increase  in  the 
number  of  small  lymphocytes  in  the  differential  leucocyte  count.  Out  of  every 
hundred  leucocytes  it  is  not  at  all  uncommon  to  find  that  90,  or  even  95  or  98 
are  lymphocytes  ;  so  that  there  is  an  enormous  relative  and  sometimes  absolute 
reduction  in  the  other  corpuscles  of  the  blood.  When  a  very  large  number  of 
cells  are  examined,  amongst  them  will  be  found  an  occasional  myelocyte  and 
one  or  two  basophile  corpuscles.  The  red  cells  and  the  hasmoglobin  become 
progressively  diminished,  and  the  former  may  exhibit  all  the  other  changes 
described  above  as  characteristic  of  any  very  severe  anaemia.  It  is  worthy 
of  note  that  whereas  in  most  cases  the  colour  index  becomes  less  than  i  as 
the  disease  progresses,  in  a  few  instances,  especially  some  time  before  the  end, 
the  colour  index  has  been  found  to  be  greater  than  i,  as  it  is  in  pernicious 
auEemia.  There  is  no  likelihood  of  mistaking  one  condition  for  the  other 
however,  on  account  of  the  changes  in  the  white  cells. 

There  are  some  authorities  who  describe  two  varieties  of  lymphatic  leukaemia, 
according  as  the  lymphocytes  seen  in  the  films  are  of  relatively  large  or 
small  size  ;  as  has  been  explained  above,  however,  there  is  always  difficulty  in 
deciding  whether  differences  in  apparent  size  of  the  lymphocytes  constitute 
differences  in  kind,  and  there  is  no  very  great  clinical  purpose  served  in  drawing 
the  distinction  here,  unless  perhaps  that  upon  the  whole  the  larger  the  lympho- 
cytes present,  the  greater  the  number  of  weeks  the  patient  is  likely  to  survive. 

The  chief  difficulties  that  arise  in  the  diagnosis  occur  in  two  ways  :  namely, 
first,  that  there  are  a  few  instances  in  which  lymphatic  leukaemia  has  run  its 
course  without  any  actual  increase  in  the  number  of  leucocytes  per  c.mm. 
of  blood,  the  diagnosis  being  afforded  only  by  the  enormous  relative  increase 
in  the  small  lymphocytes  ;  and  secondly,  from  the  fact  that  children  normally 
have  a  relatively  high  leucocyte  count,  from  which  it  happens  that  lymphatic 
leukaemia  may  sometimes  be  suspected  when  it  is  really  not  present  at  all. 
Suppose,  for  instance,  that  a  child  suffering  from  an  obscure  illness  associated 
with  anaemia  had  the  chlorotic  type  of  changes  in  the  blood-cells  and  haemo- 
globin together  with  an  increase  in  the  total  number  of  leucocytes  up  to  25,000' 
per  c.mm.,  and  a  relative  increase  of  the  small  lymphocytes  up  to  55  per 
cent,  would  one  be  justified  in  making  a  diagnosis  of  lymphatic  leukaemia  ? 
One  might  do  so  if  there  was  general  enlargement  of  the  lymphatic  glands 
together  with  enlargement  of  the  spleen  ;  but  otherwise  both  the  leucocytosis 
and  the  relative  increase  in  the  lymphocytes  might  be  due  to  some  other  com- 
plaint, and  the  only  means  of  arriving  at  the  diagnosis  might  be  by  awaiting 
developments.  It  is  not  safe  to  insist  upon  a  diagnosis  of  lymphatic  leukaemia 
unless  there  is  either  a  very  large  increase  in  the  total  number  of  leucocytes, 
or  a  relative  increase  in  the  small  lymphocytes  up  to  90  per  cent  or  over,  or  both 
these  changes  at  the  same  time. 

Mixed  Forms  of  Leukaemia. — Ahhoughthe  great  majority  of  cases  of  leukaemia 
belong  either  to  the  spleno-medullary  or  the  lymphatic  form,  there  are  cases 
in  which  the  symptoms  and  the  blood  changes  partake  of  the  characters  of  both. 
Either  the  splenic  enlargement  or  the  lymphatic  glandular  enlargement,  or  both. 


AN  JEM  I A  33 


may  be  well  marked  ;  there  may  be  no  anaemia  until  the  disease  has  passed  its 
earher  stages,  when  the  red  cells  and  haemoglobin  pass  through  the  chlorotic 
type  of  changes  until  they  reach  those  severe  alterations  characteristic  of  all 
anaemias  in  their  last  stages ;  the  white  corpuscles  show  more  or  less  increase  in 
their  total  numbers,  and  the  differential  leucocyte  count  shows  not  only  consider- 
able numbers  of  myelocytes,  such  perhaps  as  20  per  cent  or  more,  but  also  a 
great  relative  increase  in  the  Ij-mphocytes  up  to,  it  may  be,  60  per  cent  or  over. 
The  occurrence  of  these  cases  of  "  mixed  "  leukaemia  would  seem  to  indicate 
that  there  is  really  no  absolute  difference  in  kind,  but  rather  onh^  a  difference 
in  tvpe  betAveen  the  lymphatic  and  the  spleno-medullary  forms  already  described. 

Parasitic  Anaemia  associated  with  Eosinophilia.  —  Many  varieties  of  the 
parasites  that  affect  man  produce  hardly  any  blood  changes  at  all — Tricho- 
cephalus  dispar,  Oxyuris  verniicularis,  Ascaris  lumbricoides .  Other  parasites, 
however,  produce  very  marked  changes  in  the  blood,  and  one  may  mention 
in  particular  Bothriocephalus  latus,  Ankylostomum  duodenale,  Trichina  spiralis, 
Bilharzia  hcematobia,  and  not  a  few  cases  of  hydatid  disease.  The  anaemia  which 
results  may  be  very  profound,  and  the  blood  may  exhibit  all  the  changes  described 
above  as  common  to  the  severest  anaemias.  The  colour  index  is  usually  less 
than  I,  but  sometimes  it  may  be  greater  than  i,  and  so  simulate  pernicious 
anaemia  ;  but  whatever  the  total  number  of  leucocytes  in  the  blood,  the  differential 
count  very  commonly  presents  a  considerable  increase  in  the  coarsely  eosinophile 
corpuscles,  and  this  Eosinophilia  [q.v.)  in  association  with  severe  anaemia  is 
highlv  suggestive  of  the  presence  of  some  toxic  parasite.  It  does  not  indicate 
which  parasite  is  present,  however,  this  being  determined  by  careful  examination 
of  the  faeces,  urine,  and  so  forth.     (See  Parasites,  Intestinal.) 

Parasitic  Anaemia  associated  with  Parasites  in  the  Blood. — The  four  best  known 
varieties  of  disease  in  which  human  beings  have  parasites  in  the  blood  are  : 
malaria,  filariasis,  trypanosomiasis,  and  relapsing  fever.  In  all  of  these  con- 
ditions there  may  be  much  destruction  of  the  red  corpuscles  with  consequent 
anaemia  of  the  chlorotic  type.  It  is  probable  that  in  most  cases  the  history, 
particularly  of  residence  in  some  tropical  country  where  the  disease  in  question 
is  hkely  to  occur,  will  suggest  the  diagnosis  in  the  first  instance,  and  the  exami- 
nation of  the  blood,  either  fresh  or  in  films,  will  merely  be  confirmative. 

Relapsing  fever  used  to  be  prevalent  in  various  parts  of  Great  Britain,  and  it 
still  occurs  in  epidemic  form  in  times  of  famine  in  association  with  uncleanness. 
It  is  commoner  abroad.  It  is  due  to  infection  by  the  spirochaete  of  Ober- 
meier  [Plate  XII,  Fig.  I).  This  is  a  long  spiral  organism,  40  fi  long  and 
I  jj.  broad,  which  is  actively  motile  in  fresh  blood,  but  is  best  seen  in  films 
stained  with  Leishman's  stain.  They  first  appear  a  day  or  two  before  the 
paroxysms  of  fever,  and  may  reach  large  numbers.  In  the  intervals  between 
the  paroxysms  they  are  not  to  be  found.  The  course  of  the  disease  is  usually 
very  suggestive  of  the  diagnosis,  there  being  outbursts  of  pyrexia  associated 
with  extreme  prostration  and  severe  illness,  lasting  about  a  week  or  rather  less, 
with  complete  intermissions  of  about  the  same  length.  There  may  be  an 
indefinite   number  of  relapses  before  the  patient  either  dies  or  recovers. 

Filariasis  may  be  latent  for  a  long  time  before  it  produces  actual  symptoms. 
Its  best  known  effects  are  elephantiasis  of  the  legs  or  genital  organs,  with  or 
without  chyluria.  It  occurs  in  many  parts  of  the  tropics,  particularly  in  some 
of  the  Pacific  Islands,  such  as  Fiji ;  and  in  certain  parts  of  China.  The 
elephantiasis  and  chyluria  are  due  to  mechanical  obstruction  to  the  pelvic 
lymphatics  by  the  mature  worms.  The  blood  exhibits  more  or  less  anaemia  of 
the  simple  chlorotic  type,  together  Avith  a  varying  degree  of  eosinophiUa,  whilst 
at  certain  times  of  the  day  or  night,  the  peripheral  blood  also  contains  the 
long  but  narrow  filarial  embryos  (Plate  XII,  Fig.  F).  There  are  probably 
D  3 


34  AN  JEM  I A 


different  varieties  of  the  organism,  but  they  cannot  be  distinguished  easily  by 
the  appearance  of  these  embryos  alone.  Without  laying  stress  upon  generic 
differences,  it  is  important  to  know  that  in  most  cases  they  are  to  be  found  in 
the  peripheral  blood  only  at  night  {Filaria  nocturna  bancrofti)  ;  during  the  day 
in  these  cases  they  seem  to  retreat  into  the  deep  vessels  ;  there  are  other  cases, 
however,  in  which  embryos,  very  similar  in  appearance,  occur  in  the  peripheral 
blood  in  the  daytime  and  not  at  night  {Filaria  diurna)  ;  whilst  in  Filaria 
Persians  they  are  present  in  the  blood  both  day  and  night.  Roughly  speaking 
one  may  say  that  each  embryo  when  stretched  out  is  200  f.i  long  and  4  to  5  ju 
wide,  and  they  stain  by  Leishman's  method.  The  parasites  may  be  found  in 
the  blood  of  patients  who  have  returned  to  England  from  foreign  parts  in 
which  they  have  contracted  the  disease. 

Trypanosomiasis. — -This  is  the  cause  of  sleeping  sickness.  Trypanosomes  of 
many  different  kinds  are  known  to  affect  various  animals,  birds  and  fish,  but 
the  only  one  which  is  important  in  man  is  the  Trypanosoma  gambiense 
{Plate  XII,  Fig.  G).  It  is  to  be  found  in  blood  films  stained  by  Leishman's 
method  in  infected  patients,  months  or  years  before  it  finds  its  way  into  the 
cerebrospinal  fluid  to  produce  sleeping  sickness.  It  has  a  large  and  definite 
nucleus  about  its  middle,  surrounded  by  protoplasm  which  becomes  prolonged 
into  a  relatively  long  undulating  membrane  terminating  in  a  flagellum.  It  is  an 
extra-corpuscular  organism  readily  distinguishable  when  seen  in  its  mature 
stage.  It  occurs  particularly  in  people  who  have  been  resident  in  Uganda 
or  other  district  in  which  the  fly  Glossina  palpalis  abounds  which  spreads  the 
disease.  The  diagnosis  is  much  less  easy  when  the  blood  contains  only  imma- 
ture forms.  In  this  connection  it  is  worthy  of  note  that  one  variety  of  severe 
anaemia  occurring  in  Assatn,  associated  with  pyrexia  and  enlargement  of  the 
spleen,  and  formerly  thought  to  be  a  variety  of  malaria,  has  been  shown  to  be 
due  to  a  variety  of  trypanosomiasis  in  which  only  immature  forms  of  the 
parasite  (Leishman-Donovan  bodies)  have  been  found  [Plate  XII,  Fig.  H)  ; 
and  here  not  in  the  general  blood  stream,  but  in  the  fluid  obtained  by  splenic 
puncture.     The  disease  is  termed  Kala-azar. 

Malaria. — Malaria  is  not  essentially  associated  with  anaemia  ;  but  in  patients 
who  have  had  recurrent  attacks  blood  destruction  by  the  parasites  leads  to 
considerable  reduction  both  in  the  red  cells  and  in  the  haemoglobin,  the  colour 
index  generally  being  of  the  chlorotic  type.  The  changes  in  the  white  corpuscles 
are  described  above.  The  diagnosis  can  often  be  surmised  when  a  patient 
who  is,  or  has  been,  resident  in  a  malarial  district  suffers  from  the  typical 
periodic  rigors  with  pyrexia.  Theoretically,  there  are  two  main  types  of  the 
disease, — the  tertian,  in  which  the  paroxysms  come  on  every  alternate  day  with 
complete  freedom  every  intermediate  day  ;  and  the  quartan,  in  which  there  are 
two-day  intervals,  so  that  the  paroxysms  occur  every  fourth  day.  What 
happens  in  a  malarial  district,  however,  is  that  after  a  patient  has  been  infected 
by  one  set  of  mosquito  bites  with  a  tertian  or  quartan  ague,  he  becomes  sub- 
sequently infected  upon  different  days  by  other  mosquitoes  with  other  tertian 
or  quartan  parasites,  so  that  there  is  a  mingling  together  of  the  effects  of  different 
sets  of  haematozoa.  For  instance,  if  a  patient  had  become  infected  by  two 
tertian  parasites,  the  one  producing  rigors  upon  Monday,  Wednesday,  Friday, 
and  Sunday,  and  the  other  similar  attacks  upon  Tuesday,  Thursday,  Saturday, 
and  Monday,  this  patient  would  have  a  paroxysm  every  day,  the  type  being  then 
spoken  of  as  quotidian.  If  he  were  infected  by  two  quartan  parasites,  the  one 
producing  attacks  upon  Monday,  Thursday,  and  Sunday,  and  the  other  upon 
Tuesday,  Friday,  and  Monday,  the  occurrence  of  the  paroxysms  becomes  less 
obviously  regular,  for  the  patient  would  have  a  rigor  upon  Monday,  another  on 
Tuesday,  none  on  Wednesday,  a  rigor  upon  Thursday  and  Friday,  but  none  on 


AN.¥.MIA  35 

Saturday,  and  so  on.  Each  infection  by  a  fresh  brood  of  malarial  parasites 
complicates  the  clinical  picture,  until  finally,  in  those  who  have  been  long  in 
malarial  districts,  the  attacks  of  pyrexia  may  be  quite  irregular  or  even  almost 
continuous.  Each  paroxysm  has  three  characteristic  stages,  any  one  of  which 
may  last  from  half  an  hour  to  two  or  three  hours,  or  even  more.  During  the 
first  or  cold  stage,  the  patient  shivers  with  a  severe  rigor,  feels  cold,  looks  blue 
and  pinched,  but  nevertheless  has  a  rise  of  temperature  to  102°  F.  or  103°  F.  The 
teeth  chatter  and  the  patient  wraps  himself  up  to  try  and  keep  warm.  This  is 
followed  by  the  hot  stage,  which  begins  with  flushing  of  the  face,  severe  headache, 
pains  in  the  back,  further  rise  of  the  temperature  to  104°  F.  to  106°  F.,  and  a 
sensation  of  such  heat  that  the  patient  throws  oft  the  clothes  and  calls  for  cooling 
drinks.  This  ends  in  the  third  or  sweating  stage,  during  which  the  skin,  previously 
dry,  breaks  out  into  perspiration  so  severe  that  all  the  bed-clothes  may  become 
wringing  wet.  The  temperature  now  falls,  and  the  patient,  more  or  less 
exhausted,  sleeps,  and  on  waking  feels  comparatively  well  except  for  a  sense 
of  weakness  ;  he  may  be  able  to  do  his  ordinary  work  until  the  next  paroxysm 
comes  on.  Onlv  in  a  few  cases  do  much  severer  symptoms  supervene  if  proper 
treatment  be  adopted.  In  the  absence  of  treatment,  however,  malaria  may 
lead  to  h^•perp^^:exia  (107°  F.-ii2°  F.)  ;  to  coma;  or  to  a  condition  of  algidity 
and  collapse ;  any  one  of  which  may  end  in  death.  The  diagnosis  may  be 
confirmed  to  some  extent  by  finding  that  the  pyrexial  outbursts  diminish  or 
cease  altogether  under  the  administration  of  quinine,  but  the  only  real  proof 
of  the  nature  of  the  complaint  is  the  discovery  in  the  blood  of  the  malarial 
parasites  (Plate  XII,  Figs.  A,  B,C,  D,  and  E).  In  this  connection  it  is  important 
to  note  that  the  administration  of  quinine  renders  it  difficult  or  impossible  to 
find  these  in  blood  films,  and  then  the  behaviour  of  the  leucocytes  (see  above) 
may  be  very  helpful.  For  a  detailed  account  of  all  the  stages  and  appearances 
of  various  malarial  parasites,  text-books  of  tropical  medicine  should  be  consulted. 
There  are  two  main  t^^es  to  be  seen  in  films  stained  by  Leishman's  method — 
the  ring-form  and  the  crescent-form.  The  latter  are  perhaps  the  rarer,  though 
the  severer  t^'pes  of  malaria,  particularly  the  sestivo-autumnal  form  met  with 
on  the  West  Coast  of  Africa,  are  generally  due  to  it  ;  the  crescentic  parasites 
cannot  be  mistaken  for  anything  else.  The  ordinary  tertian  and  quartan  agues 
are  due  to  the  ring  form  of  parasites,  which,  though  the  two  types  are  distinct 
from  one  another,  are  sufficiently  similar  not  to  be  distinguishable  in  films 
except  by  experts.  In  either  case  the  Hcemamceba  malaria;,  tertian  or  quartan 
as  the  case  may  be,  has  a  double  hfe  cycle,  half  of  which  is  spent  in  the  mosquito, 
the  other  half  in  man.  The  bite  of  an  infected  mosquito  introduces  spores  into 
man's  blood,  where  they  grow,  become  amceboid,  and  invade  red  corpuscles, 
enlarging  at  the  expense  of  the  haemoglobin,  producing  pigment  granules, 
finally  segmenting,  and  then  breaking  up  into  spores  again,  which  in  their  turn 
invade  fresh  corpuscles,  and  repeat  the  cycle,  which  lasts  48  hours  in  the  case 
of  the  tertian,  and  72  hours  in  the  case  of  the  quartan  parasite.  Plate  XII, 
Fig.  A  represents  the  first  stage  in  which  the  haemamoeba  spore  has  invaded  a 
red  corpuscle  ;  Plate  XII,  Fig.  C  represents  it  when  it  is  approaching  maturity 
within  the  red  cell ;  and  Plate  XII,  Fig.  D  represents  it  when  ready  to  break 
up  into  spores.  If  blood  is  examined  at  the  very  beginning  of  the  rigor,  the 
stage  most  commonly  seen  is  that  of  Plate  XII,  Fig.  B.  The  two  chief  points 
of  morphological  distinction  between  tertian  and  quartan  parasites  are,  first, 
that  the  pigment  granules  are  much  blacker  and  fewer  in  number  with  the 
quartan  than  the  tertian,  and  secondly,  that  in  the  rosette  stage,  the  quartan 
segments  are  fewer  than  the  tertian.  One  remarkable  feature  about  malaria 
is  that  it  may  remain  latent  for  many  years,  and  yet  recur  in  those  who  have 
long  since  returned  to  Great  Britain  from  the  tropics.     What  has  happened  to 


36  ANEMIA 


the  parasites  in  the  interval  is  not  known,  but  their  re-appearance  is  brought 
about  by  such  conditions  as  general  depression  of  health  from  overwork  or 
worry,  or  as  the  result  of  some  intercurrent  malady. 

(B).— ANEMIAS    WITH    AN    INDETERMINATE    OR    NEGATIVE 
BLOOD    PICTURE. 

The  diagnosis  of  the  fact  of  anaemia  is  made  by  means  of  a  blood-count,  but 
the  cause  of  the  anaemia  itself  is  not  indicated  by  the  blood  condition  in  the 
great  majority  of  cases.  The  differential  diagnosis  has  to  be  made  on  other 
grounds.  One  may  subdivide  Group  B  into  four  sub-groups,  namely,  (i)  Those 
cases  in  which  the  anaemia  is  slight  and  in  itself  not  a  very  prominent  symptom  ; 
e.g.,  in  an  indoor  worker  or  a  convalescent :  (2)  Those  cas'es  in  which,  though  the 
anaemia  may  be  severe,  the  routine  examination  of  the  patient  discovers  some 
more  or  less  obvious  and  not  absolutely  uncommon  cause  for  it  ;  e.g.,  chronic 
tubal  nephritis  :  (3)  Those  cases  in  which,  though  the  anaemia  naay  be  severe, 
no  obvious  lesion  can  be  discovered,  but  in  which  there  is  nothing  about  the 
case  to  suggest  that  the  condition  is  a  rare  or  unusual  one ;  e.g.,  chlorosis  : 
(4)  Those  cases  in  which  the  anaemia  may  be  more  or  less  severe,  in  which  there 
may  or  may  not  be  obvious  lesions  to  account  for  it,  but  in  which  the  circum- 
stances of  the  case  suggest  that  the  disease  is  unusual  or  rare ;  e.g.,  chloroma. 

1.  Cases  in  which  the  anaemia  is  slight  and  in  itself  not  a  very  prominent  symptom. 
— It  is  quite  clear  that  before  a  so-called  anaemia  reaches  its  severe  stage  it  must 
pass  through  a  phase  when  it  would  be  regarded  as  slight  or  mild.  This  group 
therefore  really  includes  all  the  other  groups  at  some  stage  of  their  development, 
and  it  is  clear  that  the  diagnostician  will  often  label  a  case  to  start  with  as 
comparatively  mild  or  unimportant,  when  the  course  of  events  ultimately  shows 
that  this  was  wrong.  For  instance,  a  case  of  pernicious  anaemia  may  exhibit 
what  seems  to  be  unimportant  symptoms  for  months  or  years  before  the  anaemia 
reaches  so  definite  and  severe  a  stage  as  to  be  diagnosed  correctly.  For  the 
purpose  of  the  present  work,  the  group  now  under  discussion  is  meant  to  include 
only  such  slight  degrees  of  anaemia  as  are  themselves  not  important  in  the  matter 
of  diagnosis  ;  for  instance,  in  people  who  live  too  much  indoors,  in  those 
who  are  convalescent  from  some  acute  or  subacute  illness,  in  those  who 
suffer  from  chronic  indigestion,  constipation,  obesity,  some  forms  of  chronic 
intoxication  by  microbial  products,  as  in  cases  of  infective  synovitis  and  arthritis, 
pyorrhoea  alveolaris  and  oral  .sepsis,  uterine  or  ovarian  disease,  the  earlier  stages 
of  phthisis,  latent  or  deep-seated  caseous  glands  or  tuberculous  affection  of 
joints,  vertebrae  or  peritoneum  in  children,  the  milder  cases  of  plumbism,  and 
so  on  ;  in  all  these  cases  there  may  be  a  sufficient  degree  of  anaemia  to  attract 
some  attention,  but  the  diagnosis  will  rest  upon  other  symptoms  and  signs  than 
those  connected  with  the  blood,  and  in  most  cases  the  anaemia  will  not  be 
extreme. 

2.  Cases  in  which,  though  the  anaemia  may  be  severe,  a  routine  examina- 
tion of  the  patient  discovers  some  more  or  less  obvious  and  not  absolutely 
uncommon  cause  for  it. 

HcBmorrhage. — Some  of  the  most  striking  cases  of  anasmia  in  this  group  are 
those  in  which  there  has  been  recurrent  or  severe  loss  of  blood.  When  the 
latter  has  been  lost  by  epistaxis,  haemoptysis,  haematemesis,  haematuria, 
menorrhagia,  metrorrhagia,  metrostaxis,  purpura,  or  by  the  escape  of  blood  per 
rectum,  the  nature  of  the  anaemia  will  generally  be  obvious,  and  the  differential 
diagnosis  will  depend  upon  the  cause  of  the  particular  haemorrhage  in  question 
(see  Epistaxis,  etc.).  One  should  insist  upon  the  necessity  for  a  complete 
blood-count  in  all  these  cases,  however,  in  order  to  exclude  pernicious  anaemia. 


AN  MM  I A  37 


leukaemia,  and  the  other  conditions  in  which  the  blood-picture  is  positive,  lest 
the  bleeding  be  due  to  the  blood  state  and  not  the  blood  state  to  the  bleeding. 
The  possibility  of  meljena  should  also  be  borne  in  mind,  for  without  examination 
of  the  faeces  the  extreme  pallor  resulting  from  loss  of  blood  from  such  a  lesion 
as  a  duodenal  ulcer  may  not  be  diagnosed  correctly.  The  possibility  of  hcsmo- 
philia  should  not  be  forgotten,  though  the  way  in  which  the  patient  bleeds 
excessively  from  sUght  scratches  or  cuts  will  generally  point  to  the  diagnosis, 
especially  if  there  is  a  family  history  of  a  similar  condition,  males  being  affected 
more  than  females.  The  blood-picture  in  cases  of  haemophilia  is  entirely 
negative,  the  anaemia  that  results  from  the  bleeding  being  of  the  chlorotic 
type.  It  is  sometimes  stated  that  the  result  of  blood-loss  is  to  produce  an 
anaemia  in  which  the  red  corpuscles  and  the  haemoglobin  are  equally  reduced,  so 
that  the  colour  index  remains  more  or  less  normal.  This  may  be  true  of  an 
acute  bleeding  such  as  venesection  or  post-partum  haemorrhage,  but  the  effect 
of  recurrent  blood-loss  is  to  produce  the  chlorotic  type  of  anaemia,  in  which  the 
red  corpuscles  are  less  diminished  than  is  the  haemoglobin. 

Cachexia. — A  similar  blood  picture,  namely  an  anaemia  of  the  chlorotic  type 
more  or  less  severe,  but  without  anything  which  may  be  called  pathognomonic, 
either  as  to  the  red  cells  or  the  leucocytes,  is  to  be  found  in  almost  all  forms  of 
cachexia,  whether  due  to  s^^hihs,  tuberculous  or  maUgnant  disease,  malaria, 
oesophageal  stenosis,  or  starvation.  A  careful  physical  examination  of  the 
patient  and  enquiry  into  his  symptoms,  may  point  to  the  correct  diagnosis ;  but 
it  is  to  be  borne  in  mind  how  difficult  it  sometimes  is  to  detect  phthisis,  or  some 
cases  of  carcinoma  or  sarcoma,  even  when  far  advanced.  Sputum  analysis 
should  not  be  omitted  ;  rectal  examination  should  not  be  forgotten  ;  the  ;ir-rays 
may  serve  to  detect  lesions  within  the  thorax,  and  Wassermann's  serum  reaction 
may  be  employed  when  syphilis  is  suspected.  It  is  remarkable  how  little 
anaemia  may  result  from  some  varieties  of  cancer,  particularly  carcinoma  of 
the  breast ;  whilst  other  varieties,  especially  perhaps  carcinoma  of  the  stomach, 
produce  progressive  anaemia  comparatively  early.  It  is  noteworthy  that, 
whereas  in  former  times  the  absence  of  free  hj^drochloric  acid  from  the  gastric 
juice  at  the  proper  interval  after  a  test  meal,  was  regarded  as  good  evidence  in 
favour  of  a  carcinoma  ventricuU,  it  has  now  been  firmly  established  that  the 
hydrochloric  acid  may  be  very  deficient  or  entirely  absent  in  a  great  many  other 
conditions  also  ;  it  is  absent  in  almost  all  cases  of  advanced  carcinoma,  whether 
of  the  stomach  or  not  ;  and  in  many  chronic  maladies  associated  with  ill-health 
all  the  secretions  of  the  body  suffer,  and  amongst  them  the  hydrochloric  acid  of 
the  gastric  juice.  It  follows  therefore,  that  it  is  only  when  the  diagnosis  has 
been  narrowed  down  to  there  being  some  lesion  of  the  stomach,  that  the 
discovery  that  the  hydrochloric  acid  is  very  deficient  or  absent  affords 
evidence  that  the  lesion  is  a  carcinoma. 

Parasitic  affections  sometimes  escape  recognition,  even  w^hen  they  have 
led  to  sufficient  anaemia  to  attract  attention  (see  Parasites,  Intestinal). 
The  two  varieties  most  apt  to  be  associated  with  anaemia  are  Ankylostomum 
duodenale  and  Bothriocephalus  latus.  Bilharzia  hcsniatobia  may  also  lead  to 
severe  anaemia,  but  generally  does  so  on  account  of  the  H.^maturia  [q.v.)  that 
it  produces. 

Certain  drugs  are  apt  to  produce  anaemia  of  the  simple  chlorotic  type  if  their 
administration  is  continued  over  a  long  period  ;  one  may  mention  in  this 
connection  particularly  mercury,  arsenic,  lead  and  salicylates.  Acute  mercurial- 
ism  is  more  commonly  associated  with  severe  stomatitis  and  saHvation,  but  in 
chronic  cases,  in  addition  to  anaemia  there  is  very  apt  to  be  a  motor  type  of 
peripheral  neuritis,  affecting  the  limbs  and  associated  with  a  remarkable  tremor, 
particularly  of   the    hands.      The    diagnosis   is    generally   arrived  at  from  the 


ANEMIA 


fact  that  the  patient  has  either  been  receiving  mercury  inedicinall}',  or  else 
is  employed  in  some  work  in  which  mercury  is  used,  such  for  instance  as  the 
making  of  thermometers,  mirrors^  and  so  forth,  or  the  curing  of  rabbit  skins  for 
the  manufacture  of  hats. 

Arsenical  poisoning  seldom  gives  rise  to  anaemia  as  its  sole  symptom  ;  but  it 
is  noteworthy  that  although  hquor  arsenicalis  is  an  admirable  remedy  for  the 
rehef  of  pernicious  anaemia,  arsenic  itself  is  also  a  cause  of  ansemia  amongst  those 
who  work  in  it.  As  a  rule,  in  addition  to  anaemia  there  is  marked  pigmentation 
of  the  skin,  and  on  this  account  Addison's  disease  may  be  simulated.  In  the 
latter,  however,  the  pigmentation  occurs  on  the  mucous  membranes,  particularly 
of  the  lips  and  cheeks,  as  well  as  upon  the  skin,  and  this — though  in  very  excep- 
tional cases  a  similar  pigmentation  within  the  mouth  has  been  observed  in 
pernicious  anaemia,  and  perhaps  after  taking  arsenic  for  long  periods — is  always 
very  suggestive  of  Addison's  disease,  and  the  diagnosis  may  be  confirmed  by 
finding  a  slight  degree  of  eosinophiha,  a  remarkably  low  blood-pressure,  down 
even  to  80  mm.  Hg  or  less,  attacks  of  vomiting,  syncope,  and  remarkable 
asthenia.  If  there  is  active  tuberculosis  of  the  suprarenal  capsules,  Calmette's 
or  von  Pirquet's  reactions  with  tubercuhn  may  be  positive,  but  these  two 
tests  are  now  less  rehed  on  than  formerly.  In  arsenical  cases  it  is  very  possible 
that  there  may  also  be  evidence  of  peripheral  neuritis  and  of  hyperkeratosis 
of  the  soles  and  palms.  Analysis  of  the  hair  will  discover  an  abnormalh^  high 
percentage  of  arsenic.  The  chlorotic  type  of  anaemia  in  lead  poisoning  may  be 
very  pronounced,  but  the  diagnosis  will  depend  upon  other  symptoms  of  which 
any  or  all  of  the  following  may  occur  : — a  blue  line  upon  the  gums  ;  constipation  ; 
abdominal  colic  ;  a  tendency  to  repeated  abortion  in  women  ;  peripheral  neuritis, 
particularly  of  the  wrist-drop  type  ;  various  cerebral  symptoms  of  anj^  degree 
between  mere  headache  or  insomnia  and  epileptic  convulsions  or  acute  mania  ; 
optic  neuritis  ;  ophthalmoplegia,  chiefly  affecting  the  sixth  cranial  nerve  ;  a 
tendency  to  gout,  to  albuminuria  and  granular  kidney,  and  the  secondary  effects 
of  the  latter.  The  absence  of  a  blue  line  on  the  gums  does  not  exclude  lead 
poisoning  in  those  whose  teeth  are  clean ;  nor  does  its  presence  prove  lead 
poisoning,  for  most  workers  in  lead  exhibit  a  blue  line,  whether  they  have  other 
symptoms  or  not.  In  cases  of  doubt,  it  may  be  necessary  to  collect  an  abund- 
ance of  urine,  evaporate  it,  and  apply  the  ordinary  tests  for  inorganic  lead. 
The  occupation  of  the  patient  will  often  suggest  the   diagnosis. 

Salicylates  are  said  to  produce  anaemia  if  their  administration  is  continued 
for  a  long  period ;  but  it  is  also  possible  that  the  anaemia  may  be  due  to  the  con- 
dition for  which  the  salic^dates  are  being  given,  namely  acute  rheumatism.  The 
diagnosis  is  generally  obvious.  In  addition  to  the  anaemia  that  may  result  from 
acute  rheumatism  itself,  there  is  apt  to  be  pronounced  anaemia  in  some  forms 
of  valvular  heart  disease,  particularly  in  affections  of  the  aortic  valves,  whether 
rheumatic  or  syphilitic.  Mitral  valvular  disease,  particularly  mitral  stenosis,  is 
more  likely  to  cause  polycythaemia,  unless  there  is  fungating  infective  endo- 
carditis. The  occurrence  of  a  progressive  anaemia  in  chronic  heart  cases  always 
arouses  suspicion  of  the  latter  ;  most  cases  of  fungating  endocarditis  present 
symptoms  of  failing  compensation,  which  are  often  very  difficult  to  distinguish 
from  those  due  to  the  mechanical  effects  of  chronic  valvular  disease  ;  so  that  it 
is  very  difficult  to  distinguish  a  heart  case  without  fungating  endocarditis  from 
a  similar  case  in  which  fungating  endocarditis  has  supervened.  In  addition 
to  the  anaemia,  the  following  points  would  be  in  favour  of  the  latter  :  sijdden 
and  radical  changes  in  the  character  of  the  heart  bruits,  for  instance  from 
musical  to  blowing,  and  vice  versa  ;  enlargement  of  the  spleen  ;  the  occurrence 
of  haemorrhages,  particularly  subcutaneous  or  retinal  ;  optic  neuritis  ;  p5='rexia, 
whatever  its  type,  provided  it  cannot  be  explained  by  any  intercurrent  affection 


ANEMIA  39 


such  as  tonsillitis  or  pleurisy  ;  and  symptoms  of  infarction  or  embolism  in  the 
spleen,  kidney,  brain,  intestine,  retinal  or  peripheral  vessels.  It  is  noteworthy 
that  there  is  but  little  leucocytosis  in  infective  endocarditis.  Cultivations 
from  the  blood  obtained  by  aseptic  venesection  may  serve  to  clinch  the  diagnosis, 
and  also  to  indicate  what  serum  or  vaccine  treatment  should  be  employed. 

It  is  in  some  cases  very  eas}',  but  in  others  relatively  difficult,  to  be  sure  of  the 
diagnosis  of  subacute  nephritis.  Anaemia  is  a  prominent  symptom  in  the  chronic 
nephritis  of  young  people,  though  the  reverse  is  generally  the  case  in  the  red 
granular  kidney  of  later  Hfe  ;  for  the  differential  diagnosis,  see  Albuminuria. 
The  old  aphorism  of  "  the  large  white  person  being  associated  with  the  large 
white  kidnev  "  may  sometimes  suggest  the  nature  of  the  malady. 

The  anaemia  of  fungating  endocarditis  is  probably  due  to  the  direct  or 
indirect  effects  of  bacteria.  Many  other  subacute  or  chronic  maladies  associated 
with  a  continual  absorption  of  microbial  toxins  may  have  anaemia  as 
a  prominent  sj^mptom.  One  may  mention,  for  instance,  chronic  colitis, 
whether  muco  -  membranous,  "  simple  "  ulcerative,  or  tropical  dj'senteric  (see 
Diarrhcea)  ;  deep-seated  suppuration  acts  in  the  same  wa}-,  and  one  is  familiar 
with  the  pallor  of  patients  suffering  from  empyema  ;  the  development 
of  this  anaemia  after  the  crisis  of  lobar  pneumonia,  or  in  connection  with 
broncho-pneumonia  in  children,  not  infrequently  suggests  that  an  empyema  has 
developed  ;  the  diagnosis  will  be  confirmed  to  some  extent  by  the  physical 
signs,  but  it  will  be  chnched  by  finding  pus  when  the  chest  is  needled.  The 
occurrence  of  leucocytosis  or  of  a  relative  increase  in  the  polymorphonuclear 
cells  does  not  help  in  determining  the  presence  of  pus  in  the  case  of 
empyema  so  much  as  in  other  cases  of  suppuration,  because  empyema  is 
nearly  ahvays  secondary  to  lobar  or  lobular  pneumonia,  and  in  each  of  these 
there  is  also  a  polymorphonuclear  leucocytosis.  Other  examples  of  chronic 
sepsis  which  may  produce  severe  ansemia  are  chronic  appendicular  abscess  ; 
pyosalpinx  ;  hepatic  abscess  ;  the  breaking  down  of  ovarian  or  uterine  tumours  ; 
chronic  endometritis  ;  pyorrhoea  alveolaris  ;  infection  of  sinuses  connected  with 
bones  or  joints,  particularly  in  association  with  unclean  tuberculous  hip  or  knee- 
joints  ;  psoas  abscess  ;  suppurative  periostitis  or  osteomyehtis,  with  necrosis  of 
bone  ;  secondary  coccal  infections  in  phthisis  with  cavitation,  or  in  bronchiectasis. 
In  all  these  cases  there  will  be  fear  lest  chronic  sepsis  may  be  producing  lardaceous 
disease,  which  itself  is  also  a  cause  of  profound  anaemia,  with  a  pecuhar  pale 
yellowish  or  transparent  appearance  of  the  skin,  though  its  diagnosis  is  exceed- 
ingly difficult  in  any  but  advanced  cases.  It  is  guessed  at,  as  a  rule,  on  account 
of  there  being  a  chronic  purulent  discharge  from  lung,  joint  or  limb,  or  else 
severe  tertiary  syphilis.  There  may  be  enlargement  of  the  Liver  and  spleen, 
albuminuria,  and  a  tendency  to  diarrhoea  ;  but  even  when  all  these  symptoms 
are  present,  it  not  infrequently  happens  that  the  post-mortem  examination 
shows  that  there  was  no  lardaceous  disease  at  all. 

Rheumatoid  arthritis  is  an  indefinite  group  of  joint  diseases  which  differ 
essentially  from  osteo-arthritis,  in  that  whereas  in  the  latter  there  are  extensive 
bony  as  well  as  joint  lesions  and  few-  constitutional  symptoms,  with  the  former 
the  changes  affect  the  bones  very  little  compared  to  the  synovial  membrane, 
hgaments  and  tendons,  and  there  are  more  or  less  severe  constitutional  svm- 
ptoms,  including  slight  pyrexia,  loss  of  appetite  and  weight,  pigmentation  of  the 
skin,  and  anemia.  The  nearest  lymphatic  glands,  e.g.,  the  epitrochlear,  when 
the  hands  are  affected,  are  often  enlarged  and  tender.  The  diagnosis  seldom 
depends  upon  the  anemia,  however.  Probably  there  are  manv  varieties  of 
rheumatoid  arthritis  which  will  some  day  be  classified  upon  a  bacteriological 
basis  into  those  due  to  gonococci,  streptococci,  staphvlococci,  pneumococci, 
Bacillus  coli  communis,  SpirochcBta  pallida,  and  so  on.     There  are  two  particular 


40  ANEMIA 


types  of  rheumatoid  arthritis  in  which  anaemia  is  particular!}^  hable  to  be 
pronounced,  and  these  are,  first,  the  form  in  which  there  is  marked  spindle- 
shaped  enlargement  of  all  the  first  interphalangeal  joints  in  adults,  whatever 
other  joints  may  be  affected  at  the  same  time ;  and  secondly,  a  general  destruc- 
tive affection  of  the  joints  in  children,  associated  with  emaciation,  anaemia, 
enlargement  of  the  spleen  and  of  the  h-mphatic  glands,  and  known  as  Still's 
disease.      (See  Joints,  Affections  of.) 

Cirrhosis  of  the  liver,  sooner  or  later,  leads  to  more  or  less  anaemia  of  the  chlorotic 
type,  although  in  the  earher  stages  the  alcoholic  patient  may  have  a  rubicund 
complexion  ;  b^'  the  time  the  anoemia  is  produced  there  would  almost  certainly 
have  been  other  symptoms  of  the  complaint,  particularly  Hfmatemesis  {q.v.), 
Jaundice  [q-v.),  or  Ascites  {q-v.).  Patients  suffering  from  cirrhosis  of  the  liver 
often  have  some  degree  of  evening  p^Texia,  and  they  also  tend  to  undue  pigmen- 
tation of  the  skin. 

Hyperlactation  is  a  prominent  cause  of  anaemia  and  general  ill-health,  especially 
in  women  in  towns.  It  is  stated  that  the  cause  for  prolongation  of  the  period 
of  lactation  is  an  idea  that  pregnancy  will  not  recur  whilst  the  last  infant  is  being 
suckled.      The  diagnosis  is  generally  obvious  if  its  possibility  is  borne  in  mind. 

Gastric  ulcer,  or  rather  the  symptoms  which  are  often  stated  to  be  those  of 
gastric  ulcer,  is  frequently  associated  ^\dth  anaemia  ;  the  latter  in  a  few  cases 
is  the  result  of  direct  loss  of  blood  by  H.5Matemesis  (q-v.),  or,  in  the  case  of 
duodenal  ulcer,  Mel-bna  {q.v.) .  A  duodenal  ulcer  may  sometimes  simulate  gastric 
ulcer,  but  more  often  it  produces  s^'mptoms  which  are  apt  to  be  mistaken  for 
gall-stones,  the  pain  being  referred  to  a  spot  about  an  inch  below  the  tip  of  the 
ninth  right  rib.  As  a  rule,  the  pain  in  cases  of  duodenal  ulcer  bears  a  definite 
relationship  to  food,  being  greatest  when  the  patient  is  beginning  to  be  hungry, 
and  reheved  by  the  taking  of  food.  Gastric  ulcer,  on  the  other  hand,  is  much 
more  difficult  to  diagnose,  for  even  when  the  patients  have  suffered  from 
epigastric  pain  coming  on  immediateh^  after  food,  from  vomiting  Avhich  relieves 
the  pain,  and  from  one  or  more  attacks  of  haematemesis,  it  is  possible  for  the 
latter  to  be  due  to  generalized  oozing  from  the  gastric  mucosa — Hale  White's 
"  gastrostaxis  " — rather  than  a  definite  measurable  ulcer.  AATien  there  has 
been  no  haematemesis,  the  diagnosis  is  still  more  difficult,  though  it  is  noteworthy 
that  in  nearly  half  the  cases  in  which  the  presence  of  an  ulcer  has  been  proved 
by  operation,  there  has  been  no  history  of  haematemesis.  It  was  formerly 
stated  that  gastric  ulcers  are  common  in  the  female  sex  between  the  ages  of 
fifteen  and  thirt}.',  especially  in  the  unmarried  and  the  ansmic  ;  notably  amongst 
the  servant  class  ;  operative  demonstrations  of  gastric  ulcers,  however,  would 
seem  to  show  that  they  are  really  commoner  in  later  fife,  and  affect  men  as  often 
as  women,  so  that  there  is  a  very  decided  possibihty  that  the  gastric  symptoms 
of  anaemic  women  are  not  in  fact  due  to  ulcer.  One  meets  with  patients  who 
have  pain  the  moment  they  take  food,  in  whom  vomiting  after  meals  is  persistent, 
in  whom  the  diagnosis  of  gastric  ulcer  would  certainly  have  been  made  in  former 
j'-ears,  but  in  whom  that  diagnosis  is  made  now  onh^  with  considerable  caution. 
It  has  become  increasingly  recognized  that  the  vomiting  and  the  gastric  signs 
are  often  due  to  the  anaemia  itself,  and  it  is  possible  that  they  are  in  some  way 
related  to  anaemic  dilatation  of  the  heart.  In  diagnosing  betAveen  this  condition 
and  that  of  true  gastric  ulcer,  one  of  the  best  plans  is  to  put  the  patient  to  bed, 
and  when  she  has  been  recumbent  for  twenty-four  or  thirty-six  hours,  to  see 
what  is  the  effect  of  giving  her  full  diet.  Full  diet  will  be  borne  quite  well  in 
cases  of  severe  anaemia  associated  with  gastric  symptoms  without  ulcer,  so  long 
as  the  patient  remains  in  bed  ;.but  if  she  gets  up  and  returns  to  work  before  the 
anaemia  is  cured,  the  gastric  symptoms  come  on  again  directly.  The  vomiting 
and  the  epigastric  pain  seem  to  be  related  not  so  much  to  food  as  to  work  in 


ANEMIA  41 


these  cases.  When  there  is  an  ulcer,  however,  an  attempt  to  adopt  full  meat 
and  vegetable  diet  on  the  second  day  of  resting  in  bed  nearly  always  fails  if  there 
have  been  severe  symptoms  up  to  that  time. 

3.  Conditions  in  which,  though  the  anaemia  may  be  severe,  no  obvious 
lesion  can  be  discovered,  whilst  at  the  same  time  there  is  nothing  to  suggest 
that  the  case  is  a  rare  or  unusual  one. 

Chlorosis  is  almost  the  only  malady  which  comes  under  the  above  heading, 
provided  one  also  includes  the  milder  anaemias  of  girls  and  young  women,  as 
well  as  tho.se  severe  cases  of  yellow-green  sickness  to  which  the  term  should 
strictly  speaking  be  limited.  The  cases  of  ansemic  vomiting  just  discussed 
might  also  come  under  the  same  heading.  Chlorosis  and  simple  chlorotic 
anaemia,  without  obvious  organic  lesions,  are  affections  of  the  female  sex — absent 
before  puberty  and  common  immediately  after,  seldom  lasting  after  thirtj^  years 
of  age,  and  generally  not  so  long  ;  cured  as  a  rule  by  marriage  ;  never  fatal  even 
when  severe  ;  an  affection  of  all  classes,  but  mostly  of  indoor  workers  such  as 
servant  girls,  and  not  often  affecting  those  who  are  employed  in  outdoor 
pursuits.  The  diagnosis  is  generally  easy.  The  patients  are  comparatively 
well  covered  though  they  often  eat  very  little.  Emaciation  is  rare  in  chlorosis, 
and  this  is  probably  due  to  the  fact  that  the  blood  is  less  deficient  in  quantity 
than  diluted  by  excess  of  water.  The  leucocytes  are  normal  both  in  total 
number  and  in  their  differential  count.  The  red  corpuscles  are  often  much  less 
diminished  than  might  be  expected  from  the  appearance  of  the  patient,  the  chief 
feature  of  the  complaint  being  the  great  reduction  in  the  haemoglobin,  so  that 
the  colour  index  may  fall  to  05,  0-3,  or  even  less.  As  the  condition  improves, 
the  red  cells  return  to  normal  fairly  quickly,  and  the  haemoglobin  rises  steadily 
but  less  rapidly.  The  way  in  which  the  patients  react  to  treatment 
by  rest  in  bed,  by  the  giving  of  iron,  by  keeping  the  bowels  open,  and 
by  living  in  a  sunny  atmosphere,  is  remarkable,  and  helps  to  clinch 
the  diagnosis  in  any  case  of  doubt.  It  has  been  mentioned  above  that  there 
are  many  blood  changes  which  are  common  to  severe  anaemias  ;  it  should  be 
noted  that  even  when  the  haemoglobin  has  fallen  to  30  per  cent  of  normal  in  a 
severe  case  of  chlorosis,  the  changes  in  the  blood-cells  enumerated  on  page  27 
seldom  appear.  Chlorosis,  more  often  than  any  other  form  of  anaemia,  leads 
to  haemic  cardiac  bruits,  particularly  a  blowing  systolic  bruit  in  the  pulmonary 
area  and  a  bruit  de  diable  in  the  neck.  The  patients  are  nearly  always  more  or 
less  constipated,  and  are  apt  to  suffer  from  menstrual  irregularity,  particularly 
amenorrhoea  which  may  last  for  months,  and  a  tendency  to  oedema  of  the  feet. 
Examination  of  the  viscera  discovers  no  abnormality  in  any  of  them.  Chlorosis, 
unlike  many  other  forms  of  severe  anaemia,  seldom  produces  albuminuria. 

4.  Cases  in  which  the  anaemia  may  be  more  or  less  severe,  in  which  there 
may  or  may  not  be  obvious  lesions  to  account  for  it,  but  in  which  the  circum- 
stances of  the  case  suggest  that  the  disease  is  unusual  or  rare. 

Hodgkin's  disease  is  often  spoken  of  as  though  it  were  an  affection  in  which 
the  blood-count  indicates  the  diagnosis.  This  is  not  the  case,  however,  the 
blood  changes  being  merely  negative,  though  a  blood-count  is  essential  in 
order  to  exclude  leukaemia  by  finding  that  there  is  no  leucocytosis.  At 
first  there  is  no  anaemia  ;  later  there  is  progressive  anaemia  of  the  chlorotic 
type,  with  finally  all  the  changes  in  the  red  cells  common  to  the  severe 
anaemias  (see  above).  There  is  no  leucocytosis,  or  none  of  moment.  The 
differential  leucocyte  count  may  be  like  that  of  a  normal  person  ;  more  often, 
however,  there  is  some  relative  increase  in  the  lymphocytes  with  proportionate 
relative  diminution  in  the  polymorphonuclear  cells,  and  when  a  large  number 
of  white  corpuscles  are  examined,  it  is  probable  that  an  occasional  myelocyte 
and  one  or  two  basophile  corpuscles  will  be  detected.     The  diagnosis  is  made 


42 


AX.EMIA 


upon  the  enlargement  of  the  Lymphatic  Glands  (q-v.)  and  of  the  Spleen  (q-v.), 
and  in  a  negative  way  upon  the  blood  changes. 

Splenic  aiiiBmia  is  a  malady  in  which  there  is  considerable  enlargement  of 
the  spleen,  progressive  and  persistent  anaemia  of  the  simple  chlorotic  type, 
and  no  other  verj'  obvious  evidence  as  to  what  is  wrong  with  the  patient. 
It  is  very  probable  that  more  than  one  condition  is  at  present  labelled  splenic 
anaemia  ;  a  considerable  number  of  the  cases  turn  out  ultimately  to  be  cirrhosis 
of  the  hver,  in  which  enlargement  of  the  spleen  happens  to  have  been  the  first 
symptom  to  attract  attention,  ver}'  likely  years  before  the  other  effects  of 
cirrhosis  manifested  themselves.  \Mien  splenic  anaemia  is  the  original  diagnosis 
in  a  case  which  ultimatelj'  proves  to  be  cirrhosis  of  the  hver,  the  condition  is 
often  spoken  of  as  Banti's  disease. 

Aplastic   ancFmia   has  been  mentioned  above,   and  there  are  a  considerable 

number  of  obscure  cases  of  severe  anaemia 
to  which  up  to  the  present  no  definite  labels 
can  be  attached.  Some  of  these  simulate 
pernicious  anemia,  but  all  differ  from  the 
latter  in  having  a  colour  index  persistently 
less  than  i.  One  can  only  refer  to  them  as 
severe  and  even  fatal  un-named  anaemias. 

Pseiido-lenkizmia  infantum  is  a  condition 
in  which  enormous  enlargement  of  the  spleen 
takes  place  in  a  young  child  or  infant  {Fig.  2) , 
associated  as  a  rule  with  more  or  less  ascites 
and  huge  enlargement  of  the  abdomen.  So 
great  is  the  splenic  enlargement,  that  the 
condition  at  first  suggests  leukaemia  ;  but 
when  a  blood-count  is  made,  although  the 
red  cells  ma}^  be  very  much  diminished  and 
exhibit  all  the  changes-  characteristic  of 
severe  anaemia,  there  is  no  leucocytosis,  so 
that  the  condition  cannot  be  classified  as  a 
leukaemia,  and  hence  is  termed  '  pseudo- 
leukaemia  infantum.'  From  its  first  de- 
scriber,  it  has  also  been  called  '  von  Jaksch's 
disease.'  It  generally  begins  at  an  age  of 
less  than  two  years.  The  hver  is  enlarged, 
but  less  so  than  the  spleen.  There  may 
be  severe  haemorrhage  from  the  mucous 
membranes,  and  there  is  often  periodic 
pyrexia.  The  disease  may  be  mistaken  for 
rickets  or  for  congenital  S5'phihs  ;  indeed  some  authorities  think  that  it  is 
really  due  to  one  or  other  or  both  of  these  causes  in  an  exaggerated  degree. 
Others,  however,  consider  this  not  to  be  the  case.  "WTiether  this  is  so  or  not, 
the  prognosis  is  fair  even  when  the  ansmia  has  reached  a  severe  degree.  The 
ascites  ma}'  disappear,  the  huge  spleen  may  become  restored  to  its  normal 
dimensions,  and  the  patient  recover  completely  in  the  course  of  months. 

Myxcedema  is  a  condition  which  is  often  mistaken  in  its  earlier  stages'  for 
simple  anaemia,  and  consequently  it  is  apt  to  be  overlooked,  particularly  at  that 
stage  which  merits  the  term  '  hii'pothyroidism  '  rather  than  myxoedema.  It 
is  an  affection  of  women  rather  than  of  men  ;  it  comes  on  verj'  slowh"  and  some- 
times it  can  be  diagnosed  only  by  watching  the  beneficial  effects  of  th}-roid 
treatment.  There  is  general!}''  excess  of  subcutaneous  tissue  of  a  gelatinous 
nature,  which  gives  the  patient  the  appearance  of  being  puffy  or  oedematous. 


J^!£:  2.  —  Pseudo-leukaemia  infantum 
(von  Jaksch's  disease).  The  black  line 
demarcates  the  spleen. 


A  N.'EMIA 


43 


especially  in  the  face  (Fig.  4),  ha.nd?r{Fig.  5),  and  lower  limbs,  so  that  not  a  few 
cases   are   mistaken   for   nephritis.     The    urine   is    copious    and   of   low   specific 


I^ig.  3. — The  same  patient  as  Fig^.   4, 
previous  to  the  development  of  rayxoedema. 


Fig.  4.  —  Myxo?denia  :  the  character- 
istic facies,  illustrating  the  broadening  of 
the  features  and  the  malar  flush,  (Com- 
pare Fig:  3).  ■ 


gravity,  but   it  does  not  necessarily  contain   albumin.     The  apparent    oedema 
does  not  pit  on  pressure,  or  pits  far  less  easily  than  it  would  if  it  were  ordinary 


Fig^.  5. — Hands  of  a  patient  suflFering  from  myxoedema,  illustrating  the 
swelling  of  the  soft  parts,  the  broadening  of  the  fingers,  and  their  consequent 
stumpy  or  podgy  appearance. 

oedema  ;    the  skin  becomes  thickened,  and  the  hair  decreases  in   quantity  and 
becomes  brittle.     Physical   movements  are  lethargic,  and  the  intellect  dull,  so 


44  A  X.EM  I A 

that  there  is  a  slowness  of  action  both  of  the  body  and  of  the  mind,  symptoms 
that  disappear  in  a  remarkable  way  under  th\Toid  treatment.  The  chlorotic 
type  of  ana;mia  which  accompanies  it  may  be  masked  by  a  local  flush  over  the 
malar  bones,  not  unhke  that  of  mitral  stenosis. 

Scurfy  is  a  rare  disease,  which  may  lead  to  the  most  profound  anaemia,  though 
it  seldom  does  so  without  also  producing  extensive  haemorrhage  into  the  skin, 
beneath  the  periosteum  of  bone,  from  mucous  membranes,  and  especially  from 
the  spongy  and  foetid  gums.  It  is  not  a  common  disease  now-a-days,  except 
in  a  mild  form  in  children,  in  which  the  tenderness  of  the  bones  associated 
with  anaemia,  often  mistaken  for  rickets,  is  the  main  symptom.  The  ten- 
derness in  question  is  due  to  local  sub-periosteal  haemorrhage,  and  the  way 
in  which  the  complaint  rapidly  gets  better  under  suitable  treatment  with  fresh 
vegetable  diet  helps  in  chnching  the  diagnosis.  The  severer  forms  of  scurvy 
are  due  to  prolonged  deprivation  of  fresh  food,  such  as  is  rare  in  modern 
practice,  though  it  used  to  be  common  on  board  ships. 

Chloroma  is  a  very  rare  affection,  related  to  honphatic  leukaemia  on  the 
one  hand  and  to  hinpho-sarcoma  on  the  other.  It  is  associated  with  the 
formation  of  multiple  tumours,  especially  in  connection  with  bones,  and  a 
progressive  and  severe  anaemia  of  indeterminate  t^.'pe.  The  condition  is  fatal, 
and  the  diagnosis  is  at  once  suggested  by  the  green  colour  of  the  neoplastic 
deposits.  Herbert  French. 

ANESTHESIA. — (See  Sexsatiox,  Abnormalities  of.) 

ANALGESIA. — (See  Sexsatiox,  Abxormalities  of.) 

ANASARCA.— (See  CEdema.) 

ANKLE-CLONUS. — Is  best  elicited  when,  the  patient  lying  on  his  back  with 
his  knees  slightly  flexed,  the  observer  quickly  but  not  violently,  dorsifiexes  the 
foot  by  pressing  it  firmly  upwards,  the  hand  being  applied  along  its  outer  border 
in  such  a  way  as  to  keep  it  well  outwardly  rotated.  The  result,  when  ankle- 
clonus  is  present,  is  a  series  of  rhythmical  jerks  at  the  ankle-joint,  at  the  rate 
of  about  7  per  second — the  contractions  continuing  as  long  as  the  pressure  is 
maintained.  The  last  proviso  is  important,  because  it  often  happens  that  a 
few  ankle- jerks  are  obtained,  var\-ing  in  number  from  two  or  three  to  as  many 
as  twenty  or  thirtj^,  but  gradually  tailing  off  and  ceasing,  although  the  pressure 
on  the  sole  is  maintained.  This  is  sometimes  spoken  of  as  a  "  tendency  to 
ankle-clonus,"  but  for  clinical  purposes  it  is  not  ankle-clonus  at  all,  and 
indicates  nothing  more  than  hj-persensitiveness  of  the  nervous  s^'stem,  and  not 
organic  disease.  Ankle-clonus,  on  the  other  hand,  denotes  changes  in  connection 
with  the  corresponding  crossed  p}Tramidal  tract,  and  it  is  to  be  expected  in 
association  with  increased  knee-jerk  and  extensor  plantar  reflex.  Its  chief 
value  lies  in  determining  between  functional  and  organic  exaggerations  of  the 
knee-jerk  ;  the  latter  may  be  very  brisk  as  the  result  of  pure  nervousness,  but 
if  it  is  associated  with  either  an  extensor  plantar  reflex  or  ankle-clonus,  or  both, 
the  exaggeration  is  due  to  organic  disease  of  the  upper  neurone,  hemiplegic 
or  paraplegic  as  the  case  may  be  (q.v.).  Whereas,  however,  the  presence  of 
maintained  ankle-clonus  is  conclusive  proof  of  an  upper  neurone  affection,  the 
absence  of  such  clonus  does  not  exclude  such  lesion  ;  ankle-clonus  is  not  met 
with  until  there  is  a  relatively  large  amount  of  lateral  column  change  ;  it  comes 
later,  as  a  rule,  than  the  extensor  plantar  reflex.  .     Herbert  French 

ANOSMIA. — (See  Smell,  Abnormalities  of.) 


ANURIA  45 

ANURIA — or  complete  suppression  of  urine — may  arise  from  a  variety  of 
causes,  as  a  complication  of  surgical  disorders  of  the  urinary  apparatus,  or 
as  a  late  symptom  in  a  progressive  incurable  disease.  From  whatever  cause  it 
arises,  anuria  is  a  symptom  of  grave  import,  requiring  urgent  surgical  measures 
to  reheve  any  obstruction  to  the  passage  of  urine  from  the  kidney  that  may 
exist  if  impending  death  from  uraemia  is  to  be  avoided. 

Anuria  may  be  complete,  or  occasionally,  after  a  period  of  suppression,  a  small 
quantity  of  urine  may  be  secreted  again,  to  continue  in  sufficient  amount  to 
meet  the  requirements  of  the  patient,  or  again  to  return  to  complete  anuria. 
It  must  be  distinguished  carefully  from  retention  of  urine,  in  which  urine  is 
secreted  from  the  kidneys,  but  is  retained  in  the  bladder  from  some  lesion 
causing  obstruction  to  the  urethra,  as  in  urethral  stricture  or  prostatic  obstruc- 
tion in  the  male,  or  from  the  pressure  or  drag  upon  the  urethra  by  a  large  pelvic 
tumour  or  by  a  retroverted  gravid  uterus  in  the  female.  Retention  of  urine 
may  also  occur  in  either  sex  without  any  urethral  obstruction,  in  various  forms 
of  disease  of  the  spinal  nervous  system  affecting  the  lumbar  centres.  In 
retention  of  urine  there  is  pain  above  the  pubes,  constant  and  urgent  desire  to 
pass  urine,  and  the  distended  bladder  can  be  felt  as  a  tense,  oval,  dull  tumour 
above  the  pubes  in  the  middle  line,  and  rising  from  the  pelvis.  In  many  cases 
a  previous  history  of  obstruction  to  the  urinary  flow  will  be  obtained,  whilst 
in  others  the  involuntary  dribbling  of  urine  from  the  urethra  from  an  over- 
distended  bladder  will  readily  distinguish  the  case  from  one  of  anuria. 

CAUSES  OF  ANURIA. 
A. — Obstructive  : — 

Calculus  in  kidney  or  ureter 

Vesical  carcinoma  involving  the  ureteric  orifices 

Uterine   carcinoma 

Large  pelvic  or  abdominal  tumours. 
B. — Non-obstructive  : — 

Toxic,  in  acute  fevers 

In    renal    disease,    nephritis,    lardaceous    disease,    tuberculosis,    polycystic 
disease,  suppurative  pyelonephritis 

Reflex,  after  operations  or  trauma 

In  poisoning  from  mercury,  lead,  phosphorus,  or  turpentine 

In  severe  collapse 

Hysteria. 
Anuria  may  occur  and  be  complete  without  any  other  symptom,  and  it  is 
a  remarkable  fact  that  in  the  obstructive  forms,  especially  perhaps  with  calculus, 
anuria  may  be  complete  for  several  days  without  any  other  symptom — latent 
uraemia.  In  the  non-obstructive  forms,  anuria  may  be  accompanied  from  the 
earliest  onset  by  the  various  symptoms  of  uraemia,  such  as  vomiting,  convulsive 
muscular  twitchings,  dyspnoea,  and  headache.  In  the  obstructive  form  of  anuria, 
there  may  be  total  absence  of  any  urine  secreted,  or  a  small  quantity  may  be 
passed  of  low  specific  gravity,  and  containing  very  Little  urea  or  solids.  Albumin 
is  absent  unless  there  be  haematuria  or  cystitis,  when  pus  may  be  present  also. 
The  patient  may  complain  of  aching  in  one  or  both  lumbar  regions,  but,  with 
the  exception  that  no  urine  is  passed,  seems  to  be  in  ordinary  health.  The 
appetite  is  good  and  the  mental  state  quite  clear  ;  but  after  a  variable  period, 
from  seven  to  ten  days,  the  patient  becomes  drowsy,  the  tongue  dry,  temperature 
subnormal,  appetite  deficient,  and  pupils  small.  There  may  be  muscular 
twitching ;  but  the  drowsiness  gradually  becomes  deeper,  without  any  true 
urasmic  convulsions,  and  death  may  be  postponed  for  as  long  as  twenty  days 
from  the  onset  of  the  anuria.     This  sequence  is  very  different  from  that  seen 


46  ANURIA 

when  anuria  occurs  from  non-obstructive  causes,  when  there  is  frequently 
marked  disturbance  of  the  nervous  system ;  headache  and  giddiness  are 
rapidly  followed  by  convulsions,  dehrium,  and  dyspnoea,  with  vomiting  and 
small  pupils,  the  patient  rapidly  becoming  comatose  and  dying  in  a  few  days. 
It  remains  to  consider  the  diagnosis  of  any  case  in  which  anuria  is  a  symptom. 

A. — Obstructive  Anuria. 

Calculous  Disease  is  the  most  frequent  cause  of  obstructive  anuria.  It  may 
occur  at  any  age,  but  is  more  common  in  men  about  forty  years  of  age. 
Suppression  of  urine  may  arise  from  the  impaction  of  a  small  calculus  in  the 
ureter  of  a  kidnQj  which  is  practicallj'  normal  in  structure,  or  may  be  due  to 
the  total  destruction  of  the  renal  secreting  substance,  which  has  progressed 
gradually  and  without  marked  symptoms.  Between  these  two  extremes  there 
may  be  many  stages,  and  the  two  conditions,  namety,  ureteric  impaction  and 
renal  destruction,  ma^'  exist  at  the  same  time.  Chnically,  it  is  rare  to  find 
that  calculous  anuria  is  due  to  the  simultaneous  blockage  of  both  ureters  by 
calcuU,  but  rather  that  one  kidney  has  been  previoush^  destroyed  b}^  previous 
disease  or  is  absent,  whilst  the  ureter  of  the  remaining  functional  organ  has 
become  obstructed.  Exceptionally,  the  blockage  of  one  ureter  by  stone  may 
cause  a  reflex  suppression  of  urine  in  the  other  kidney,  especially  if  the 
function  of  the  latter  is  already  impaired  by  disease  and  so  rendered  more 
susceptible  to  nervous  influences  ;  but  in  these  cases  the  anuria  is  usually  but 
temporary.  Calculous  anuria  may  occur  suddenly,  and  in  patients  who  are 
apparently-  in  good  health,  for  it  is  no  uncommon  thing  for  a  patient  to  go  on 
in  good  health  when  he  possesses  only  one  functionally  active  kidney,  the  other 
having  been  destroyed  by  slow  disease,  or  being  absent.  Though,  as  a  rule,  there 
is  an  old-standing  disease  in  one  kidnej^  before  the  other  functional  organ 
becomes  obstructed,  yet  the  damaged  organ  carries  on  a  certain  amount  of 
excretion  until  the  sudden  obstruction  to  the  sound  kidney  occurs  ;  the  additional 
stress  thrown  upon  the  damaged  kidney  proves  too  much  for  it,  and  complete 
suppression  occurs. 

Calculous  anuria  may  occur  suddenly  in  a  patient  who  has  thought  himself 
pre\dously  well,  or  there  may  be  a  history  of  previous  lumbar  pain,  haemat- 
uria,  p^Tiria,  or  the  passage  of  calcuU.  At  the  onset  of  anuria  there  is  usually 
pain  in  the  lumbar  region  along  the  course  of  the  ureter  of  the  side  most  recently 
affected ;  it  commonly  lasts  a  day  or  so  and  then  subsides,  or  it  may  last 
throughout  the  period  of  anuria.  In  addition,  there  is  frequently  a  constant 
desire  to  micturate,  although  no  urine  is  passed,  or  if  the  anuria  is  intermittent, 
urine  of  pale  colour  and  low  specific  gravity,  sometimes  blood-stained,  may  be 
passed.  If  the  anuria  remains  complete,  no  other  symptoms  may  occur .  for 
several  days,  a  feature  which  is  common  to  the  obstructive  forms  of  anuria, 
but  is  in  marked  contrast  to  the  non-obstructive  variety.  After  a  period  of 
anuria  lasting  from  seven  to  ten  days,  the  patient  becomes  drowsy,  the  tongue 
is  dn,-,  there  is  disinchnation  for  food,  and  the  general  symptoms  of  uraemia 
may  come  on ;  but  in  many  cases  the  patient  maj'  die  before  any  symptoms 
of  uraemia  occur.  Thus,  it  is  usual  to  speak  of  a  tolerant  and  a  urcemic 
period  in  obstructive  anuria.  The  tolerant  stage  of  obstructive  anuria  may 
be  even  further  prolonged  if  the  functional  kidney  be  already  hydronephrotic 
from  previous  intermittent  obstruction,  even  to  twenty  days.  The  sudden 
obstruction  to  the  urinary  flow  in  a  comparativel}^  normal  kidney  causes  complete 
suppression,  whilst  a  partial  or  intermittent  obstruction  causes  dilatation  of  the 
kidney.  If  such  a  kidney  be  the  functionating  organ,  and  become  completely 
obstructed,  the  dilatation  will  increase  ;  thus  the  presence  of  a  lumbar  tumour 
with  anuria  indicates    that   urinary  secretion  is  still  going  on,  and,   although 


ANURIA  47 

insufficient  to  maintain  life,  yet  enough  to  form  an  important  element  in  prognosis, 
and  an  indication  for  immediate  operation. 

If  there  have  been  previous  attacks  of  renal  colic,  accompanied  or  followed 
by  the  passage  of  blood  or  of  a  calculus,  the  sudden  onset  of  pain  in  one  loin  and 
anuria  suggest  obstruction  of  a  calculous  form.  If  there  is  any  swelhng  or 
pain  on  pressure  over  the  kidney  or  along  the  course  of  the  ureter,  the  diagnosis 
is  strengthened,  or  there  may  be  evidence  in  the  history  pointing  to  disease 
of  one  kidney,  or  information  obtained  by  an  operation  or  previous  skiagraphic 
examination.  In  some  cases  in  which  one  kidney  has  been  destroyed  gradually 
without  pain,  and  anuria  occurs,  there  may  be  great  difficulty  in  determining 
which  of  the  two  kidneys  is  the  functional  organ  which  has  recently  become 
obstructed,  so  that  appropriate  surgical  measures  may  be  undertaken  to 
relieve  it.  In  these  cases,  the  onset  of  pain  in  one  side  points  to  the  side 
more  recently  affected,  and  it  is  a  good  rule  to  operate  upon  the  side  on  which 
the  pain  has  most  recently  occurred.  Assistance  may  be  obtained  by  the 
palpation  of  the  ureter  through  the  abdominal  parietes,  if  the  patient  is  not  too 
stout,  when  a  distinct  area  of  pain  may  be  obtained  over  a  calculus  impacted  in 
the  course  of  the  ureter  ;  or  by  a  careful  rectal  or  vaginal  examination,  a  calculus 
impacted  in  the  vesical  end  of  the  ureter  may  be  felt.  If  the  case  is  seen  early, 
evidence  of  ureteric  calculus  may  be  obtained  by  inspection  of  the  ureteric 
orifice  by  the  cystoscope,  or  a  ureteric  bougie  impermeable  to  the  Rontgen  rays 
may  be  passed  into  the  ureter  and  a  skiagram  obtained,  but  it  is  only 
exceptionally  that  this  can  be  carried  out.  In  any  case  one  may  strongly  urge 
the  necessity  of  operation  upon  the  side  of  the  recent  pain,  when  the  kidney 
can  be  opened  and  drained,  and  opportunity  taken  to  explore  as  much  of  the 
ureter  as  can  be  felt  by  the_ parietal  incision  and  by  catheterization  from  above. 
In  a  recent  case  of  partial  calculous  anuria  under  the  writer's  care,  one  kidney 
had  been  unsuccessfully  explored  for  calculus  two  years  previously.  The 
patient  complained  of  pain  on  the  other  side,  and  per  rectum  a  calculus  could 
be  felt  in  the  lower  end  of  each  ureter.  As  the  anuria  was  not  complete,  a 
skiagram  was  obtained,  and  the  diagnosis  confirmed.  The  calculi  were 
removed,  with  an  excellent  result. 

Anuria  from  Vesical  Carcinoma. — Anuria  occurring  from  vesical  carcinoma 
implies  that  either  both  ureteric  orifices  must  be  involved  in  the  disease,  or 
that  the  ureteric  orifice  of  the  only  functional  kidney  is  implicated.  The 
condition  is  uncommon  as  a  pure  obstructive  anuria,  for  in  most  cases  the 
kidneys  are  already  the  seat  of  changes  due  in  part  to  the  back  pressure  and  in 
part  to  sepsis,  so  that  when  anuria  terminates  a  case  of  vesical  carcinoma,  it  is 
more.often  due  to  renal  disease  than  to  ureteric  obstruction.  If  the  bladder  has 
remained  uninfected  by  septic  organisms,  the  gradually  increasing  ureteric 
obstruction  may  first  cause  hydronephrosis,  so  that  when  the  obstruction 
becomes  complete,  the  renal  distention  may  increase  quickly,  and  the  sym- 
ptoms of  uraemia  be  delayed.  In  cases  arising  from  vesical  carcinoma,  it  is 
very  rare  for  the  anuria  to  occur  before  any  symptoms  of  vesical  growth  are 
apparent,  such  as  haematuria,  pyuria,  increased  frequency  and  pain  on  micturi- 
tion, but  in  the  infiltrating  type  of  carcinoma,  haematuria  and  frequency  of 
micturition  may  be  absent  for  a  long  time.  In  all  cases,  a  careful  vaginal  or 
rectal  examination  will  detect  a  distinct  infiltration  and  thickening  of  the  base 
of  the  bladder. 

Uterine  Carcinoma. — Anuria  is  a  very  frequent  symptom  in  the  terminal 
stage  of  uterine  carcinoma,  when  the  growth  has  extended  into  the  cellular 
tissues  of  the  broad  ligament  and  involved  the  terminal  portions  of  the  ureters, 
or  when  the  orifices  of  the  latter  are  implicated  in  the  direct  infiltration  of  the 
growth  into  the  bladder  base.      In  the  very  large  majority  of  cases  dying  from 


48  ANURIA 

uterine  cancer  in  the  inoperable  wards  of  the  London  Cancer  Hospital,  the 
kidneys  are  found  to  be  hydronephrotic,  the  renal  pelvis  dilated,  or  the  renal 
secreting  tissue  sclerosed,  apart  from  the  frequent  infection  with  septic  micro- 
organisms. In  all  cases  the  growth  has  reached  an  advanced  stage,  and  the 
disease  has  been  apparent,  but  it  has  been  recorded  that  anuria  has  occurred 
before  the  patient  has  complained  of  any  symptom  pointing  to  the  uterine  con- 
dition. These  cases  might  simulate  other  forms  of  obstructive  anuria,  but  the 
diagnosis  would  be  apparent  upon  the  vaginal  examination. 

Pelvic  or  Abdominal  Tumours,  such  as  uterine  fibromyomata  or  ovarian 
carcinomata,  may  cause  anuria  from  the  direct  pressure  on  the  ureters, 
especially  if  a  part  of  the  tumour  is  impacted  in  the  pelvic  cavity.  The 
cause  of  the  anuria  will  be  apparent  on  examination  of  the  abdomen  and 
of  the  pelvic  organs. 

B. — Non-obstructive  Anuria. 

Marked  diminution  in  the  amount  of  urine  or  complete  anuria,  may  occur 
without  any  obstructive  lesion  of  the  urinary  apparatus,  due  in  many  instances 
to  disease  of  the  renal  secreting  tissues.  In  many  of  these  cases  the  symptoms 
differ  in  a  remarkable  manner  from  those  seen  in  obstructive  anuria,  in  that 
the  occurrence  of  anuria  is  accompanied  by  marked  symptoms  of  urEemia  in  a 
short  time,  and  not  after  an  interval  of  days,  as  in  the  obstructive  cases. 

Anuria  may  occur  under  certain  toxic  conditions,  as  in  acute  fevers,  or  in 
acute  poisoning  by  mercury,  lead,  phosphorus,  or  turpentine  ;  the  history  and 
accompanying  symptoms  of  such  cases  are  usually  sufficient  to  point  to  the 
nature  of  the  urinary  suppression. 

Anuria  in  Renal  Disease. — In  acute  nephritis,  anuria  may  occur  early  or  after 
the  disease  is  well  established,  and  is  usually  accompanied  by  marked  disturbance 
of  the  nervous  system.  The  sudden  onset  of  the  disease  after  exposure  to  cold, 
or  in  the  course  of  an  acute  specific  fever  such  as  scarlet  fever,  associated  with 
pallor,  backache,  puf&ness  of  the  face  and  ankles,  and  shght  p3''rexia,  together 
with  the  small  amount  of  urine  passed  before  the  suppression  becomes  complete, 
are  points  all  suggesting  acute  nephritis.  If  the  urine  has  been  tested  before  the 
onset  of  anuria,  it  is  often  of  reddish-brown  colour  from  the  presence  of  blood, 
and  contains  abundant  albumin,  together  with  renal,  epithehal,  and  blood-casts. 
In  chronic  nephritis,  anuria  may  occur  as  a  late  sj^mptom  in  the  disease,  and  is 
occasionally  preceded  by  a  period  in  which  polyuria  is  marked.  Anuria  in 
chronic  nephritis  is  accompanied  by  prominent  sjonptoms  of  uraemia,  such  as 
headache,  giddiness,  convulsions,  stertor,  and  coma,  and  unless  the  flow^  of  urine 
is  quickly  re-estabhshed,  death  rapidly  ensues.  The  previous  histor}'  of  the 
case,  high  arterial  tension,  cardiac  hypertrophy,  retinal  changes,  and  signs  of 
back-pressure,  with  or  without  ascites  and  anasarca,  will  point  to  the  nature 
of  the  anuria.  In  other  diseases  of  the  kidney,  such  as  lardaceous  disease, 
suppurative  pyelonephritis,  or  in  bilateral  tuberculosis,  anuria  may  be  preceded 
by  general  failing  health,  with  loss  of  appetite,  subnormal  temperature,  a  dry 
brown  tongue,  and  headache  ;  frequentl}^  there  may  be  pohnaria  before  suppres- 
sion occurs.  In  these  cases  the  anuria  is  a  terminal  symptom  of  the  case,  when 
in  all  probabihty  the  condition  of  the  kidneys  has  been  known  previously.  With 
the  occurrence  of  anuria  there  may  be  great  restlessness,  with  muscular  twitch- 
ing, loss  of  sphincteric  control,  convulsions,  and  a  gradual  lapse  into  coma. 

Polycystic  disease  of  the  kidneys  frequently  terminates  in  anuria  and  uraemia, 
but  the  diagnosis  of  the  disease  has  probably  been  arrived  at  previousl}'.  The 
symptoms  resemble  in  a  great  measure  those  of  chronic  nephritis,  with  the 
exception  that  ascites  and  oedema  of  the  extremities  are  uncommon.  Headache, 
flatulence,  and  digestive  troubles,  sickness,  and  general  lassitude  are  symptoms 


APPETITE,     ABNORMAL  49 

of  renal  inefficiency,  whilst  arteriosclerosis,  a  bilateral  renal  tumour,  and  a 
low-specific-gravity  urine  in  increased  quantity,  would  suggest  polycystic 
disease. 

Anuria  following  Operations  or  Trauma. — Anuria  may  occur  in  patients  who 
have  undergone  an  operation  and  who  are  the  subjects  of  renal  disease,  or 
may  occur  occasionally  even  when  no  renal  disease  is  present.  Any  extensive 
operation  which  involves  a  good  deal  of  shock  in  a  patient  with  renal  disease, 
or  in  whom  the  kidneys  have  been  subjected  to  back-pressure,  as  in  uterine 
m.yomata,  may  succumb  to  anuria  unless  appropriate  measures  are  undertaken, 
whilst  on  the  other  hand  an  apparently  trivial  operation  on  the  urinary  organs 
may  cause  acute  suppression  of  urine.  This  must  be  differentiated  carefully 
from  the  retention  of  urine  in  the  bladder  often  seen  after  operations,  such 
as  for  haemorrhoids  or  for  hernia.  Acute  suppression  of  urine  may  follow 
operations  upon  the  lower  urinary  tracts,  such  as  the  passage  of  instruments, 
and  in  one  case  under  the  writer's  care  it  occurred  in  a  patient  with  apparently 
healthy  kidneys,  after  internal  urethrotomy.  Anuria  is  particularly  liable  to 
occur  when  a  catheter  is  passed  to  relieve  an  over-distended  bladder  in  a  case 
of  prostatic  enlargement  or  urethral  stricture,  in  which  the  kidneys  are  already 
distended  from  back-pressure  or  infected  with  septic  processes,  and  it  must 
be  laid  down  as  a  golden  rule,  that  if  a  catheter  is  passed  in  these  cases, 
the  urine  must  be  withdrawn  very  gradually,  so  as  to  allow  the  kidneys  to 
maintain  their  function  under  the  altered  condition  of  pressure.  Anuria 
following  operations  upon  the  lower  urinary  tract  is  diagnosed  by  the  direct 
relationship  between  the  operation  and  the  onset  of  symptoms  ;  by  the  rigors, 
pyrexia,  and  the  profound  prostration,  rapidly  followed  by  convulsive  move- 
ments  and    coma. 

Anuria  may  also  occur  in  the  severe  collapse  following  an  injury,  in  the  late 
stages  of  cholera  or  yellow  fever ;  and  occasionally  as  a  manifestation  of 
hysteria ;    or  it  may  be  due  to  fraud.  R.  h.  Jocelyn  Swan. 

APHASIA (See  Speech,  Abnormalities  of.) 

APHONIA. — (See  Speech,  Abnormalities  of.) 

APPETITE,  ABNORMAL. — Appetite  may  be  :  (i)  Increased  ;  (2)  Diminished  ; 
(3)   Perverted. 

1.  Increase  of  Appetite  sometimes  occurs  in  cases  of  hyperchlorhydria.  The 
general  condition  is  then  well  maintained,  there  is  usually  pain  or  discomfort  in 
the  later  period  of  digestion,  relieved  (temporarily)  by  the  taking  of  more  food. 
A  test  meal  shows  excess  of  hydrochloric  acid. 

In  diabetes,  especially  in  its  earlier  stages,  there  is  often  an  abnormal  craving 
for  food  ;  but  in  spite  of  large  meals  the  patient  wastes.  Examination  of  the 
urine  will  establish  the  diagnosis. 

Intestinal  parasites  (round-worms  and  tape-worm)  are  believed  to  be  a  cause 
of  excessive  appetite  in  some  cases.  This  is  doubtful  ;  but  in  any  case  the  point 
can  always  be  cleared  up  by  giving  an  anthelmintic. 

In  some  cases  of  hysteria  an  excessive  appetite  is  present  (bulimia).  The 
patient  is  usually  a  young  woman,  and  other  stigmata  of  hysteria  are  present. 

2.  Diminution  of  Appetite  occurs  in  many  forms  of  dyspepsia,  especially 
when  associated  with  a  lessened  gastric  secretion.  Thus  it  is  almost  constantly 
present  in  gastritis,  except,  perhaps,  in  the  acid  form.  If  renal  disease,  advanced 
mitral  disease,  or  cirrhosis  of  the  liver  be  present,  secondary  gastritis  may  be 
diagnosed.  If  there  be  a  history  of  the  abuse  of  alcohol  or  tobacco,  or  of  indiscre- 
tions in  diet,  or  if  there  be  a  marked  defect  of  the  chewing  apparatus,  there  is 
probably  primary  gastritis.     In  any  case,  the  tongue  will  probably  be  furred, 

D  4 


50  APPETITE,     ABNORMAL 


and  a  test  meal  shows  diminished  acidity  and  probably  an  excess  of  mucus,  but 
the  examination  of  the  stomach  otherwise  is  negative.    (See  also  Indigestion.) 

Loss  of  appetite  is  also  an  early  symptom  in  cases  of  gastric  carcinoma,  and 
should  lead,  especially  in  elderly  subjects,  to  careful  examination  for  other  signs 
of  that  disease.  There  is  frequently  a  special  distaste  for  meat  in  such  cases. 
(See  Indigestion.)  In  children  a  profound  anorexia  is  sometimes  an  early 
symptom  of  tuberculosis. 

In  hysterical  young  women  complete  disinclination  for  food  {anorexia  nervosa) 
is  sometimes  met  with.  The  diagnosis  is  based  upon  the  absence  of  other 
causes  of  the  symptom,  the  presence  of  other  signs  of  hysteria,  and  the  history 
of  mental  or  emotional  shock.  The  loss  of  appetite  in  such  cases  may  amount 
to  a  complete  refusal  of  all  food,  and  the  patient  may  emaciate  to  a  dangerous 
degree.  Obstinate  constipation  is  usually  present  as  well.  Allied  to  these 
cases  is  the  loss  of  appetite  which  occurs  in  melancholic  forms  of  insanity. 
In  such  a  case  delusions  may  be  present. 

3,  Perverted  Appetite  may  occur  in  the  course  of  pregnancy ,  and  is  of  no 
special  significance.  It  is  met  with,  too,  in  nervous,  anaemic  children,  in  whom 
it  often  takes  the  form  of  dirt-eating  {pica) .  Here,  also,  it  is  not  a  sign  of  any 
diagnostic  value.  Perverted  appetite  is  also  a  common  occurrence  in  insanity  ; 
but  other  evidence  of  mental  disturbance  is  always  present  as  well. 

Robert  Hutchison. 

ASCITES.^ — Ascites,  or  the  accumulation  of  serous  fluid  in  the  peritoneal 
cavity,  is  an  indication  of  disease,  and  it  may  be  the  main  symptom  in  a  particular 
case  ;  but  it  is  not  a  disease  in  itself.  It  may  be  produced  by  a  great  variety  of 
conditions — Bright's  disease,  cirrhosis  of  the  liver,  tuberculous  peritonitis, 
cardiac  disease.  It  is  easy  to  determine  its  precise  cause  in  some  cases  ;  in 
others  it  may  be  almost  impossible  to  say  what  is  the  primary  condition  pro- 
ducing the  ascites. 

One  may  discuss  (I)  Its  physical  signs  ;  (II)  How  to  distinguish  it  from  other 
conditions  which  may  simulate  it  ;  (III)  A  classified  list  of  its  causes  ;  and 
finally,  (IV)  The  chief  points  about  each  particular  variety  which  will  help  in 
arriving  at  a  correct  difjerential  diagnosis  when  a  case  is  met  with  in  practice. 

I. — The  Physical  Signs  of  Ascites. 

Inspection. — The  abdomen  is  uniformly  distended,  the  degree  varjdng  with 
the  amount  of  fluid.  If  the  quantity  is  large,  and  its  accumulation  has  been 
rapid,  the  abdomen  presents  a  rounded,  globular  appearance,  the  umbilical 
region  being  the  most  prominent.  The  skin  is  tense  and  shiny.  If  the  quan- 
tity of  fluid  is  large,  but  its  accumulation  has  been  gradual,  bulging  of 
the  flanks  is  the  most  prominent  feature  of  the  general  distention.  Large 
effusions  cause  well-marked  linese  albicantes  in  the  lower  half  of  the  abdominal 
wall,  the  lower  ribs  may  be  somewhat  pushed  outwards,  and  the  epigastric 
angle  widened.  If  the  quantity  of  fluid  is  small,  only  a  slight  bulging 
of  the  flanks  may  be  noticed.  The  appearance  of  the  abdomen  depends  a 
good  deal  on  the  position  of  the  patient.  If  lying  on  one  side  more  than  the 
other,  the  most  dependent  part  is  the  most  prominent,  owing  to  the  fluid 
gravitating  to  that  side  of  the  abdomen.  If  the  patient  stands  or  sits  upright, 
the  hypogastric  and  iliac  regions  will  be  most  bulged.  The  umbiUcus  becomes 
stretched  transversely  and  flush  with  the  surface,  or  even  protruded ;  it 
retains  its  position  in  the  median  abdominal  line,  and  remains  nearer 
to  the  pubes  than  to  the  ensiform  cartilage.  In  tuberculous  peritonitis 
the   skin   in   its   immediate   neighbourhood   may   be   reddened,    inflamed,   and 


ASCITES  51 

oedematous,  or  there  may  even  be  a  small  fajcal  fistula  here.  In  cirrhosis 
of  the  liver,  the  veins  around  the  umbilicus  are  said  to  be  dilated,  but  the  so- 
called  '  caput  medusae  '  is  of  extreme  rarity.  The  superficial  veins  all  over  the 
abdomen  and  lower  part  of  the  chest  may  be  dilated,  the  blood  flowing  in  an 
upward  direction,  this  reversal  of  the  stream  occurring  mainly  when  the  inferior 
vena  cava  is  obstructed  either  by  the  tension  of  the  ascites  or  by  something 
related  to  its  cause.  (See  Veins,  Varicose  Abdominal.)  The  abdominal 
respiratory  movements  may  be  absent  or  much  diminished.  The  cardiac 
impulse  may  be  displaced  upwards  and  outwards.  The  legs  and  thighs  may 
be  oedematous,  and  so  may  the  loins. 

Palpation. — The  abdomen  may  be  anything  between  quite  flaccid  and  very 
tense.  A  fluid  thrill  may  be  obtained  by  placing  the  palm  of  one's  hand  flat 
against  one  of  the  lumbar  regions,  and  gently  flicking  the  other  flank  with  the 
fingers  of  the  other  hand  ;  the  possibility  of  a  thrill  being  transmitted  in  the 
abdominal  wall  should  be  eliminated  by  getting  the  patient  or  an  assistant  to 
place  the  side  of  his  hand  on  the  front  of  the  abdomen,  so  as  to  stop  the  mural 
thrill  at  the  point  of  contact  of  the  hand  with  the  abdominal  wall.  If  the  above 
precaution  is  taken  and  a  thrill  is  still  obtainable,  it  denotes  the  presence  of 
fluid. 

If  the  liver  or  spleen  have  enlarged,  they  sink  backwards,  so  that  between 
these  organs  and  the  abdominal  wall  a  layer  of  fluid  is  present ;  if  the  hand 
placed  on  the  abdomen,  in  the  right  or  left  h^'pochondriac  regions,  as  the  case 
mav  be,  is  suddenly  depressed,  this  fluid  is  displaced,  and  the  surface  of  the 
enlarged  organ  can  then  be  felt.  This  phenomenon  of  "  dipping  "  is  almost 
pathognomonic  of  ascites. 

The  direction  of  the  blood-flow  in  dilated  veins,  the  position  of  the  cardiac 
impulse,  and  the  diminished  respiratory  movements  may  be  confirmed  by 
palpation. 

Percussion. — When  the  patient  lies  flat  on  his  back  the  fluid  gravitates  to  the 
posterior  part  of  the  abdomen,  and  the  air-containing  viscera  float  to  the  anterior 
part,  so  that  the  percussion  note  is  resonant  in  front  and  dull  in  the  flanks.  As 
the  fluid  increases  in  quantity,  the  line  of  dullness  creeps  forward  from  the 
flanks  and  upwards  from  the  pubes,  and  keeps  a  concave  upper  border  ;  in 
extreme  cases  the  abdomen  may  be  dull  all  over,  particularly  in  children. 

One  of  the  most  prominent  physical  signs  of  ascites  is  the  effect  produced  on 
the  percussion  note  by  a  change  in  the  posture  of  the  patient.  If,  after  examining 
him  lying  on  the  backhand  finding  dullness  in  the  flanks  and  resonance  in  the 
front,  he  be  turned  on  one  side,  the  uppermost  flank  becomes  resonant  and  the 
line  of  dullness  on  the  other  side  rises  nearer  to  the  median  abdominal  line. 
This  phenomenon  is  due  to  the  fluid  gravitating  to  the  most  dependent  part. 

In  some  cases,  especially  of  tuberculous  peritonitis,  shortening  of  the  mesentery 
is  apt  to  be  associated  with  the  ascites  ;  the  intestines  cannot  then  rise,  and 
the  result  is  dullness  all  over  the  abdomen.  Chronic  peritonitis  may  cause 
the  fluid  to  be  loculated  through  matting  together  of  the  intestines.  The 
abdominal  distention  may  then  not  be  uniform,  and  change  of  posture  may  not 
alter  the  character  of  the  percussion  note. 

If  only  a  very  small  quantity  of  fluid  is  present,  the  abdomen  may  be  resonant 
all  over  when  the  patient  hes  on  his  back  ;  but  if  he  is  percussed  in  the  knee- 
elbow  position,  the  umbilical  region  may  be  found  to  be  dull. 

Mensuration. — The  abdomen  should  be  measured,  fixed  points  being  taken 
in  front  and  behind,  e.g.,  the  umbilicus  in  front  and  the  tip  of  the  third  lumbar 
spine  behind.  This  is  important  in  order  to  watch  the  effect  of  treatment.  The 
distance  of  the  umbihcus  from  the  ensiform  cartilage,  pubes,  and  anterior 
superior  iliac  spines  should  also  be  noted.     In  ascites,  the  navel  is  nearly  always 


52  ASCITES 

nearer  the  pubes  than  the  ensiform  cartilage,  and  equidistant  from  the  two 
anterior  superior  ihac  spines  when  the  patient  hes  flat  on  his  back. 

It  is  always  important  to  examine  the  abdomen  carefull}^  after  paracentesis 
has  been  performed.  The  diagnosis  of  the  cause  of  the  ascites  can  often  be 
made  or  confirmed  in  his  way,  tumours,  or  enlargements  of  organs  being  made 
out  which  previously-  were  hidden  or  obscured  by  the  tenseness  of  the  abdominal 
waU. 

II. — The  Diagnosis  of  Ascites. 

Ascites  has  to  be  distinguished  from  other  conditions  which  maj-  give  rise  to 
general  abdominal  distention,  especiall]/  from  : — (i)  Tympanites  ;  (2)  Ovarian 
and  parovarian  cysts  ;  (3)  Gravid  uterus  with  hydrops  amnii ;  {4)  Distended 
bladder  ;  (5)  Distention  associated  with  obesity  ;  (6)  Phantom  tumour  ;  (7)  Large 
abdominal  cysts  and  solid  tutnoiirs. 

1.  Tympanites  is  distinguished  from  ascites  b}^  the  following  signs  : — The 
outhne  of  distended  coils  of  intestine  may  be  visible,  and  peristaltic  move- 
ments ma}'  be  noticed.  There  is  no  fluid  thriU  if  precautions  to  prevent  a 
thrill  being  transmitted  by  the  abdominal  w-all  are  taken.  The  abdomen  is 
resonant  all  over,  both  in  front  and  in  the  flanks. 

2.  Ovarian  Cyst. — There  ma}'  be  a  historj'  of  the  enlargement  of  the  abdomen 
having  been  noticed  at  an  earl}^  date  to  be  more  on  one  side  than  the  other,  and 
to  have  arisen  from  the  pelvis.  The  umbihcus  may  be  nearer  to  the  ensiform 
cartilage  than  the  pubes,  and  nearer  to  one  anterior  superior  iliac  spine  than 
the  other.  A  fluid  thrill  may  not  be  obtained  far  back  in  the  flanks,  but  only 
in  front  of  the  mid-axiUary  lines.  There  is  usually  dullness  in  front,  with 
resonance  in  the  flanks.  The  outhne  of  the  cyst  may  possibly  be  noticed 
during  the  respiraton,-  movements.  On  measuring  the  abdomen  the  greatest 
circumference  is  usuallj'  below  the  umbilicus  ;  whereas  in  ascites  it  is  generally 
at  the  umbihcus.  A  vaginal  examination  may  reveal  that  the  uterus  is  drawn 
upwards  and  that  its  mobihty  is  impaired  ;  whereas  in  ascites  it  is  low  down 
and  movable.  If  paracentesis  has  been  performed,  the  nature  of  the  ovarian 
fluid  is  characteristic,  being  usually  thick,  tenacious,  \ascid,  and  of  a  brownish 
or  greenish  colour  ;   whereas  ascitic  fluid  is  yellowish,  hmpid,  and  clear. 

iluch  difiiculty  arises  when  there  are  both  ovarian  cyst  and  ascites,  owing  to 
infection  of  the  peritoneum  b}'  secondary  deposits  from  the  ovary.  Even 
without  this,  however,  it  is  by  no  means  alwaj^s  easy  to  distinguish  between 
ovarian  cyst  and  ascites,  particularly  when  the  resultant  abdominal  distention 
has  become  extreme. 

3.  A  Gravid  Uterus  with  Hydrops  Amnii. — In  this  condition  it  maj-  be  possible 
to  make  out : — 

The  outhne  of  the  enlarged  uterus  ;  and  the  tumour  may  varj-  in  consistency 
as  the  uterine  wall  contracts  and  relaxes. 

On  vaginal  examination,  the  cervix  is  soft  and  patulous  and  the  uterus  is 
enlarged. 

The  presence  of  other  signs  of  pregnancy,  the  characteristic  condition  of  the 
breasts,  foetal  movements  and  heart  sounds,  and  the  histor}^  of  amenorrhoea. 

There  will  be  dullness  in  the  front  of  the  abdomen,  resonance  in  the  flanks. 

4.  A  Distended  Bladder  may  reach  well  above  the  level  of  the  umbihcus.  This 
condition  occurs  most  frequently  in  women  as  the  result  of  a  retroverted  gravid 
uterus,  or  in  men  over  sixty  as  the  result  of  enlargement  of  the  prostate.  The 
most  important  symptoms  are  :  incontinence  of  urine  from  over-distention 
and  overflow,  and  abdominal  distention.  There  is  generally  a  globular  mass 
to  be  palpated  in  the  middle  Hne  above  the  pubes  and  reaching  up  to  the 
umbihcus  or  higher  ;  it  is  dull  to  percussion  in  front,  with  resonance  in  the 
flanks.     The  passage  of  a  catheter  should  clear  up  all  doubt. 


ASCITES  53 

5.  General  Obesity  may  cause  much  abdominal  distention.  The  mesentery, 
omentum,  and  abdominal  wall  may  be  very  much  thickened  with  fat  ;  under 
such  conditions  it  is  very  difficult  to  make  a  satisfactory  examination,  and  it 
may  be  almost  impossible  to  determine  with  certainty  the  presence  of  a  small  or 
even  a  moderate  amount  of  fluid. 

6.  Phantom  Tumour. — The  abdomen  may  occasionally  be  much  distended  in 
women,  especially  at  the  time  of  the  climacteric.  Such  a  distention  may 
present  difficulties  in  diagnosis,  and  may  be  mistaken  for  ascites,  ovarian 
tumour,  or  pregnancy.  If  an  ansesthetic  is  administered  it  often  disappears,  the 
rigid  abdominal  wall  becomes  flaccid,  and  it  can  be  determined  with  certainty 
whether  fluid  in  the  peritoneal  cavity  or  any  abdominal  tumour  is  present  or  not. 

7.  Large  abdominal  Cysts  may  occasionally  simulate  ascites,  e.g.,  hydro- 
nephrosis, pancreatic  cyst,  and  hydatid  cyst ;  they  do  not,  however,  cause 
uniform  distention  of  the  abdomen  as  a  rule.  They  are  most  likely  to  be 
mistaken  for  simple  chronic  peritonitis,  in  which  case  local  collections  of  fluid 
may  occur,  owing  to  matting  together  of  the  intestines. 

Hydronephrosis  may  be  distinguished  by  its  position  and  by  the  fact  that  it 
may  vary  in  size,  a  decrease  being  associated  with  an  increase  in  the  amount 
of  urine  passed. 

Pancreatic  cyst  may  be  differentiated  by  its  position  in  the  upper  part 
of  the  abdomen  and  by  its  more  or  less  spherical  outline.  If  paracentesis 
abdominis  has  been  performed,  the  character  of  the  fluid  and  its  ferments  would 
point  to  the  nature  of  the  disease. 

III. — The  Causes  of  Ascites. 

Having  made  up  one's  mind  that  the  general  abdominal  distension  is  due  to 
the  presence  of  fluid  in  the  peritoneal  cavity,  one  must  next  differentiate  the 
cause  of  the  ascites.     The  following  is  a  classified  list  of  its  causes  :■ —  ■ 

1.  Diseases  of  the  Peritoneum. 

Non-suppurative    acute    peritonitis 

"  Simple  "  chronic  peritonitis 

Tuberculous  peritonitis 

Malignant  peritonitis,  generally  secondary  to  a  primary  growth  elsewhere 

Hj^datid  cysts  in  the  peritoneal  cavity. 

2.  Obstruction  to  the  main  Portal  Vein   by  : — 

Non-suppurative    thrombosis. 

Enlarged   portal   lymphatic   glands  : — 

Malignant  I  Tuberculous 

Lymphadenomatous  |  Lymphatic  leuksemic 

Tumours  of  adjacent  organs,  such  as  : — 

Liver  Duodenum 

Pancreas  Colon 

Kidney  Suprarenal  capsule 

Stomach 

Aneurysm  of  hepatic  artery. 

3.  Diseases  of  the  Liver. 

Cirrhosis 

Perihepatitis,  really  part  of  chronic  simple  peritonitis 

Carcinoma  /    Doubtful    causes  if  the  lesions   are   confined   to  the 

Sarcoma  I        liver  ;  i.e.,  if  there  is  ascites,  it  is  probably  not  due 

„      ,  .,.  -[        to  the  carcinoma,  etc.,  in  the  liver,  but  to  simul- 

bypnuis  .            taneous  affection  either  of  the  peritoneum  or  of  the 

Hydatid  disease  (        portal  lymphatic  glands. 


54  ASCITES 

4.  Obstruction  of  the  Inferior  Vena  Cava  above  the  Hepatic  Veins  by  :— 

Thrombosis 

Stenosis  by  chronic  mediastinitis 

Occlusion  by  mediastinal  growth. 

5.  Chronic  Failure  of  the  right  side  of  the  Heart  ("  backward  pressure  ")  the 
result  of  : — 

VahTilar  disease  : — • 

]\Iitral  stenosis 

antral  regurgitation 

Aortic  stenosis  or  regurgitation  with  secondary  mitral  regurgitation : — - 
Rheumatic  or  s^-phihtic 

Congenital   pulmonar}"    stenosis    (rarely). 
Chronic  myocardial  affections  : — • 

Fatt}'  degeneration  1  Fibroid  heart 

Fattv   infiltration  '  Primarj-  alcoholic  heart. 

Fatty  superposition  j 

Adherent    pericardium. 

Chronic  lung  afl'ections,  especiall}'  : — 

Emphvsema  1  „  ,,  •   .   j 

^    ^   -      ,    ,  .  .,.    -Generally    associated 

Recurrent  bronchitis  ' 

Fibroid  lung. 

Chronic  high  blood-pressure  conditions  : — 

Red  granular  contracted  kidneys 

Pale  contracted  kidneys 

Arteriosclerosis. 

6.  Bright's  Disease.     In  Bright's  disease  ascites  may  be  caused  in  at  least 
four  different  ways,  namel}^,  as  the  result  of  : — 


Part  of  a  general  dropsj^ 
Acute   peritonitis 
Chronic  peritonitis 


Secondar}^  to  h^-pertrophy  and  dila- 
tation of  the  heart,  followed  by 
failure   of  compensation. 


7.  Severe  Anaemias,  in  which  the  ascites  is  usually  no  doubt  the  result  of  acute, 
subacute,  or  chronic  intercurrent  peritonitis,  as  in  : — 


Splenomedullar}-  leukaemia 
Lj-mphatic  leukaemia 
Hodgkin's  disease 


Splenic  anaemia 
Pernicious  anemia 
Aplastic    anaemia. 


IV. — -The  Differential  Diagnosis  of  the  Cause  of  Ascites. 

If  ascites  is  the  only  fluid  accumulation  present  in  the  patient  ;  if,  although 
there  is  also  swelhng  and  oedema  of  the  legs,  the  ascites  is  known  to  have  appeared 
first ;  or  if  the  ascites  is  out  of  proportion  to  dropsy  elsewhere  ;  it  is  most  probably 
due  either  to  some  form  of  peritonitis,  to  portal  obstruction  from  thrombosis 
of  or  pressure  on  the  portal  vein,  or  to  cirrhosis  of  the  hver. 

If  it  is  associated  ^\ith  general  anasarca,  that  is  to  say,  with  oedema  of  the  legs, 
body,  and  face,  perhaps  even  of  the  scalp,  and  possibly  with  other  serous  effusions, 
the  probable  cause  is  acute,  or  acute  on  chronic,  Bright's  disease. 

If  swelling  and  oedema  of  the  legs  were  first  noticed  and  the  ascites  followed, 
heart  failure  from  one  of  the  causes  in  Group  5,  or  obstruction  of  the  inferior 
vena  cava  above  the  hepatic  veins,  would  be  the  most  likeh-  cause  ;  it  is  impor- 
tant to  remember,  however,  that  in  the  slighter  cases,  or  in  those  of  long  stand- 
ing, the  patient  is  often  uncertain  which  swelled  first,  his  legs  or  his  abdomen, 
and  his  statements  on  the  point  may  be  misleading. 

If  jaundice  is  associated  Avith  the  ascites,  it  points  to  some  form  of  portal 


ASCITES  55 

obstruction  as  the  cause,  either  cirrhosis  of  the  Uver,  or,  if  the  jaundice  is  intense, 
to  some  actual  pressure  on  the  portal  vein  and  common  bile  ducts. 

If  enlargement  of  the  liver  is  associated  with  the  ascites,  this  may  be  due  to 
carcinoma,  sarcoma,  cirrhosis,  perihepatitis,  syphilis  of  the  liver,  or  to  nutmeg 
change  the  result  of  backward  pressure  from  chronic  heart  or  lung  disease. 

If  the  ascites  is  associated  with  multiple  abdominal  tumours,  it  suggests 
tuberculous  or  malignant  peritonitis,  or  in  rarer  cases  hydatid  disease  of  the 
peritoneum. 

Diseases  of  the  Peritoneum. 

Acute  Nonsuppurative  Peritonitis. — By  this  is  meant  an  acute  inflammation 
of  the  peritoneum  analogous  to  acute  '  simple  '  pleurisy  with  serous  effusion. 
One  seldom  speaks  of  ascites,  however,  in  connection  with  acute  infective  peri- 
tonitis such  as  would  certainly  lead  to  pus  formation  if  immediate  laparotomy 
were  not  resorted  to  ;  and  it  is  difficult  to  draw  a  decided  line  between  acute 
peritonitis  in  which  the  fluid  should  be  called  ascites,  and  other  conditions  of 
acute  generalized  peritonitis  to  which  the  term  would  not  be  applied.  There 
are,  however,  cases  in  which  acute  serous  effusion  due  to  non-suppurative 
peritonitis  occurs  in  acute  and  chronic  Bright's  disease  ;  acute  tuberculous 
peritonitis  almost  simulating  general  suppurative  peritonitis  is  also  familiar, 
and  both  pneumococcal  and  gonococcal  peritonitis  may  be  acute  in  onset,  and 
yet  take  the  form  of  an  ascitic  effusion,  recovery  occurring  without  the 
necessity  for  laparotomy.  It  is  probably  a  question  of  the  dose  of  the  micro- 
organism that  affects  the  peritoneum,  and  it  is  by  no  means  impossible  that, 
whereas  the  perforation  of  a  gastric  ulcer,  duodenal  ulcer,  dysenteric,  typhoid, 
or  tuberculous  ulcer  of  the  intestines,  or  leakage  from  a  pyosalpinx,  an  appen- 
dicular abscess,  stercoral  ulcer  of  the  colon,  or  a  perirectal  or  prostatic  abscess, 
generally  gives  rise  to  acute  general  peritonitis  which  would  prove  suppura- 
tive if  it  were  not  operated  on,  the  same  conditions  may  in  some  cases  lead  to 
a  slighter  affection  with  a  severe  but  non-suppurative  ascitic  effusion  ending  in 
spontaneous  recovery.  Whether  laparotomy  is  indicated  or  not  in  any  given 
instance,  must  depend  upon  the  individual  circumstances  of  the  case  ;  but  it  is 
probably  much  safer  for  the  patient  to  be  operated  upon  for  acute  non-suppura- 
tive peritonitis  of  the  type  of  which  we  are  now  speaking,  than  for  general 
suppurative  peritonitis  to  escape  operation. 

Simple  Chronic  Peritonitis. — By  this  is  meant  a  chronic  inflammation  that 
is  not  tuberculous  or  malignant.  It  may  follow  simple  acute  peritonitis,  but 
its  two  commonest  causes  are  first,  a  former  tuberculous  peritonitis  from  which 
the  tubercles  have  disappeared  ;  and  secondly,  the  chronic  inflammation  which 
results  from  repeated  paracentesis  abdominis  for  any  other  variety  of  ascites. 
The  latter  is  important  to  remember,  for  it  sometimes  happens,  in  a  heart 
case  for  instance,  that  both  oedema  of  the  legs  and  ascites  have  been  promi- 
nent symptoms,  paracentesis  abdominis  being  indicated  on  account  of  the 
cardiac  distress  ;  the  tapping  of  the  abdomen  may  have  had  to  be  repeated 
many  times,  and  yet  ultimately  the  cardiac  compensation  may  have  been 
restored,  the  patient's  general  condition  becoming  quite  good  and  the  oedema 
of  the  legs  disappearing  ;  yet  in  spite  of  this  general  improvement,  ascites 
may  still  persist  and  require  further  tapping  at  intervals.  In  such  a  case, 
whereas  at  first  the  ascites  was  due  to  backward  pressure  from  the  failing 
heart,  it  ultimately  becomes  due  to  chronic  peritonitis,  the  result  of  the  repeated 
tappings.  It  is  usually  associated  with  perihepatitis,  which  indeed  is  only  one 
of  the  local  manifestations  of  chronic  peritonitis.  Even  when  all  inflammation 
has  ceased,  the  great  thickening  of  the  peritoneum  over  the  diaphragm,  liver, 
and  spleen  may  have  blocked  up  those  pores  through  which  the  peritoneal 
secretions  naturally  drain  away,  so  that  the  fluid  keeps  on  re-accumulating, 


56  ASCITES 

and  necessitates  repeated  tapping,  which  in  some  cases  has  been  performed 
over  three  hundred  times.  The  peritoneum  becomes  generally  thickened,  and 
the  intestines  bound  down  and  matted  together.  There  may  be  local  or  general 
abdominal  distention,  depending  on  whether  loculi  are  formed  or  not  by  the 
adhesions.  On  account  of  the  shortening  of  the  mesentery  and  matting  together 
of  the  intestines,  there  may  be  dullness  all  over  the  abdomen,  so  that  this  form 
of  ascites  is  particularly  liable  to  be  mistaken  for  ovarian  cyst  or  tumour. 
Albuminuria  is  a  frequent  symptom  on  account  of  the  interference  with  the 
renal  circulation,  and  there  may  even  be  a  few  tube  casts  ;  there  inay  or  may 
not  be  actual  renal  disease,  but  this  should  not  be  diagnosed  from  the  albumin- 
uria unless  there  is  also  a  high  blood-pressure,  retinitis,  or  other  confirmatory 
sign.  Abdominal  pain  is  generally  slight,  and  although  there  may  be  vomiting 
or  constipation,  there  is  usually  neither. 

Tuberculous  Peritonitis. — This  is  the  most  common  cause  of  ascites  in  children. 
There  are  several  varieties,  of  which  the  following  may  be  distinguished  : — 

1.  The  acute  ascitic  form,  which  may  simulate  acute  general  peritonitis  due 
to  perforation  of  a  viscus  (see  above). 

2.  The  peritoneum  may  be  studded  all  over  with  miliary  tubercles  without 
there  being  any  caseous  masses.  The  physical  signs  of  this  form  are  those  of 
ascites  without  any  abdominal  tumour,  and  it  is  not  difficult  to  mistake  it  when 
it  occurs  in  an  adult  for  cirrhosis  of  the  liver  or  for  malignant  peritonitis, 
especially  that  form  which  is  secondary  to  ovarian  tumour.  In  a  child,  the 
occurrence  of  ascites  without  oedema  of  the  legs  at  once  suggests  tuberculous 
peritonitis,  whilst  in  an  older  person  tuberculous  peritonitis  is  much  less  common. 

3.  The  omentum  may  be  contracted  and  thickened  from  infiltration  with 
caseous  or  fibro-caseous  material,  and  a  hard  abdominal  tumour  simulating  an 
enlarged  liver  may  be  felt.  It  may  be  distinguished,  however,  by  the  presence 
of  a  resonant  percussion  note  between  its  upper  limit  and  the  costal  margin, 
and  it  may  be  possible  to  feel  the  edge  of  the  liver  itself  distinctly  above  the 
omental  mass  which  simulates  it.  Ascites  in  cases  of  this  kind  is  generally  less 
in  amount  than  in  the  miliary  tuberculous  form. 

4.  The  intestines  may  be  matted  together  and  the  adhesions  thickened  and 
infiltrated  with  tuberculous  deposits,  so  that  the  peritoneal  cavity  may  be  divided 
into  several  loculi  of  fluid,  the  abdominal  distention  being  not  uniform,  and 
paracentesis  only  removing  part  of  the  ascites. 

5.  The  mesentery  may  be  thickened  and  contracted,  and  the  intestines  bound 
down  to  the  posterior  parts  of  the  abdominal  cavity,  so  that  if  there  is  ascites 
there  will  either  be  dullness  all  over  the  abdomen,  or  dullness  in  front  with 
resonance  in  the  flanks,  suggesting  ovarian  cyst  rather  than  tuberculous 
peritonitis.  After  paracentesis,  a  more  or  less  defined  irregular  deeply  situated 
tumour  may  often  be  felt. 

6.  When  the  caseation  affects  the  mesenteric  glands  in  particular,  multiple 
irregular  tumours  are  felt,  sometimes  but  not  always  associated  with  ascites. 

7.  Occasionally  local  thickenings  in  the  abdominal  wall  are  to  be  felt  as  the 
result  of  subperitoneal  inflammatory  deposits,  a  condition  which  may  often  be 
mistaken  for  rigid  contraction  of  the  recti  muscles  or  for  disease  of  the  parietes 
rather  than  of  the  peritoneum  ;  if,  however,  there  is  ascites  at  the  same  time, 
tuberculous  peritonitis  would  be  very  probable,  particularly  in  a  child. 

It  will  naturally  depend  upon  the  acuteness  of  the  tuberculous  process  whether 
there  will  be  pyrexia  or  not,  and  whether  there  will  be  abdominal  pain  and 
tenderness.  In  the  caseous  varieties,  whether  of  the  glands,  omentum, 
mesentery,  or  abdominal  wall,  pain  and  tenderness  are  the  rule,  and  the 
temperature  generally  rises  to  io3°F.  or  io4°F.  each  evening.  It  is  not  at  all 
uncommon  in  such  cases  for  redness  and    oedema    to  develop  for   some  little 


ASCITES  57 

distance  round  the  umbilicus,  and  for  a  purulent  discharge  to  occur  from  the 
latter,  or  for  a  fascal  fistula  to  develop.  The  commonest  cause  for  spontaneous 
fzEcal  fistula  of  the  umbiUcus  is  tuberculous  peritonitis.  When  the  active 
tuberculous  process  has  become  quiescent,  there  may  still  be  ascites,  though 
the  temperature  is  subnormal.  When  paracentesis  is  performed,  it  is  advisable 
that  some  of  the  fluid  should  be  injected  into  a  guinea-pig,  to  see  whether  the 
latter  develops  general  tuberculosis  or  not.  The  nature  of  the  case  may  some- 
times be  suggested  by  the  presence  of  tuberculous  lesions  elsewhere  in  the 
patient's  body;  for  instance,  in  the  spine,  kidney,  a  joint  such  as  the  hip  or 
knee,  glands  in  the  neck,  or  lupus,  though  very  often  tuberculous  peritonitis  is 
the  only  objective  lesion. 

Ascitic  Fluids. — It  has  been  stated  that  chemical  analyses  of  ascitic  fluid  often  afford 
material  assistance  in  arriving  at  a  diagnosis  of  its  cause  ;  but  in  practice  only  the  broadest 
conclusions  can  be  drawn.  The  higher  the  specific  gravity,  the  larger  the  percentage 
of  albumin,  and  the  greater  the  tendency  to  spontaneous  coagulation,  the  more  definitely 
can  one  conclude  that  the  condition  is  an  inflammatory  exudate,  e.g.  specific  gravity 
1,025,  twenty  parts  per  thousand  of  albumin  with  a  spontaneous  coagulation.  The 
lower  the  specific  gravity,  the  smafler  the  percentage  of  albumin,  and  the  more  definite 
the  absence  of  spontaneous  coagulation,  the  more  likely  is  the  condition  to  be  a  non- 
inflammatory transudate,  e.g.,  specific  gravity  1,005,  Ave  parts  per  thousand  of  albumin 
and  no  coagulation.  There  are,  however,  a  large  number  of  intermediate  cases  in  which 
chemical  investigation  of  the  fluid  leaves  one  in  doubt  as  to  whether  the  condition  is 
inflammatory  or  not. 

It  has  also  been  stated  that  differential  analyses  of  the  proteids  are  helpful,  notably 
as  to  whether  there  is  more  globulin  or  more  albumin  present ; 
but  it  is  doubtful  whether  this  really  is  so. 

Microscopical  examinations  are  of  considerably  more  value  <^~^    '^ 

than    chemical  ;     the   centrifugalized  deposit  should  always  ^O:^  ^ 

be  examined   under    the   high   power,    and  it   may    exhibit  ^ 

either   many  leucocytes   in  inflammatory    conditions,    poly-        ^         1(\ 
morphonuclear  cells  predominating  in  acute  inflammations,  ^ 

and   small    lymphocytes    in   subacute    or    chronic  affections  ^^^     o  p^ 

such  as  tuberculous  peritonitis  ;    or  peritoneal  cells  in  cases  ^^i'  \^  y^'^^ 

of  inflammation  ;    and    in    rare  instances   it   is    possible    to        /T  ^ 

clinch   the  diagnosis   by  finding    actual    fragments    of    new        v|j 
growth   or    hydatid  booklets    [Fig.    6).      The  deposits  may  '^''^ 

also  be  stained  for  bacteria,  and  sometimes  tubercle  bacilli 
or  even  streptococci,   staphylococci,    gonococci,   or   pneumo-  Fig.  6. — Echinococcal 

cocci    may    be    found.      When    investigating    ascitic    fluid  booklets, 

bacteriologically,  however,  it  is  probably  better  to  resort  to 
cultural  or  inoculation  methods  than  to  rely  solely  upon  films  prepared  from  the  deposit. 

Cancerous  Peritonitis  usually  occurs  in  patients  over  forty  years  of  age,  and 
the  growth  is  practically  always  secondary.  Primary  carcinoma  of  the  peri- 
toneum is  very  rare,  and  it  is  usually  colloid  and  not  associated  with  ascites. 
In  secondary  cases  the  omentum  may  be  thickened  and  infiltrated,  the 
umbilicus  fixed,  the  urachus  palpably  infiltrated,  and  nodules  and  masses  may 
develop  all  over  the  peritoneum.  Rapid  emaciation  and  marked  cachexia  are 
the  rule.  A  large  quantity  of  fluid  may  be  present,  and  if  it  is  blood-stained 
at  the  first  tapping  it  is  very  suggestive  of  malignant  disease.  Ascites  may  be 
the  first  and  only  evidence  of  growth,  and  it  may  be  mistaken  for  tuberculous 
peritonitis  or  cirrhosis  of  the  liver,  especially  when  the  abdominal  distention 
is  so  marked  that  no  nodules  can  be  felt.  Evidence  of  a  primary  growth  should 
always  be  looked  for  with  care,  especially  in  connection  with  the  stomach, 
pancreas,  colon,  rectum,  or  ovaries.  Rectal  examination  should  never  be 
omitted,  and  if  need  be  the  sigmoidoscope  may  be  used.  It  should  not  be 
forgotten  that  useful  indication  of  intra-abdominal  malignant  disease  is  some- 
times afforded  by  there  being  enlargement  of  the  left  supra-clavicular  lymphatic 
glands  by  secondary    deposits. 


58  ASCITES 

There  is  one  variety  of  secondary  malignant  peritonitis  which  merits  special 
mention — namely,  that  which  may  result  from  a  proliferating  papillomatous 
ovarian  cyst.  The  mahgnancy  of  the  latter  is  sometimes  relative,  so  that 
although  there  may  be  thousands  of  papilloma  deposits  on  the  peritoneum, 
causing  ascites  that  may  need  tapping  scores  of  times  at  short  intervals,  there 
may  be  no  other  secondary  deposits  anj^where.  The  diagnosis  may  be  made  as 
the  result  of  careful  vaginal  examination,  or  b}^  finding  fragments  of  the  malig- 
nant papillomata  in  the  ascitic  fluid,  or  perhaps  the  case  may  be  regarded  as 
chronic  "  simple  "  peritonitis  until  the  abdomen  is  opened. 

Hydatid  Cysts  in  the  peritoneal  cavity  may  be  primary,  but  more  often  they 
are  secondary  to  hydatid  disease  of  the  liver.  The  malady  is  rare  in  this  country, 
though  commoner  in  Australasia  and  elsewhere.  The  patient  is  generally  an 
adult  and  the  diagnosis  is  often  obvious,  though  sometimes  it  may  be  very 
obscure.  There  may  be  a  large  globular  tumour  in  the  liver,  rarely  giving  the 
tj^pical  hydatid  thrill ;  there  may  be  Eosinophilta  (q-v.),  and  an  investigation 
of  the  blood  serum  in  special  laboratories  may  show  the  specific  h3^datid  serum 
reaction.  In  some  cases  in  which  there  are  hydatid  cysts  associated  with 
ascites,  it  is  possible  to  make  the  diagnosis  certain  by  rectal  examination. 
One  has  felt  globular  bodies  about  the  size  of  grapes  in  front  of  the  anterior 
rectal  wall,  and  when  one  has  pressed  upon  these  to  investigate  them  more  fully, 
they  have  slipped  away  from  under  one's  finger  through  being  pushed  up  into 
the  ascitic  fluid  ;  after  waiting  a  moment  the  finger  has  felt  them  come  back 
into  Douglas'  pouch.  Similar  mobihty  of  spherical  masses  in  the  ascitic  fluid 
may  be  noted  elsewhere — for  instance,  in  an  iliac  fossa.  The  ultimate  diagnosis 
depends  upon  the  detection  of  booklets  {Fig.  6)  in  the  fluid  obtained  by  para- 
centesis or  by  laparotomy.  It  is  important  to  bear  in  mind,  however,  that  the 
absence  of  booklets  does  not  exclude  hydatid  disease,  the  cysts  sometimes  being 
sterile,  and  in  that  case  not  producing  booklets. 

Chylous  Ascites  is  not  in  itself  a  specific  malady,  for  there  is  more  than  one 
condition  in  which  the  ascitic  fluid  may  be  loaded  with  fat  droplets  so  as  to 
appear  like  milk.  This  is  generally  the  result  of  obstruction  to  the  main 
abdominal  lymphatics,  particularly  the  receptaculum  chyU  and  thoracic  duct. 
Occasionally  this  is  due  to  rupture  after  an  injury  to  the  abdomen  ;  more  often 
the  condition  is  associated  in  this  country,  in  some  way  which  is  not  fully  under- 
stood, with  the  peritonitis  of  chronic  Bright's  disease.  The  best  known  tropical 
cause  for  chylous  ascites  is  Filaria  sanguinis  hominis,  producing  elephantiasis. 
In  rare  cases  the  secondary  deposits  of  malignant  disease  may  be  such  as 
to  obstruct  the  thoracic  duct,  and  so  produce  the  chylous  condition  of  the  ascitic 
fluid.     Chyluria  may  or  may  not  occur  at  the  same  time. 

Obstruction  to  the  Main  Portal  Vein. — This  is  most  commonly  due  to  enlarge- 
ment of  the  portal  lymphatic  glands  by  secondary  deposits  of  malignant  disease ; 
it  is  common  for  the  main  bile-ducts  to  be  obstructed  at  the  same  time,  so  that 
an  increasing  depth  of  jaundice  accompanies  the  ascites.  When  there  are 
masses  of  secondary  growth  in  the  hver  associated  with  jaundice,  or  ascites, 
or  both,  it  is  seldom  that  the  hepatic  masses  are  themselves  responsible  for  the 
symptoms,  these  being  more  often  due  to  the  associated  deposits  in  the  portal 
lymphatic  glands.  The  diagnosis  is  made  as  the  result  of  discovering  a  primary 
growth,  which  is  more  often  a  carcinoma  than  a  sarcoma.  It  is  much  rarer  for 
the  lymphatic  glandular  enlargement  to  be  lymphadenomatous,  tuberculous,  or 
due  to  lymphatic  leukaemia.  If  ascites  were  a  prominent  symptom  in  any  of 
these  conditions,  it  would  be  regarded  as  consequent  on  affection  of  the 
peritoneum  rather  than  on  obstruction  to  the  portal  vein,  unless  there  were 
deepening  jaundice  at  the   same  time.     In  the  latter  case  itialignant  disease 


ASCITES      ■  59 

would  be  simulated.  General  enlargement  of  the  lymphatic  glands  in  the 
axillae,  groins,  and  neck,  with  or  without  evidence  of  enlargement  of  those  in 
the  thorax  or  abdomen,  together  with  enlargement  of  the  spleen,  would  suggest 
either  lymphadenoma  or  Ij^mphatic  leuka3mia  ;  the  absence  of  positive  blood 
changes  would  render  the  former  more  likely,  for  in  lymphatic  leukaemia  there 
is  more  or  less  considerable  leucocytosis  with  a  great  relative  increase  in  the 
small  lymphocytes  up  to  go  per  cent  or  more.  Only  in  very  rare  cases  do  tuber- 
culous portal  glands  cause  ascites,  and  when  they  do  the  diagnosis  must  be  one 
of  guess-work  onl}^,  unless  in  association  with  definite  tuberculous  peritonitis 
there  were  jaundice  suggesting  obstruction  to  the  common  bile-duct  and  to  the 
portal  vein  at  the  same  time. 

Thrombosis  of  the  portal  vein  may  be  suppurative,  in  which  case  there  is  no 
ascites,  but  rather  a  pyrexial  condition  with  rigors  and  possibly  jaundice,  which 
is  diagnosed  as  a  rule  only  when  there  has  been  some  definite  inflammatory  or 
suppurative  focus  in  the  portal  area,  such  as  appendicitis,  which  might  lead  to 
infection  of  the  portal  vein.  Primary  thrombosis  of  the  portal  vein  is  relatively 
rare,  and  its  diagnosis  can  seldom  be  more  than  guessed  at.  It  leads  to  marked 
ascites,  possibly  with  simultaneous  increase  in  any  tendency  there  may  be  to 
piles,  and  without  evidence  of  tuberculous  or  malignant  disease  of  the  peritoneum 
or  cirrhosis  of  the  liver.  It  is  by  a  process  of  exclusion  that  the  diagnosis  of 
portal  vein  thrombosis  might  be  arrived  at,  especially  if  the  ascitic  fluid  with- 
drawn by  paracentesis,  when  examined  chemically,  were  found  to  contain  a 
relatively  very  high  proportion  of  coagulable  proteids  without  any  particular 
tendency  to  spontaneous  coagulation,  and  without  those  polymorphonuclear 
cells  or  h'mphocytes  in  the  centrifugalized  deposit  that  would  be  found  if  the 
high  percentage  of  proteid  were  due  to  the  ascites  being  inflammatory. 

Tumours  of  adjacent  organs  seldom  obstruct  the  portal  vein  enough  to  cause 
ascites  without  presenting  other  symptoms  which  suggest  the  diagnosis.  Some- 
times, however,  unless  the  tumour  can  be  felt,  great  difficulty  may  be  experienced 
in  determining  the  nature  of  the  case.  Carcinoma  of  the  pancreas  may  be 
accompanied  by  glycosuria  and  the  passage  of  fatty  stools,  together  with  deepen- 
ing jaundice,  progressive  enlargement  of  the  gall-bladder,  and  a  positive 
Cammidge's  Pancreatic  Reaction  (q-v.).  Onaccountof  the  relation  of  the  tumour 
to  the  aorta,  marked  transmitted  pulsation  may  be  felt  in  it,  and  by  inflating  the 
stomach  it  may  be  demonstrated  that  the  tumour  lies  posterior  to  the  latter. 
Renal  tumours  may  be  difficult  to  distinguish  from  enlargement  of  the  liver 
when  they  are  big  ;  but  they  are  generally  associated  with  Albuminuria  (q.v.), 
H.5MATURIA  (q.v.),  or  Pyuria  (q.v.).  Carcinoma  of  the  stomach,  duodenum,  colon, 
or  suprarenal  capsule  would  be  suggested  by  the  position  of  the  mass,  or  by  the 
gastric  or  intestinal  symptoms  ;  if  there  were  ascites  accompanying  them,  it 
would  generally  be  attributed  not  to  the  primary  tumour  itself,  but  to  secondary 
deposits  either  in  the  peritoneum  or  in  the  portal  lymphatic  glands. 

Aneurysm  of  the  hepatic  artery  is  a  pathological  curiosity,  though  in  recorded 
cases  it  has  produced  ascites  and  jaundice.  The  commonest  cause  of  aneurysm 
of  the  hepatic  artery  is  fungating  endocarditis  with  embolism. 

Diseases  of  the  Liver. — Cirrhosis  of  the  Liver. — When  ascites  is  due  to 
this  cause,  the  diagnosis  is  sometimes  very  easy  on  account  of  the  history  of 
chronic  alcoholism,  and  very  possibly  of  former  hsematemesis,  metena  or 
jaundice.  There  may  also  be  acne  rosacea  and  telangiectases  on  the  cheeks, 
a  furred  and  tremulous  tongue,  a  history  of  morning  sickness,  cramps  in  the 
legs  at  night  and  loss  of  appetite,  epistaxis,  perhaps  the  presence  of  distended 
veins  around  the  umbilicus,  enlargement  of  the  liver,  the  surface  of  which  is 
hard  and  rough,  and  the  edge  irregular  and  perhaps  beaded,  enlargement  of 
the  spleen,  icteric  tinge   of  the  conjunctivae,  and  a  peculiarly  sallow,  slightly 


6o  ASCITES 

pigmented  facies,  which  is  almost  characteristic  in  the  later  stages  of  the 
malad5^  Cirrhosis  is  a  slowly  progressive  disease  sometimes  extending  over 
twenty  j'ears  or  more,  producing  a  large,  smooth,  unilobular  cirrhotic  liver, 
associated  with  jaundice  and  a  tendency  to  haematemesis  in  its  earlier  stages  ; 
but  later  a  small  liver  in  which,  in  addition  to  the  unilobular  iibrous  tissue,  there 
has  developed  a  much  coarser  multilobular  meshwork  which,  by  progressive 
contraction,  has  led  to  the  previously  large,  smooth  organ  becoming  smaller, 
rougher,  and  harder,  until  it  may  sometimes  be  so  small  as  to  be  no  longer 
palpable.  Only  in  the  very  last  stage  does  it  produce  ascites.  People  have  been 
known  to  be  total  abstainers  for  as  long  as  eighteen  years  or  more  after  the  first 
symptoms  of  cirrhosis  have  developed,  and  yet  to  die  with  a  granular,  contracted, 
"  hob-nail  "  liver  and  ascites. 

Perihepatitis. — It  is  generally  stated  that  a  case  of  cirrhosis  of  the  liver  seldom 
survives  long  after  it  has  first  become  necessary  to  tap  the  abdomen,  and  that 
therefore  when  paracentesis  abdominis  has  to  be  performed  more  than  once  or 
twice  in  a  case  supposed  to  be  cirrhosis  of  the  liver,  this  points  to  the  diagnosis 
being  wrong,  the  case  being  one,  not  of  cirrhosis,  but  of  perihepatitis.  As  a 
matter  of  fact,  however,  this  is  not  always  so,  for  it  sometimes  happens  that 
even  when  the  ascites  was  originally  due  to  cirrhosis,  the  repeated  tapping  pro- 
duces perihepatitis,  the  greatly  thickened  capsule  of  the  liver  being  the  result 
of  multiple  tappings  for  what  was  at  first  cirrhotic  ascites.  It  is  exceedingly 
difficult  to  be  certain  of  the  diagnosis  of  simple  perihepatitis  ;  the  condition 
is  really  only  part  of  a  chronic  peritonitis.  The  capsule  of  the  liver  becomes 
much  thickened,  and  it  contracts  and  distorts  the  organ,  and  rounds  the  edge, 
or  else  turns  it  up  or  under,  in  a  way  which  is  characteristic.  It  is  only  if 
this  curled-under  or  turned-up  edge  can  be  detected  that  the  diagnosis  of 
perihepatitis  can  be  made  with  certainty.  It  is  possible  that  syphilis  is  the 
cause  of  the  malady  in  some  cases. 

Ascites  associated  with  carcinoma  or  sarcoma  of  the  liver  is  usually  accom- 
panied by  intense  jaundice,  and  there  will  always  be  doubt  as  to  whether  these 
symptoms  are  not  due  rather  to  coincident  affection  of  the  portal  lymphatic 
glands  than  to  the  deposits  in  the  liver  itself.  The  latter  becomes  much  enlarged, 
very  hard,  the  edge  often  coming  well  below  the  umbilicus.  Probably  the 
largest  livers  that  occur  are  due  to  secondary  carcinoma  or  sarcoma.  They 
may  reach  a  weight  of  22  lb.  or  more.  Besides  being  very  hard,  the  liver  may 
be  tender,  and  umbilicated  nodules  may  be  felt  on  its  surface.  Primary  growth 
of  the  liver  is  exceedingly  rare,  and  though  it  leads  to  progressive  and  deepening 
jaundice,  it  does  not  often  produce  ascites.  Secondary  growth  is  so  much  more 
common,  that  it  is  always  most  important  to  look  for  the  primary  growth  else- 
where with  great  care  before  primary  growth  in  the  liver  is  diagnosed.  Rectal 
examination  should  not  be  omitted  ;  and  Cammidge's  pancreatic  reaction  in 
the  urine  should  be  tested,  in  case  the  primary  growth  be  in  the  pancreas. 

Syphilis  may  produce  local  peritonitis  over  a  gumma  ;  it  may  also  lead 
to  general  chronic  peritonitis  and  thus  to  ascites.  The  diagnosis  is  made 
upon  the  history,  upon  the  signs  of  syphilis  elsewhere,  and  upon  Wassermann's 
serum  reaction. 

Hydatid  disease  of  the  liver  seldom  of  itself  causes  ascites,  though  it  may  be 
associated  with  coincident  affection  of  the  peritoneum  with  ascites. 

We  may  now  pass  on  to  consider  those  cases  in  which,  if  the  history  is  correct, 
there  has  been  swelling  of  the  legs  before,  or  at  any  rate  not  later  than,  swelling 
of  the  abdomen  ;  and  if  one  continues  the  classification  as  given  on  pages  53 
and  54,  one  comes  next  to — 

Obstruction  of  the  Inferior  Vena  Cava  above  the  Hepatic   Veins.  —  This    is 


ASCITES  6r 

a  very  rare  cause  of  ascites,  and  it  will  seldom,  be  diagnosed  unless  there  is  either 
(i)  clear  evidence  of  extension  of  thrombosis  to  the  inferior  vena  cava  from  a 
previous  thrombus  in  one  leg,  associated  with  extension  of  oedema  up  the  back, 
followed  by  albuminuria  and  perhaps  hsematuria  when  the  renal  veins  are 
involved,  and  then  by  ascites,  together  with  varicose  distention  of  the  abdominal 
veins  and  alteration  in  the  blood-stream  in  them,  or  (2)  a  history  or  the  physical 
signs  of  chronic  mediastinitis,  which  generally  results  from  recurrent  attacks  of 
pleurisy  and  pericarditis,  especially  rheumatic,  or  of  intrathoracic  new  growthy 
which  is  distinguished  from  chronic  mediastinitis  by  the  shorter  history  and 
by  the  ,Y-ray  appearances.  (See  Veins,  Varicose  Thoracic  ;  and  Veins, 
Varicose  Abdominal). 

Chronic  Failure  of  the  Right  Side  of  the  Heart  (Backward  Pressure).  — 
Ascites  as  the  result  of  backward  pressure  in  chronic  heart  and  lung  disease  is 
nearly  always  preceded  by  swelling  and  oedema  of  the  legs.  Careful  examination 
of  the  heart  and  lungs,  a  history  of  acute  rheumatism,  or  of  recurrent  winter 
cough,  or  an  abundant  and  offensive  periodic  expectoration,  may  suggest  valvular 
disease  of  the  heart,  chronic  bronchitis  and  emphysema,  or  fibroid  lung  with  or 
without  bronchiectasis,  to  account  for  the  ascites.  It  should  be  remembered 
that  enlargement  of  the  liver — nutmeg  liver — also  results  in  these  cases,  the 
enlargement  varying  pari  passu  with  the  degree  of  heart  failure,  the  surface  of 
the  organ  being  smooth,  sometimes  pulsating  synchronously  with  the  heart, 
tender,  with  a  Avell-defined  edge  which  may  reach  to  below  the  level  of  the 
umbilicus  in  the  right  nipple  line.  The  urine  is  apt  to  contain  albumin,  and 
when  the  heart  failure  has  reached  an  advanced  degree  it  may  be  exceedingly 
difficult  to  say  whether  it  is  due  to  primary  valvular  disease,  primary  lung 
disease,  primary  kidney  disease,  primary  arterial  disease,  or  to  primary  affec-; 
tion  of  the  muscle  of  the  heart.  The  iraportance  of  casts  in  the  urine  in  the 
differential  diagnosis  has  been  referred  to  under  Albuminuria  (q-v.),  where  the 
significance  of  the  blood-pressure,  of  retinal  changes,  and  so  forth,  are  also 
discussed. 

The  valvular  heart  lesion  most  apt  to  be  mis-diagnosed  in  connection  with 
ascites  is  mitral  stenosis-,  for  by  the  time  the  heart  failure  has  reached  a  sufficient 
degree  to  cause  ascites,  characteristic  bruits,  especially  the  presystolic,  become 
no  longer  audible  in  many  cases.  The  heart  beats  very  rapidly  and  very 
irregularly,  so  that  no  bruits  may  be  audible  at  all.  Mitral  stenosis  may  still 
be  suggested  by  the  characteristic  appearance  of  the  face,  with  its  yellowish 
pallor  of  the  forehead,  and  around  the  nose  and  mouth,  with  bright  or  dark  red 
coloration  over  the  malar  bones  and  upper  portions  of  the  cheeks  and  lips  ; 
or  by  the  history  of  acute  rheumatism  or  chorea,  though  absence  of  such  a. 
history  by  no  means  excludes  the  possibihty  of  valvular  heart  disease.  It  may, 
however,  be  impossible  to  say  whether  there  is  mitral  stenosis  or  not  until  the 
patient  has  been  kept  in  bed,  given  digitalis,  and  watched  for  a  week  or  more, 
until  there  is  some  degree  of  recovery  of  the  cardiac  compensation  ;  by  which 
time  the  characteristic  bruits  of  mitral  stenosis  very  often  return  with  increasing 
force  of  the  heart's  beat. 

Some  of  the  hardest  of  heart-failure  cases  to  diagnose  with  certainty  are  those 
due  to  chronic  affections  of  the  myocardium  or  to  adJierent  pericardium.  In  each 
case  the  diagnosis  is  mainly  arrived  at  by  a  process  of  exclusion.  Chronic 
myocardial  degeneration  seldom  occurs  in  young  people,  or  at  any  rate  it  is 
much  commoner  in  middle  life  and  later.  The  symptoms  are  those  which  are 
common  in  all  varieties  of  chronic  heart  failure,  whatever  the  cause  of  the  latter. 
There  may  or  may  not  be  the  systolic  bruit  of  mitral  regurgitation,  or  an  aortic 
systolic  bruit  due  to  atheroma  of  the  aortic  valves,  but  upon  the  whole,  the 
physical  signs  do  not  suggest  valvular   disease  ;    the  urinary  changes  and  the 


62  ASCITES 

absence  of  casts  do  not  suggest  nephritis  or  granular  kidney;  the  blood -pressure 
may  or  may  not  suggest  arteriosclerosis  ;  the  lung  signs  do  not  suggest  bron- 
chitis and  emphysema^  or  fibroid  lung :  so  that  some  myocardial  affection  is  all 
that  is  left  to  diagnose.  If  there  has  been  a  history  of  the  drinking  of  much 
alcohol,  particularly  beer,  primary  alcoholic  heart  may  be  suspected,  though 
this  is  much  less  common  in  England  than  it  is  said  to  be  in  Germany.  Fatty 
superposition  would  be  suggested  if  there  was  general  obesity  of  the  patient 
with  shortness  of  breath  on  ordinary  exertion  ;  whilst  overloading  of  the 
surface  of  the  heart  seldom  occurs  without  some  fatty  infiltration  at  the  same 
time.  Fatty  degeneration  is  more  likely  after  a  long  febrile  illness,  or  chronic 
poisoning  by  phosphorus,  arsenic,  or  by  the  supposed  toxins  of  severe  anccmias, 
such  as  pernicious  anaemia,  or  aplastic  anaemia. 

Fibroid  heart  is  very  difficult  to  distinguish  from  fatty  heart,  but  it  is  the 
more  likely  diagnosis  in  a  syphilitic  patient,  particularly  if  the  patient  is  not 
obese  and  if  there  is  a  history  of  syphilis  or  evidence  of  syphilitic  atheroma 
leading  to  aortic  regurgitation  or  angina  pectoris. 

Adherent  pericardium  is  not  in  itself  an  explicit  term,  for  there  are  three 
different  conditions  which  come  under  the  one  heading  ;  thus  there  may  be 
(i)  Adhesions  between  the  parietal  and  visceral  layers  of  the  pericardium  ; 
(2)  Adhesions  between  the  parietal  pericardium  and  the  structures  around 
it,  particularly  the  pleuree,  diaphragm,  and  chest  wall  ;  and  (3)  Adhesions 
both  of  the  parietal  and  visceral  layers  of  pericardium  and  of  the  parietal 
layer  to  the  structures  outside  it.  It  is  quite  clear  that  the  physical  signs 
will  be  different  according  to  which  of  these  three  things  has  happened. 
That  which  ought  to  be  implied  strictly  by  the  term  adherent  pericardium,  is 
adhesion  of  the  parietal  to  the  visceral  layers,  without  any  other  adhesions 
whatever,  and  of  this  condition  there  are  no  positive  physical  signs  at  all,  nor 
need  there  be  any  symptoms.  The  diagnosis  is  generally  made  by  guess-work, 
the  patient  being  known  to  have  had  pericarditis,  or  being  suspected  of  having 
had  it  because  of  having  suffered  from  acute  rheumatism  with  severe  compli- 
cations, and  the  heart  now  being  found  much  larger  than  it  ought  to  be  in 
proportion  to  the  apparent  valvular  disease  as  indicated  by  the  bruits.  It  is 
quite  possible,  however,  for  the  parietal  and  visceral  layers  of  pericardium  to 
be  universally  adherent  to  one  another  without  the  heart  being  big,  and 
without  there  being  any  ill  effects  at  all,  the  condition  being  met  with  not 
uncommonly  in  the  post-mortem  room  in  patients  who  die  of  something  entirely 
different.  It  is  only  when  the  parietal  layer  has  become  adherent  to  the  visceral 
layer  when  the  heart  was  already  dilated  at  the  time  of  the  pericarditis,  that 
symptoms  subsequently  accrue,  the  result  rather  of  the  inability  of  the  already 
big  heart  to  maintain  its  dilatation  and  hypertrophy  than  of  any  intrinsic 
interference  with  its  action  by  the  adherent  pericardium  itself.  It  quite  often 
happens,  indeed,  that  when  there  has  been  rheumatic  myocardial  affection 
without  pericarditis,  the  big  heart  that  results  is  out  of  all  proportion  to  the 
valvular  disease,  and  yet  in  the  post-mortem  room  no  abnormality  of  the 
pericardium  is  found. 

The  three  following  points  in  connection  with  heart  disease  in  children  are 
as  true  as  most  aphorisms.  First,  mitral  stenosis  is  almost  unknown  before 
puberty,  whatever  the  bruits  that  suggest  it.  Secondly  and  thirdly,  heart 
disease  never  proves  fatal  before  puberty  unless  as  the  result  either  of  the 
severity  of  the  acute  inflammation  of  valves,  muscle,  or  pericardium,  or  else 
from  adherent  pericardium.  Fatal  mechanical  failure  of  the  heart  before 
puberty,  therefore,  in  a  patient  who  presents  no  symptoms  of  rheumatic 
reinfection,  points  to  there  being  adherent  pericardium  in  the  sense  of  there 
being  adhesions  between  the  parietal  and  visceral  layers. 


ASCITES  63 

Adhesions  between  the  parietal  pericardium  and  the  structures  outside  it, 
without  there  being  any  adhesions  between  the  parietal  and  visceral  layers 
within  the  pericardium,  are  of  exceedingly  common  occurrence,  generally  result- 
ing from  former  pleurisy.  The  former  inflammation  must  have  extended  outside 
both  the  pericardium  and  the  pleurae,  so  that  it  was  really  a  mediastinitis  ;  but 
clinically  the  condition  is  seldom  spoken  of  as  mediastinitis,  because  it  is  of  very 
little  importance,  and  in  itself  it  produces  no  symptoms  at  all ;  the  physical 
sign  which  might  suggest  it  would  be  deficiency  in  the  degree  of  movement  of 
the  position  of  the  cardiac  impulse  to  the  left  or  to  the  right,  as  the  case  might 
be,  as  the  patient  rolls  from  one  side  to  the  other. 

The  third  variety  of  adherent  pericardium,  namely,  that  in  which  there  are 
adhesions  between  the  parietal  and  visceral  layers,  and  between  the  parietal 
layer  and  the  chest  wall,  pleurae,  and  other  structures  outside  it,  is  really  a 
combined  condition  of  adherent  pericardium  and  mediastinal  adhesions  which, 
when  an  extreme  degree  is  reached,  becomes  what  is  known  as  chronic  medias- 
tinitis. Here  again,  it  is  possible  for  neither  symptoms  nor  physical  signs  to 
present  themselves,  the  condition  being  found  unexpectedly  in  the  post-mortem 
room.  It  is  this  condition  which  is  generally  diagnosed  under  the  name  of 
adherent  pericardium.  There  will  be  a  history  of  former  pericarditis,  pleurisy, 
or  both,  probably  of  a  rheumatic  nature.  The  heart  will  be  large  out 
of  all  proportion  to  any  valvular  disease  that  is  present,  without  there  being 
other  obvious  cause  for  its  hypertrophy  and  dilatation,  such  as  nephritis,  arterio- 
sclerosis, hard  work,  alcoholism,  fatty  or  fibroid  heart,  or  chronic  lung  disease. 
If  the  parietal  pericardium  is  firmly  adherent  both  to  the  pleurse  and  to  the 
diaphragm — particularly  the  latter — there  will  very  likely  be  retraction  of  the 
lower  ribs  in  the  left  axillary  line  synchronously  with  the  heart-beat  ;  it  is 
this  physical  sign — systolic  retraction  of  the  lower  left  ribs — which  is  generally 
regarded  as  pathognomonic  of  adherent  pericardium  ;  it  is  really  evidence,  of 
course,  of  adhesions  outside  rather  than  within  the  pericardium.  Another  physical 
sign  which  is  regarded  by  some  as  indicative  of  general  pericardial  adhesions, 
is  an  ingoing  impulse  of  the  third  or  fourth  intercostal  space  half  way  between 
the  left  nipple  and  the  left  border  of  the  sternum,  synchronous  with  an  out- 
going impulse  nearer  the  apex,  giving  an  oscillating  or  see-saw  appearance  to 
the  precordial  region — some  of  the  intercostal  spaces  moving  inwards  at  the 
same  time  as  others  move  out  with  the  heart-beat.  As  a  matter  of  fact,  the 
probable  explanation  of  the  ingoing  movement  nearer  the  sternum  when  the 
part  of  the  heart  which  is  nearer  the  apex  causes  the  ordinary  outgoing  impulse, 
is  the  visible  withdrawal  of  the  hypertrophied  right  ventricle  as  it  contracts. 
This  see-saw  appearance  in  the  precordial  region  is  indicative  therefore  of  great 
hypertrophy  of  the  right  ventricle  ;  it  does  not  indicate  what  is  the  cause  of 
this  hypertrophy,  though  amongst  its  causes  would  be  adherent  pericardium. 
A  similar  appearance  is  often  seen  in  cases  of  extreme  mitral  stenosis  of  long 
standing,  even  when  there  is  no  adherent  pericardium. 

Bright's  Disease  may  produce  ascites  in  more  ways  than  one  ;  the  effusion 
may,  for  instance,  simply  be  part  of  a  general  anasarca,  the  accumulation 
of  the  ascitic  fluid  in  the  peritoneal  cavity  corresponding  precisely  with  its 
accumulation  in  the  subcutaneous  tissues  ;  or  the  Bright's  disease  may  lead  to 
acute  or  chronic  peritonitis  of  the  types  described  above  ;  or,  especially  in 
chronic  cases  associated  with  pale  or  red  granular  contracted  kidneys,  there  may 
be  failure  of  the  dilated  and  hypertrophied  heart,  with  ascites,  which  it  may  be 
very  difficult  to  distinguish  from  that  of  primary  heart  disease,  especially  as  the 
greater  part  of  the  albuminuria  which  may  be  associated  with  the  ascites  and 
the  failing  heart,  is  now  the  result  of  the  heart  failure  rather  than  of  the 
renal  sclerosis,  so  that  the  number  of   casts  may  seem  to   be  unduly  few  in 


64  ASCITES 

relation  to  the  albumin.  If  the  blood-pressure  is  very  high,  the  diagnosis  is  in 
favour  of  arteriosclerosis  or  granular  kidney  rather  than  primary  heart-failure, 
though,  curiously  enough,  the  blood-pressure  is  always  above  normal  in  heart- 
failure  from  any  cause,  even  when  the  pulse  is  as  irregular  and  feeble  as  it  often 
is  in  the  late  stages  of  mitral  stenosis.  This  terminal  rise  of  blood-pressure  in 
heart  cases  probably  results  from  the  partial  asphyxia. 

Severe  Anaemias  often  cause  ascites,  but  they  do  not  give  rise  to  much 
difficulty  in  diagnosis,  because  the  sub-acute  or  chronic  peritonitis  which  is  the 
cause  of  the  ascitic  exudate  in  these  cases,  arises,  as  a  rule,  comparatively  late 
in  the  disease,  after  the  diagnosis  has  been  made  on  other  grounds,  by  blood- 
counts  and  otherwise.  (See  An.^mia  ;  Spleen,  Enlargement  of  ;  Lymphatic 
Gland  Enlargement.)  One  need  not  do  more  here  than  refer  to  the  huge 
enlargement  of  the  spleen  without  lymphatic  glandular  enlargement,  and 
the  great  leucocytosis  Avith  a  large  portion  of  myelocytes,  in  splenomedullary 
leukcsmia ;  the  considerable  leucocytosis,  the  enlargement  of  the  lymphatic 
glands  and  probably  of  the  spleen,  and  the  great  relative  increase  of  the  small 
lymphocytes,  in  lymphatic  leukcBinia  ;  the  enlargement  of  the  lymphatic  glands 
and  of  the  spleen,  and  the  absence  of  any  positive  blood  changes,  beyond  anaemia 
of  the  chlorotic  type  without  leucocytosis,  in  Hodgkin's  disease  ;  the  enlargement 
of  the  spleen,  the  absence  of  lymphatic  glandular  enlargement,  and  the  occur- 
rence of  a  progressive  and  ultimately  severe  anaemia,  of  the  simple  chlorotic  type 
without  leucocytosis,  but  with  an  occasional  myelocyte  and  basophile  corpuscle, 
in  splenic  ancemia  (which  often,  as  the  course  of  the  disease  goes  on,  turns  out 
to  be  cirrhosis  of  the  liver)  ;  the  profound  anaemia  and  the  high  colour-index 
without  leucocytosis,  in  pernicious  ancemia ;  the  severe  anaemia  suggestive 
of  pernicious  anaemia  but  with  a  persistently  low  colour-index,  in  aplastic 
ancBwiia  ;  and  the  splenic  enlargement  with  profound  chlorotic  anaemia  without 
leucocytosis,  in  pseudo-leukcemia  infantum.  Herbert  French. 

ATAXY. — ^Ataxy  is  the  term  used  to  describe  voluntary  movements  which 
are  imperfectly  controlled  or  co-ordinated.  It  is  displayed  in  its  simplest  form 
by  infants  under  the  age  of  one  year.  With  excellent  muscular  power,  and  with 
the  ability  to  make  their  limbs  assume  any  position,  they  are  yet  unable  to 
carry  out  any  action  requiring  the  careful  adjustment  of  force  to  a  particular 
end.  They  are  clumsy  with  their  fingers,  and  lack  stability  on  their  feet.  Ex- 
perience eventually  teaches  them  unconsciously  to  utilize  the  information  which 
their  higher  nervous  centres  receive  from  the  peiiphery  of  their  bodies,  for  the 
purpose  of  adapting  their  expenditure  of  muscular  energy  to  the  accomplishment 
of  the  object  in  view.  Subconscious  memories  of  the  afferent  impressions 
produced  by  any  particular  movement  are  gradually  stored  by  the  higher 
centres,  with  the  result  that  each  repetition  of  that  movement  is  kept  more  and 
more  under  guidance  and  control,  and  some  degree  of  economj'  is  established 
in  carrying  on  the  business  of  voluntary  action. 

In  pathological  states,  ataxy  is  often  a  symptom  of  great  diagnostic  import- 
ance ;  but  before  its  value  as  a  localizing  sign  of  disease  can  be  utilized,  it 
is  necessary  to  appreciate  broadly  the  physiological  mechanism  by  which  co- 
ordination is  brought  about,  and  the  possible  situations  where  a  lesion  is  able 
to  disturb  the  smooth  working  of  that  mechanism. 

For  the  proper  co-ordination  of  voluntary  movement,  impulses  from  the 
muscles,  tendons,  joints,  and  skin  of  the  part  which  is  moved  must  reach  the 
brain.     It  is  expedient  to  regard  these  impulses  as  being  of  two  kinds  : — 

I.  Sensory  afferent  impulses  which  are  carried  to  the  cerebrum  by  way  of  the  peri- 
pheral nerves,  the  posterior  columns  of  the  cord,  the  fillet  in  the  brain-stem,  and  finally- 
some  path  from  the  basal  ganglia  to  the  cortex  in  the  neighbourhood  of  the  motor  area 


ATAXY  65 

These  impulses  cross  from  one  side  of  the  body  to  the  opposite  hemisphere,  the  crossing 
taking  place  in  the  medulla.  The  path  is  not  an  uninterrupted  one  ;  that  is  to  say,  the 
impulses  are  not  carried  bv  fibres  which  stretch  from  the  peripheral  tissues  to  the  cere- 
brum. On  the  contrary,  there  are  probably  at  least  two  points  where  one  neuronic 
system  ends  and  its  work  is  taken  up  by  another. 

2.  Non-sensory  afferent  impulses,  so-called  because  they  never  reach  consciousness, 
pass  from  the  peripheral  structures  concerned  in  movement,  by  way  of  the  peripheral 
nerves  and  the  ascending  cerebellar  tracts  of  the  cord,  to  the  cerebellum,  and  principally 
to  the  cerebellar  lobe  of  the  same  side  of  the  body.  In  some  manner  which  is  not  per- 
fectly understood,  but  in  which  preservation  of  muscular  tone  is  probably  concerned, 
the  co-operation  of  the  cerebellum  is  required  if  movements  initiated  in  the  motor  area 
of  the  cerebrum  are  to  be  carried  out  in  a  co-ordinate  manner. 

Not  only  must  these  two  sets  of  impulses  reach  the  brain,  but  the  parts  of 
the  brain,  cerebral  and  cerebellar,  \vhich  form  their  destination,  miust  also  be 
intact  if  vcluntary  movement  is  to  be  carried  out  with  accuracy  and  co-ordination. 

From  the  clinical  point  of  view  it  is  necessary  to  ascertain  in  the  first  place 
whether  a  patient  is  ataxic,  and  in  the  second  whether  the  ataxy  can  be  attributed 
to  the  loss  of  the  sensory  or  non-sensor}^  afferent  impulses. 

In  some  cases  the  ataxy  is  obvious  ;  in  others  its  presence  can  be  detected 
only  by  the  careful  application  of  certain  tests.  For  instance,  a  patient  may 
walk  into  a  \vell-lighted  room  with  perfect  ease  and  without  anything  remarkable 
in  liis  gait,  but  if  he  is  asked  to  walk  along  a  line,  placing  one  foot  exactly  in 
front  of  another,  he  may  at  once  display  his  lack  of  co-ordination.  Such  ataxy 
is  just  as  important  from  a  diagnostic  standpoint  as  the  imperfect  attempts 
of  an  advanced  tabetic  patient  to  walk  even  when  supported  by  companions 
on  either  side.  It  is  the  quality  and  not  the  quantity  of  a  defect  which  gives 
the  needed  information. 

The  co-ordination  of  movements  performed  by  the  upper  extremities  must 
also  be  investigated  with  the  same  care.  The  patient  may  handle  his  stick 
in  quite  a  natural  manner,  but  if  asked  to  unbutton  and  button  his  coat,  to  touch 
the  tip  of  his  nose  with  the  tip  of  his  finger,  to  write,  etc.,  he  may  fail  to  convince 
the  observer  that  his  control  of  fine  movements  is  up  to  the  normal  standard. 

Having  ascertained  the  existence  of  ataxy,  the  next  step  is  to  decide  whether 
it  is  dependent  on  the  loss  of  sensory  or  non-sensory  afferent  impulses,  or  on 
the  imperfect  function  of  the  cerebrum  or  cerebellum.  If  the  ataxy  is  due  to 
loss  of  sensorv  impulses,  it  wall  be  increased  by  the  loss  of  visual  impulses  brought 
about  bv  closing  the  eyes.  It  will  also  be  possible  to  demonstrate  the  loss  of 
sensorv  impulses  by  asking  the  patient  to  describe  the  position  of  a  limb  with 
his  eyes  closed  after  it  has  been  moved  by  the  observer.  When  these  two  tests 
are  positive,  it  may  safely  be  assumed  that  the  lesion  affects  the  first  set  of 
impulses  or  their  cerebral  destination. 

If,  on  the  other  hand,  the  ataxy  is  uninfluenced  by  closing  the  eyes  and  the 
patient  is  perfectly  accurate  in  describing  the  position  of  his  limbs,  it  is  probable 
that  the  cerebellar  tracts  or  the  cerebellum  itself  is  at  fault. 

For  further  localization  of  the  lesion  in  any  particular  case  it  will  be  necessarj' 
to  take  into  account  concomitant  phenomena,  and  for  this  purpose  it  is  advisable 
to  consider  different  parts  of  the  nervous  system  separately. 

It  is  clear,  from  what  has  been  stated  above,  that  interference  with  the  passage 
of  impulses  necessary  for  proper  co-ordination  may  be  provoked  by  lesions  in 
(i)  The  peripheral  nerves;  (2)  The  spinal  cord;  (3)  The  brain-stein;  (4)  The 
cevebrum  ;  and  (5)  The  cerebellum.  Let  us  now  consider  the  effect  of  lesions  in 
these  different  regions,  and  the  diagnostic  evidence  afforded  by  ataxy  of  their 
localization. 

I.  Peripheral  Nerves, — A  severe  lesion  of  a  peripheral  nerve  must  necessarily 
lead  to  ataxy  of  movements  performed  by  the  muscles  to  which  it  is  distributed. 
It  is  obvious,  how^ever,  that  a  severe  lesion  will  also  paralyze  the  muscles  and 
D  5 


66  ATAXY 

thus  effectually  prevent  any  ataxy  being  demonstrated.  Less  severe  lesions, 
such  as  occur  in  slight  cases  of  peripheral  neuritis,  allow  of  some  volun 
tary  movement,  with  the  result  that  ataxy  becomes  a  demonstrable  physical 
sign.  Thus  a  case  of  peripheral  neuritis  of  alcoholic  or  diphtheritic  origin  may 
show  impaired  strength,  together  with  ataxy  in  all  four  limbs.  The  diagnosis 
of  a  peripheral  nerve  affection  in  such  a  case  will  depend  on  the  following  points  : 
In  the  first  place,  the  symptoms  will  be  found  to  be  symmetrical,  and  in  the 
affected  limbs  the  impairment  of  strength  will  be  most  marked  in  the  extensors 
of  the  wrists  and  ankles.  Secondly,  slight  ansesthesia  to  cotton-wool  may  be 
detected  over  the  glove  and  stocking  areas.  With  regard  to  pain,  there  may  be 
blunted  cutaneous  sensibility  to  the  prick  ot  a  pin  over  the  same  area,  but, 
almost  constantly,  deep  pressure  on  the  affected  muscles  will  establish  the  fact 
that  these  tissues  are  abnormally  sensitive.  This  is  a  most  important  point 
in  diagnosis,  because  it  strikes  an  essential  distinction  between  cases  of  ataxic 
peripheral  neuritis,  sometimes  described  as  pseudo-tabes,  and  cases  of  true 
spinal  tabes,  in  which  it  is  an  almost  invariable  rule  to  find  diminution  or  loss 
cf  painful  sensibility  on  squeezing  the  muscles.  In  the  third  place,  the  tendon 
reflexes  will  be  markedly  diminished  or  completely  absent,  while  the  plantar 
reflexes  will  probably  be  unobtainable.  Finally,  the  use  of  electrical  currents 
upon  the  muscles  will  show  that  the  response  to  faradic  currents  is  materially 
lessened  or  abolished,  and  that  the  contraction  excited  by  the  make  and  break 
of  the  galvanic  current  may  be  of  the  slow,  worm-like  type  so  characteristic 
of  the  reaction  of  degeneration. 

The  ataxy  of  peripheral  neuritis  has  no  reliable  characteristic  to  distinguish 
it  from  what  may  be  observed  in  the  ataxy  due  to  spinal  disease.  The  gait  is 
unsteady,  and  the  patient  keeps  his  legs  apart  in  order  to  lessen  the  tendency 
to  lose  his  balance.  The  clumsiness  of  the  upper  extremities  may  be  demion- 
strated  by  his  inability  to  bring  the  first  finger  of  one  hand  accurately  into 
apposition  with  that  of  the  other,  or  to  touch  the  tip  of  his  nose  with  either. 
Both  the  unsteadiness  of  gait  and  the  awkwardness  of  the  fingers  are  exaggerated 
if  he  attempts  to  walk,  or  carry  out  movements  with  his  hands,  when  his  eyes 
are  closed.  A  tendency  to  high-steppage  will  be  noticeable  in  walking  if,  in 
addition  to  the  ataxy,  there  is  well-marked  paresis  of  the  dorsifiexors  of  the 
ankles.  In  such  a  case  the  patient  is  obliged  to  lift  the  feet  to  an  unusual  height 
in  order  to  clear  the  ground.  We  conclude,  therefore,  that  ataxy  is  due  to 
a  lesion  of  the  peripheral  nerves,  not  from  the  nature  of  the  ataxy,  but  from  the 
presence  of  other  symptoms  also  referable  to  interference  with  the  functions  of 
the  nerves. 

2.  Spinal  Cord. — -The  ataxy  due  to  disease  of  the  spinal  cord  is  seen  best  in  cases 
of  tabes  dor  sails  or  locomotor  ataxia,  in  which  malady  degeneretion  of  the  posterior 
column  ascending  tracts  is  ah  early  pathological  feature,  and  in  which,  conse- 
quently, the  patient  does  not  receive  the  normal  impulses  from  the  muscles, 
tendons,  and  joints  so  necessary  for  the  preservation  of  his  sense  of  position 
and  movement.  Contrary  to  popular  ideas,  gross  ataxy  is  only  met  with  in  a 
small  proportion  of  the  cases  of  this  disease,  and  it  is  often  necessary  to  apply 
delicate  tests  to  demonstrate  its  presence  in  slighter  degrees.  The  patient's 
gait  may  not  be  remarkable  in  good  daylight,  but  he  may  complain  of  its  un- 
certainty in  the  dark,  or  he  may  be  obviousl}^  ataxic  with  his  eyes  closed.  Another 
patient  may  have  noticed  nothing  amiss  with  his  walking  in  the  ordinary  way, 
but  if  he  is  asked  to  follow  a  line  on  the  carpet  of  the  floor,  placing  one  foot 
exactly  in  front  of  the  other,  his  impaired  power  of  balance  will  become  apparent 
at  once,  especially  if  he  is  directed  to  accomplish  this  test  with  his  head  raised 
and  his  eyes  fixed  on  something  in  front  of  him  instead  of  upon  his  feet,  whither 
they  will  incline  to  wander. 


ATAXY  67 

In  cases  of  moderate  ataxy  the  gait  and  stance  of  the  patient  are  remarkable 
for  the  wide  base  he  assumes,  and  his  tendency,  as  it  were,  to  guide  his  feet  by 
means  of  his  vision.  Romberg's  sign  can  be  obtained  easily.  This  sign  is 
not  diagnostic  of  tabes,  as  is  so  often  assumed,  but  is  merely  used  for  the  purpose 
of  ascertaining  whether  the  removal  of  visual  impulses  will  convert  a  condition 
of  stability  into  one  of  instability.  Many  students,  and  perhaps  some  medical 
men,  if  asked  to  describe  Romberg's  sign,  at  once  reply,  "  You  direct  the  patient 
to  put  his  feet  together  and  close  his  eyes  ;  if  he  sways  or  falls,  the  sign  is  present." 
This  is  obviously  incorrect,  because  the  patient  may  sway  even  before  his  eyes 
are  closed.  In  order  to  test  a  patient  for  this  sign,  he  must  be  directed  to  stand 
with  his  feet  as  near  together  as  he  is  able  to  do  with  steadiness,  and,  having 
esta Wished  his  stability  in  that  position  with  open  eyes,  he  must  be  told  to 
close  the  latter.  If  he  sways  or  tends  to  fall,  it  is  clear  that  he  had  been  depending, 
in  part  at.  any  rate,  on  his  visual  impulses,  and  that,  without  their  aid,  the 
impulses  derived  from  his  legs  and  trunk  were  insufficient  for  the  preservation 
of  his  equilibrium.  We  have  in  this  test,  therefore,  a  valuable  method  of 
ascertaining  whether  the  function  of  the  posterior  columns  is  being  carried  out 
normally. 

To  judge  from  the  descriptions  given  in  some  text-books,  the  typical  gait  of 
tabes  is  one  in  which  the  legs  are  thrown  into  the  air  and  the  feet  brought  to 
the  ground  with  a  more  or  less  noisy  stamp.  As  a  matter  of  fact,  this  type  of 
gait  is  only  seen  in  a  small  proportion  of  cases,  and  is  rarely  observed  except 
when  the  patient  is  depending  for  support  either  on  a  couple  of  sticks  or  on  one 
or  two  attendants.  In  other  words,  he  has  become  so  ataxic  that  he  cannot 
walk  unsupported,  and,  being  supported,  he  no  longer  attempts  to  control  the 
exuberance  of  his  leg  movements  by  means  of  his  sight.  The  exuberance  of 
the  movements  may  be  explained  on  the  ground  that  excessive  muscular  action 
is  necessary  before  the  patient  becomes  aware  that  the  parts  are  being  moved. 

Tabetic  ataxia  in  its  moderate  and  extreme  degrees  can  be  demonstrated, 
when  the  patient  is  at  rest  in  bed,  by  asking  him  to  carry  out  accurate  movements 
with  his  hands  and  feet,  with  and  without  the  aid  of  his  vision.  In  slighter 
degrees,  the  fact  that  the  ataxia  is  dependent  on  interference  with  his  sense  of 
position  and  movement  may  be  proved  by  asking  him  to  describe  the  position 
of  a  finger  or  toe  which  the  observer  moves  in  different  directions.  Sometimes 
it  is  as  well  in  testing  this  sense  in  one  limb  to  ask  the  patient  to  place  the  corres- 
ponding limb  in  the  same  position,  when  the  error  will  be  made  more  obvious. 
The  diagnosis  of  tabes  cannot  be  made  from  the  character  of  the  ataxy  alone, 
since  in  other  diseases,  such  as  Friedreich's  ataxy,  disseminated  sclerosis,  or 
combined  degeneration  of  the  cord,  there  is  or  may  be  sclerosis  of  the  posterior 
columns  resulting  in  similar  inco-ordination.  It  is  important,  therefore,  to 
remember  that  in  tabes  the  posterior  roots  are  affected  also,  and  that  there  is 
practically  always  some  interference  with  other  sensory  impulses,  especially 
those  which  convey  sensations  of  pain  from  the  muscles  and  skin.  Thus,  in 
this  disease  one  of  the  earliest  symptoms  is  relative  analgesia  to  pin-pricks  and 
to  deep  pressure  on  the  muscles  in  the  lower  extremities. 

In  Friedreich's  ataxy,  disseminated  sclerosis,  and  other  spinal  disease,  as  well 
as  in  some  cases  of  tabes,  the  ataxy  due  to  the  lesion  of  the  posterior  columns 
may  be  complicated  and  intensified  by  the  fact  that  there  is  also  interference 
in  the  path  of  the  non-sensory  afferent  impulses,  which,  as  has  already  been 
pointed  out,  pass  from  the  extremities  to  the  cerebellum  via  the  ascending 
cerebellar  tracts  in  the  spinal  cord.  If  this  form  of  ataxy  is  present,  the  help 
which  the  patient  derives  from  vision  for  the  purpose  of  controlling  his  inco- 
ordinate movements  is  largely  discounted,  and  he  may  be  as  markedly  ataxic 
with  open  as  with  closed  eyes. 


68  ATAXY 

In  some  lesions,  such  as  those  resulting  from  syringomyelia  or  new  growths, 
only  one  side  of  the  cord  may  be  affected,  and  a  Brown-Sequard  form  of  paralysis 
be  exhibited.  In  this  case  the  loss  of  sense  of  position  and  movement  is  on  the 
same  side  as  the  paralysis,  and  on  the  opposite  side  to  the  loss  of  other  sensory 
impulses  such  as  those  of  touch,  pain,  and  temperature,  owing  to  the  fact  that 
the  former  do  not  cross  with  the  latter  to  the  other  side  of  the  cord.  If  the 
paralysis  is  not  complete,  some  ataxy  may  be  observed  in  the  paretic  limb,  and 
in  any  case  the  loss  of  sense  of  passive  position  and  movement  may  be  demon- 
strated by  the  means  already  referred  to. 

3.  The  Brain-stem. — Lesions  of  the  medulla,  pons,  or  crura  may  produce  ataxy 
if  they  interfere  with  the  passage,  either  of  sensory  afferent  impulses  to  the 
cerebrum  or  of  non-sensory  afferent  impulses  to  the  cerebellum.  The  cerebellar 
impulses  can  only  be  interfered  with  at  the  medullary  level ;  that  is  to  say,  before 
they  have  passed  into  the  cerebellum  via  the  inferior  peduncle.  A  good  example 
of  hemiataxia  of  this  origin  is  afforded  by  any  case  of  thrombosis  of  one  posterior 
inferior  cerebellar  artery.  This  uncommon  condition  affects  the  structures  on 
one  side  of  the  medulla,  and  is  characterized  by  hemiataxia  of  the  homolateial 
limbs,  together  with  loss  of  sensibility  to  pain,  heat,  and  cold,  on  the  contra- 
lateral side.  The  ataxy  is  of  the  cerebellar  type ;  that  is  to  say,  it  is  not  associated 
with  loss  of  sense  of  position  and  movement  in  the  affected  limbs,  and  is  little 
influenced  by  closure  of  the  eyes.  Above  the  medulla,  lesions  which  are  capable 
of  producing  ataxy  by  interfering  with  the  sensory  impulses  from  the  muscles, 
joints,  and  tendons,  usually  cause  paralysis  of  the  same  parts,  so  that  the  co- 
ordination is,  if  we  may  use  the  term,  more  latent  than  real,  and  therefore  of 
little  diagnostic  importance. 

4.  The  Cerebrum. — From  the  basal  ganglia  to  the  cortex,  the  path  of  the 
afferent  impulses  which  are  so  necessary  for  co-ordinate  movements  lies  near  to 
that  of  the  efferent  impulses  from  the  motor  area,  and  it  is  only  rarely  that  lesions 
affect  the  sensory  fibres  and  leave  the  motor  ones  intact.  Every  now  and  then, 
however,  a  patient  complaining  of  loss  of  use  of  the  limbs  on  one  side,  is  found 
on  examination  to  be  suffering  from  impaired  sense  of  position  and  movement 
in  those  limbs  rather  than  from  paralysis.  His  co-ordination  may  be  fairly 
good  so  long  as  he  can  utilize  his  vision,  but  with  closed  eyes  he  has  no  notion 
of  the  position  of  his  arm  or  leg,  and  no  knowledge  of  the  nature  of  objects 
placed  in  his  hand  [aster eognosis).  This  may  even  be  the  case  when  other 
sensory  stimuli,  such  as  those  of  touch,  pain,  and  heat,  are  appreciated  perfectly. 
A  similar  condition  may  be  observed  during  recovery  from  a  slight  hemiplegic 
"  stroke,"  the  patient  displaying  a  degree  of  clumsiness  and  awkwardness  with 
his  fingers  quite  out  of  proportion  to  his  loss  of  voluntary  power.  A  process  of 
re-education  for  finer  movements,  similar  to  the  education  of  early  life,  is 
necessary  before  he  is  able  to  overcome  this  form  of  ataxy. 

Ataxic  movements  are  not  uncommon  in  the  subjects  of  infantile  hemiplegia. 
The  hand  on  the  affected  side  may  be  permanently  clumsy  and  incapable  of 
carrying  out  the  delicate  manipulations  necessary  for  writing,  seM'ing,  etc. 
In  other  cases  all  voluntary  efforts  are  interfered  with  by  the  constant  presence 
of  involuntary  movements  of  an  athetotic,  choreiform,  or  tremulous  character, 
sufficient  to  prevent  their  attaining  any  dexterity. 

Whatever  the  nature  of  the  lesion,  cerebral  ataxy  is  generally  characterized 
by  its  hemiplegic  distribution,  and  by  the  fact  that  it  is  increased  when  the  eyes 
are  closed  ;  generally  the  loss  of  impulses  subserving  the  sense  of  position  and 
movement,  and  often  of  other  sensory  impulses,  can  be  demonstrated  by  suitable 
tests. 

5.  The  Cerebellum. — Cerebellar  ataxy  may  be  unilateral,  as  in  some  cases  of 
tumour  of  one  lateral  lobe,  or  bilateral,  as  in  the  acute  cerebellar  ataxia  of  children 


ATROPHY,     MUSCULAR  69 

due  to  encephalitis.  In  unilateral  cases  the  ataxy  is  most  marked  on  the  same 
side  as  the  lesion,  and  is  associated  with  hypotonia  and  some  paresis  of  the 
affected  limbs.  On  the  other  hand,  it  is  important  to  note  that  the  reflexes  on 
the  affected  side  are  normal,  that  the  ataxy  is  not  accompanied  by  any  loss  of 
sense  of  position  and  movement,  and  that  closure  of  the  eyes  does  not  materially 
increase  the  patient's  disability.  The  ataxy  often  differs  from  that  due  to  disease 
of  the  posterior  spinal  column  in  the  fact  that  it  is  complicated  by  vertigo.  This 
may  take  the  form  of  a  sensation  of  rotation  on  the  part  of  the  patient,  or  of 
rotation  of  surrounding  objects,  sometimes  of  both.  The  vertigo  and  the  ataxy 
are  generally  much  less  noticeable  when  the  recumbent  position  is  assumed. 
The  so-called  cerebellar  gait  resembles  that  of  a  drunken  man  ;  the  patient 
reels  from  side  to  side,  with  a  general  tendency  to  deviate  or  fall  to  the  side  of 
the  lesion  if  only  one  lobe  is  affected.  He  is  unable  to  balance  himself  properly 
on  the  homolateral  foot,  and  his  manual  dexterity  is  greatly  impaired,  so  that 
he  may  be  quite  unable  to  feed  or  clothe  himself.  The  ataxia  is  not  always 
limited  to  the  trunk  and  limbs,  but  may  affect  the  tongue,  lips,  palate,  and 
vocal  cords,  so  that  their  movements  may  be  imperfectly  controlled  and  a 
characteristic  "  cerebellar  articulation  "  attract  the  observer's  attention. 
Finally,  a  lesion  of  the  cerebellum  sufficient  to  cause  ataxy  is  nearly  always 
responsible  for  nystagmus,  which,  in  disease  of  one  lobe,  is  more  marked  during 
deviation  of  the  eyes  to  that  side. 

6.  Hysterical  Ataxy. — Ataxy  is  sometimes  hysterical,  and  may  then  be  the  only 
disorder  of  function  exhibited  by  the  patient,  or  may  be  associated  with  hysterical 
hemiplegia,  paraplegia,  hemianaesthesia,  etc.  The  diagnosis  of  hysterical  ataxy 
depends  partly  upon  the  absence  of  signs  of  organic  disease,  partly  on  the 
presence  of  other  hysterical  stigmata,  and  partly  on  its  character.  For  example, 
we  may  cite  the  case  of  a  boy  who,  when  lying  in  bed,  was  able  to  feed  himself 
and  to  carry  out  all  movements  of  his  upper  and  lower  limbs  with  perfect 
accuracy,  but  who,  when  placed  on  his  feet  and  told  to  walk,  displayed  the 
wildest  inco-ordination  and  loss  of  equilibrium.  It  was  noticeable,  however, 
that  he  always  reached  some  chair  or  bed  on  which  to  collapse  finally,  even  when 
placed  in  the  middle  of  the  room  at  some  distance  from  any  support.  It  would, 
of  course,  be  unjustifiable  to  apply  this  last  test  before  the  observer  was  satisfied 
from  careful  examination  that  there  were  no  signs  of  organic  disease. 

E.  Farquliar  Buzzard 

ATHETOSIS — (See  Contractions.) 

ATROPHY,  MUSCULAR. — Muscular  atrophy  is  often  merelv  a  part  of  a 
general  wasting  of  the  whole  body,  the  result  either  of  chronic  lesions,  such  as 
carcinoma,  sarcoma,  tuberculosis,  syphilis,  malaria,  ulcerative  colitis,  marasmus, 
starvation,  hepatic  abscess,  cirrhosis  of  the  liver,  diabetes,  anorexia  nervosa , 
or  from  acuter  maladies,  such  as  diarrhoea  and  vomiting,  ptomaine  poisoning, 
typhoid  fever,  dysentery,  cholera,  and  so  forth.  The  history,  and  the  other 
symptoms  in  the  case,  will  usually  serve  to  indicate  the  diagnosis.  If  any  doubt 
remains  as  to  whether  the  atrophy  is  neurotrophic  or  not,  the  electrical  reactions 
will  be  tested  ;  there  will  be  no  reaction  of  degeneration  (R.D.)  when  the  atrophy 
is  merely  part  of  a  general  wasting,  whereas  if — as  might  be  the  case  in  a  dia- 
betic patient,  for  instance — there  is  peripheral  neuritis  in  addition,  this  will  be 
indicated  by  a  partial  or  complete  R.D.      (See  Reaction  of  Degeneration.) 

In  the  next  place,  the  atrophy  may  be  the  result  of  disuse,  especially  in  the 
legs.  Organic  disease  of  the  nervous  system  may  or  may  not  be  present  at  the 
same  time  ;  the  patient  may  be  bedridden  from  locomotor  ataxj^  for  example, 
or  from  general  paralysis  of  the  insane  :  and  the  muscles  of  the  limbs  may 
consequent!}'  become  so   thin   that  peripheral  neuritis  or  degeneration  of  the 


70 


ATROPHY,     M  use  ULA  R 


anterior  cornual  cells  may  be  simulated,  and  a  determination  of  the  absence  of 
R.D.  mav  be  the  only  means  of  excluding  these.  It  is  important  to  remember 
that  in  the  primary  muscular  dystrophies,  whether  of  the  pseudo-hypertrophic, 
the  juvenile,  the  infantile,  the  facio-scapulo-humeral  or  Landouzy-Dejerine 
or  other  types,  there  is  no  reaction  of  degeneration,  the  electrical  responses 
and  the  superficial  and  deep  reflexes  remaining  normal  in  type,' though  they 
diminish  in  degree  as  the  amount  of  muscle  grows  less  and  less,  until  finally 
there  is  no  muscle  to  respond  at  all.  The  primary  muscular  dystrophies  are 
comparatively  easy  to  diagnose,  however,  on  account  of  their  insidious  onset 
in  children,  their  slow  but  progressive  downhill  course,  their  occurrence  in 
different  members  of  the  same  familv,  the  absence  of  sensory  disorder,  and  the 


F/'s:  7-- 


-Atrophy  of  the  muscles  of  the  left  shoulder  and  upper  arm,  the  result  of  former 
acute  anterior  poliomyelitis — infantile  paralysis. 


absence  of  reaction  of  degeneration.  Thej^  are  distinguished  from  the  infantile 
parah'sis  which  results  from  acute  anterior  poliomj'elitis  {Fig.  7)  bj-  the  sudden 
onset  of  the  latter,  the  R.D.  at  its  height,  and  by  the  fact  that  the  resultant 
wasting  does  not  advance  beyond  a  certain  point,  but  rather  tends  to  remain 
stationary,  after  recovering  to  a  certain  degree. 

Peripheral  neuritis  is  to  be  distinguished  from  primary  muscular  dvstrophv 
by  the  history  and  course,  and  by  the  presence  of  R.D.  at  some  period  of  the 
malady. 

Two  other  affections  that  may  be  confused  with  a  primary  muscular  dystrophy, 
particularh^  as  they  also  are  hereditary,  that  begin  insidiously  at  an  earlv  age, 
and   slowly   advance — are   Friedreich's    ataxy,    and    Tooth's    peroneal    tvpe   of 


ATROPHY,     MUSCULAR 


71 


progressive  muscular  atrophy.  Each  of  these  may  cause  tahpes,  moreover,  and 
therefore  simulate  infantile  paralysis,  except  that  in  the  latter  the  talipes  is 
generally  one-sided,  whereas  in  the  other  two  it  is  bilateral.  In  Friedreich's 
ataxy  there  is  no  real  wasting,  but  rather  a  lack  of  development;  the  knee-jerks 
are  lost,  the  big  toes  are  permanently  erect,  there  is  no  Argyll- Robertson  pupil, 
the  bladder  and  rectum  are  not  involved  until  quite  late,  there  is  no  R.D.,  and 
although  the  legs  are  chiefly  affected,  there  may  also  be  ataxic  movements  of 


Fi^.  8. — Tooth's  peroneal  type  of  neuro-niuscular 
dystrophy — early  :  the  patient  is  the  younger 
brother  of  the  girl  in  Fig.  9. 


Fig-,  g. — Tooth's  peroneal  typeof  neuro-muscular 
dystrophy  :  the  patient  is  sister  to  the  boy  in 
Fig.  8  ;  her  malady  is  in  a  much  more  advanced 
stage  than  is  his. 


the  hands,  and  the  eyes  may  present  nystagmus  and  even  optic  atrophy.  In 
Tooth's  peroneal  type  of  progressive  muscular  atrophy,  the  illness  is  apt  to 
come  on  after  some  febrile  malady  such  as  measles  or  whooping-cough,  the  first 
thing  to  be  noted  being  an  inability  to  dorsifiex  the  big  toe,  which  hangs  down 
in  a  way  that  is  the  exact  converse  of  its  erect  position  in  Friedreich's  atax}- 
{Fig.  8) ;  the  paresis  takes  months  or  years  to  spread  to  the  rest  of  the  legs,  and 
finally  to  the  hands  [Fig.  9),  the  slowness  of  the  progress  and  the  absence  of 


ATROPHY.     MUSCULAR 


sensory  symptoms  showing  that  it  is  not  peripheral  neuritis,  whilst  the  R.D. 
in  the  affected  muscles  excludes  a  primary  muscular  d3'Stroph^^  The  lesion  is 
in  the  anterior  cornual  cells  and  starts  in  the  lumbar  enlargement.  The  knee- 
jerks  are  retained  until  the  quadriceps  of  the  thigh  is  involved. 

Local  muscular  atrophj'  may  be  due  to  disease  of  the  parts  beneath,  as  in 
the  case  of  the  pectoralis  major,  the  supraspinatus,  the  deltoid,  the  infra- 
spinatus, and  other  shoulder  muscles  when  the  underlying  lung  is  the  site  of 
active  phthisis.  Similar  local  atrophy  results  very  quickly  from  acute  and 
subacute  affections  of  joints,  especially  in  the  muscles  whose  origin  is  above  the 
affected  joint.  The  gluteal  atrophy  associated  with  tuberculous  hip- joint 
is  well  known  ;  similarly,  knee-joint  disease  leads  to  thigh  atrophy,  elbow  disease 
to  atroph}^  of  the  muscles  of  the  upper  arm,  and  so  on.  The  same  applies  to 
the  effects  of  fractures,  new  growths,  sprains,  and  splints  ;  the  atrophy  is  some- 
times so  rapid  that  some  think  it  cannot  be  due  simpl}^  to  disuse,  but  must  have 
a  neuropathic  factor  also.  The  affected  muscles  present  no  R.D.,  however.  One 
particular  form  of  paralj'sis  associated  with  the  use  of  splints  merits  special 
mention,  namelj^,  Volckmann's  paralysis  of  the  forearm.  (See  Paralysis  of 
THE  Upper  Extremity.) 

Hemiatroph}'  of  the  face  or  trunk  is  generally  congenital,  and  the  diagnosis 
is  not  difficult. 

If  it  can  be  decided  definitely  that  there  is  some  nervous  cause  for  muscular 
atrophy,  the  best  proof  of  which  is  the  detection  of  partial  or  complete  R.D. 
in  the  affected  muscles,  the  diagnosis  lies  between  one  or  other  of  the  following 
conditions  : — 

1.  Causes  in  the  Spinal  Cord. — Progressive  muscular  atrophy.  Am j^o trophic 
lateral  sclerosis.  A  few  cases  of  transverse  m^^elitis.  Syringomyelia.  Tooth's 
peroneal  type  of  progressive  muscular  atrophy.     Acute  anterior  poliomj^elitis. 

2.  Causes   in  the  Peripheral  Nerves. — 


Tumours  of  the  cauda  equina 
Pelvic  tumours  involving  the 

lumbo- sacral  plexus 
Sciatica 
Aneurysm 
New  growth 


Accessory  cervical  rib,  etc.,  pressing 

on  the  brachial  plexus 
Gummata,  etc.,  involving  the  cranial 

or  other  nerves 
Injury  to  peripheral  nerves,  including 

the  effects  of  callus  after  fractures 


Peripheral  neuritis,  of  which  the  following  are  some  of  the  causes  :- 


Certain  inorganic   chemical  sub- 
stances, notably 

Lead 

Arsenic 

Mercury 
Certain    organic    chemical    com- 
pounds,  notably 

Alcohol 

Ether 

Carbon  bisulphide 

Naphtha 
Certain  severe  anaemias  : 
Pernicious  anaemia 
Spleno-meduUary    leukaemia 
Lymphatic  leukaemia 
Hodgkin's  disease 
Splenic  anaemia 


Certain  microbial  or  allied  toxins  : 
Diphtheria 
Leprosy 
Malaria 

Chronic  p3'aemia 
Infective  endocarditis 
Beri-beri 
Syphilis 
Tj'phoid  fever 
Influenza 
Oral  sepsis 
Certain  constitutional  diseases,  some- 
times    attributed    to     endogenous 
poisons  : 
Gout 

Diabetes  mellitus 
Pregnancy 
Other  causes  as  j'et  undetermined. 


ATROPHY,     MUSCULAR  73 

In  arriving  at  a  diagnosis  in  a  particular  case,  it  is  important  not  to  use  the 
term  "  neuritis  "  until  all  the  other  possible  lesions  have  been  excluded.  Tooth's 
peroneal  type  of  progressive  muscular  atrophy  and  acute  anterior  poliomj'elitis 
have  already  been  discussed.  The  latter  is  sometimes  regarded  as  essentially 
a  disease  of  earlv  life,  but  it  is  important  to  remember  that  it  is  by  no  means 
impossible  for  it  to  affect  an  adult,  in  whom  the  symptoms  and  results  may  be 
preciselv  similar  to  what  they  would  be  in  a  child. 

Progressive  muscular  atrophy  is  a  disease  of  adults.  It  shows  no  particular 
tendency  to  occur  in  several  members  of  the  same  family.  It  begins  insidiously, 
and  advances  slowly  for  months  and  years,  affecting  first  the  small  muscles  of 
the  hands,  causing  atroph}'  with  R.D.  in  the  interossei  and  in  the  muscles  of 
the  thenar  and  hypothenar  eminences  ;  the  peculiar  deformity  described  by 
the  term  "  main-en-griffe  "  results.  In  the  course  of  months  the  paresis  spreads 
from  the  hands  to  the  forearm  muscles,  and  later  to  those  of  the  upper  arm. 
Disease  of  the  peripheral  nerves,  such  as  the  ulnar,  is  excluded  by  the  fact  that 
the  paralyzed  muscles  are  not  all  supplied  from  the  same  nerve  trunk — the 
thenar  muscles  supplied  by  the  median  being  affected  equally  with  the  hypo- 
thenar supplied  by  the  ulnar.  All  the  muscles  below  the  wrist  are  involved 
more  or  less  together,  then  all  the  muscles  below  the  elbow,  and  so  on  ;  this 
paralysis  of  associated  groups  of  muscles,  as  distinct  from  muscles  supplied  by 
the  same  nerve,  at  once  suggests  a  progressive  degeneration  of  the  anterior 
cornual  cells  of  the  cervical  enlargement  of  the  cord.  Disease  of  the  brachial 
plexus  would  be  excluded  first  by  the  fact  that  the  lesion  is  bilateral  and 
symmetrical,  and  secondly  by  the  absence  of  pain  or  other  sensory  disturbance. 
The  pathology  of  the  disease  is  analogous  to  the  nuclear  cell  degeneration  in  the 
medulla  oblongata  that  leads  to  bulbar  (labio-giosso-pharyngo-laryngeal) 
paralysis  ;  and  indeed,  progressive  muscular  atrophy  may  either  follow  or  be 
followed  by  bulbar  paralysis. 

If,  at  the  same  time  that  there  are  the  signs  of  progressive  muscular  atrophy 
in  the  hands,  there  is  also  spastic  paresis  of  the  legs,  with  no  wasting,  but  increased 
knee-jerks,  ankle  clonus,  and  extensor  plantar  reflexes,  the  onset  having  been 
quite  gradual,  without  sensory  disorder,  and  without  bladder  or  rectal  trouble 
unless  the  disease  has  reached  quite  a  late  stage,  the  condition  is  amyotrophic 
lateral  sclerosis. 

It  is  important  that  the  character  of  the  onset  and  the  absence  of  sensory 
symptoms  be  insisted  on,  in  order  to  exclude  syringomyelia  and  anomalous 
cases  of  transverse  mj-elitis.  Syringomyelia  is  rare,  but  it  has  one  very  character- 
istic feature,  namely,  the  preservation  of  ordinary  cutaneous  sensibility  with 
the  loss  of  power  of  distinguishing  heat  from  cold,  or  pain  from  touch,  in 
some  part  of  the  limbs  or  trunk.  There  need  be  no  other  symptom  than  this 
dissociation  of  sensations,  or  skin  lesions  in  the  paresthetic  parts  may  be  a 
prominent  feature — Morvan's  disease  ;  if  the  enlargement  in  and  around  the 
central  canal  of  the  cord  displaces  and  destroys  the  anterior  cornual  cells  in 
the  lower  part  of  the  cervical  enlargement,  progressive  muscular  atrophy  is 
simulated  ;  if  at  the  same  time  the  bulging  of  the  central  canal  and  the  changes 
around  it  cause  compression  of  the  crossed  pyramidal  tracts,  there  will  be  all 
the  motor  symptoms  and  signs  of  amyotrophic  lateral  sclerosis,  the  diagnosis 
being  only  possible  when  the  sensory  symptoms  are  typical. 

It  is  generally  stated  that  transverse  myelitis  causes  spastic  paraplegia  without 
muscular  wasting  or  R.D.  This  is  in  the  main  true,  because  the  few  anterior 
cornual  cells  destroyed  by  the  transverse  softening  of  the  cord  in  the  commonest 
site,  namely,  the  dorsal  region,  correspond  to  an  intercostal  or  abdominal  segment, 
the  wasting  of  which  is  difficult  to  detect.  If,  however,  the  transverse  myelitis 
occurs  so  high  up  as  to  involve  the  lower  part  of  the  cervical  enlargement — to 


74  ATROPHY,     MUSCULAR 


involve  the  cord  yet  higher  up  is  incompatible  with  life,  because  both  the 
intercostals  and  the  phrenic  nerves  would  be  paralysed — a  certain  number  of 
the  anterior  cornual  cells  sending  motor  nerves  to  the  hands  and  arms  would  be 
destroyed,  the  result  being  a  main-en-griffe  like  that  of  progressive  muscular 
atrophy  ;  and  the  simultaneous  interference  with  the  crossed  pyramidal  tracts 
would  produce  a  picture  identical  at  first  sight  with  amyotrophic  lateral  sclerosis. 
Not  onh^  however,  would  there  very  likely  be  impairment  of  all  forms  of 
sensation  as  well  as  paresis,  in  a  case  of  transverse  myelitis,  but  instead  of  the 
onset  being  very  gradual  and  the  progress  a  steady  advance  downhill,  as  in 
progressive  muscular  atrophy  or  amyotrophic  lateral  sclerosis,  the  onset  would 
have  been  a  comparatively  rapid  one,  followed  by  a  cessation  or  even  by  an 
improvement  if  the  patient  lived.  Similarly,  if  transverse  mj^elitis  occurs  so 
low  down  as  to  involve  the  lumbar  enlargement  of  the  cord,  it  would  cause, 
not  spastic  paraplegia  with  increased  knee-jerk,  ankle  clonus,  extensor  plantar 
reflex,  no  wasting  and  no  R.D.  ;  but  absence  of  knee-jerk,  no  ankle  clonus,  no 
extensor  plantar  reflex,  marked  muscular  atrophy  of  the  legs,  with  R.D., 
paraesthesia,  bladder  and  rectal  trouble.  The  involvement  of  the  sphincters 
in  such  a  case  would  be  of  considerable  aid  in  excluding  peripheral  neuritis ; 
whilst  Tooth's  peroneal  type  of  progressive  muscular  atophy  and  acute  anterior 
poliomyelitis  would  be  excluded  not  only  by  the  paraesthesia,  but  also  by  the 
history  of  the  mode  of  onset  and  the  course  of  the  malady. 

•  A  tumour  involving  the  cauda  equina  is  rare,  but  it  is  not  altogether  difficult 
to  diagnose.  It  may  be  more  difficult  to  determine  the  nature  of  the  mass — 
gumma,  glionaa,  primary  sarcoma,  secondary  sarcoma  or  carcinoma — than  its 
site.  The  onset  of  symptoms  is  generally  gradual,  and  one  leg  is  affected  either 
earlier  than,  or  more  than,  the  other.  Weakness  in  the  leg,  together  Avith  severe 
pains  both  in  it  and  in  the  lower  part  of  the  lumbar  region  of  the  spinal  column, 
will  be  followed  by  muscular  atrophy  and  R.D.  Sciatica  may  at  first  suggest 
itself,  until  it  is  found  that  neither  the  pains  nor  the  paresis  correspond  to  one 
single  nerve  ;  and  when  the  disease  progresses  and  the  other  leg  is  affected, 
anaesthesia  supervenes  upon  the  paralysis.  The  site  of  the  pain  over  the  region 
of  the  Cauda  equina  is  an  important  point  in  the  diagnosis,  whilst  rectal  and 
possibly  vaginal  examinations  are  essential  for  the  exclusion  of  a  pelvic  mass — 
such  as  carcinoma  of  the  rectum,  uterus,  or  ovary,  a  fibromyoma,  a  cyst,  a 
sarcomatous,'  gummatous,  tuberculous,  or  inflammatory  mass,  or  even  a  displace- 
ment of  the  womb — which,  by  interfering  with  the  nerves  at  the  back  of  the 
pelvis,  might  produce  very  similar  symptoms.  Sacro-iliac  joint  disease  can 
generally  be  excluded  by  the  fact  that  the  pains  are  not  definitely  referred  to 
the  joint,  whilst  any  wasting  that  might  be  associated  with  disease  of  that  joint 
would  not  be  accompanied  by  R.D. 

Sciatica  does  not  always  give  rise  to  wasting  of  the  corresponding  muscles  ; 
but  sometimes  it  does,  and  occasionally  it  may  do  so  bilaterally,  with  R.D. 
The  localization  of  the  pain,  tenderness,  and  atrophy  to  the  parts  supplied  by 
the  great  sciatic  nerve,  without  affection  of  other  nerves  and  muscles  in  the  leg 
or  calf,  would  point  to  sciatica,  especially  if  the  lesion  was  unilateral,  and  if 
the  patient,  though  unable  to  flex  his  thigh  to  a  right  angle  with  his  abdomen 
at  the  same  time  that  he  keeps  his  knee  extended,  can  extend  his  leg  back- 
wards at  the  hip-joint  in  a  way  that  would  be  impossible  if  he  had  a  psoas 
abscess  ;  and  if  he  is  able  to  bear  firm  backward  pressure  on  the  knee  when 
the  leg  of  the  affected  side  is  flexed  and  outwardly  rotated  in  such  a  way  that 
the  foot  lies  across  the  opposite  knee — a  test  which  will  exclude  hip-joint  disease. 

When  the  lesion  is  a  thoracic  aneurysm  or  neoplasm,  or  an  accessory  cervical 
rib  pressing  on  or  involving  the  brachial  plexus,  the  wasting  is  almost  certain 
to  affect  one  arm  only,  or  one  arm  much  more  than  another,  and  the  diagnosis 


ATROPHY,     MUSCULAR  75 

will  be  made  by  physical  examination  of  the  thorax,  assisted  by  the  use  of  the 
;ir-rays. 

The  only  cranial  nerve  paralyses  that  are  likely  to  be  associated  with  marked 
atrophy  of  muscles,  are  those  of  the  seventh  with  facial  atrophy,  and  of  the 
twelfth  with  atrophy  of  the  tongue. 

Injuries  to  peripheral  nerves,  or  inclusion  of  the  latter  in  callus,  will  generally 
be  diagnosed  by  the  history,  and  by  the  fact  that  in  distribution  the  muscular 
atrophy  and  R.D.  correspond  accurately  with  one  or  more  of  the  peripheral 
nerves  that  may  have  been  divided  or  otherwise  injured. 

If  all  the  conditions  described  above  can  be  excluded,  it  is  probable  that  the 
cause  of  the  muscular  atrophy  is  some  variety  of  peripheral  neuritis.  To  merit 
this  diagnosis,  the  affected  muscles  should  be  multiple  and  symmetrical  ;  partial 
or  complete  R.D.  should  be  obtained  ;  there  may  or  may  not  be  sensory  changes  ; 
the  reflexes,  both  superficial  and  deep,  are  for  a  short  time  exaggerated,  and 
then  become  deficient  or  disappear  altogether  for  the  time  being.  Wasting 
may  be  extreme,  but  the  tendency  is  for  slow  recovery  to  ensue,  improvement 
beginning  to  set  in  some  three  or  four  months  after  the  neuritis  ceases.  Some- 
times the  nature  of  the  case  is  obvious,  but  it  is  often  easier  to  diagnose  peripheral 
neuritis  than  to  discover  its  exact  cause. 

The  different  conditions  that  may  produce  it  are  enumerated  above.  In 
diagnosing  between  them  the  history  is  very  important.  If  the  patient  has 
never  been  abroad  leprosy  and  beri-beri  are  unlikely,  whereas  if  he  has  been 
abroad  amongst  lepers,  and  if  he  has  areas  of  anaesthesia  without  much  paresis, 
with  or  without  the  characteristic  nodules  and  bosses  of  subcutaneous  infiltra- 
tion," followed  by  ulceration  and  necrosis,  the  diagnosis  of  leprosy  will  at  once 
suggest  itself.  The  chief  difficulties  wall  perhaps  be  to  exclude  syringomyelia 
on  the  one  hand  and  tertiary  syphilis  on  the  other.  The  good  effects  of  treat- 
ment by  potassium  iodide  and  mercury  may  assist  in  detecting  syphilis,  and 
Wassermann's  reaction  may  also  be  positive  ;  in  syringomyelia  there  is  little  or 
no  loss  of  cutaneous  sensibility  like  there  is  in  leprosy,  though  there  is  loss  of 
power  to  distinguish  heat  from  cold,  and  pain  from  touch.  The  ultimate  test  of 
leprosy  would  be  to  excise  a  small  portion  of  the  affected  tissue  and  to  examine 
it  for  the  acid-fast  leprosy  bacillus. 

Beri-beri  is  sometimes  seen  in  this  country,  generally  in  patients  who  have 
come  into  port  in  a  ship  from  the  East ;  several  of  the  crew  have  generally 
been  affected  at  the  same  time,  some  may  have  died  ;  the  peripheral  neuritis 
and  muscular  wasting  will  often  be  associated  with  subcutaneous  oedema,  and 
there  is  often  a  history  that  the  dietary  has  consisted  of  rice  that  has  not  been 
absolutely   fresh. 

The  presence  or  absence  of  glycosuria  will  serve  to  diagnose  or  exclude  diabetic 
neuritis.  Loss  of  knee-jerk  in  diabetes  mellitus  is  comparatively  common, 
but  extensive  peripheral  neuritis  is  much  rarer.  It  is  associated  with  pain 
and  parsesthesia  as  well  as  paresis  and  muscular  atrophy,  and  it  affects  the 
limbs,  especially  the  legs,  rather  than  the  trunk. 

Gout  as  a  cause  of  peripheral  neuritis  is  always  open  to  doubt,  for  there  is 
often  a  possibility  that  the  neuritis  of  a  gouty  subject  may  really  be  due  to  the 
same  indulgences  that  brought  on  the  gout.  Difficulty  may  also  arise  in 
attributing  a  neuritis  to  pregnancy  even  when  the  patient  is,  or  has  been  recently, 
pregnant. 

In  the  case  of  blood  diseases  it  is  important  to  bear  in  mind  that  these  are 
usually  treated  with  arsenic,  so  that  the  peripheral  neuritis  may  be  due  to  the 
Treatment  rather  than  the  disease.  This  will  be  rendered  the  more  probable 
if  there  are  or  have  been  other  symptoms  of  subacute  or  chronic  arsenical 
poisoning,    such    as     corvza,     nausea,     vomiting,    abdominal    colic,    diarrhoea, 


76  A  TROPH  Y,     M  USC  ULA  R 

headache,  pigmentation  of  the  skin  not  unhke  that  of  Addison's  disease,  hyper- 
keratosis of  the  pahns  and  soles,  or  herpetiform  eruptions.  With  arsenical 
neuritis,  the  limbs  are  involved  most,  particularly  the  legs,  and  there  are  pains 
and  paraesthesia  as  well  as  paresis.  It  is  held  by  some,  however,  that  the  blood 
diseases  may  themselves  cause  peripheral  neuritis,  and  there  seems  no  reason 
wh}-  this  should  not  be  so,  for  it  is  well  known  that  the  severe  anaemias  such  as 
pernicious  ansemia  may  cause  degeneration  in  other  parts  of  the  nervous  system 
also,  notably  in  the  long  tracts  in  the  spinal  cord,  with  consequent  sensorjr, 
ataxic,  or  paretic  s\-mptoms,  varjdng  with  the  parts  involved.  If  the  peripheral 
neuritis  occurs  early  in  the  blood  disease,  the  latter  may  not  come  to  mind  as 
a  possibihty.  A  blood-count  is  essential.  Oligocythaemia  with  high  colour 
index,  no  leucoc]ii;osis,  a  relative  h-mphoc^^osis,  and  the  presence  in  blood 
films  of  a  preponderance  of  megaloc}^:es,  are  changes  characteristic  of  pernicious 
ancBtnia,  in  addition  to  which  the  primrose-yellow  skin  may  be  tjrpical.  Great 
increase  in  the  total  number  of  leucocytes  up  to  an3rthing  from  50,000  to 
1,000,000  per  c.mm.  would  suggest  leucocythcemia  :  if  this  were  the  spleno- 
meduUar\'  form,  myelocytes  would  probablj^  be  30  per  cent  or  more  of 
all  the  white  cells  seen  in  films,  whilst  in  the  Ijnnphatic  form  the  Ij^mpho- 
cytes  w^ould  similarly  amount  to  90  per  cent ;  in  both  forms,  particularly^ 
the  spleno-medullarjr,  the  spleen  and  liver  would  be  big,  whilst  in  the 
lymphatic  t^-pe  there  would  probably  be  general  enlargement  of  the  lyra.- 
phatic  glands. 

Hodgkin's  disease  or  lymphadenoma  suggests  itself  when  the  spleen  and  many 
of  the  l\Tnphatic  glands  are  enlarged,  without  any  characteristic  blood  changes 
— at  most  a  simple  anaemia  without  leucocytosis,  with  relative  l5?mphocytosis, 
and  an  occasional  mj-eloc^rte,  basophUe  corpuscle,  and  nucleated  red  cell  in 
films.  Splenic  ancsmia  is  a  doubtful  entity?',  the  name  being  apphed  when  there 
is  simple  anemia  A^ith  apparently  idiopathic  enlargement  of  the  spleen.  Many 
such  patients  ultimately  turn  out  to  have  cirrhosis  of  the  liver — Banti's  disease. 
Peripheral  neuritis  in  such  a  case  may  well  be  alcoholic. 

Malaria  or  ague  will  be  diagnosed  by  the  history,  and  by  the  discovery  of  the 
haematozoa  in  the  blood  during  an  attack.  The  difficult}'  may  be  to  exclude 
alcohol  as  a  cause  for  the  neuritis  in  a  patient  who  has  also  suffered  from  severe 
malaria. 

Infective  endocarditis  is  sometimes  so  chronic  and  insidious  that  it  escapes 
detection.  Points  to  la}-  stress  on  are  the  presence  of  a  cardiac  bruit  or  bruits, 
especiaU}'  if  the  latter  change  radically  in  character  under  observation,  pro- 
gressive anaeraia,  p^Texial  periods,  enlargement  of  the  spleen,  evidence  of 
embolism  or  infarction,  retinal,  subcutaneous  or  other  haemorrhages,  and  optic 
neuritis. 

It  may  not  be  easy  to  convince  oneself  that  some  other  cause  of  chronic 
pycemia,  whether  uterine,  pelvic,  pulmonar}^,  oral,  or  otherwise,  is  the  cause  of 
peripheral  neuritis  in  a  given  case.  The  same  applies  to  syphilis,  especially 
if  the  patient  is  also  addicted  to  alcohol. 

Jniluenza  is  not  to  be  diagnosed  as  the  cause  until  ever}'  other  possible 
explanation  has  been  exhausted  ;  it  is  too  easy  to  attribute  things  to  influenza. 
Peripheral  neuritis  in  connection  with  typhoid  fever  generall}^  arises  as  a  direct 
sequela  of  a  ts'pical  attack  confirmed  by  Widal's  test,  so  that  the  diagnosis  is 
not  difficult  as  a  rule.  It  has  the  same  t^-pe,  sensor}-  and  motor,  as  arsenical 
neuritis. 

Diphtheria  is  one  of  the  most  important  of  all  the  causes,  and  if  the  diphtheria 
itself  has  been  slight  it  may  have  been  entirely  overlooked,  especially  as  the 
neuritis  develops  two  or  three  weeks  or  longer  after  the  sore  throat.  It  is 
important,  therefore,  to  lose  no  time  in  taking  cultivations  from  the  throat  in 


ATROPHY,     MUSCULAR  77 

all  doubtful  cases  of  peripheral  neuritis,  lest  it  be  still  possible  to  find  the  causal 
organisms  in  swabbings.  The  nature  of  the  case  may  be  suggested  at  once, 
however,  if  there  has  been  a  nasal  alteration  in  the  voice,  or  if  there  is  an  inability 
to  swallow  liquids  owing  to  'their  regurgitation  through  the  nose — evidence  of 
paralysis  of  the  palate  that  is  almost  characteristic  of  diphtheria  ;  the  pupil 
reflexes  are  also  apt  to  be  affected,  and  the  patient  may  be  thought  to  have  an 
error  of  refraction  because  paresis  of  the  ciliary  muscle  renders  accommodation 
difficult  or  impossible  for  the  time  being.  The  symptoms  may  stop  at  the  palate 
and  eye  ;  but  in  bad  cases — perhaps  as  the  result  of  a  toxin  different  from 
that  which  directly  affects  the  palate — paralysis  and  extreme  atrophy  of  the 
limbs,  without  much  sensory  disorder,  follows  too.  The  vagus  nerves  may  be 
involved,  causing  tachycardia,  and  perhaps  death  ;  equally  serious  may  be 
the  involvement  of  the  phrenic  nerves,  with  weakness  or  paralysis  of  the 
diaphragm. 

In  regard  to  the  various  chemical  substances  that  may  produce  peripheral 
neuritis,  inquiries  into  the  patient's  occupation  may  assist  the  diagnosis. 
Workers  amongst  indiarubber  come  in  contact  with  carbon  bisulphide  fiimes, 
this  compound  being  used  to  dissolve  the  rubber.  Naphtha  is  extensively  used 
in  some  trades.  The  use  of  a  chemical  may  not  always  be  obvious  until  careful 
inquiries  are  made — for  instance,  one  may  not  at  first  see  what  a  person  who 
prepares  rabbit  skins  for  conversion  into  hats  has  to  do  with  mercury,  until  it  is 
learned  that  mercurials  are  used  to  preserve  the  pelts.  Mercurial  neuritis  is 
characterized  by  a  remarkable  tremor  of  the  hands  and  arms,  in  addition  to  the 
muscular  atrophy  in  the  arms  and  legs  ;  there  are  not  many  sensory  symptoms 
as  a  rule.  Lead  neuritis  is  easily  diagnosed  when  it  causes  the  characteristic 
wrist-drop  ;  all  the  muscles  supplied  by  the  musculo- spiral  nerve  beyond  the 
triceps  become  paralyzed,  except  the  supinator  longus  and  the  extensor  ossis 
metacarpi  pollicis,  and  there  is  no  sensory  disorder  ;  the  diagnosis  is  confirmed 
by  finding  a  blue  line  upon  the  gums  and  the  other  signs  of  lead  poisoning, 
particularly  abdominal  pains  and  colic,  anaemia,  constipation,  nausea,  vomiting, 
headache,  impairment  of  sight,  a  tendency  to  abortion  in  women,  gouty  joint 
pains,  albuminuria,  and  even  epileptiform  convulsions  and  other  serious  cerebral 
symptoms  that  are  spoken  of  as  saturnine  encephalopathy.  The  difficulty  arises 
in  those  less  typical  cases  in  which  the  lead  causes  generalized  peripheral  neuritis 
in  both  legs  and  both  arms,  perhaps  without  any  other  symptoms,  without  even 
a  blue  line  upon  the  gums  if  the  teeth  are  kept  clean.  The  source  of  the  lead 
may  be  very  far  from  obvious — it  may  be  some  obscure  thing,  such  as  a  hair- 
wash,  or  the  result  of  water  contamination  due  to  electrolysis  in  w-ater-pipes, 
the  result  of  leakage  in  an  electric  main.  In  case  of  doubt  it  may  even  be  worth 
while  to  evaporate  down  a  large  bulk  of  urine  and  apply  the  ammonium  sulphide 
test  for  lead  to  the  residue  :  a  drop  or  two  of  the  latter,  allowed  to  fall  into  a  tall 
glass  full  of  ammonium  sulphide,  will  cause  a  white  trail  to  develop  in  the  fluid 
as  the  drop  descends. 

Arsenical  neuritis  has  been  mentioned  above  ;  it  may  arise  in  patients  who 
are  taking  arsenic  in  medicinal  doses,  for  instance  for  chorea  or  pernicious 
anaemia,  or  the  poison  may  be  taken  unawares,  as  in  the  Manchester  epidemic, 
in  which  fatal  results  followed  contamination  of  beer  wdth  arsenic.  It  has  even 
been  held  that  alcohol  itself  is  no  cause  of  peripheral  neuritis,  and  that  those 
patients  who  have  developed  it  as  the  result  of  long-continued  drinking  to 
excess  —possibly  without  a  single  actual  intoxication  in  the  popular  sense — 
owe  the  nerve  trouble  and  generalized  muscular  atrophy,  not  to  the  chemical 
substance  C.,HgO,  but  to  other  bodies  associated  with  it.  Clinicalh^  however, 
it  is  sufficient  if  the  diagnosis  of  the  cause  of  peripheral  neuritis  can  be  narrowed 
down  to  alcohol  in  some  form  or  other,  and  for  this  to  be  possible  an  accurate 


ATROPHY,     MUSCULAR 


history  is  essential.  The  greatest  dif&culty  arises  in  the  case  of  secret  drinkers, 
especially  women  who  may  appear  to  be  above  suspicion.  The  neuritis  is 
ushered  in  with  pains  and  cramps  in  the  limbs,  followed  by  wasting,  which  may 
reach  an  extreme  degree  ;  the  trunk  and  limbs  so'metimes  look  like  those  of  a 
person  who  has  been  starved  to  death.  Associated  signs  of  alcoholism  should 
be  looked  for. 

It  only  remains  to  add  that  there  will  always  be  some  cases  in  which  the 
cause  of  the  peripheral  neuritis  fails  to  be  found ;  if  arsenic  is  suspected,  a  portion 
of  hair  should  be  sent  for  chemical  analysis  ;  for  it  has  been  shown  that  the 
hair  of  a  person  taking  arsenic  stores  the  latter  in  proportions  sufficient  to  allow 
of  its  detection.  Herbert  French 

ATROPHY,   OPTIC. — (See  Ophthalmoscopic  Appearances,  Xotes  on.) 

ATROPHY,  TESTICULAR.— When  the  fact  that  one  testicle  is  smaller 
than  the  other  is  a  prominent  feature  in  a  case,  it  is,  in  the  first  place,  necessary 
to  determine  which  of  the  two  organs  is  the  abnormal  one  ;  for  when  one 
testicle  is  shghtly  enlarged,  one  may  sometimes  be  led  into  the  error  of  regarding 
the  enlarged  organ  as  normal  and  the  other  as  too  small. 

The  next  point  to  remembej:  is  that  the  condition  may  be  physiological  ;  a 
certain  amount  of  inequaH1r\-  of  the  two  organs  is  not  an  uncommon  result  of 
developmental  difierences  here,  just  as  in  the  case  of  paired  organs  generally. 
Further  than  this,  atrophy  of  one  testicle  is  seldom  in  itself  of  serious  import 
even  when  it  has  a  pathological  basis.  It  may  be  of  some  value  in  its  bearing 
upon  other  features  of  the  case,  however,  so  that  it  may  be  important  to  deter- 
mine why  the  patient  presents  the  symptom. 

Deahng  first  with  the  question  of  a  testicle  which  is  in  an  abnormal  position, 
such  as  one  that  has  been  retained  in  the  inguinal  canal  or  elsewhere,  it 
is  clear  that  in  addition  to  such  causes  of  atrophy  as  the  normally  situated 
testicle  may  be  subject  to,  there  is  here  another  and  a  special  factor, 
namely,  inhibition  of  gro%vth  owing  to  compression  by  the  surrounding  parts. 
A  retained  or  misplaced  testicle  is  frequently  undersized.  At  the  same  time 
it  should  be  remembered  that  inflammatory  and  other  lesions  which  may- 
produce  atrophy  of  a  normally  situated  testicle,  may  also  affect  one  that  is 
retained  or  misplaced. 

In  speaking  of  testicular  atrophy  it  is  important  to  take  into  consideration 
the  age  of  the  patient,  because  a  physiological  atrophy  of  the  testicles  is  apt  to 
occur  in  advanced  life.  This  senile  change  may  begin  as  early  as  the  fiftieth 
year,  but  on  the  other  hand,  there  are  many  quite  old  men  whose  testicles  are 
no  smaller  than  when  they  were  young. 

Atrophy  of  a  normally  situated  testicle  is  nearly  always  due  to  one  or  other 
of  three  main  groups  of  causes,  namely,  either  :  (I)  Interference  with  its  blood- 
supply  ;  (II)  A  preceding  inflammation  ;  or  (III)  A  neurotrophic  cause.  The 
following  is  a  list  of  causes  arranged  under  these  main  headings  : — 

I. — Interference  with  the  Blood  Supply  : — 

Compression  of  the   spermatic    cord,    as  by    an   inguinal   hernia    or  by   a 

spermatocele. 
\'enous  stasis,  the  result  of  varicocele. 
Compression  of  the  testicle  by  affections  of  the  tunica  vaginahs,  such  as 

hydrocele  or  haematocele. 
The  wearing  of  an  ill-fitting  truss  in  the  inguinal  region. 
As  a  sequela  of  operations  in  the  region   of  the   spermatic   cord,    such  as 

those  for  the  cure  of  varicocele,  spermatocele,  or  hernia. 
Elephantiasis 


ATROPHY,     TESTICULAR  79 

II. — Atrophy,  the  result  of  Orchitis,  due  to  such  causes  as  the  following  : — 


Gonorrhoea 

Injury 

Syphilis 

Mumps 

Typhoid    fever 

Tubercle 


Gout 

Strain 

X-rays 

Rheumatism 

Influenza 


III. — Neurotrophic  Causes,  especially  after  injury  to  the  brain  or  spina 
cord. 

It  has  been  stated  that  atrophy  of  a  testicle  may  result  from  the 
administration  of  iodide  of  potassium  ;  but  this  is  exceedingly  difficult  to 
prove,  for  it  will  seldom  happen  that  this  drug  will  be  given  unless  there  is 
already  present  some  other  possible  cause  of  testicular  atrophy,  particularly 
syphilis  or  an  orchitis. 

Dealing  now  with  the  differential  diagnosis  of  the  above  causes  in  greater 
detail,  it  will  be  clear  that  the  history  of  the  case  will  in  most  instances  have  a 
very  important  bearing  upon  it. 

Group  I. — The  cause  in  any  of  the  cases  in  this  group  will  generally  be 
obvious.  It  is  only  necessary  to  bear  in  mind  that  an  operation  for  varicocele, 
for  instance,  may  have  been  successfully  performed,  and  the  patient  may  there- 
after contract  an  orchitis  followed  by  testicular  atrophy,  for  which  the  operation 
may  then  be  unjustly  blamed. 

As  regards  Group  II,  one  may  say  at  once  that  it  is  very  doubtful  whether 
either  influenza  or  rheumatism  ever  really  produced  either  orchitis  or  testicular 
atrophy.  There  may  be  a  definite  history  of  the  orchitis  itself,  which  preceded 
the  atrophy,  and  then  diagnosis  should  not  be  difficult,  provided  it  is  remembered 
that  by  no  means  every  orchitis  is  gonococcal.  If  mumps,  typhoid  fever,  gout, 
and  injury  are  borne  in  mind,  these  causes  of  orchitis  and  testicular  atrophy 
will  be  recognized  more  often  than  they  are.  Mumps  is  particularly  apt  to 
be  overlooked,  and  yet  it  is  well  known  that  orchitis  may  be  the  sole  evidence 
of  this  complaint. 

If  the  patient  has  been  seen  when  the  orchitis  was  active,  bacteriological 
examination  of  any  urethral  discharge  is  essential  to  the  diagnosis,  which  depends 
on  whether  gonococci  are  detected  or  not.  If  gonorrhoea  can  be  excluded,  then 
the  diagnosis  of  the  nature  of  the  orchitis  is  arrived  at  by  considering  the  evidence 
as  to  gout,  mumps,  and  so  on. 

It  is  sometimes  stated  that  orchitis  may  result  from  strain,  atrophy  resulting 
in  due  course.  There  are  a  few  reported  cases  where,  apparently  as  the  result 
of  great  bodily  exercise,  especially  the  lifting  of  heavy  loads,  inflammation  of 
the  testicle  followed  ;  but  it  is  difficult  to  say  that  in  these  cases  the  strain  alone 
produced  the  symptoms  ;  there  is  the  possibility  that  a  residual  gonorrhoea 
may  have  been  present  in  the  prostate  or  posterior  urethra,  the  action  of  the 
strain  being  merely  to  light  up  the  latent  inflammation. 

There  remain  a  large  number  of  cases,  however,  in  which  there  is  no  clear 
history  of  any  orchitis,  the  latter  having  been  relatively  slight.  Testicular 
atrophy  will  then  seem  to  have  arisen  idiopathically,  and  it  will  be  very  im- 
portant to  remember  how  often  it  is  the  result  of  former  injury,  such  as  a  kick 
at  football,  a  blow  from  a  cricket  ball,  contusion  from  falling  astraddle  on  a 
fence  or  bicycle,  and  so  on.  The  injury  may  date  back  to  boyhood,  many  years 
before  testicular  atrophy  is  noticed,  and  it  will  often  be  difficult  to  prove  that 
the  latter  was  really  due  to  the  former. 

It  is  noteworthy  that,  apart  from  obviously  tuberculous  epididymo-orchitis, 
it  not  infrequently  happens  that  transient  enlargement  of  a  testicle  is  to  be 


8o  ATROPHY,     TESTICULAR 

obser\-ed,  if  looked  for,  in  tuberculous  subjects,  and  whether  this  can  be 
regarded  as  a  definite  tuberculous  orchitis  or  not,  it  sometimes  results  in 
atrophy.  In  a  consumptive  patient  some  degree  of  atrophy  of  one  testicle 
is  not  infrequent  ;  so  that  when  a  thin  patient  presents  himself  for  exam- 
ination, and  one  testicle  is  found  to  be  unduly  sniall  without  obvious  cause, 
the  examination  of  the  lungs,  and  if  necessarj^  of  the  sputum,  should  be  made 
with  particular  care. 

The  ;t;-rays  as  a  possible  cause  of  testicular  atrophy  should  not  be  forgotten, 
and  all  users  of  ^--rays  should  be  careful  to  have  a  suitable  lead  shield.  That 
sterility  can  result  from  repeated  applications  of  these  rays  is  well  known. 

Group  III. — Here,  the  history  of  the  cases  as  a  rule  gives  the  diagnosis. 
Remarkable  instances  have  been  recorded  in  which,  within  a  few  months  of 
injury  to  the  brain  or  spinal  cord,  particularly  after  injury  to  the  lumbar 
vertebrae,  or  the  occipital  region  of  the  skull,  the  glandular  elements  of  the 
testicle  have  disappeared.  A  case  of  Kocher's  exemplifies  this  very  well  : 
A  man,  ast.  41,  the  father  of  four  children,  fell  on  his  head  from  a  consider- 
able height.  At  first  he  did  not  appear  to  be  greatly  damaged,  but  presently 
twitchings  occurred,  and  the  patient  became  unable  to  work.  From  this  time 
on  his  sexual  powers  greatly  diminished,  and  his  beard  and  pubic  hair  fell  out. 
Eighteen  months  later  this  hair  was  completely  gone,  and  about  five  years 
after  the  accident  the  left  testicle  was  the  size  of  a  hazel  nut,  and  the  right  one 
the  size  of  a  bean.  Herbert  French. 

AURA  is  the  term  applied  to  the  immediate  prelude  of  an  epileptic  seizure. 
It  is  recognized  in  some  form  or  another  in  about  30  or  40  per  cent  of  epileptics, 
and  with  rare  exceptions  alwaj^s  takes  the  same  shape  with  every  attack  in 
each  individual.  An  aura  may  be  motor,  sensory,  psychical,  visceral,  or  related 
to  some  special  sense.  A  motor  aura  may  be  represented  by  an  involuntary^ 
movement  of  a  limb  or  a  part  of  a  limb  ;  in  other  cases  it  takes  the  form  of  a 
general  movement  such  as  running.  A  sensory  aura  is  common,  and  is  described 
as  a  pain,  a  numbness,  or  a  tingling  in  some  part  of  the  patient's  body.  A 
psychical  aura  is  often  expressed  as  a  vague  apprehension,  or  an  indescribable 
feeling,  or  a  sense  of  unreality.  A  visceral  aura  is  frequently  present,  usually  as 
an  "  epigastric  sensation  "  or  queer  feeling  starting  in  the  region  of  the  stomach 
and  rising  to  the  throat,  or  less  often  as  a  peremptory  desire  to  go  to  stool.  An 
aura  of  special  sense  may  be  oljactory,  visual,  auditory,  or  gustatory.  In  one 
case  a  pleasant  or  unpleasant  odour  or  flavour  may  be  perceived  by  the  patient. 
In  other  cases  some  alteration  in  vision  or  other  special  sense  may  be  realized 
by  him,  warning  him  of  the  onset  of  a  seizure.  In  the  case  of  an  auditory 
aura  it  is  customary  for  the  patient  to  hear  voices  or  some  particular  kind  of 
sound. 

The  aura  of  epilepsy  is,  in  relation  to  diagnosis,  important  from  at  least  two 
points  of  view.  In  the  first  place,  it  often  affords  a  clue  to  the  particular  locality 
in  the  brain  from  which  the  "  fit  "  or  "  storm  "  originates  and  spreads.  This 
may  not  be  of  much  value  in  the  case  of  idiopathic  epilepsy,  because  there  is 
no  method  at  present  known  to  us  by  which  the  seat  of  the  disease  can  be 
successfully  treated.  In  the  case  of  Jacksonian  epilepsy,  on  the  other  hand, 
the  knowledge  of  the  locality  in  which  a  fit  is  generated  sometimes,  although 
unfortunately  not  often,  allows  of  benefit  being  obtained  from  surgical  assist- 
ance. For  instance,  an  aura  ma}''  be  the  first  symptom  of  the  presence  of  an 
intracranial  growth.  A  tumour  of  the  uncinate  region  of  the  temporo-sphenoidal 
lobe  may  be  revealed  by  the  presence  of  signs  of  increased  intracranial  pressure 
and  the  repeated  occurrence  of  an  olfactory  aura,  followed  by  a  vague,  dreamy 
state  of  consciousness.     A  lesion  of   one  occipital  lobe  may  be  suspected  from 


BABINSKFS     SIGN 


the  occurrence  of  epileptiform  fits,  immediately  preceded  by  an  aura  in  which 
there  is  loss  of  sight  in  the  opposite  visual  field.  An  aura  of  pain  starting  in 
the  left  foot,  spreading  up  the  left  side  of  the  body,  and  terminating  in  a 
generalized  convulsion,  suggests  a  lesion  in  the  post-Rolandic  region  of  the 
right  parietal  lobe.  Such  instances  of  the  importance  of  an  aura  as  a  local- 
izing sign  in  diagnosis  might  easily  be  multiplied  were  it  necessary;  but  a 
general  knowledge  of  the  functional  anatom^^  of  the  brain  will  suffice  to  supply 
other  examples  of  a  similar  kind  to  the  reader's  mind. 

In  the  second  place,  the  importance  of  recognizing  a  subjective  sensation  as 
an  aura,  and  so  recognizing  the  existence  of  epilepsy  in  its  simplest  and  some- 
times earliest  form,  can  hardly  be  over-estimated  from  the  point  of  view  of 
treatment.  When  a  patient  describes  himself  as  being  liable  to  subjective 
sensations  occurring  at  intervals,  and  for  which  he  cannot  account,  careful 
inquiry  should  be  made  as  to  their  nature.  The  chief  characteristics  of  an 
aura  are  :  (i)  Its  spontaneous  development  without  cause,  generally  during 
good  health  ;  (2)  The  suddenness  of  its  onset  ;  and  (3)  The  identity  of  each 
sensation  with  the  last. 

It  should  be  understood  clearly  that  an  aura  may  occur  alone,  or  may  be 
followed  by  momentary  loss  of  consciousness  (petit  mal),  or  by  loss  of  conscious- 
ness with  convulsions  (grand  mal).  In  some  cases  an  aura  may  be  repeated 
with  frequency  for  many  months  before  a  typical  epileptic  seizure  supervenes, 
and  if  recognized  as  such  during  this  stage,  it  is  reasonable  to  expect  that  treat- 
ment will  have  more  chance  of  success  than  at  a  later  period,  when  the  "  habit  " 
of  convulsions  has  been  firmly  established. 

Finally,  it  should  be  emphasized  that  in  cases  of  epilepsy  the  recurrence  of 
an  aura,  even  without  further  manifestations  of  the  disease,  must  be  regarded 
as  evidence  that  the  morbid  tendency  is  not  completely  controlled,  and  that 
discontinuance  of  treatment  must  inevitably  lead  to  the  reappearance  of  more 
serious  attacks.  E.  Farquhar  Buzzard. 

BABINSKI'S  SIGN — consists  in  a  modification  of  the  plantar  reflex.  In 
testing  the  latter  the  patient  should  be  lying  upon  his  back,  with  his  legs  very 
slightly  flexed  and  each  foot  everted  so  that  its  outer  border  lies  comfortably  in 
contact  with  the  bed  or  couch  ;  the  sole  should  be  warm  and  dry  ;  the  ankle 
should  be  gently  but  firmly  grasped  by  one  of  the  observer's  hands,  to  prevent 
the  undue  dorsiflexion  of  the  whole  foot  which  often  makes  it  difficult  to 
decide  which  way  the  toes  themselves  move,  whilst  the  outer  side  of  the 
sole  is  firmly  and  steadily  stroked  from  the  heel  forwards  with  some  such 
instrument  as  the  butt  end  of  a  pencil.  In  healthy  adults  the  big  toe  and 
the  other  toes  will  become  plantar-flexed  ;  when  the  great  toe  becomes 
dorsiflexed  instead,  it  presents  the  extensor  plantar  reflex,  or  Babinski's 
sign.  It  is  important  to  bear  in  mind  that  whichever  way  the  other  toes 
move,  it  is  with  the  direction  of  movement  of  the  big  toe  alone  that  Babinski's 
sign  is  concerned. 

It  is  also  noteworthy  that  if  Babinski's  sign  is  present,  the  fact  is  usually 
ascertained  with  ease  ;  when  there  is  any  doubt  as  to  which  way  the  great  toe 
moves,  the  plantar  reflex  is  seldom  really  extensor. 

The  great  value  of  the  sign  is  in  distinguishing  between  certain  functional  and 
organic  affections  of  the  nervous  system.  If  the  patient  is  an  adult  who  is  fully 
conscious,  and  presents  symptoms  of  paresis  of  one  or  both  legs,  the  existence 
of  an  extensor  plantar  reflex  is  proof  that  the  lesion  is  organic.  The  converse 
is  not  true  ;  for  with  locomotor  ataxy,  and  with  lower  neurone  affections, 
such  as  infantile  paralysis.  Tooth's  peroneal  type  of  progressive  muscular 
atrophy,  peripheral  neuritis,  Landry's  acute  ascending  paralysis,  and  primary' 
D  <3 


82  BABINSKVS     SIGN 


muscular  dvstrophies,  the  plantar  reflex  is  flexor  so  long  as  it  is  obtain- 
able at  all. 

It  is  when  there  is  a  lesion  in  any  part  of  the  crossed  pyramidal  tracts  that 
Babinski's  sign  is  best  seen.  Thus,  it  is  present  in  cases  in  which  tumour, 
abscess,  haemorrhage,  thrombosis,  or  embolism  have  caused  hemiparesis  or 
hemiplegia  by  affecting  either  the  pyramidal  cells  themselves  in  the  motor 
cortex,  or  the  pyramidal  fibres  in  the  internal  capsule  ;  in  cases  of  cerebellar 
tumour,  owing  to  the  fact  that  this,  by  compressing  the  medulla,  nearly  always 
•causes  lateral  sclerosis  of  the  cord  as  well  ;  and  in  cases  of  disseminated  sclerosis, 
transverse  mvelitis,  either  primarj^  or  due  to  compression,  ataxic  paraplegia, 
Friedreich's  ataxv,  amvotrophic  lateral  sclerosis,  primary  lateral  sclerosis,  some 
cases  of  syringomA'elia,  and  in  those  cases  of  irregular  sclerosis  of  the  cord  that 
may  be  associated  with  severe  oligoc^j-thaemias,  such  as  pernicious  anaemia.  The 
■differential  diagnosis  of  these  conditions  will  be  found  under  Hemiplegia  (q.v.) 
and  Paraplegia  (q.v.).  Babinski's  sign  is  not  found  in  those  cases  of  hysteria 
that  sometimes  simulate  one  or  other  of  the  above  conditions  ;  provided  always 
that  the  patient  is  a  conscious  adult.  This  is  an  important  proviso,  because  the 
plantar  reflex  may  be  extensor  without  there  being  any  decided  changes  in  the 
cord  or  brain  in  infants  and  quite  young  children  ;  and  also  sometimes  in  adults, 
during  deep  sleep,  or  under  conditions  of  unnatural  unconsciousness,  such  as 
that  due  to  a  general  anaesthetic,  or  acute  alcoholic  intoxication,  or  such 
affections  as  epilepsy,  uraemia,  concussion,  saturnine  encephalopathy,  and  in 
some  other  forms  of  coma. 

These  exceptions,  however,  scarcely  detract  from  the  great  value  the  sign  has 
as  a  means  of  distinguishing  between  organic  and  functional  paralysis  of  the  legs 
of  the  upper  neurone  tT,-pe.  Herbert  French. 

BACILLURIA (See  Bacteriuria.) 

BACTERIURIA  (see  Plate  XII)  is  a  comprehensive  term  employed  to  indicate 
that  the  urine  when  freshly  voided  contains  micro-organisms  derived  from 
some  portion  of  the  genito-urinary  tract.  Bacilluria  is  a  term  of  similar  import, 
but  is  restricted  to  those  cases  in  which  rod-shaped  bacteria  are  present.  The 
normal  urethra  (male  and  female)  is  the  habitat  of  certain  non-pathogenic 
bacteria  (chiefly  cocci,  such  as  Streptococcus  brevis,  Staphylococcus  albus,  also 
varieties  of  Bacillus  xerosis,  etc.),  Avhich  are,  of  course,  present  in  urine  obtained 
under  ordinarj-  conditions.  Bacteriuria  as  a  pathological  condition  can  onlj- 
be  recognized  with  certainty  bj'  the  examination  in  the  laboratory  of  a  catheter 
specimen  of  the  urine  collected  with  the  most  scrupulous  attention  to  asepsis  ; 
for,  on  the  one  hand,  a  perfectlj^  clear  acid  urine  xsia.y  be  heavily  loaded  with 
bacteria,  and,  on  the  other,  a  urine  may  owe  its  turbidity  either  to  purely 
physico-chemical  causes,  or  to  the  growth  in  it  of  bacteria  which  have  gained 
access  after  its  exit  from  the  urethra. 

Moreover,  although  the  identity  of  the  infecting  organism  may  be  suspected 
from  general  clinical  considerations,  cultivation  experiments  are  essential  in 
order  to  settle  the  matter  beyond  doubt. 

Bacteriuria  may  indicate  either  general  or  local  infection.  It  is  a  rare  symptom 
of  general  infection,  save  one  of  such  intensity  that  an  acute  nephritis,  associated 
with  a  definite  haematuria,  has  supervened.  Usualh'  its  appearance  indicates 
a  purely  local  infection  ;  it  then  occurs  with  greatest  frequency  in  young  children 
and  pregnant  women,  when  the  micro-organism  concerned  is  usually  B.  coli,  and 
the  site  of  the  infection  the  pelvis  of  the  right  kidne3^  It  is,  however,  met  with 
at  all  ages  and  in  both  sexes,  and  many  different  bacteria  have  been  recorded  as 
the   causative   factors. 


BACTERIURIA 


83 


Bacteriuria  may  be  a  symptom  in  :— 

A.  General  Infections  due  to  : — 

Streptococcus  pyogenes  longus 

Pneumococcus 

Micrococcus  melitensis 

Gonococcus 

Staphylococcus  pyogenes  aureus 

B.  typhosus 

B.   coli  communis 

B.  paratyphosus 

B.  Local  Infections  :^ 


I'ith   or   without   associated 
nephritis. 


Nephritis  | 

Pyelo -nephritis  - 
Ureteritis  ) 


Cystitis 


Prostatitis 


Urethritis 


due  to- 


due  to 


due  to- 


due  to 


B.   coU 

B.  tuberculosis 

B.  pyocyaneus 

B.  pneumoniae  (Friedlander's  bacillus) 

Streptococcus  pyogenes  longus 

Pneumococcus. 

B.  coli 

B.  tuberculosis 

B.  typhosus 

Streptococcus  pyogenes  longus. 

B.  coli 

Gonococcus 

Staphylococcus  pyogenes  aureus 

Streptococcus  pyogenes  longus. 

Gonococcus 

Staphylococcus    pyogenes    aureus    or 
albus 

Pneumococcus 

Streptococcus  pyogenes  longus 

Micrococcus  catarrhalis. 
Finally,  a  slight  and  transitory  bacteriuria  due  to  B.  coli  communis,  and  usually 
passing  oirf  without  any  treatment,  can  frequently  be  observed  following  operative 
measures  upon  the  rectum  or  anus,  or  the  organs  of  generation. 

In  general  infections  the  urine  is  either  normal  in  appearance,  or  by  reason  of 
its  admixture  wdth  blood  may  present  any  tint  from  "  smoky  "  to  bright  red. 
The  reaction  is  acid,  albumin  is  present,  varying  in  amount  from  a  trace  to  7, 
8,  or  more  parts  per  thousand,  and  microscopical  examination  of  the  centri- 
fugalized  deposit  shows  the  presence  of  blood-cells,  renal  tube-casts,  and  renal 
epithelium,  in  addition  to  the  infecting  bacterium.  The  clinical  symptoms 
presented  by  the  patient  are  those  of  the  general  systemic  infection. 

In  local  infections  of  the  genito-urinary  tract  where  infection  is  due  to  one 
species  of  micro-organism  only,  the  urine  presents  a  somewhat  similar  appear- 
ance ;  blood,  however,  may  be  entirely  absent,  while  pus  is  usually  present  in 
larger  or  smaller  amount,  and  when  measured  by  the  help  of  the  centrifuge  may 
vary  in  volume  from  a  trace  to  10  or  20  per  cent  of  the  total  bulk  of  urine.  In 
the  early  stages  of  a  local  infection,  however,  the  microscopical  examination  of 
the  deposit  may  merely  show  the  presence  of  leucocytes  slightly  in  excess  of 
normal,  so  that  without  the  use  of  the  microscope  the  fact  of  pyuria  may  easily 
be  missed  altogether. 

Occasionally,  and  particularly  in  adult  cases,  it  may  be  noted  that  the  urine 
passed  during  the  day  is  neutral  or  faintly  alkaUne — ^the  change  in  reaction  then 
being  due  to  physiological  causes.     In  those  cases  where  the  urine  is  strongly 


84  BACTERIURIA 


alkaline,  the  alkalinity  is  due  to  ammonia  resulting  from  the  decomposition  of 
urea,  not  bv  the  pathogenic  infecting  organism,  but  bj-  non-pathogenic  sapro- 
phytes which  have  gained  access  to  the  urine,  either  after  it  has  been  voided,  or 
whilst  still  intra  vesicam.  In  the  latter  instance  the  contamination  may  have 
taken  place  as  a  result  of  careless  instrumentation,  or  (as  in  the  female)  b}^  con- 
tinuit}-  of  surface,  but  it  also  frequently  occurs  o-v\ing  to  the  passage  of  micro- 
organisms through  the  inflamed  bladder  walls  from  the  lumen  of  the  adjacent 
large  intestine. 

The  chnical  s^-mptoms  associated  with  bacteriuria  due  to  local  infection  \-ary 
enormously  \^ith  different  patients.  Frequencj^  of  micturition,  scalding,  dull 
aching  pains  in  one  or  both  loins,  with  tenderness  on  deep  pressure  over  the 
kidne\-,  pains  in  the  perineum  and  h\-pogastrium  (according  to  the  situation  of 
the  primary,-  infection),  severe  rigors,  p^Texia,  anorexia,  nausea,  and  vomiting 
are  amongst  those  commonly  observed.  It  is  important  to  remember  its  rela- 
tivelv  common  occurrence  in  children,  in  whom  the  constitutional  symptoms 
may  be  prominent  ^\ithout  any  special  urinary  s^-mptoms  attracting  notice.  The 
urine  generallv  contains  onlj-  a  trace  of  albumin,  and  no  obvious  pus  ;  the 
diagnosis  depends  upon  bacteriological  investigation  of  a  catheter  specimen, 
the  need  for  which  A\-ill  be  suggested  hy  the  discovery  of  a  decided  excess  of 
leucoc\-les  in  the  centrifugahzed  deposit.  /no.  Eyre. 

BALDNESS. — Alopecia,  or  baldness,  may  vary  in  degree  from  shght  thinning 
to  the  complete  loss  of  hair.  There  are  three  main  varieties  of  simple  baldness, 
namely  (i)  Congenital,  (2)  Senile,  and  (3)  Prematiire  alopecia. 

1.  In  the  congenital  variet3^  the  baldness  is  seldom  complete,  and  the  hair  may 
be  lanugo-hke.  In  the  latter  case  the  diagnosis  is  certain,  as  it  also  is  when  the 
baldness  is  accompanied  by  developmental  defects  in  the  skin  or  its  appendages. 

2.  Senile  alopecia  needs  neither  description  nor  diagnosis. 

3.  Premature  alopecia  may  be  (a)  idiopathic  or  (6)  symptomatic.  The  former, 
much  less  frequent  than  the  latter,  and  due  to  no  recognizable  cause  except 
heredity-,  usually  begins  between  the  ages  of  tsventy  and  thirty-five  ;  in  man}- 
cases  at  the  vertex,  hke  senile  baldness,  but  often  at  the  temple,  when  it  extends 
backwards  elHptically. 

S\-mptoinatic  premature  baldness  may  be  either  temporar\-  or  permanent, 
gradual  or  rapid,  and  is  dependent  upon  a  great  variety-  of  local  or  constitutional 
causes,  including  seborrhcea  of  the  scalp,  psoriasis,  chronic  eczema,  erysipelas, 
ringworm,  favus,  lupus  erythematosus,  syphilis  ;  it  is  also  a  sequela  of  fevers  or 
other  acute  systemic  diseases.  \Mien  it  occurs  as  a  sequel  to  fevers,  in  syphilis, 
ring^vorm  (except  after  severe  kerion),  er\-sipelas,  and  eczema,  the  loss  of  hair 
is  usually  but  temporary- ;  in  seborrhcea,  favus,  lupus  erythematosus,  morphoea, 
and  folliculitis  decalvans,  it  is  generally  permanent,  and  is  alwaj'S  so,  of  course, 
when  the  hair-folhcles  have  been  destroyed. 

The  most  important  form  of  symptomatic  baldness  is  that  which  is  associated 
with  seborrhcea,  whether  of  the  oily  or  of  the  dry  kind.  Seborrhoeic  alopecia 
has  the  same  distribution  as  idiopathic  baldness,  as  described  above.  Another 
form  of  symptomatic  baldness  is  the  condition  known  as  alopecia  areata,  in 
which  the  hair  falls  out  in  patches,  generally  of  irregular  distribution.  Usually 
the  patches  continue  to  spread  for  a  time,  and  may  run  into  others,  denuded  areas 
thus  being  formed,  of  irregular  outhne,  with  a  surface  white  and  smooth  as  a 
billiard  ball.  The  hairs  at  the  edges  of  the  patches  are  looser  than  the  others, 
and  among  them  may  be  seen  short  hairs  that  show  signs  of  atroph}-  close  to  the 
root,  so  that  the}'  resemble  a  note  of  exclamation  (?) .  In  rare  cases,  the  hair  falls 
out  not  in  patches  but  more  generalh',  and  very  rapidly  ;  and  soon  the  whole 
.scalp  may  be  bared,  and  even  the  hair  of  the  whole  body  may  be  lost,  and  with 


BLEEDING     GUMS  85 


it  the  nails  of  the  fingers  and  toes.  The  affection  with  which  alopecia  areata  is 
most  easily  confounded  is  ringworm  of  the  trichophytic  variety  :  the  differential 
diagnosis  between  the  two  affections  will  be  found  under  Fungoid  Affections 
OF  THE  Skin. 

Alopecia  areata  may  also  be  confused  with  another  form  of  symptomatic 
baldness,  namely,  alopecia  cicatrisata,  the  pseudo-pelade  of  Brocq,  in  which 
depressed  islands  of  baldness,  round  or  of  irregular  shape,  occur  on  the  scalp, 
the  patches  usually  spreading  and  coalescing  into  large,  smooth,  shiny  areas. 
But  here  the  patches  are  cicatricial  ;  there  is  destruction  of  the  follicles,  so 
that  the  hair  is  never  restored  ;  there  are  normal-looking  hairs  on  the  bald 
areas,  and  the  note-of-exclamation  stumps  of  alopecia  areata  are  absent.  The 
bald  patches  sometimes  met  with  in  secondary  syphilis  may  be  distinguished 
from  those  of  alopecia  areata  by  the  co-existence  of  other  s\'philitic  symptoms, 
and  by  the  effects  of  specific  treatment.  The  bald  areas  of  lupus  erythematosus 
are  in  greater  or  less  degree  cicatricial,  there  is  destruction  of  the  folhcles,  and 
a  border  which  is  slightly  or  distinctly  inflamed.  Folliculitis  decalvans  is 
cicatricial  also,  and  at  the  edge  of  the  bare  patches  a  small  red  papule  or  patch 
of  erythema  can  be  seen  surrounding  each  follicle.  Malcolm  Morris. 

BEARING-DOWN  PAIN (See  Pain,  Bearing-down.) 

BLEEDING  GUMS. — A  spongy,  bleeding  condition  of  the  gums,  attaining 
such  a  degree  that  the  teeth  became  covered  over  by  the  exuberant  blood-oozing 
tissues,  was  a  prominent  feature  of  scurvy,  a  serious  and  often  fatal  disease  which 
used  to  be  common  on  sailing  ships  when  fresh  food  was  necessarily  absent 
from  the  diet  for  weeks  or  even  months  at  a  time.  It  is  now,  fortunatel}-,  very 
rare  in  its  full  development,  but  is  still  found  in  a  mild  form  amongst  children 
— infantile  scurvy,  or  Barlow's  disease — as  the  result  of  long-continued  feeding 
with  tinned  milk  without  fresh  food.  Its  chief  features  are  aneemia  and  tender- 
ness of  the  long  bones  due  to  haemorrhages  under  the  periosteum  ;  in  severer  cases, 
there  may  be  purpura  and  other  obvious  haemorrhages,  including  sponginess 
and  bleeding  of  the  gums,  with  a  more  or  less  general  condition  of  stomatitis. 
The  diagnosis  is  suggested  by  the  history  of  tinned-milk  diet,  and  confirmed  by 
the  benefit  that  follows  the  addition  of  fresh  milk  and,  in  older  children,  fresh 
vegetables.  A  similar  condition  may  arise  in  adults  whose  circumstances 
compel  them  to  live  on  tinned  foods. 

There  are,  however,  many  other  causes  of  bleeding  of  the  gums  besides  scurvy. 
The  differential  diagnosis  is  generally  easy,  but  sometimes  may  be  very  difficult. 
The  first  point  to  determine  is  whether  the  gum  condition  is  due  to  local  changes 
only,  or  whether  it  is  part  of  a  more  general  condition. 

{A).  Bleeding  Gums  due  to  General  Conditions  or  preceded  by  Lesions  else- 
where than  in  the  Mouth  : — 


Scurvy 

Splenomedullary  leukaemia 
Lymphatic  leukaemia 
Hodgkin's  disease 
Pernicious  anaemia 
Aplastic  anaemia 
Splenic  anaemia 
Haemophilia 


Iodide  poisoning 

Phosphorus  poisoning 

Arsenic  poisoning 

Lead  poisoning 

Tuberculous  gingivitis 

Febrile  or  asthenic  states  accom- 
panied by  sordes,  e.g.,  pneu- 
monia,    the     later     stages     of 


Purpura,  whether  due  to  any  of  malignant      cachexia,      general 

the  above  causes,  or  to  others     ;  paralysis,  acute  yellow  atrophy 


(see  Purpura) 
Syphilis 
Mercurialism 


of  the  liver,  and  so  forth 
Dyspepsia. 


BLEEDING     G  UMS 


(B).  Bleeding  Gums  due  to  purely  Local  Conditions 


Injury,  e.g.,  by  tooth  brush  ;  the 
result  of  bee  or  wasp  sting  ;  and 
so  forth 

Dental  caries 

Tartar 

Pyorrhoea  alveolaris 

Alveolar  abscess 

Papilloma 

Epulis 

Myeloid  sarcoma 

Epithelioma 

Actinomycosis 


Acute    or   chronic   stomatitis,  not 
obviously  due    to    any    of   the 
causes  already  mentioned  ;  e.g. : 
Aphthous  stomatitis 
Ulcerative  stomatitis 
Gangrenous    stomatitis    (can- 
crum  oris,  phagedsena  oris, 
or  noma  oris) 
Erythema     buUosum,     dermatitis 
herpetiformis,  pemphigus,  affect-, 
ing   the  mouth  as    well   as    the 
epidermis 


A.  Bleeding  Gums  due  to  General  Conditions. — Many  of  the  above  conditions 
are  discussed  under  other  and  more  prominent  symptoms,  so  that  here  we  need 
refer  but  briefly  to  them  (see  Spleen,  Enlargment  of  ;  Anaemia  ;  Purpura  ; 
etc.).  A  blood-count  may  be  required,  in  order  to  diagnose  or  exclude  spleno- 
medullary  or  lymphatic  leukcBwiia,  or  pernicious  ancemia.  The  family  history 
may  suggest  hcsmophilia.  Splenic  ancsmia,  Hodgkin's  disease,  and  aplastic 
ancemia  attract  attention  more  on  account  of  the  enlargement  of  the  Spleen 
iq.v.),  or  of  the  Lymphatic  Glands  {q.v.),  or  of  the  Anemia  [q.v.),  than  because 
of  spongy  gums.     Purpura  (q.v.)  is  itself  a  symptom  and  not  a  disease. 

Syphilis,  particularly  in  its  secondary  stage,  may  produce  stomatitis,  pharyn- 
gitis, laryngitis,  and  gingivitis,  with  more  or  less  tendenc}^  to  bleeding,  even 


/•'I'g:  lo  — Primary  syphilitic  sore  on  the  lower  lip. 


when  no  mercurial  treatment  has  been  adopted  ;  the  secondary  roseola  may 
still  be  present,  or  the  history  may  be  obvious.  Difficulty  arises  mainly  in  women 
and  children,  and  when  the  chancre  has  been  extragenital  {Fig.  lo).  Wasser- 
mann's  serum  test  may  be  tried,  or  the  Spirochceta  pallida  [Plate  XII,  Fig.  J) 
looked  for  in  scrapings  from  the  mucous  lesions. 

Mercury  is  very  liable  to  cause  profuse  salivation  and  acute  stomatitis,  with 
most  distressing  and  painful  swelling  of  lips,  gums,  tongue,  and  cheeks  ;  swallow- 
ing may  become  impossible,  the  glairy  saliva  hangs  in  strings  from  the  protruding 
tongue  and  bulging  lips,  the  mucosa  bleeds  on  the  slightest  touch,  and  the  patient 
is  the  picture  of  abject  misery.  Some  persons  are  far  more  susceptible  than  others 
to  the  effects  of  mercury  ;  but  its  worst  effects  have  occurred  when  the  remedy 
has  been  employed  in  excess  in  the  treatment  of  syphilis,  especially  when  the 
teeth  are  carious,  or  when  the  mouth  has  not  been  kept  clean  with  a  tooth-brush 
after  each  meal,  and  when  there  is  albuminuria  (syphilitic  nephritis)  at  the  same 
time.  The  diagnosis  depends  upon  a  knowledge  of  the  drugs  that  are  being  given 
or,  in  occupation  cases,  of  the  chemicals  that  the  patient  has  been  working  with. 


BLEEDING     GUMS  87 


Iodides  may  cause  profuse  coryza,  due  to  conjunctival,  nasal,  and  oral  catarrh, 
but  the  amount  of  bleeding  that  accompanies  it  is  slight.  The  nature  of  the 
drugs  being  taken  will  suggest  the  diagnosis,  or  if  there  is  doubt  as  to  the  drugs, 
the  urine  may  be  tested  for  iodides. 

Phosphorus  used  to  produce  very  severe  stomatitis,  going  on  to  necrosis  of  the 
jaw — "  phossy  jaw  " — not  infrequently  ending  in  death  as  the  result  of  fatty 
degeneration  of  the  liver  and  heart  ;  this  is  uncommon  since  restrictions  have 
been  laid  upon  the  use  of  crude  yellow  phosphorus  in  the  manufacture  of 
matches.     The  occupation  generall}^  serves  to  suggest  the  diagnosis. 

Arsenic  and  lead  are  both  rare  causes  of  bleeding  gums  ;  occupation,  or  medical 
prescription,  or  habits  as  regards  drinking,  may  suggest  the  diagnosis,  and  there 
may  be  other  signs  of  the  poisoning,  particularly  pigmentation  of  the  skin, 
vomiting,  diarrhoea,  hyperkeratosis  of  the  soles  and  palms,  and  generalized 
peripheral  neuritis  in  the  case  of  arsenic  ;  and  the  symptoms  given  elsewhere  in 
the  case  of  lead.  Arsenic  may  be  found  in  excess  in  the  hair,  or  lead  may  be 
detected  in  the  residue  from  a  bulk  of  urine. 

Tuberculous  gingivitis  is  rare,  but  when  it  does  occur  it  is  very  severe.  The 
nature  of  the  bleeding  gums  will  be  suggested  by  the  co-existence  of  phthisis  with 
cavitation,  and  abundant  sputum  teeming  with  tubercle  bacilli  ;  the  latter  may 
also  abound  in  scrapings  from  the  gum. 

Febrile  and  asthenic  states  onlv  cause  sordes  and  bleeding  gums  when  the 
patient  has  already  been  ill  some  while,  or  when  the  nursing  has  been  remiss  • 
the  diagnosis  will  depend  on  symptoms  other  than  those  connected  with  the  gums. 

Dyspepsia  is  a  recognized  cause  for  sponginess  of  the  gums,  shallow  peptic 
ulcers,  and  bleeding  on  sUght  provocation  ;  but  there  is  often  difficulty  in  being' 
sure  that  the  dyspepsia  is  not  due  to  the  swallowing  of  septic  products  from 
infected  teeth  and  gums,  rather  than  the  gum  condition  secondary  to  the  stomach. 

B.  Bleeding  Gums  due  to  Local  Conditions. — When  care  has  been  taken  to 
exclude  general  causes  of  bleeding  of  the  gums,  differentiation  between  the 
various  local  causes  is  not  difficult.  Some  patients  are  alarmed  by  the 
symptom  when  its  cause  is  nothing  more  than  the  use  of  a  new  tooth-brush, 
whose  bristles  have  slightly  lacerated  gums  that  are  accustomed  to  an  older 
and  softer  brush.  The  history  will  indicate  other  forms  of  local  injury — an 
ill-fitting  tooth-plate,  perhaps. 

Dental  caries  inay  be  obvious,  or  it  may  be  hidden  away  between  adjacent 
teeth  and  yet  be  irritating  the  gum  enough  to  cause  it  to  bleed  with  undue 
readiness,  for  instance  when  the  teeth  are  brushed.  Tartar  will  be  obvious  on 
inspection.  Pyorrhoea  alveolaris,  also  known  as  suppurative  gingivitis  or  Rigg's 
disease,  is  the  result  of  septic  infection  around  the  teeth  extending  down  into  the 
sockets  and  loosening"  them,  causing  the  gum  margins  to  recede  by  a  process  of 
erosion,  and  leading  to  a  purulent  discharge  from  between  the  gums  and  the 
teeth.  It  is  possible  for  this  condition  to  be  present,  even  when  the  external 
aspect  of  the  teeth  seems  perfect  ;  a  very  fine  probe  may  sometimes  be  passed 
painlessty  down  into  the  tooth-socket  between  adjacent  teeth,  where  the  sup- 
purative process  has  been  progressing  unsuspected,  and  out  of  the  reach  of  the 
tooth-brush  as  used  in  the  ordinary  way.  The  gums  bleed  with  the  greatest 
ease  in  severe  cases,  the  breath  is  foul,  and  the  constant  swallowing  of  pyogenic 
organisms  and  their  products  leads  to  dyspepsia,  anaemia,  chronic  ill  health, 
listlessness,  functional  nerve  disorders,  and  sometimes  more  acute  symptoms  of 
general  pyaemia,  especially  multiple  infective  synovitis  and  arthritis.  Neur- 
asthenia and  depression  ultimately  ensue  in  many  cases,  and  sometimes  very 
severe  and  even  fatal  anaemia. 

The  diagnosis  of  alveolar  abscess  is  generally  obvious,  though  infection  of  a 
benign   or   malignant   new   growth   may   simulate   it   for   a   time.     Microscopical 


BLEEDING     GUMS 


examination  of  the  excised  tumour  is  the  only  certain  way  of  diagnosing  the 
nature  of  an  odontoma,  papilloma,  simple  epulis,  myeloid  sarcomatous  epulis, 
myeloid  sarcoma  of  the  jaw,  or  epithelioma  of  the  gum. 

Actinomycosis  is  a  very  rare  lesion  in  man  ;  but  the  jaws,  gums,  or  cheeks  are 
parts  that  are  least  uncommonly  affected.  The  chronic  nature  of  that  which 
partakes  of  the  characters  partly  of  a  neoplasm  and  partly  of  an  abscess,  in  a 
person  who  has  had  occasion  to  put  straws,  cotton,  or  other  vegetable  products 
into  his  mouth  or  between  his  teeth,  may  suggest  the  diagnosis,  which  will  be 
confirmed  by  the  finding  of  the  ray  fungi  in  the  purulent  discharge,  or  in  sections 
from  parts  excised.  Minute  grey  or  yellowish-grey  specks  in  the  pus  are  said 
to  be  characteristic,  but  they  are  not  always  to  be  seen,  and  it  is  only  by  micro- 
scopical examinations  that  the 
diagnosis  can  be  made  with  cer- 
tainty (see  Plate  XII,  Fig.  S). 

Stomatitis  in  its  various  degrees 
may  have  a  general  cause,  such  as 
mercurialism  (see  above)  ;  or  it 
may  be  due  to  purely  local  infec- 
tion with  micro-organisms.  It 
might  perhaps  be  classified  bac- 
teriologically — the  variety  spoken 
of  as  thrush  being  due  to  the 
oidiimi  albicans,  for  instance. 
Clinically,  however,  it  is  more 
often  classified  by  its  degree,  into 
acute  catarrhal,  ulcerative,  and 
gangrenous.  All  these  affect  the 
mucosa  of  cheeks,  lips,  tongue,  and 
palate,  in  addition  to  the  gums, 
and  any  of  the  inflamed  parts 
bleed  readily.  The  first  degree  is 
characterized  by  redness,  swelhng, 
tenderness,  and  pain,  with  inability 
to  move  the  tongue  about  in  order 
to  eat  and  swallow,  swelling  and 
protrusion  of  the  hps,  foulness  of 
the  breath,  and  very  often  saliva- 
tion. There  may  or  may  not  be 
localized  greyish  or  white  aphthous  patches  ;  these  are  commoner  in  children. 
When  ulcers  occur,  these  are  generally  multiple  and  shallow,  very  painful,  with 
more  or  less  glazing  of  the  ulcerated  surface,  and  acute  hyperaemia  of  the  margins. 
The  gangrenous  form  is  better  known  by  the  title  cancrum  oris  (Fig.  ii),  fortu- 
nately rare,  though  sometimes  seen  in  ill-cared-for  children  who  have  contracted 
measles  or  some  other  acute  debilitating  fever.  The  cheek  is  the  first  affected 
by  the  gangrene,  acute  generahzed  stomatitis  being  followed  by  the  appearance 
of  a  black  spot  within  and  without,  rapidly  spreading  and  leading  to  sloughing 
and  perforation  of  the  cheek,  gangrene  of  the  gums  and  jaw,  falling  out  of 
the  teeth,  a  very  foul  nauseating  odour  of  the  breath,  and  death  from  utter 
exhaustion.     The  diagnosis  is  generally  obvious. 

Erythema  bullosum,  dermatitis  herpetiformis,  and  pemphigus — particularly  the 
first  of  these — may  affect  mucous  membranes  as  well  as  the  skin,  especially  the 
mouth,  colon,  and  vagina.  The  result  as  regards  the  mouth  is  very  distressing  ; 
the  crusts  and  resultant  inflammation  of  lips,  gums,  tongue,  cheeks,  palate, 
fauces,  and  pharynx,  may  make  it  impossible  for  food  to  be  taken  orally,  and 


-Cancrum  oris. 


BLOOD     PER     ANUM  89 


the  patient  rapidly  loses  weight  and  becomes  very  ill.  The  mucous  membrane 
everywhere  bleeds  on  the  slightest  touch,  and  the  condition  is  pitiable.  There 
is  generally  pyrexia.  The  diagnosis  is,  as  a  rule,  easy,  for  the  mucous  membranes 
are  very  seldom  attacked  unless  the  skin  is  affected  also  (see  Bull.;^,  and 
EosiNOPHiLiA).  Herbert  French 

BLINDNESS.— (See  Vision,  Defects  of.) 

BLISTERS. — (See  Bull.e.) 

BLOOD  PER  ANUM. — Blood  may  be  passed  per  anum  whenever  bleeding 
takes  place  from  any  part  of  the  alimentary  canal.  If  it  comes  from  a  point 
high  up,  as  from  the  stomach  or  duodenum,  it  is  usually  altered  in  appearance, 
so  that  black,  tarry  stools  are  passed  (melaena)  ;  whereas,  if  it  comes  from  the 
large  intestine  or  from  the  lower  end  of  the  ileum,  it  is  passed  as  red  blood, 
easily  recognizable  as  such.  If  the  quantity  is  very  large,  it  may  be  bright  red, 
even  in  the  case  of  highly  situated  lesions  ;  the  colour  depends  on  the  rapidity 
of  passage  through  the  bowel  and  the  consequent  extent  to  which  the  digestive 
juices  have  acted  upon  it. 

Recognition  of  the  actual  presence  of  blood,  pure  or  mixed  with  the 
motions,  is  not  often  difficult,  except  when  the  quantity  is  small.  The  typical 
tarry  stools  of  haemorrhage  high  up  in  the  alimentary  tract  are  unlike  anything 
else.  The  black  colour  is  much  more  pronounced  than  in  such  conditions  as 
pigmentation  of  the  stools  with  iron  or  bismuth  sulphide,  which  produce  rather 
a  slatey  or  dirty  greyish-black  tint  ;  while  the  viscid  consistency  of  the  haemor- 
rhagic  stool  is  also  characteristic.  Administration  of  charcoal  by  the  mouth 
may  produce  deep  black  stools,  and  eating  bilberries  is  also  said  to  do  so.  In 
case  of  doubt,  the  chemical  and  spectroscopical  tests  for  blood  may  be  applied  ; 
for  which  purpose  it  is  best  to  acidulate  the  faeces  strongly  with  acetic  acid 
and  to  extract  the  acid  mixture  with  ether  ;  a  clear  solution  of  blood-pigment  is 
thus  obtained,  suitable  for  the  spectroscope  or  for  the  guaiacum  test.  In  some 
cases  blood-corpuscles  may  be  recognizable  under  the  microscope,  if  a  portion 
of  the  faeces  is  rubbed  up  with  physiological  saline  solution.  Grains  of  charcoal 
will  be  distinguishable  under  the  microscope  if  this  substance  has  been  taken. 

The  conditions  associated  with  the  passage  of  blood  per  anum  may  be 
most  conveniently  divided  for  diagnostic  purposes  into  :  (i)  Those  in  which 
large  quantities  of  altered  blood  are  passed  (true  melaena)  ;  (2)  Those  in  which 
large  quantities  of  red  or  unaltered  blood  are  voided  ;  (3)  Those  in  which  small 
amounts  of  such  blood  are  seen  ;  and  (4)  Cases  of  so-called  occult  hcemorrhage 
only  recognizable  by  chemical  or  other  special  tests.  The  conditions  classed 
under  headings  (2)  and  (3)  necessarily  overlap,  inasmuch  as  the  exact  quantity 
of  blood  discharged  is  very  variable  ;  the  former  comprises,  roughly  speaking, 
affections  of  the  bowel  ;    the  latter,  lesions  about  the  rectum  and  anus. 

I.  Large  quantities  of  blood  may  escape  in  cases  of  ulceration  of  the  stomach 
or  duodenum.  It  is  usually  mixed  with  acid  gastric  juice,  and  thus  blacketied. 
Such  cases  are  generally  associated  with  pain  after  meals,  vomiting,  haemat- 
emesis,  and  increased  acidity  of  the  gastric  juice.  Tenderness  will  be  elicited  on 
pressure  over  the  epigastrium,  most  often  at  a  point  rather  to  the  right  of  the 
middle  line  and  about  four  inches  below  the  xiphisternal  junction  in  the  pyloric 
region.  Distinction  between  the  two  lesions  is  difficult  :  but  in  gastric  ulcer- 
ation the  pain  usually  arises  within  an  hour  after  meals,  and  is  relieved  by 
vomiting  ;  in  duodenal  ulcer,  the  pain  often  reaches  its  acme  about  three  or  four 
hours  after  a  meal,  and  it  may  at  first  be  relieved  by  taking  food.  In  gastric  ulcer, 
the  greater  part  of  the  blood  which  escapes  is  likely  to  be  vomited  ;  in  duodenal, 
most  of  it  to  be  passed  per  anum.     Duodenal  ulceration  is  most  common  in 


90  BLOOD     PER    ANUM 


men.  The  symptoms  of  gastric  ulcer  are  much  more  common  in  women,  but 
it  has  been  shown  that  in  many  such  instances  no  actual  ulcer  can  be  found, 
the  blood  escaping  apparently  by  a  process  of  oozing  through  the  mucous 
membrane — a  condition  referred  to  by  Dr.  Hale  White  as  gastrostaxis. 

2.  Large  quantities  of  unaltered  or  but  slightly  altered  blood  may  be  due 
to  ulceration  of  the  small  intestine,  as  in  enteric  fever,  tuberculosis,  or  the 
peculiar  lesions  associated  with  chronic  interstitial  nephritis.  The  phenomena 
of  enteric  fever  need  not  be  detailed  at  length — initial  headache,  epistaxis,  and 
fever  ;  fullness  of  the  abdomen  and  possibly  diarrhoea,  rose  spots,  enlargement 
of  the  spleen  mental  dullness  or  delirium  ;  leucopenia,  and  Widal's  agglu- 
tinative reaction  in  the  blood.      Tuberculous  ulceration  of  the  intestine  seldom, 

.  if  ever,  occurs  apart  from  tuberculosis  of  the  lungs,  and  it  is  a  rare  cause  of 
profuse  intestinal  haemorrhage.  It  is  associated  with  pain  and  tenderness  in 
the  abdomen,  and  with  emaciation  and  signs  of  pulmonary  disease. 

Chronic  Bright's  disease  may  be  associated  with  haemorrhage  from  the  bowel 
as  from  other  parts  of  the  body.  The  absence  of  other  causes,  such  as  ulceration  ; 
the  existence  of  high  blood-pressure  and  enlargement  of  the  left  ventricle,  the 
cardiac  impulse  being  displaced  outwards  and  downwards  ;  polyuria  ;  and  the 
constant  or  occasional  appearance  of  albumin  and  renal  tube-casts  in  the  urine, 
with  weakness,  anaemia,  and  perhaps  epistaxis,  will  point  to  this  cause. 

Bleeding  into  the  pancreas  and  embolism  or  thrombosis  of  one  of  the  mesenteric 
vessels  may  both  lead  to  moderate  haemorrhage  from  the  bowel.  In  both  alike, 
there  will  be  symptoms  of  sudden  abdominal  pain  and  constipation,  with 
collapse,  closely  resembling  the  phenomena  of  intestinal  obstruction.  A  certain 
diagnosis  can  hardly  be  made  without  laparotomy.  Patients  who  suffer  from 
pancreatic  apoplexy  are  usually  fat.  Blocking  of  a  mesenteric  vessel  by  embolism 
is  most  likely  to  occur  in  sufferers  from  some  form  of  cardiac  disease,  especially 
malignant  or  ulcerative  endocarditis. 

A  good  deal  of  blood  may  be  passed  per  anum  in  some  cases  of  general 
hcemorrhagic  conditions,  such  as  profound  anaemia,  leukaemia,  and  purpura  haemor- 
rhagica.  The  general  appearance  of  the  patient,  and  examination  of  the  blood, 
will  suffice  to  distinguish  the  two  former ;  and  in  the  last  there  will  probably  be 
visible  haemorrhages  in  the  skin  and  bleeding  from  other  mucous  surfaces. 

In  the  peculiar  condition  known  as  Henoch's  purpura  there  occur  attacks 
of  colic,  constipation  and  vomiting,  with  passage  of  blood  per  anum.  The 
symptoms  may  closely  simulate  intestinal  obstruction  or  intussusception,  and 
may  be  indistinguishable  from  mesenteric  embolism.  A  diagnosis  may  some- 
times be  made  when  other  phenomena  of  bleeding  are  present,  such  as  haemat- 
emesis,  haematuria,  petechiae  in  the  skin,  or  epistaxis,  or  by  concomitant 
affections  of  joints  (haemorrhagic  arthritis)  :  the  patient  is  generally  3'oung  ; 
a  history  of  previous  attacks  may  also  be  obtained. 

The  possibility  of  the  rupture  of  an  aneurysm  into  the  stomach  or  bowel  may 
be  mentioned  for  the  sake  of  completeness  ;  a  diagnosis  can  only  be  made  by 
recognition  of  the  pulsating  aneurj^smal  swelling,  and  the  condition  will  probably 
be  rapidly  fatal. 

In  infants,  considerable  quantities  of  blood  may  be  passed  per  anum  owing  to 
septic  infection  of  the  umbilical  cord,  the  haemorrhage  arising  either  from  an 
actual  ulcer  of  the  stomach  or  duodenum,  or  from  a  purpuric  condition  caused 
by  bacterial  toxaemia. 

3.  Haemorrhage  of  moderate  degree  is  usually  associated  with  disease  of  the 
large  intestine,  though  occasionally  profuse  bleeding  may  occur  in  such  affections. 
The  blood  is  bright  in  colour  and  generally  mixed  with  mucus.  In  tropical 
dysentery  there  is  severe  tenesmus  and  great  frequency  of  defaecation,  only 
blood-stained  mucus  in  small  quantities   being  passed  when  the  disease  is  well 


BLOOD     PER     ANUM  91 


established.  In  ulcerative  colitis,  which  appears  to  be  a  bacillary  dysentery 
of  temperate  cHmates,  there  are  the  same  diarrhoea,  frequency  of  defaeca- 
tion,  and  wasting,  as  characterize  the  tropical  malady,  but  tenesmus  is  less 
marked  and  the  stools  are  usually  more  faecal.  Some  cases  of  ulcerative 
colitis  closely  simulate  enteric  fever  ;  they  may  be  distinguished  by  absence 
of  Widal's  reaction,  and  by  recognition  of  the  ulcers  in  the  lower  part  of  the 
large  bowel  by  means  of  the  sigmoidoscope. 

Examination  of  the  stools  in  cases  of  tropical  dysentery  may  reveal  the 
presence  of  the  Amoeba  histolytica  {Fig.  12).  This  large  organism  measures 
some  30  to  40  J.L  in  diameter,  and  is  distinguished  from  the  harmless  A  moeba  coli 
by  its  well-developed  clear  outer  layer  of  ectoplasm,  by  its  small  and  eccentric- 
ally placed  nucleus,  and  by  the  presence  of  ingested  blood-corpuscles  within  its 
substance.  In  bacillary  dysentery  the  pathogenic  organisms  belong  to  a  group 
of  closely  allied  bacteria  grouped  under  the  title  B.  dysenteries.  They  are  short, 
rod-shaped  bacteria,  with   rounded  ends,  somewhat  resembling  B.  typhosus,  but 

N 


ct 


N 


N 


i? 


Fig.  12. — {aa)  Ainceba  histolytica  (after  Jiirgen.s)  ;  (i^)  Auiceba  coli,  motile  form  ; 
{b')  Aviceba  coli,  encysted  (after  Casagrandi  and  Barbagallo.  (N)  Nucleus  ;  (N')  Nuclei 
atter  division  ;  (C)  Blood  corpuscles.     (High  power  of  the  microscope.) 

non-motile.  These  bacilli  grow  on  ordinary  laboratory  media,  do  not  coagulate 
milk,  and  do  not  form  indol.  They  are  not  stained  by  Gram's  method.  The 
exact  bacteriology  of  ulcerative  colitis  is  undetermined. 

Malignant  disease  0/  the  intestine  may  give  rise  to  some  degree  of  haemorrhage. 
In  a  typical  case  of  cancer  of  the  large  bowel,  an  elderly  person  has  suffered  from 
gradually  increasing  weakness,  wasting,  and  constipation.  Attacks  of  colicky 
pain  may  supervene,  and  some  enlargement  of  the  abdomen  may  be  noticed. 
Blood  may  be  present  in  the  motions  from  time  to  time,  but  is  not  often  a  marked 
eature  ;  rarely,  a  moderate  degree  of  haemorrhage  may  occur.  Examination 
of  the  abdomen  may  reveal  vermicular  movements  of  the  hypertrophied  bowel, 
which  tend  to  pass  in  a  definite  direction  along  the  course  of  the  colon,  and  to 
cease  at  a  particular  point.  Here  a  definite  tumour  may  be  palpable  ;  but  as 
the  flexures  of  the  colon  are  favourite  seats  for  neoplasms,  it  often  happens 
that  the  growth  is  situated  deeply  in  the  pelvis  or  beneath  the  lower  ribs,  and 
cannot  be  felt.     There  is  little  or  no  fever  unless  there  are  extensive  secondary 


92  BLOOD     PER     ANUM 


deposits,  especially  in  the  liver.     Acute  intestinal  obstruction  may  finally  occur. 

As  contrasted  with  the  above,  non-malignant  ulceration  of  the  colon  is 
likely  to  have  a  more  marked  onset,  with  pain,  frequency  of  defaecation, 
and  loose  motions.  The  stools  often  contain  considerable  quantities  of  blood 
mixed  with  mucus.  The  bodily  temperature  is  raised,  often  to  a  high  degree 
(103°  F.),  pain  is  more  constant,  and  tenderness  may  be  elicited  all  along 
the  course  of  the  large  intestine.  Often  the  ulceration  extends  into  the  sigmoid 
flexure  of  the  colon,  and  may  be  visible  on  examination  with  the  sigmoidoscope. 

In  intussusception,  blood  and  mucus  are  passed  without  fsecal  matter  accom- 
panying them.  The  condition  is  commonest  in  infants  and  young  children. 
There  are  usually  symptoms  of  severe  illness,  with  screaming,  drawing  up  of  the 
legs,  frequent  pulse,  and  some  collapse  ;  rarely  the  condition  may  be  encountered 
with  but  few  grave  signs  ;  a  rectal  examination  is  essential  in  case  the  intus- 
susceptum  may  be  felt  with  the  finger  ;  a  careful  palpation  of  the  abdomen 
will  usually  reveal  an  elongated  tumour,  which  may  sometimes  be  felt  to  harden 
and  relax  again  with  the  peristalsis  of  the  gut. 

In  infants,  simple  colitis  may  give  rise  to  the  appearance  of  blood  and  mucus 
in  the  motions,  but  there  is  generally  some  faecal  material  passed  at  the  same 
time,  which  is  not  the  case  in  intussusception  after  the  contents  of  the  colon 
below  the  intussusception  have  been  evacuated.  In  simple  colitis,  the  motions 
are  frequent  and  loose,  and  they  may  contain  mucus.  In  milder  cases  they 
may  be  green  and  slimy,  but  in  the  more  severe  they  are  brownish  and 
very  offensive,  and  in  the  worst  cases  consist  of  little  more  than  a  dirty 
serous  discharge.  The  child's  temperature  will  probably  be  raised  ;  the 
pulse  is  frequent,  and  there  may  be  vomiting.  A  collapsed  condition  may 
occur  at  a  late  period  of  this  malady — rarely,  in  acute  choleraic  cases  it  may 
ensue  within  the  first  twenty-four  hours.  In  intussusception,  on  the  other  hand, 
collapse  usuallv  occurs  quickly  ;  and  there  is  absolute  constipation,  with  passage 
only  of  a  small  amount  of  blood-stained  mucus.  The  only  cases  which  can  give 
rise  to  a  difficulty  of  diagnosis  are  the  rare  instances  in  which  intussusception  is 
present  without  severe  symptoms  ;  and  here  a  rectal  examination  will  probably 
reveal  the  true  condition  of  affairs.  By  means  of  rectal  examination  in  an 
infant  a  considerable  area  of  the  abdomen  can  be  investigated,  especially  if  an 
anaesthetic  be  administered.  In  all  cases  of  doubt  in  intestinal  affections 
accompanied  by  bleeding,  this  procedure  is  urgently  demanded. 

The  intense  diarrhoea  accompanying  arsenical  poisoning  may  be  accompanied 
by  the  passage  of  traces  of  blood  and  mucus.  The  condition  will  be  distinguished 
by  its  rapid  onset,  some  half-hour  or  so  after  a  meal,  by  the  epigastric  pain, 
tenderness,  and  vomiting,  followed  by  collapse,  with  rapid  irregular  pulse,  and 
clammy  skin.  A  chemical  examination  of  the  vomited  matters  should  be  made 
in  suspected  cases,  either  by  Reinsch's  or  Marsh's  test. 

Traces  of  blood  smeared  over  the  motions  are  suggestive  of  piles,  which 
may  be  seen  on  inspection  if  external,  and  felt  by  the  examining  finger  if 
internal  to  the  sphincter.  Occasionally  a  sharp  attack  of  bleeding  may  occur 
from  this  cause,  if  a  varix  be  ruptured.  The  condition  is  usually  accompanied 
by  a  sense  of  fullness,  weight,  and  even  pain  in  the  rectum,  and  the  patient 
may  be  conscious  of  "  something  coming  down"  and  having  to  be  replaced 
after  defaecation. 

Some  amount  of  blood  may  arise  from  an  anal  fistula,  which  may  also  lead  to 
a  discharge  of  mucus  and  of  pus.  Inspection  and  digital  examination  will  readily 
discover  this  affection,  the  external  opening  of  the  fistula  being  close  to  the 
margin  of  the  anus,  the  internal  often  just  above  the  border  of   the  sphincter. 

Cancer  of  the  rectum  does  not  usually  give  rise  to  much  haemorrhage,  but  traces 
of  blood  may  be  passed  from  time  to  time,  and  sometimes  a  sanious  discharge 


BLOOD     PER     ANUM  93 


occurs.  The  main  syniptonis  are  usually  wasting  and  cachexia,  gradually 
increasing  difficulty  in  defecation  ;  and  rarely,  alteration  in  the  size  and  shape 
of  the  fecal  masses,  which  may  be  thin  or  ribbon-like.  Pain  in  the  sacral  region 
generally  occurs  at  some  period  of  the  disease,  and  it  may  radiate  down  the 
thighs.  The  growth  may  be  seen  by  means  of  the  speculum  or  sigmoidoscope, 
and  also  felt  by  the  examining  finger. 

Rectal  polypi  are  common  in  children,  and  may  rarely  be  encountered  in 
adults.  They  give  rise  to  frequent  bleeding,  which  may  occasionally  be 
considerable  in  amount.  The  patient  may  be  conscious  of  something  present 
in  the  rectum,  giving  rise  to  a  sensation  of  fullness  and  frequent  desire  to 
defsecate.  Digital  examination  will  reveal  the  existence  of  a  pedunculated 
tumour,  or  rarely  of  multiple  tumours.  Occasionally  a  polypus  may  protrude 
at  the  anus  after  defascation. 

Another  condition  affecting  the  rectum  which  may  be  signalized  by  free 
bleeding  is  that  of  papilloma  or  villous  tumour.  The  symptoms  will  closely 
resemble  those  described  under  rectal  polypi,  but  the  blood  is  likely  to  appear 
in  large  quantities.  Digital  examination  may  discover  a  soft,  velvety  patch 
on  the  rectal  wall,  and  the  examining  finger  will  be  withdrawn  covered  with 
blood.  The  growth  may  be  seen  by  means  of  a  speculum  as  a  soft,  vascular 
mass,  bleeding  on  the  slightest  touch.  The  condition  is  uncommon.  It  is 
likely  to  occur  at  an  earlier  age  than  cancer,  but  the  latter  is  not  unknown  in 
persons  under  20  years  of  age. 

Simple  prolapse  of  the  anal  mucosa  will  lead  to  slight  haemorrhage.  The 
condition  is  often  seen  in  children,  and  may  be  recognized  on  inspection  of  the 
anus,  when  a  red  globular  swelling  of  everted  mucous  membrane  is  visible. 
Adults  will  be  conscious  of  having  to  push  the  part  back  after  passing  a  motion. 
Such  prolapse  often  accompanies  piles. 

Ulceration  of  the  rectum,  of  venereal  origin,  occurs  chiefly  in  women.     Bleeding 
is  not  usually  a  very  marked  feature,  but  attacks  of  haemorrhage  may  take  place. 
The    condition    is    recognizable    by 
digital  examination,  and  by  inspec-  A 

tion   through  a  rectal   speculum   or  p.       /""■ 

the  sigmoidoscope.     The  ulceration  \       -^ 

usually  extends  right  down   to   the 

anus,  whereas  there  is  nearly  always  -  "-  ■        '       \ 

an   interval   of  normal   mucosa   be-  '  \  ■         ■• 

tween  the   anus   and    an   ulcerating         '  ^  ^  / 

cancer  of  the  rectum. 

The     parasite     called      Bilharzia 
hcBmatobia  may  occur  in  the  rectum,  .'  ,       -     X 

though  less  frequently  here  than  in  '  / 

the  bladder.     Its  presence  gives  rise  ~ — =^ — — ^  %^ 

to   the   passage    of   mucus   and    blood  Fi^i^.     13.— t)va    of    Bilharzia    hannatobia:     one 

per    anum.       There    may   be    discom-  e>^hibiting   a   terminal     spine— the    common     form: 

^                                                    •'  the  other  presenting  a  lateral  spme.     (High  power 

fort  in  the  rectum  and  frequency  of  of  the  microscope). 

defaecation.     Infection  is  contracted 

abroad,  especially  in  Egypt — a  fact  which  may  lead  to  a  suspicion  of  the  presence 
of  the  affection  in  patients  who  have  resided  out  of  England.  Diagnosis  can 
only  be  made  by  finding  the  ova  of  the  parasite  in  the  faeces.  Their  well-known 
shape — oval  with  a  pointed  spike  at  one  end,  or  rarely  at  the  side  {Fig.  13) — 
renders  them  unmistakeable  objects  under  the  microscope. 

In  children  the  presence  of  thread-worms  (Oxyuris  vermicular  is)  in  the  rectum 
may  lead  to  the  discharge  of  small  amounts  of  mucus  coloured  by  a  trace  of 
blood.     The  worms  will  be  readilj'  seen  on  inspection  of  the  child's  motions.     They 


94 


BLOOD     PER     ANUM 


are  white,  about  the  thickness  of  coarse  thread,  and  some  ^  to  ^  in.  in  length. 

4.  Occult  haemorrhage  is  the  term 
applied  to  the  presence  of  minute 
traces  of  blood  in  the  motions, 
revealed  only  by  chemical  or  micro- 
scopical examination.  It  may  occur 
in  any  lesion  of  the  alimentary  canal 
in  which  there  is  breach  of  surface, 
as  in  ulcer,  cancer,  or  severe  infiam- 
mation.  Such  haemorrhage  will  also 
be  present  constantly  in  cases  of 
infection  with  the  parasitic  worm 
Ankylostomum  duodenale  (Fig.  14). 
This  condition,  which  is  met  with  in 
persons  who  have  worked  in  mines  or 
tunnels,  leads  to  profound  anaemia ; 
and  the  ova  of  the  worms  may  be  found 
in  the  faeces  by  microscopical  exann- 
ination  (Figs.  15  and  16).  The  tests 
for  occult  bleeding  may  be  applied  in 
cases  of  difficulty  when  there  is 
reason  to  suspect  ulceration  or  can- 
cer. No  meat  or  meat- extracts  must 
be  administered  for  a  day  or  two 
before  the  test  is  made,  lest  the 
haemoglobin  present  in  them  should 
vitiate    the    results.       The    existence 

of  any  bleeding  from  the  gums  must  also  be  excluded. 

One  of  the  simplest  methods  of   detecting  occult  haemorrhage  is  to   rub  up 


J^y^.    I4. — Ankylostoimiin   diiodcnalc.     A   Head 
'ith  hooks  ;   B  Tail  ;  C  Entire  worm  (low  power). 
(From  Medical  Laboratory  Methods. 

Dr.  Herbert   French.) 


»r^'f-rv.     ^jo-     ^   >i"< 


V 


i^\ 


Fi^^.  15. — Ankylostomum  duodenale.  Ova  at  different 
stages.  Near  the  centre  is  an  ovum  of  I'ricliocephalKs 
dispar  (x  50).  By  permission  from  Dr.  Haldane  and 
Dr.  Boycott's  paper  in  The  Jourjial  of  Hygiene,  Vol.  III. 


Fig.  16. — Ankylostomum  duodenale. 
Two-cell  stage  of  developing  ovum 
( X  200).  By  permission  from  Dr. 
Haldane  and  Dr.  Boycott's  paper  in 
'I  he  Journal  of  Hygiene,  Vol.  III. 


some  of  the  faeces  with  water,   acidify  with  strong  acetic  acid,  and  then  shake 
out  with  about    \  volume  of  ether  ;    the  latter  extracts  the  haematin,  and  the 


BLOOD-PRESSURE     [ABNORMAL) 


95 


characteristic  bands  mav  be  detected  in  the  ethereal   extract  by  means  of  the 
spectroscope    (see  Figs.   20  and   21). 

SPECTRAL     ABSORPTION     BANDS. 


■ 

IT 

^^H 

Fig-.  17. — Oxyhaemoglobin. 

■ 

■ 

^^^H 

Fig.   iS. — Reduced  haemoglobin. 

■ 

II 

^^H 

Fig  ig. — Carboxyhcemoglobin. 

I 

1 

^^^B^B 

J'lg.   20. — Haeinatin  in  alkaline  solution. 

■1 

l^^^^^^l 

Jug.   21. — Acid  hajmatin. 

Fig.  22. — Methaemoglobin. 


E 


Fig. 


-Urobilin. 


ir.   Cecil  Bosanquet. 

BLOOD -PRESSURE  (ABNORMAL).  —  Blood-pressure  cannot  be  gauged 
accurately  with  the  finger  ;  when  instruments  of  precision  are  used  to  verify 
opinions  expressed  as  the  result  of  merely  feehng  the  pulse,  it  is  astounding 
how  erroneous  digital  impressions  of  pulse-tension  and  blood-pressure  are  found 
to  be.  Thev  may  be  more  than  100  mm.  Hg  out ;  and  it  is  most  important  not 
to  diagnose  an  abnormality  of  blood-pressure  until  the  latter  has  been  accurately 
measured  instrumentally.  There  are  four  main  kinds  of  blood-pressure,  namely, 
maximum  systolic  systemic  arterial  pressure  ;   minimum  arterial  blood-pressure  ; 


96  BLOOD-PRESSURE     (ABNORMAL) 

mean  arterial  blood-pressure  ;  and  venous  blood-pressure.  Instruments  have 
been  devised  for  measuring  all  of  these,  but  for  clinical  purposes  the  only  variety 
which  is  really  important  is  the  maximum  systemic  arterial  blood-pressure.  This 
may  be  either  abnormally  low  or  abnormally  high,  but  no  stress  should  be  put 
upon  any  but  considerable  departures  from  the  normal.  Healthy  individuals 
who  have  not  been  kept  in  bed,  have  an  average  pressure  in  early  adult  life  of 
1 20  to  130  mm.  Hg.  Children  have  less  than  this,  though  at  this  early  age  it 
very  seldom  happens  that  anything  is  to  be  learned  by  measuring  the  blood- 
pressure.  As  years  advance,  the  blood -pressure  tends  normally  to  rise,  so  that  in 
a  person  of  lifty  or  sixty,  a  reading  of  150  or  160  mm.  Hg,  or  thereabouts,  which 
in  a  younger  person  would  indicate  disease,  would  be  normal.. 

Abnormally  high  blood-pressure  may  reach  figures  such  as  320  mm.  Hg, 
and  anything  from  170  mm.  Hg  upwards  is  essentially  abnormal,  whatever  the 
age  of  the  patient.  It  nearly  always  indicates  rigidity  of  the  vessels  as  the 
result  of  arteriosclerosis ,  and  it  is  very  often  associated  with  renal  degeneration, 
which,  as  time  goes  on,  ultimately  becomes  red  granular  contracted  kidney. 
Curiously  enough,  and  contrary  to  what  might  be  expected,  the  maximum 
systolic  blood-pressure  is  higher  than  normal  in  cases  of  heart  failure  such  as 
result  from  mitral  stenosis,  even  when  the  pulse  is  so  irregular  and  feeble  that 
it  can  only  be  felt  with  certain  beats,  and  when  one  would  have  thought  that 
there  must  be  a  fall  in  the  blood-pressure  ;  the  cause  for  the  rise  in  such  cases 
is  probably  the  partial  asphyxia  acting  upon  the  vasomotor  centre.  Provided 
the  fact  is  borne  in  mind,  little  difficulty  in  diagnosis  will  arise  from  it.  The 
chief  importance  of  high  blood-pressure  is  in  diagnosing  arterial  or  renal  degenera- 
tion, with  consequent  tendency  to  apoplexy,  in  patients  in  whom  there  may  not 
be  any  other  very  obvious  signs  of  disease.  It  should  be  remembered,  however, 
that  any  patient  who  is  kept  at  rest  in  bed,  tends  to  have  a  diminution  in  the 
blood-pressure,  and  this  applies  to  arteriosclerotic  patients  as  well  as  others. 
Indeed,  a  person  may  have  a  blood-pressure  of  250  mm.  Hg  or  more  when  up 
and  about,  and  yet  when  he  is  kept  in  bed  the  pressure  may  fall  to  150  mm.  Hg, 
to  rise  again  when  the  patient  returns  to  active  life.  Prolongation  of  the  first 
sound  at  the  impulse  or  a  ringing  accentuation  of  the  aortic  second  sound,  may 
sometimes  serve  to  indicate  that  there  is  a  high  blood-pressure  when  no 
instrument  is  at  hand  to  verify  the  fact. 

A  clinical  fact  which  may  sometimes  prove  helpful  is,  that  cases  of  melancholia 
have  abnormally  high  blood-pressures,  and  that  when  the  melanchoha  begins  to 
improve,  the  pressure  falls,  and  may  return  to  normal  when  the  patient  recovers 
from  the  mental  symptoms. 

Abnormally  low  blood-pressures  may  be  observed  in  many  different  cir- 
cumstances associated  with  asthenia,  but  without  renal  or  arterial  degeneration. 
In  itself  a  low  maximum  systemic  blood-pressure  is  seldom  of  diagnostic  sig- 
nificance excepting  in  Addison's  disease.  In  a  case  in  which  the  degree  of 
pigmentation  of  the  skin  or  of  mucous  membranes  may  leave  it  still  in  doubt  as 
to  whether  Addison's  disease  is  the  diagnosis  or  not,  the  discovery  of  a  blood- 
pressure  so  low  as  80  mm.  Hg  would  be  confirmative  of  the  diagnosis,  although 
there  are  cases  of  Addison's  disease  in  which  the  blood-pressure  may  be  no  lower 
than  no  mm.  Hg.  Herbert  French. 

BOILS. — (See  Pustules.) 

BORBORYGMI  are  gurgling  noises  in  the  abdomen  produced  by  peristaltic 
movements  of  the  bowel  acting  upon,  their  mixed  gaseous  and  fluid  contents. 
They  are  probably  more  frequent  in  the  small  intestine  than  elsewhere  ;  but 
they  may  sometimes  be   gastric  or  colonic.     With  the  stethoscope   applied  to 


BRADYCARDIA  97 


the  abdomen,  they  may  be  heard  in  all  normal  persons,  varying  in  intensity  at 
different  times  of  the  day  according  to  the  different  phases  of  digestion.  When 
a  meal  has  been  taken  after  a  period  of  fasting,  the  passage  of  the  intestinal 
contents  through  the  ileoczecal  valve  may  be  heard  distinctly  with  the  stethoscope 
placed  over  the  right  iliac  fossa  some  six  or  eight  hours  after  the  meal  ;  but  it 
is  seldom  possible  to  decide  what  precise  portion  of  the  bowel  is  responsible  for 
the  production  of  borborygmi  heard  elsewhere. 

Normally,  these  sounds  should  not  be  audible  either  to  the  patient  or  to  other 
persons  ;  but  occasionally  even  in  health  they  may  be  heard  quite  loudly.  In 
some  individuals  indeed,  especially  in  women,  the  sounds  become  annoyingly 
obtrusive,  and  they  may  even  acquire  a  pathological  degree.  It  may  be  very 
difficult,  however,  to  decide  exactly  as  to  their  cause  ;  sometimes  the  patient 
seems  to  be  otherwise  perfectly  healthy,  so  that  they  might  be  called  a  normal 
abnormality  in  such  a  case.  More  often  there  is  more  or  less  evidence  of 
functional  nerve  disorder  or  hysteria,  so  that  the  borborygmi  may  be  due  to 
functional  errors  in  the  intestinal  peristalsis  or  in  the  secretions  within  the  bowel. 
They  may  be  associated  with  Flatulence  {q-v.),  though  this  is  by  no  means 
necessarily  the  case.  When  there  is  excess  of  gas  in  the  alimentary  canal, 
observation  of  the  patient  may  detect  air-swallowing  ;  intestinal  putrefaction 
is  said  to  be  indicated  by  the  presence  of  excess  of  indican  in  the  urine,  or  by 
there  being  a  high  ratio  of  organic  to  inorganic  urinary  sulphates  ;  fermentation 
of  carbohydrate  is  suggested  when  there  is  no  evidence  of  air-swallowing,  when 
the  urine  analyses  do  not  confirm  any  suspicion  of  proteid  putrefaction,  and 
when  the  borborygmi  are  increased  by  the  giving  of  carbohydrate  foods. 

The  absence  of  borborygmi  may  sometimes  be  a  sign  of  clinical  importance, 
for  one  of  the  first  effects  of  peritonitis  is  to  inhibit  the  peristaltic  movements 
of  the  bowel  ;  in  the  absence  of  peristalsis  borborygmi  cannot  be  produced,  and 
therefore,  in  a  case  suspected  to  be  one  of  peritonitis,  the  presence  of  well-marked 
borborygmi  upon  auscultation  of  the  abdomen  is  an  argument  against  there 
being  general  peritonitis,  whilst  complete  silence  of  the  abdomen  is  in  favour  of 
this  diagnosis. 

Borborygmi  may  be  increased  in  asphyxial  conditions,  so  that  they  may 
be  a  very  marked  symptom  in  cases  of  heart  failure  with  cyanosis. 

Herbert  French. 

BRADYCARDIA,  or  undue  slowness  of  the  pulse-rate,  is  not  incompatible 
with  health,  some  individuals  having  a  normal  pulse-rate  of  50  per  minute, 
whilst  in  a  few  it  does  not  exceed  40  or  even  30  per  minute.  Occasionally 
bradycardia  of  this  kind  is  found  in  more  than  one  member  of  the  same  family. 

It  is  important  to  auscultate  the  heart  in  order  to  exclude  the  possibility 
of  the  rate  of  the  pulse  as  felt  at  the  wrist  not  being  the  same  as  the  rate  of  the 
heart-beat ;  it  sometimes  happens,  particularly  when  there  is  mitral  stenosis, 
that  by  no  means  every  pulse  wave  becomes  palpable  at  the  wrist,  and  the  rate 
may  then  seem  to  be  slow  when  perhaps  in  reality  it  is  twice  the  apparent  rate. 

Absolute  slowness  of  the  pulse-beat,  as  distinct  from  its  relative  slowness 
in  proportion  to  the  pyrexia,  is  best  seen  in  that  symptom-complex  which 
has  been  termed  Stokes- Adams'  disease,  the  phenomena  of  which  are  attacks 
of  unconsciousness  associated  with  one  or  several  epileptiform  convulsions, 
coma,  stertor,  and  cyanosis,  the  rate  of  the  heart-beat  being  found  to  have 
dropped  to  a  half  or  even  to  less  than  half  of  that  which  is  natural.  These 
symptoms  are  due  to  difficulty  in  the  transmission  of  the  contraction-stimulus 
from  the  auricle  to  the  ventricle  along  the  auriculo-ventricular  bundle  of  His. 
The  inhibitory  factor  is  not  the  same  in  all  cases,  but  is  very  often  associated 
with  arteriosclerosis  and  degenerative  changes  in  the  bundle  of  His,  together 
with  myocardial  degeneration  and  atheroma  of  the  coronary  arteries  ;  less 
D  7 


gS  BRADYCARDIA 


often  it  is  due  to  syphilis  of  the  bundle  of  His  or  to  destruction  of  that  bundle 
by  a  gumma,  sarcoma,  or  carcinoma.  The  diagnosis  is  apt  to  be  that  of  epilepsy 
until  the  fact  has  been  established  that  the  pulse-rate  falls  during  an  attack  to 
about  half  the  normal ;  but  when  this  observation  has  been  made,  the  difference 
between  Stokes- Adams'  disease  and  ordinary  epilepsy  is  clear. 
'  Increased  intracranial  pressure  is  another  cause  for  bradj^cardia  ;  it  may 
thus  be  observed  in  cases  of  cerebral  haemorrhage,  cerebral  tumour,  cerebral 
abscess,  and  in  the  early  stages  of  tuberculous  meningitis ;  but  in  other  forms 
of  meningitis  and  in  the  later  stages  of  tuberculous  meningitis  the  initial 
bradycardia  changes  to  tachj-cardia.  If  in  a  given  case  there  is  otitis  media 
or  some  other  local  infective  focus  which  might  produce  a  cerebral  abscess,  the 
occurrence  of  pyrexia  with  a  pulse-rate  of  50,  55,  or  60  per  minute  is  an  argument 
in  favour  of  intracranial  abscess ;  for  the  other  complications  of  otitis  media, 
especially  lateral  sinus  thrombosis,  mastoid  abscess,  or  suppurative  meningitis, 
produce  a  rapid  pulse-rate  instead  of  a  slow  one  ;  the  reverse  is  not  true,  that 
is  to  say,  it  is  not  possible  to  exclude  cerebral  abscess  merely  on  the  ground 
that  there  is  no  bradycardia.  Cerebral  tumour  can  generally  be  distinguished 
from  cerebral  abscess  by  the  greater  length  of  the  history,  the  more  pronounced 
optic  neuritis ;  or  by  the  absence  of  predisposing  cause  to  cerebral  abscess,  for 
instance  otitis  media,  or  bronchiectasis  ;  whilst  cerebral  haemorrhage  is  much 
more  rapid  in  its  onset,  is  less  likely  to  have  marked  optic  neuritis,  and  if  there 
is  pyrexia  it  is  apt  to  be  extreme,  reaching  the  level  of  hyperpyrexia ;  generally 
the  patient  is  an  elderly  man  who  has  either  high  blood-pressure,  albuminuria 
or  other  evidence  of  degenerated  arteries  or  granular  kidneys. 

Myxoedema  is  a  disease  in  which  the  pulse-rate  is  not  fast,  but  in  which  it 
seldom  becomes  absolutely  slow. 

Certain  drugs  are  apt  to  slow  the  heart  very  markedly  when  they  have  been 
administered  in  full  doses  over  a  long  period  ;  amongst  these  the  two  most 
important  are  digitalis  and  strophanthus,  while  sodium  salicylate  also  is  likely 
to  have  a  similar  effect:  the  diagnosis  will  depend  upon  the  knowledge  of  the 
medicine  the  patient  is  taking. 

Jaundice  is  generally  stated  to  be  a  cause  for  marked  slowing  of  the  pulse- 
rate  :  it  is  true  that  the  artificial  introduction  of  bile  salts  and  pigments  into  the 
circulation  in  animals  slows  the  heart,  but  clinically  in  man  it  is  rare  to  find 
jaundice  and  absolute  bradycardia  associated.  Herbert  French. 

BREATH,  FOULNESS  OF  THE. — This  is  due  to  one  or  other  of  four  main 
groups  of  conditions,  namely,  septic  and  putrefactive  changes  within  the  mouth 
or  nose  ;  septic  or  putrefactive  changes  within  the  lungs  ;  the  ingestion  of 
certain  substances  such  as  tobacco  smoke,  garhc  or  onions,  whose  products  are 
excreted  by  the  lungs  or  saliva  ;  and  severe  toxic  conditions,  especial^  those 
affecting  the  alimentary  canal  or  peritoneum. 

When  the  foulness  of  the  breath  is  not  habitual,  but  occurs  as  the  result  of  a 
recent  illness,  there  will  be  symptoms  of  the  latter  Avhich  point  to  the  diagnosis 
quite  apart  from  the  condition  of  the  breath  ;  so  that  one  need  not  do  more  than 
indicate  as  possible  causes  of  the  symptom  such  things  as  typhoid  fever,  general 
peritonitis,  post-puerperal  sepsis,  intestinal  obstruction,  and  a  host  of  other 
conditions  of  this  kind  in  which,  even  though  the  mouth  be  clean,  there  may  be 
foulness  of  the  breath,  such  tendency  to  foulness  being  greatly  exaggerated  if 
sordes  have  been  allowed  to  collect. 

Foulness  of  the  breath  due  to  the  ingestion  of  foodstuffs  such  as  onions  or 
garlic,  is  familiar  enough,  and  it  only  remains  to  add  that  there  are  certain  drugs, 
for  instance  guaiacol,  which  may  produce  a  similar  symptom  without  the  patient's 
friends  realizing  whv  the  breath  should  be  so  tainted. 


BREATH,     FOULNESS     OF     THE  99 

Foulness  of  the  breath  due  to  lung  conditions  will  nearly  always  be  indicated 
either  by  the  abundant  and  putrid  sputum,  or  by  the  abnormal  physical  signs 
in  the  thorax.  The  condition  may  be  due  to  phthisis  with  secondary  infection  of 
the  cavities  by  pj'Ogenic  organisms,  fcetid  bronchitis,  bronchiectasis,  gangrene  of  the 
lungs,  empyema  or  other  abscess  which  has  ruptured  into  the  lung.  The  only 
cases  which  give  rise  to  difficulty  in  the  differential  diagnosis,  are  those  in  which 
an  empyema  has  been  situated  deeply,  for  instance  between  the  lower  lobe  and 
the  diaphragm,  or  between  two  lobes,  without  reaching  the  surface  ;  in  such  a 
case  there  ma}^  be  absolutely  no  abnormal  physical  signs,  and  the  diagnosis  has 
to  be  made  from  the  symptoms  and  history.  The  patient  has  generally  had 
some  obscure  febrile  illness,  possibly  with  cough,  but  without  much  expectora- 
tion, until  one  day,  after  a  particularly  severe  bout  of  coughing,  a  large  quantity 
of  pus — perhaps  a  teacupful  or  even  more — has  suddenly  been  brought  up  at 
one  time,  since  when,  at  intervals  of  hours  or  days,  there  has  been  similar 
expectoration  of  large  quantities  of  putrid  pus.  This  condition  of  deep-seated 
empyema  without  abnormal  physical  signs  most  resembles  bronchiectasis  or 
bronchiolectasis,  but  is  distinguished  by  the  sudden  way  in  which  the  first 
large  quantity  of  purulent  expectoration  came  on.  In  both  cases  there  may  be 
clubbing  of  the  fingers  ;  and  in  both,  the  sputum  contains  pus  corpuscles,  and 
pyogenic  and  non-pyogenic  micro-organisms  other  than  tubercle  bacilli,  but 
no  elastic  fibres  indicative  of  lung  destruction. 

Gangrene  of  the  lung  produces  an  unmistakable  stench  of  the  worst  kind  ;  if 
any  doubt  remains  as  to  the  diagnosis,  the  detection  of  abundant  elastic  fibres 
in  the  sputum,  after  boiling  with  caustic  soda  to  destroy  the  other  tissue  elements 
present,  will  clinch  the  diagnosis. 

Phthisis  with  cavitation  may  produce  foulness  of  the  sputum,  but  hardly  ever 
the  stench  of  gangrene,  unless'gangrene  has  supervened.  It  is  distinguished  from 
bronchiectasis  and  from  hidden  empyema  by  the  discovery  of  tubercle  bacilh 
in  the  sputum.  The  chief  difficulty  in  the  diagnosis  arises  when  the  tuberculous 
part  of  the  malady  has  ceased,  the  cavities  formerly  excavated  by  the  tuber- 
culous process  being  now  occupied  only  by  pyogenic  organisms  that  have 
secondarily  infected  them. 

Xone  of  the  above  conditions  need  be  considered  at  all  in  arriving  at  the 
diagnosis  of  the  cause  of  foulness  of  the  breath  in  many  cases,  inspection  of  the 
mouth  at  once  indicating  the  nature  of  the  trouble  in  the  form  of  tartar,  septic 
gums,  carious  teeth  with  decomposing  food  particles  in  them,  pyorrhcea  alveolaris, 
or  even  more  extensive  stomatitis,  the  different  varieties  of  which  are  dealt  with 
under  that  heading  ;  or  it  may  be  that  the  nose  or  throat  are  at  fault  rather  than 
the  mouth,  necrosis  of  the  nasal  bones,  purulent  hypertrophic  or  atrophic  rhinitis, 
ozisna,  septic  tonsillitis  or  other  varieties  of  Sore  Throat  [q-v.),  with  more  or  less 
extensive  inflammation  of  the  tonsils,  fauces,  or  pharynx,  being  generally  obvious 
on  inspection,  or  on  bacteriological  examination  for  the  Klebs-Loffler  bacilli  of 
diphtheria,  or  the  fusiform  bacilli  and  spirilla  of  Vincent's  angina  {Plate  XII, 
Fig.  M).  Some  of  the  worst  cases  of  foulness  of  the  breath  are  to  be  met  with 
when  there  is  inoperable  squamous-celled  carcinoma  of  the  mouth  or  tongue. 

It  is  only  when  all  such  local  conditions  have  been  excluded,  and  when  there 
is  no  acute  illness  nor  an}^  lesion  of  the  lungs,  that  one  can  attribute  foulness  of 
the  breath  to  that  ill-defined  malady  dyspepsia.  It  is  sometimes  very  difficult 
to  find  out  why  the  patient's  breath  is  not  sweet,  and  indeed  there  are  some 
persons  in  whom  all  the  functions  of  the  body  seem  to  be  perfectly  good,  and  the 
mouth  perfectly  clean,  and  yet  the  breath  is  foul.  If  there  are  any  symptoms  of 
gastro-intestinal  disorder,  especially  flatulence  or  constipation,  one  is  inchned 
to  attribute  the  condition  of  the  breath  to  the  stomach  or  the  bowels  ;  but 
when  there  are  no  symptoms  of  any  error  in  these,  it  is  more  than  hkely  that 


BREATH,     SHORTNESS     OF 


the  trouble  is  due  to  some  local  condition  "which  has  not  been  discovered  upon 
ordinary  inspection,  particularly  the  accumulation  and  putrefaction  of  food 
particles  between  the  teeth,  where  they  may  become  impacted  even  in  persons 
who  vigorously  use  both  tooth-brush  and  mouth-wash  daily.  Herbert  French. 

BREATH,  SHORTNESS  OF. — This  is  a  very  common  complaint  which,  in 
our  opinion,  should  be  differentiated  carefully  from  difficulty  of  breathing,  the 
latter  term  being  reserved  entirely  for  cases  of  obstruction  in  the  main  air- 
passage,  the  larvmx,  and  trachea — using  it  as  a  lar\-ngological  expression  in  fact 
— diphtheria,  growths,  and,  very  much  more  rarely,  pressure  from  without  being 
the  main  causes. 

Shortness  of  breath  is,  in  the  patient's  mind,  a  conscious  quickening  of  the 
respiratory  movements  to  supply  a  conscious  need  of  air.  The  following  are 
the  chief  causes  of  the  symptom  : — 

Increased  Need  for  Oxygen. — Fevers  and  other  septic  processes  inducing  exces- 
sive oxygen  requirements.     Exercise  in  health.     Temporary  shortness  of  breath. 

Diminished  Supply  of  Oxygen. — (i)  Blood  conditions  in  which  the  red  corpuscles 
cannot  carry  a  sufficient  charge,  or  do  not  yield  up  their  supply  with  sufficient 
ease  ;  (2)  Cardiac  conditions  of  inefficiency  of  circulation  ;  (3)  Pulmonary  con- 
ditions of  diminished  surface  of  contact,  or  ease  in  contact,  of  air  and  blood  in 
alveoli  ;  (4)  Atmospheric  conditions  of  diminished  partial  oxygen  pressure  in 
the  alveoli  of  the  lung  ;  (5)  Deformities  of  the  chest  mechanically  preventing  the 
expansion  of  the  lung.  The  diagnosis  of  these  conditions  is  not  difficult  when 
once  attention  is  drawn  to  the  possibility  of  their  occurrence,  but  we  must 
briefly  advert  to  each  of  them  to  indicate  the  guides  to  the  cause  in  a  case  not 
at  once  obvious. 

Fevers  and  Septic  Conditions. — The  thermometer  and  the  obvious  illness  of  the 
patient  will  generally  give  sufficient  indication  of  these  ;  nor  indeed  is  shortness 
of  breath  a  common  complaint  in  such  patients,  their  minds  being  filled  with 
other  ideas. 

Exercise  in  Health. — Here  it  is  necessary  to  be  sure  of  the  health  ;  it  may, 
or  may  not  be,  that  the  person  is  merely  out  of  condition,  and  undertakes 
exercise  which  only  a  trained  athlete  can  properly  perform.  The  only  way  to 
avoid  mistakes  is  to  ask.  Does  the  shortness  of  breath  soon  disappear  ?  and  then 
to  make  a  careful  examination  of  the  patient  to  see  if  anj-  of  the  undermentioned 
causes  are  at  work. 

1.  Blood  Conditions.- — These  include:  (i)  Simple  loss  of  blood;  (ii)  Ansemia 
simplex  ;  (iii)  Anaemia,  severe  or  pernicious  ;  (iv)  Polycythsemia  ;  (v)  Some 
pathological  constituent,  as  in  diabetes,  ursmia.  Graves'  disease,  etc.  ;  (vi)  All 
forms  of  leukemia. 

The  actual  laboratory  diagnosis  of  the  blood  condition  is  simple  enough  if  we 
decide  to  have  it  examined.  The  points  that  may  lead  us  to  have  this  done 
would  naturally  come  in  the  following  order.  A  history  of  loss  of  blood  is  pretty 
sure  to  be  volunteered — piles,  excessive  menstruation,  obvious  trauma,  loss  at 
parturition,  etc.  ;  suspicion  is  very  likely  to  be  aroused  b}'  the  colour  of  the 
patient's  face,  especiallv  when  coupled  with  a  primary  complaint  of  shortness  of 
breath.  Diabetes  and  uramia  are  likely  to  show  other  signs,  and  the  urine  will 
give  the  clue  to  the  diagnosis  ;  but  great  caution  is  required  never  to  omit  to  have 
the  blood  examined  if  the  cause  of  a  shortness  of  breath  is  not  apparent  on  simple 
physical  examination  ;  indeed,  one  must  go  farther,  and  say  if  some  easily  diag- 
nosable  condition  is  not  present ;  for  it  must  be  remembered  that  blood  conditions 
are  the  very  ones  to  be  the  exciting  cause  of  cardiac  inefficiency,  which  by  itself 
is  often  hard  to  diagnose  if  there  be  no  obvious  bruit  or  irregularity  in  rhythm. 

2.  Cardiac  Conditions. — Inef&ciency  in  circulation.    These  include  :  (i)  Valvular 


BRUITS,     CARDIAC 


disease  (acute  and  chronic)  ;  (ii)  Muscular  weakness  (fatty,  fibrosis,  etc.)  ; 
(iii)  Nerve  conditions  (arrhythmia  ?)  ;    (iv)  Pericarditis  and  pericardial  effusion. 

i.  Valvular  disease. — If  a  bruit  be  present,  it  may  fairly  be  assumed  that  the 
heart  is  a  factor  in  causing  shortness  of  breath,  but  unless  some  other  tell-tale 
sign  be  present  it  must  not  be  assumed  that  it  is  the  only  factor,  for  it  is  very 
common  to  find  patients  with  bruits  who  will  not  confess  to  shortness  of  breath. 

ii.  Muscular  Weakness. — We  cannot  under  the  present  heading  give  all  the 
points  in  connection  with  "  morbus  cordis  sine  murmure  "  ;  it  must,  however,  be 
stated  that  a  diminution  in  the  muscular  energy  of  the  heart  is  a  most  important 
contributory  factor  in  producing  shortness  of  breath  in  all  pathological  conditions 
of  the  blood,  including  renal  affections  and  diabetes,  in  convalescence  from  acute 
disease,  and  in  acute  pericardial  affections ;  it  is,  perhaps,  the  commonest  cause 
of  all  of  shortness  of  breath.  Want  of  tone  in  the  sounds,  likeness  of  the  first 
to  the  second  sound,  and  irregularities  in  rhythm,  are  the  principal  points  to 
look  for.  The  urine  should  be  examined  with  care,  both  for  albumin  and  tube- 
casts  ;  the  ophthalmoscope  should  be  used  in  the  detection  of  albuminuric 
retinitis ;  and  it  is  often  wise  to  measure  the  systemic  blood-pressure  to  find 
out  whether  it  is  greatly  above  the  normal  or  not. 

iii.  Nerve  Conditions. — Local  pressure  on  the  nerves  may  cause  cardiac  arrhyth- 
mia and  breathlessness,  but  these  will  have  other  signs  and  symptoms  easily 
discoverable  ;  general  nervousness  and  neurasthenia  are  often  characterized  by 
shortness  of  breath  on  exertion  or  excitement,  there  being  frequency  of  the  beat 
without  any  arrhythmia. 

iv.  Pericardial  Diseases. — A  differential  diagnosis  between  these  and  a  hyper- 
trophy or  dilatation  of  the  ventricles  may  be  demanded  for  other  reasons,  but 
qua  shortness  of  breath,  there  is  no  difficulty  in  determining  that  either  cardiac 
or  pericardial  trouble  is  the  cause. 

3.  Pulmonary  Conditions.— These,  again,  will  be  fairly  obvious  on  proper  exami- 
nation, including,  as  they  do,  every  disease  of  the  lung ;  but  we  would  specially 
draw  attention  to  the  possible  presence  of  a  quiet  pleural  effusion,  which  not 
very  infrequently  is  so  insidious  as  to  give  rise  to  no  complaint  but  that  of 
shortness  of  breath.  Again,  in  the  early  days  of  phthisis,  it  may  be  that  a  cough 
and  shortness  of  breath  are  nearly  all  that  is  complained  of.  Bronchitis, 
advanced  tubercle,  bronchopneumonia,  lobar  pneumonia,  and  acute  pleurisy, 
are  all  easily  recognizable  causes  of  shortness  of  breath.  The  only  intrinsic 
affection  of  the  lungs  not  at  once  easily  discoverable  is  emphysema  without  its 
usually  accompanying  bronchitis  ;  the  shape  of  the  chest,  the  absence  of  vesicular 
sounds,  the  increased  resonance  to  percussion  will,  however,  generally  give  a  clue. 

4.  Atmospheric  Conditions  need  no  diagnosis  ;  partial  asphyxia  by  bad  air, 
high  mountains,  and  caisson  work,  are  the  three  chief  alterations  in  gaseous 
surroundings.     All  are  obvious. 

5.  Deformities  of  Chest  are  again  obvious  ;  Pott's  curvature  is  the  chief  one. 
They  derive  their  importance  from  the  fact  that  commonly  one  lung  is  hers  de 
combat  almost  to  start  with,  and  hence  a  very  slight  affection  of  the  other  may 
cause  great  difficulty  in  breathing.  Fred  J.  Smith. 

BRUITS,  CARDIAC. 

I. — Systolic  Bruits. 

{A).  Systolic  Bruits  over  the  Mitral  Area,  which  corresponds  to  that  portion 
of  the  chest  wall  lying  immediately  over  the  cardiac  apex.  When  a  definite 
systolic  bruit  is  audible  over  the  mitral  area,  its  cause  is  sometimes  perfectly 
obvious.  If,  for  example,  a  person  who  some  time  previously  had  an  attack 
of  rheumatic  fever  presents  a  bruit,  with  its  point  of  maximum  intensity  over 
the  cardiac   apex,  and  the   bruit  is  conducted  outwards  into  the   left  axilla, 


BRUITS,     CARDIAC 


there  being  lost,  and  heard  again  in  the  neighbourhood  of  the  inferior  angle  of 
the  left  scapula  ;  then  such  a  bruit  is  almost  certainly  due  to  old-standing 
organic  disease  of  the  mitral  valve,  which  has  caused  regurgitation  through 
it.  This  opinion  is  confirmed  by  finding  that  the  heart  is  enlarged,  as  demon- 
strated by  the  area  of  cardiac  dullness  being  increased,  and  by  the  apex  beat  of 
the  heart  being  displaced  downwards  and  to  the  left.  Such  an  enlargement  of 
the  heart  points  to  the  cardiac  condition  not  being  of  recent  origin  ;  and  any 
bulging  of  the  praecordia,  which  very  often  occurs  in  children  when  the  heart 
is  enlarged,  is  additional  evidence  in  the  same  direction. 

In  some  cases,  however,  the  diagnosis  is  not  nearly  so  obvious,  and  in  order 
that  a  definite  conclusion  may  be  arrived  at,  it  is  necessary  to  consider  all  the 
conditions  which  maj'  produce  a  systolic  bruit  in  the  mitral  area.  The  following 
are  the  possible  causes  : — 

(i).  Mitral  regurgitation,  due  to  chronic  organic  disease  of  the  mitral  valve. 

(2).  Acute  endocarditis  ;    {a)  Simple;    (b)  Ulcerative  or  malignant. 

(3).  Mitral  regurgitation  where  there  is  no  disease  of  the  mitral  valve,  but 
dilatation  of  the  left  ventricle  as  the  result  of  [a)  Disease  of  the  aortic  valve  ; 
(b)  Disease  of  the  myocardium,  such  as  mj'ocarditis,  parenchymatous  degenera- 
tion, fatty  heart,  fibroid  heart,  and  other  degenerative  changes  in  the  cardiac 
muscle  secondary  to  disease  of  the  coronary  arteries  ;  (c)  Disease  external  to 
the  heart,  causing  hypertrophy  and  dilatation  of  the  left  ventricle,  such  as 
arterial  sclerosis  and  interstitial  nephritis  ;  [d)  Adherent  pericardium,  which  is 
a  very  important  factor  in  causing  dilatation  of  the  ventricles,  but  is  very 
frequently  associated  with  organic  disease  of  the  valves. 

(4).  Functional  bruits. 

(5).  Congenital  malformation  of  the  heart. 

(6).  Aneurysm  of  the  heart. 

(7).  Acute  pericarditis. 

I.  The  following  points  are  in  favour  of  the  bruit  being  due  to  organic  disease 
of  the  mitral  valve  of  long  standing  : — 

{a).  An  enlargement  of  the  heart,  as  shown  by  displacement  of  the  apex  beat 
and  by  an  increase  in  the  area  of  cardiac  dullness.  In  mitral  regurgitation  the 
enlargement  of  the  heart  is  due  in  the  first  instance  to  hypertrophy  and  dilata- 
tion of  the  left  ventricle  ;  but  the  left  ventricle  may  become  enlarged  from  other 
causes,  such  as  disease  of  the  aortic  valve,  adherent  pericardium,  arterial  sclerosis, 
and  chronic  renal  disease  ;  these  causes  must  be  excluded  before  the  diagnosis 
of  mitral  regurgitation  due  to  organic  disease  of  the  mitral  valve  is  made. 
Lesions  of  the  aortic  valve  producing  enlargement  of  the  left  ventricle  would  be 
excluded  by  the  absence  of  systolic  and  diastolic  bruits  at  the  second  right  costal 
cartilage  or  down  the  left  side  of  the  sternum.  An  adherent  pericardium, 
causing  dilatation  of  the  left  ventricle,  and  therefore  producing  regurgitation 
through  the  mitral  orifice,  is  often  very  difficult  to  diagnose  correctly,  as  it  is 
almost  impossible  to  ascertain  that  there  is  not  disease  of  the  mitral  valve.  The 
absence  of  systolic  retraction  at  the  apex  points  to  the  pericardium  not  being 
adherent.  Arterial  sclerosis  is  not  likely  to  be  present  without  anj^  thickening 
of  the  radial  arteries.  Xo  accentuation  of  the  aortic  second  sound  over  the 
right  second  costal  cartilage  indicates  the  absence  of  arterial  sclerosis,  as  in  this 
condition  the  blood-pressure  is  higher  than  normal,  thereby  making  the  aortic 
cusps  close  more  forcibly.  In  chronic  renal  disease,  high  arterial  blood-pressure, 
arterial  sclerosis,  polyuria  of  low  specific  gravity  with  a  trace  of  albumin,  and 
often  retinal  changes,  are  present ;  if  these  be  not  found,  chronic  renal  disease 
can  be  excluded  as  cau.sing  the  enlargement  of  the  left  ventricle. 

(b).  A  previous  history  of  rheumatic  fever  is  greatly  in  favour  of  the  mitral 
regurgitation  being  due  to  organic  disease  of  the  mitral  valve  of  long  standing. 


BRUITS,     CARDIAC  103 


(c).  The  age  of  the  patient  is  also  an  important  factor  in  the  diagnosis,  for  in 
children  and  young  adults,  mitral  regurgitation  is  far  more  likely  to  be  the 
result  of  a  previous  endocarditis  than  of  dilatation  of  the  mitral  orifice  due  to. 
the  causes  just  mentioned. 

[d).  The  absence  of  p^-rexia  helps  in  excluding  a  recent  endocarditis  ;  but  it 
must  be  remembered  that  in  children  suffering  from  rheumatic  endocarditis  the 
temperature  is  often  normal  while  they  are  being  treated  with  salicylates.  In 
cases  of  recent  endocarditis  there  may  be  no  physical  signs  of  any  great  enlarge- 
ment of  the  left  ventricle,  and  usually  the  apex  beat  is  found  close  to  its 
normal  position. 

2.  Acute  endocarditis  is  nearly  always  associated  with  some  other  affection. 
For  example,  there  may  be  acute  rheumatism  or  chorea,  or  the  patient  may  be 
suffering  from  pneumonia  or  some  other  infectious  process,  such  as  erysipelas, 
septicaemia,  or  puerperal  fever.  Whatever  be  the  cause  of  the  acute  endo- 
carditis, it  will  be  a  part  of  a  general  blood-infection.  The  heart  is  not  found  to 
be  enlarged,  or  only  to  a  slight  extent,  provided  that  the  condition  is  not  one  of 
an  acute  endocarditis  affecting  old  sclerotic  valves.  In  malignant  endocarditis 
the  constitutional  disturbances  are  severe,  for  irregular  pyrexia,  rigors,  sweating, 
and  even  delirium  are  likely  to  be  present.  The  patient  is  so  ill  that  the  bruit  is 
not  likely  to  be  mistaken  for  one  due  to  old-standing  mitral  regurgitation. 
Symptoms  pointing  to  emboli  in  various  organs  help  to  confirm  the  diagnosis  of 
malignant  endocarditis. 

3.  The  points  in  favour  of  mitral  regurgitation  due  to  dilatation  of  the  left 
ventricle  are  : — 

{a).  Age  of  the  patient,  for  myocardial  degenerations,  except  those  occurring 
in  infectious  processes,  are  not  likely  to  be  present  before  middle  life. 

{b).  The  presence  of  arterial  sclerosis  and  chronic  interstitial  nephritis,  as 
determined  by  increased  arterial  blood-pressure,  accentuation  of  the  aortic 
second  sound,  thickening  of  the  radial  arteries,  retinitis,  and  polyuria  with  a 
trace  of  albumin. 

(c).  Aortic  obstruction  and  regurgitation,  which  cause  hypertrophy  and  dila- 
tation of  the  left  ventricle. 

(d).  Attacks  of  angina  pectoris. 

(e).  Shortness  of  breath,  and  cardiac  distress  upon  exertion,  without  any 
obvious  cardiac  lesion. 

If  the  bruit  be  associated  with  oedema  of  the  legs,  engorgement  of  the  lungs, 
and  enlargement  of  the  liver,  as  the  result  of  cardiac  failure,  the  lesion  may  be 
due  to  organic  disease  of  the  mitral  valve  or  dilatation  of  the  mitral  orifice  as 
the  result  of  myocardial  degeneration.  These  signs  of  failing  compensation  are 
not  likely  to  occur  in  a  recent  endocarditis,  for  they  make  their  appearance  after 
the  cardiac  lesion  has  been  present  for  a  considerable  time.  If  the  bruit  be 
due  to  dilatation  of  the  left  ventricle  as  the  result  of  fatty  infiltration  of  its 
walls,  the  patient  may  be  corpulent,  the  cardiac  condition  being  part  of  a 
general  obesity. 

Regurgitation  through  the  mitral  valve  may  be  caused  by  a  dilatation  of 
the  left  ventricle  dependent  upon  an  adherent  pericardium.  The  following  signs 
of  adherent  pericardium  must  be  looked  for  :  (a)  Systolic  retraction,  which  is 
best  determined  by  inspection  of  the  chest  wall  from  the  side,  and  is  due  to  an 
indrawing  of  the  intercostal  spaces  during  the  ventricular  systole.  When  this 
is  situated  near  the  ape.x  beat  it  is  due  to  an  adherent  pericardium  :  it  may 
also  be  noticed  over  the  lower  sternal  region,  and  even  at  the  ensiform  cartilage. 
Systolic  retraction  is  not  always  due  to  an  adherent  pericardium,  for  in  thin 
persons  and  in  children,  a  systolic  indrawing  of  the  third  and  fourth  left 
intercostal    spaces    close    to   the   sternum   is   often    seen,   and  is  produced  by 


I04  BRUITS,     CARDIAC 


the  normal  recession  of  the  base  of  the  heart  during  each  ventricular  systole. 
Systolic  retraction  due  to  adherent  pericardium  is  often  followed  by  (6)  the 
diastolic  shock,  which  can  be  felt  upon  palpation  and  is  due  to  the  sudden 
relaxation  of  the  ventricular  wall,  (c)  Diastolic  collapse  of  the  veins  of  the 
neck,  or  Friedreich's  sign,  which  is  produced  during  the  ventricular  diastole, 
is  an  indication  of  an  adherent  pericardium  ;  it  is  found  chiefly  in  this  con- 
dition, but  does  not  always  occur,  and  is  sometimes  seen  without  any  pericar- 
dial adhesions  being  present,  [d)  The  pulsus  paradoxus  is  chiefly  found  in 
adherent  pericardium,  and  is  due  to  the  cardiac  beats  becoming  more  feeble 
at  the  end  of  inspiration,  so  that  during  each  inspiration  the  pulse-beat 
becomes  very  weak,  or  is  lost. 

4.  A  systolic  bruit  at  the  cardiac  apex  may  be  functional  in  origin,  in  which 
case  it  is  localized  to  the  mitral  area,  being  conducted  only  for  a  short  distance 
into  the  axilla,  and  not  heard  posteriorly.  The  condition  is  associated  with 
anagmia  and  other  debilitating  conditions.  Other  functional  bruits  may  be 
associated  with  it,  especially  one  in  the  pulmonary  area  and  also  a  bruit  de 
diable  in  the  neck.     The  history  helps  greatly  in  the  diagnosis. 

5.  A  congenital  systolic  bruit,  when  heard  in  the  mitral  area,  is  always  part  of 
a  loud  bruit  with  its  point  of  maximum  intensity  nearer  the  base  of  the  heart. 
When  such  a  murmur  is  heard  in  children,  with  little  or  no  displacement  of  the 
apex  beat,  and  the  area  of  cardiac  dullness  is  increased  to  the  right  of  the  sternum, 
the  condition  is  always  congenital.  The  lesion  will  generally  be  either  patent 
septum  ventriculorum,  pulmonary  stenosis,  or  patent  ductus  arteriosus,  which 
are  discussed  elsewhere.  Mitral  regurgitation  due  to  a  congenital  defect  prac- 
tically never  occurs. 

6.  An  aneurysm  at  the  cardiac  apex  is  rare,  and  is  scarcely  possible  to  diagnose, 
so  that  it  need  not  be  taken  into  account  when  considering  the  differential 
diagnosis  of  apical  bruit. 

7.  When  acute  pericarditis  is  present,  a  systolic  bruit  which  is  part  of  a 
"to-and-fro"  friction  murmur  may  be  heard  in  the  mitral  area.  Such  a 
murmur  changes  its  character  with  the  pressure  of  the  stethoscope  and  with  the 
different  phases  of  respiration  ;  and  it  is  not  conducted  into  the  axilla.  Other 
signs  of  pericarditis  are  usually  present,  so  that  the  diagnosis  should  not  cause 
any  difficulty. 

{B).  Systolic  Bruits  over  the  Pulmonary  Area,  which  corresponds  to  that 
portion  of  the  chest  wall  lying  over  the  second  left  intercostal  space  close  to  the 
sternum.  When  a  systolic  bruit  is  heard  over  the  pulmonary  area,  with  its  point 
of  maximum  intensity  in  the  second  costal  space  close  to  the  left  border  of  the 
sternum,  and  conducted  upwards  and  outwards  towards  the  left  shoulder,  it 
may  be  caused  by  the  following  conditions  : — 

(i).  Congenital  cardiac  malformations,  especially  pulmonarj^  stenosis  and 
patent  ductus  arteriosus. 

(2).  Functional  bruit. 

(3).  Acquired  pulmonary  stenosis,  which  is  a  very  rare  lesion. 

To  distinguish  between  an  organic  and  congenital  defect  and  a  functional 
condition  is  usually  quite  easy.  Pulmonary  stenosis  is  nearly  always  a  congenital 
defect,  and  is  therefore  found  for  the  most  part  in  children ;  and  its  presence  is 
confirmed  by  other  signs  of  congenital  heart  disease,  such  as  little  or  no 
displacement  of  the  apex  beat  with  considerable  enlargement  of  the  right  side 
of  the  heart,  together  with  cj^anosis  of  varying  degree,  and  clubbing  of  the 
fingers  and  toes.  With  a  patent  ductus  arteriosus  the  bruit  is  often  similar, 
although  cyanosis  and  clubbing  of  the  fingers  and  toes  are  usually  absent. 
Generally,  instead  of  the  murmur  being  definitely'  either  systolic  or  diastoHc  in 
time,  a  long  rumbling  bruit,  commencing  during  systole  and  passing  on  into  the 


BRUITS,     CARDIAC  105 


diastole  of  the  ventricles,  is  heard.  Such  a  bruit  is  considered  to  be  patho- 
gnomonic of  this  congenital  defect,  as  it  is  impossible  for  a  bruit  extending 
from  sjj'stole  into  diastole  to  be  produced  within  the  heart. 

Other  congenital  malformations  may  produce  a  systolic  bruit  in  the  pulmonary 
area,  such  as  a  patent  interventricular  septum,  though  here  the  maximum  intensity 
of  the  abnormal  sound  is  lower  down  on  the  left  of  the  sternum  ;  in  many  cases 
the  differential  diagnosis  of  these  congenital  malformations  is  quite  impossible. 

2.  The  functional  pulmonary  bruit  is  common  in  chlorosis  and  other  anaemic 
and  debilitated  conditions,  and  in  exophthalmic  goitre  ;  it  is  also  frequent  in 
school-children  set.  5-15.  The  bruit  alters  with  the  position  of  the  patient, 
being  louder  in  the  recumbent  than  in  the  erect  posture,  whereas  in  congenital 
defects,  the  position  of  the  patient  has  very  little  influence  upon  the  loudness 
of  the  bruit.  The  presence  of  a  bruit  de  diable  in  the  neck  confirms  the 
diagnosis  of  the  functional  origin  of  the  bruit.  When  the  bruit  is  due  to 
functional  conditions,  there  is  no  such  increase  of  cardiac  dullness  to  the  right 
of  the  sternum  as  occurs  in  congenital  malformation  and  acquired  pulmonary 
stenosis.  A  systolic  thrill  may  be  present  in  the  pulmonary  area  both  in  organic 
and  functional  conditions,  but  is  more  common  in  the  former,  and  therefore 
in  favour  of  pulmonary  stenosis. 

3.  Pulmonary  stenosis  may  be  an  acquired  lesion,  although  very  rarely  ;  if  in  a 
young  adult  such  a  bruit  as  has  just  been  described  is  present,  and  if  there  is  a 
past  history  of  rheumatic  fever,  together  with  lesions  of  the  other  valves, 
especially  the  mitral,  then  it  may  be  fairly  presumed  that  the  bruit  is  due  to  an 
acquired  pulmonary  stenosis.  The  history  helps  greatly  in  the  diagnosis,  for  if 
the  stenosis  were  a  congenital  malformation,  there  would  be  symptoms  of  its 
presence  dating  back  to  infancy. 

Systolic  bruits  due  to  other  valvular  lesions  may  also  be  heard  over  the 
pulmonary  area  ;  but  they  have  their  point  of  maximum  intensity  over  other 
portions  of  the  praecordia,  and  are  only  heard  over  the  pulmonary  area  on 
account  of  their  loudness.  These  bruits  are  not  likely  to  be  mistaken  for  those 
that  have  just  been  described. 

(C).  Systolic  Bruits  over  the  Aortic  Area,  which  corresponds  to  that  portion 
of  the  chest  wall  overlying  the  second  right  costal  cartilage.  When  a  systolic 
bruit  is  heard  with  its  point  of  maximum  intensity  in  the  aortic  area,  and  is 
conducted  upwards  into  the  vessels  of  the  neck,  it  arises  either  at  the  aortic 
valve  or  in  the  ascending  portion  of  the  aorta.  The  chief  point  in  the  diagnosis 
between  these  two  conditions  is  the  character  of  the  aortic  second  sound.  If 
the  bruit  be  due  to  changes  in  the  valves  causing  obstruction,  then  the  second 
sound  will  be  altered  in  character,  being  muffled  and  sometimes  inaudible,  as  the 
rigidity  of  the  aortic  cusps  prevents  them  closing  suddenly  in  the  normal  manner. 
The  presence  of  an  aortic  diastolic  bruit  would  make  quite  clear  the  valvular 
origin  of  the  systolic  bruit.  When  the  bruit  is  due  to  changes  in  the  aorta,  in 
consequence  of  atheroma,  dilatation,  or  aneurysm,  and  not  to  stenosis  of  the 
semilunar  valves,  then  the  second  sound  is  usually  clear.  The  presence  of  a 
pulsating  tumour,  pulsation  in  the  second  right  intercostal  space  without  a 
tumour,  or  dullness  in  this  region,  would  confirm  the  diagnosis  of  the  bruit  arising 
in  the  aorta.  A  systolic  bruit  over  the  aortic  area  is  of  frequent  occurrence  ; 
but  for  the  purpose  of  diagnosis  it  must  be  remembered  that  such  a  bruit  is 
rarely  due  to  stenosis,  and  frequently  results  from  a  progressive  sclerosis  of  the 
aortic  valve,  or  from  changes  in  the  aorta.  Before  aortic  stenosis  is  diagnosed, 
there  should  be  a  loud  systolic  bruit  in  the  second  right  intercostal  space, 
together  with  a  systolic  thrill,  and  evidence  of  hypertrophy  of  the  left  ventricle. 
If  the  bruit  is  due  to  an  acute  endocarditis,  with  vegetations  on  the  semilunar 
valves,  then  the  left  ventricle  is  not  enlarged  to  such  an  extent  as  occurs  in 


io6  BRUITS,     CARDIAC 


aortic  obstruction,  or  in  atheroma  of  the  aorta,  which  is  most  frequently  part  of 
a  general  arterial  sclerosis. 

A  functional  bruit  confined  to  the  aortic  area  is  very  rare,  but  may  be 
distinguished  by  there  being  no  enlargement  of  the  left  ventricle,  and  by  the 
presence  of  other  functional  bruits,  especially  a  hruit  de  diable.  If  marked 
ansemia  exists,  either  from  some  primary  blood-disease  or  secondary  to  a 
cachectic  condition,  due  to  malignant  disease,  tuberculosis,  malaria,  a  large 
haemorrhage,  etc.,  then  the  diagnosis  of  a  functional  bruit  is  confirmed. 

{D).  Systolic  Bruits  over  tlie  Tricuspid  Area,  which  corresponds  to  that  part  of 
the  chest  wall  overlying  the  lower  portion  of  the  sternum.  A  bruit  heard  over 
the  tricuspid  area  is  of  diagnostic  importance  in  that  it  indicates  tricuspid 
regurgitation,  which  is  nearly  always  due  to  dilatation  of  the  right  ventricle. 
That  the  bruit  is  due  to  tricuspid  regurgitation  is  confirmed  by  finding  the 
cardiac  dullness  extending  to  the  right  of  the  sternum,  fullness  and  pulsation 
in  the  veins  of  the  neck,  and  evidence  of  failing  cardiac  compensation,  as  shown 
by  oedema  of  the  legs,  and  enlargement  and  pulsation  of  the  liver.  Many  bruits 
wliich  are  systolic  in  rhythm  and  produced  at  the  tricuspid  valves  are  best 
audible  in  the  neighbourhood  of  the  cardiac  impulse,  but  the}^  are  not  Conducted 
outwards  into  the  left  axilla  like  bruits  produced  at  the  mitral  valve.  On  the 
other  hand,  when  a  mitral  systolic  bruit  is  loud  enough,  it  may  be  audible  in 
the  tricuspid  area,  but  there  would  not  be  the  signs  of  passive  congestion, 
unless  there  was  general  failure  of  compensation.  It  should  be  borne  in  mind, 
of  course,  that  tricuspid  regurgitation  often  occurs  without  producing  any  bruit 
at  all,  so  that  absence  of  systolic  bruit  does  not  exclude  tricuspid  leakage. 

II. — Diastolic    Bruits. 

A  diastolic  bruit  heard  over  the  precordia  is  always  due  to  organic  disease 
of  the  heart.  If  it  be  present  over  the  aortic  area,  that  is,  over  the  second 
right  costal  cartilage  close  to  the  sternum,  and  conducted  downwards  along 
the  left  border  of  the  sternum,  and  sometimes  outwards  towards  the  cardiac 
impulse,  then  the  bruit  is  due  to  aortic  regurgitation.  Sometimes  the  point  of 
maximum  intensity  of  the  bruit  is  in  the  aortic  area,  sometimes  to  the  left  of  the 
sternum  in  the  third  intercostal  space.  An  examination  of  the  pulse  confirms  the 
diagnosis,  for  the  "  water-hammer  "  pulse  is  found  only  with  aortic  regurgitation. 
Capillary  pulsation  is  also  present,  and  is  best  demonstrated  by  placing  a  glass 
slide  on  the  everted  lower  lip,  or  by  pressing  the  finger  nail  so  that  the  proximal 
half  of  it  remains  pink  and  the  other  is  blanched.  Capillary  pulsation  is  found 
also  in  cases  of  marked  anaemia,  and  in  the  normal  person  in  a  Turkish  bath. 

As  the  diastolic  bruit  of  aortic  regurgitation  is  frequently  associated  with  a 
sj^stolic  one,  the  result  of  aortic  obstruction,  a  "  to-and-fro  "  murmur  is  pro- 
duced Avhich  may  sometimes  be  mistaken  for  pericardial  friction  sound.  In 
pericardial  friction  the  systolic  and  diastolic  sounds  do  not  commence  accurately 
with  the  first  and  second  sounds  of  the  heart,  are  not  conducted  in  the  recognized 
direction  of  an  endocardial  bruit,  and  are  altered  in  intensity  by  the  pressure  of 
the  stethoscope.  Having  decided  that  the  bruit  is  due  to  aortic  regurgitation, 
it  must  be  remembered  that  such  a  lesion  may  be  the  result  of  : — 

1.  A  progressive  sclerosis  of  the-  aortic  segments,  being  part  of  a  general 
arterial  degeneration,  or  due  to  a  localized  syphilitic  lesion. 

2.  Endocarditis,  either  simple  or  malignant. 

3.  Rupture  of  a  segment,  due  to  either  excessive  strain  on  an  already  diseased 
valve,  or  to  malignant  endocarditis. 

4.  Dilatation  of  the  aortic  ring,  secondary  to  dilatation  or  aneur^'sm  of  the 
ascending  portion  of  the  arch  of  the  aorta. 

5.  Congenital  malformation. 


BRUITS,     CARDIAC  107 


The  age  of  the  patient  helps  greatly  in  the  differential  diagnosis  ;  if  the 
lesion  be  found  in  a  child  or  young  adult,  the  condition  is  almost  invariablj^  the 
result  of  endocarditis ;  if,  on  the  other  hand,  aortic  regurgitation  occurs  in 
middle  life,  it  is  nearly  always  due  to  sclerosis  of  the  aortic  valve,  and  the 
diagnosis  is  confirmed  by  finding  degenerative  changes  in  the  arteries,  chronic 
renal  disease,  and  considerable  hypertrophy  of  the  left  ventricle.  If  the  regur- 
gitation be  due  to  dilatation  of  the  aortic  ring,  it  can  only  be  diagnosed  when 
the  existence  of  dilatation,  or  aneurysm  of  the  ascending  portion  of  the  arch  of 
the  aorta,  is  indicated  by  dullness  in  the  second  right  intercostal  space  close  to 
the  sternum,  and  by  pulsation  or  a  pulsating  tumour  in  this  area.  An  x-ray 
examination  is  also  useful  in  confirming  the  presence  of  an  aneurysm.  Some- 
times an  aneurysm  may  be  situated  just  above  the  sinuses  of  Valsalva,  and, 
while  producing  aortic  regurgitation  by  causing  dilatation  of  the  aortic  ring, 
may  give  no  other  physical  sign  of  its  presence.  It  may  be  very  small,  and  yet 
may  cause  sudden  death  by  rupture  into  the  pericardial  sac. 

A  diastolic  bruit  heard  only  down  the  left  border  of  the  sternum  is  nearly 
always  due  to  aortic  regurgitation,  but  occasionally  may  be  produced  by 
pulmonary  regurgitation  as  the  result  of  endocarditis,  dilatation  of  the  pulmonary 
ring,  or  a  congenital  defect.  Pulmonary  regurgitation  more  frequently  occurs 
secondarily  to  mitral  stenosis,  and  it  is  then  due  to  dilatation  of  the  pulmonary 
orifice  as  the  result  of  increased  blood-pressure  in  the  pulmonary  circulation. 
The  other  two  forms  of  pulmonary  regurgitation  are  very  rare,  and  difficult  to 
distinguish  from  aortic  regurgitation.  In  this  cardiac  lesion  there  is  no  evidence 
of  enlargement  of  the  left  ventricle,  while  the  right  side  of  the  heart  is  enlarged, 
and  there  is  no  "  water  hammer  "  pulse  as  in  aortic  regurgitation. 

Diastolic  bruits  audible  at  the  cardiac  impulse  are  due  either  to  endocarditis 
of  the  mitral  valve,  to  mitral  stenosis,  or  to  aortic  regurgitation.  An  aortic 
diastolic  bruit  is  often  conducted  as  far  as  the  cardiac  apex,  and  replaces  the 
second  sound  here  ;  sometimes,  however,  the  diastolic  bruit,  which  is  heard  in 
the  aortic  area,  is  lost  on  being  traced  down  the  left  border  of  the  sternum, 
to  reappear  at  the  apex.  The  diastolic  bruits  of  mitral  stenosis  can  be  distin- 
guished by  their  appearance  later  in  the  diastolic  period,  and  the  most  common 
is  presystolic  in  rhythm — a  crescendo  murmur  ending  in  a  loud  slapping  first 
sound.  An  aortic  regurgitant  bruit  is  blowing  in  character,  whereas  the  bruit 
of  mitral  stenosis  is  rumbling.  Early  diastolic,  mid-diastolic,  and  late  diastolic 
bruits,  also  occur  in  mitral  stenosis  ;  but  none  of  these  should  be  mistaken  for 
the  bruit  of  aortic  regurgitation,  as  the  latter  condition  would  be  associated  with 
hypertrophy  and  dilatation  of  the  left  ventricle,  the  apex  beat  being  displaced 
outwards  and  downwards,  usually  to  the  sixth  intercostal  space,  and  would  be 
confirmed  by  the  characteristic  "  water-hammer  "  pulse.  In  mitral  stenosis 
without  mitral  regurgitation,  there  is  very  little  displacement  of  the  apex  beat, 
because  the  left  ventricle  is  not  enlarged.  The  bruit  of  mitral  stenosis  is  often 
associated  with  a  presystolic  thrill,  whereas  that  of  aortic  regurgitation  is  not. 

In  order  to  understand  the  various  bruits  which  occur  in  mitral  stenosis,  the 
manner  in  which  they  are  produced  must  be  discussed.  They  are  caused  by  the 
blood  being  forced  through  the  stenosed  mitral  valves.  The  two  forces  which 
produce  this  are  the  contraction  of  the  walls  of  the  left  auricle  and  of  the  right 
ventricle.  The  suction  action  of  the  left  ventricle  during  its  diastole  is  probably 
not  sufficient  in  itself  to  cause  the  bruit,  but  simply  helps  in  the  work  of  the 
left  auricle  and  right  ventricle.  The  presystolic  bruit  of  mitral  stenosis  occurs 
during  the  end  of  the  ventricular  diastole,  and  corresponds  to  the  systole  of  the 
left  auricle.  A  mid-diastolic  bruit  sometimes  occurs  in  mitral  stenosis.  This 
may  be  the  only  bruit  present,  but  there  may  be  a  presystolic  bruit  as  well, 
resulting  in   two   distinct  bruits   during  the   ventricular   diastole.     These   two 


io8 


BRUITS,     CARDIAC 


bruits  may  be  fused  into  one,  when  the  contractions  of  the  right  ventricle  and 
left  auricle  are  vigorous.  The  mid-diastolic  bruit  is  probably  due  to  the 
previous  contraction  of  the  right  ventricle  increasing  the  blood-pressure  in  the 
lungs  and  left  auricle,  and  so  forcing  the  blood  through  the  stenosed  mitral 
valve.  The  mid-diastolic  bruit  varies  slightly  in  its  situation  in  the  ventricular 
diastole,  and  this  may  depend  upon  the  time  when  the  force  of  the  contraction 
of  the  right  ventricle  makes  itself  felt  on  the  left  side  of  the  heart.  This  bruit 
in  consequence  may  become  an  early  or  late  diastolic  bruit.  When  the  force 
of  the  contractions  of  the  left  auricle  begins  to  fail,  the  presystolic  bruit  often 
disappears.  In  mitral  stenosis  there  may  therefore  be  a  presystolic  bruit,  or  a 
mid-diastolic  bruit,  or  mid-diastolic  and  presystolic  bruits,  or  a  bruit  which 
occupies  almost  the  whole  of  the  ventricular  diastole.  With  all  these  bruits 
the  first  sound  at  the  apex  is  usually  slapping  or  thumping  in  character.  This 
alteration  in  the  first  sound  may  be  present  without  any  of  the  above-mentioned 
bruits,  and  is  in  itself  very  characteristic  of  mitral  stenosis.  In  some  cases  the 
second  sound  is  reduplicated  at  the  cardiac  apex,  while  in  others — and  this  in 
the  majority  of  the  cases — it  is  inaudible.  The  pulmonary  second  sound  is 
accentuated.  The  bruit  may  be  accompanied  by  a  mitral  systolic  bruit,  as 
regurgitation  often  occurs  through  the  stenosed  orifice. 


Accentuation    of   the   first 
sound  in  all  varieties. 


n 


H 


Short  presystolic  bruit. 


Longer  presystolic  bruit. 


L 


Mid-diastolic  bruit. 


JNIid  -  diastolic     and     pre- 
systolic bruit. 


n 


Mid  -  diastolic  and  pre- 
systolic bruits  fused  into 
one. 


Fig-.  24. — Diagram  of  the  bruits  01   mitral  stenosis  (Sawyer's  Physical  Signs). 

A  presystolic  bruit  in  the  mitral  area  is  usually  due  to  mitral  stenosis,  but  it 
also  occurs  in  aortic  regurgitation  and  in  dilatation  of  the  left  ventricle,  when  the 
bruit  is  spoken  of  as  Flint's  murmur.     To  distinguish  bet^veen  the  two  conditions 


BRUITS,     CARDIAC  109 


may  be  difficult ;  in  an  uncomplicated  case  of  mitral  stenosis  the  apex  beat  is 
normal  in  position,  but  when  Flint's  murmur  is  present,  the  apex  beat  is  greatly 
displaced  on  account  of  the  enlargement  of  the  left  ventricle.  The  presence  of 
any  aortic  disease  also  points  in  the  direction  of  the  bruit  being  Flint's  murmur. 
This  bruit  is  often  considered  to  be  caused  by  the  vibration  of  the  anterior 
curtain  of  the  mitral  valve,  as  it  lies  between  the  regurgitating  blood-stream 
through  the  aortic  orifice  and  that  flowing  into  the  ventricle  from  the  left  auricle. 
If  this  were  the  true  explanation  of  Flint's  murmur,  it  should  occur  early  in 
diastole  instead  of  being  presystolic,  as  it  invariably  is.  Another  view  is  that 
the  blood  regurgitating  through  the  aortic  orifice  lifts  the  anterior  curtain  of  the 
mitral  valve  and  so  obstructs  the  mitral  orifice  at  the  end  of  the  ventricular 
diastole.  Neither  of  these  explanations  seems  to  be  sufficient  to  account  for  the 
murmur.  In  a  normal  heart  the  ratio  of  the  diameter  of  the  mitral  opening  to 
that  of  the  left  ventricle  is  about  i  to  2  ;  in  mitral  stenosis,  on  account  of  the 
contracted  orifice,  the  ratio  is  about  -}  to  2,  the  size  of  the  left  ventricle  remaining 
the  same.  In  this  latter  condition,  a  presystolic  bruit  occurs,  and  it  is  probably 
this  alteration  in  the  ratio  which  produces  it.  In  aortic!  regurgitation,  although 
the  diameter  of  the  mitral  orifice  remains  the  same,  yet  the  diameter  of  the  left 
ventricle  is  greatly  increased  on  account  of  its  dilatation.  The  ratio  between 
the  diameter  of  the  mitral  opening  to  that  of  the  left  ventricle  would  probably 
be  I  to  4,  or  exactly  the  same  ratio  as  occurs  in  mitral  stenosis.  There  would 
be  a  relative  mitral  stenosis  when  the  size  of  the  mitral  opening  is  compared 
with  that  of  the  left  ventricle.  The  two  conditions,  therefore,  may  be  similar, 
although  the  one  is  on  a  larger  scale  than  the  other  ;  and  as  the  altered  ratio 
of  these  two  diameters  produces  in  raitral  stenosis  a  presystolic  bruit,  it  is 
probable  that  the  same  ratio,  although  the  factors  are  on  a  larger  scale,  produces 
in  aortic  regurgitation  a  Flint's  murmur — which  is  also  presystolic  in  time.  A 
presystolic  bruit  is  sometimes  present  without  any  aortic  regurgitation,  and 
without  mitral  stenosis,  but  always  with  an  enlarged  left  ventricle  •  and  this 
seems  to  point  to  the  regurgitation  of  the  blood  through  the  aortic  valves  not 
taking  any  direct  part  in  the  production  of  the  bruit. 

The  following  diagrammatic  drawings  of  the  heart  are  constructed  to  show 
the  probable  mode  of  production  of  Flint's  murmur  : — 


Normal  heart.  IMitral  stenosis.  Dilated  left  ventricle. 

Ratio     of    diameter     of  Ratio  about  i   to  2.  Ratio  about  i  to  4  ;  same  proportion 

mitral  valves  and  dia-  Presystolic   bruit.  as  in  mitral  stenosis.     Presystolic 

jueter  of  left  ventricle,  bruit  (Flint's), 

about  I  to  2. 

Fig-.   25. — Diagram  to  explain  the   origin  of  Flint's  murmur     Sawyer's  Physical  Signs). 


BRUITS,     CARDIAC 


Diastolic  bruits  are  heard  only  very  occasionally  over  other  areas  of  the  pre- 
cordia,  but  it  is  possible  for  a  presystolic  bruit  to  occur  in  the  tricuspid  region 
as  the  result  of  tricuspid  stenosis  ;  such  a  bruit  is  rareh^  present  without  valvular 
disease  of  the  left  side  of  the  heart. 

A  functional  bruit  is  never  diastolic  in  rhythm  ;  but  it  is  important  to  distinguish 
the  mid-diastolic  bruit  of  acute  endocarditis  from  the  similar  bruit  of  fibrotic 
stenosis.  During  endocarditis  there  is  some  thickening  of  the  valve-fiaps  from 
inflammatory  oedema;  and  this  leads  to  bruits  not  unlike  those  of  fibrous  stenosis. 
The  diagnosis  depends  upon  (i)  The  development  of  the  bruit  under  observation  : 
if  in  a  case  of  acute  rheumatism  a  mid-diastolic  bruit  is  noticed  to  develop 
rapidly,  it  cannot  be  due  to  fibrosis,  and  must  result  from  acute  inflammation 
of  the  valve  ;  (2)  The  course  of  the  bruit  :  if  it  is  due  to  fibrosis  it  will  persist, 
if  to  endocarditis  it  will  change  with  time,  becoming  less  definite  if  the  endocar- 
ditis resolves,  more  definite  if  the  inflammation  goes  on  to  scarring  and  stenosis  ; 
(3)  The  age  of  the  patient  :  mitral  stenosis  does  not  occur  commonly  before 
puberty,  so  that  it  is  most  risky  to  interpret  a  diastolic  apical  bruit  in  a  child  as 
being  due  to  mitral  stenosis.  /.  E.  H.  Saivvcr. 

BULLffi. — A  bulla  is  literally  a  water-bubble  ;  as  applied  to  skin  diseases,  it 
is  synonymous  with  bleb  or  blister  ;  it  differs  from  a  vesicle  only  in  its  size, 
which  may  be  from  half  an  inch  in  diameter  to  that  of  a  tangerine  orange.  It 
is  possible  for  almost  any  vesicular  skin  disease  to  be  of  bullous  degree  occasion- 
ally ;  on  the  other  hand,  there  are  certain  diseases  in  which  bullae  are  character- 
istic ;  and  there  are  yet  other  affections  in  which,  although  bullae  are  not  always 
present,  they  may  occur  in  a  marked  degree  occasionally. 

The  following  are  the  chief  conditions  under  which  bullae  are,  or  ma^^  be,  a 
prominent  feature  of  the  case  : — 

A.  Conditions  in  which  Bull.^  are  usual; — 

Pemphigus 

Erythema  bullosum 

Dermatitis  herpetiformis 

Herpes  gestationis 

Er^'thema  iris 

Epidermolysis  bullosa 

Pemphigus  neonatorum 

Local  application  of  vesicants,  such  as  cantharides,  arnica,  rhus  tcxico 

dendron,  croton  oil,  nitric  acid,  scalding  water,  or  hot  solids 
Cheiropompholyx 

Local  friction  by  splints  after  fractures  ;    or  by  boots,  oars,  tools,  etc. 
Some  cases  of  gangrene,  and  Raynaud's  disease. 

B.  Conditions  in  which  Typical  Bull.^  may  occur,  though  they  are 

NOT    USUAL : 

Erysipelas 

Impetigo  contagiosa 

lodism 

Bromidism 

Glanders 

Syphilis 

Cases  of  extreme  oedema  from  Bright's  disease  or  heart  failure 

Syringomyelia 

Workers    amongst    turpentine,    chrysarobin,    varnish,  aniline  dyes,  and 

other  chemicals  ;  tar  products,  resin,  volatile  oils  ;  satin-wood,  primula 

obconica,  and  perhaps  some  other  plant  products. 


BULL/E  III 

'  The  diagnosis  is  sometimes  obvious  ;  for  instance,  herpes  gestationis — which 
is  also  known  as  hydroa  gestationis,  erythema  gestationis,  and  dermatitis 
pruriginosa  polymorpha  recurrens  graviditatis — is  the  probable  lesion  whenever 
a  bullous  eruption  develops  in  a  pregnant  woman  ;  and  this  diagnosis  becomes 
certain  if  there  is  a  history  of  former  pregnancies,  each  associated  with  a  similar 
eruption,  whilst  between  the  pregnancies  there  has  been  complete  freedom  from 
the  complaint.  The  eruption  itself  is  precisely  similar  to  that  of  dermatitis 
herpetiformis,  which  is  described  below.  It  only  remains-  to  add  that,  whereas 
in  most  cases  the  trouble  begins  in  the  later  months  of  pregnancy,  there  is  a 
tendency  for  it  to  develop  earlier  in  each  successive  pregnancy  ;  and  that, 
whereas  in  most  cases  it  subsides  rapidly  when  the  child  is  born,  in  a  few  instances 
it  may  last  into  the  puerperium,  or  even  develop  only  during  that  period.  The 
most  troublesome  part  of  the  complaint  is  the  itching  and  irritation,  that  often 
amount  to  actual  pain.  It  is  conceivable  that  a  person  who  is  subject  to 
pemphigus  or  erythema  bullosum  might  develop  an  attack  during  pregnancy  ; 
but  herpes  gestationis  is  excluded  if  recurrence  takes  place  apart  from  pregnancy, 
whereas  the  occurrence  of  the  bullous  eruption  solely  in  association  with  preg- 
nancy makes  the  diagnosis  obvious  at  once. 

Again,  bullae  in  a  new-born  infant  will  generally  receive  the  term  pemphigus 
neonatorum.  The  two  main  points  to  be  borne  in  mind  are,  first  that  the  eruption 
is  not  related  to  that  of  ordinary  pemphigus,  so  that  it  is  a  pity  the  word  pem- 
phigus is  employed  at  all  ;  and  secondly,  that,  uncommon  though  it  may  be, 
there  are  nevertheless  two  distinct  kinds:  (i)  That  in  which  the  bullae  are 
chiefly  on  the  "hands  and  feet,  when  they  are  one  of  the  manifestations  of  a 
severe  and  generally  fatal  type  of  congenital  S3rphilis — a  type  in  which  the 
eruption  appears  almost  immediately  after  birth  instead  of  after  an  interval  of 
days  or  weeks  as  in  other  cases  ;  and  {2)  That  in  which  there  is  an  infection  of 
the  skin  of  the  nature  of  an  impetigo — generally  staphylococcal,  but  in  some 
cases  due  to  less  usual  organisms  such  as  the  Bacillus  pyocyanens — producing 
bullae  instead  of  the  more  usual  pustules  ;  the  latter  is  an  affection  of  poverty- 
stricken  districts,  occurring  in  more  or  less  epidemic  form,  sometimes  closely 
related  to  the  practice  of  a  particular  midwife,  and  fortunately  rare  now-a-days. 

Cheiropompholyx  is  another  condition  that  may  generally  be  recognized  at 
once.  It  is  a  dysidrosis,  and  the  sweat-glands  of  the  palms  of  the  hands  and  the 
soles  of  the  feet  are  most  affected,  though  those  of  the  forehead,  chest,  back,  and 
so  on,  may  sometimes  be  affected  too.  As  a  rule,  the  sweat  retained  in  the 
glands  produces  subcutaneous  vesicles  that  are  barely  larger  than  sago  grains ; 
as  the  superficial  epidermis  becomes  worn  off,  the  little  sweat-cysts  reach  the 
surface,  a  process  assisted  by  the  scratching  that  usually  results  from  the  irrita- 
tion arising  in  the  parts.  After  each  cyst  bursts  there  is  desquamation  of 
such  a  degree  that  scarlatina  may  sometimes  be  simulated.  The  malady  occurs 
in  summer  weather,  or  in  tropical  climates,  especially  in  those  who  are  apt  to 
perspire  freely. 

The  blisters  that  are  produced  by  the  external  application  of  vesicants  to  the 
skin  are  diagnosed  readily  enough  when  it  is  known  that  any  application  is  being 
used.  Difficulty  arises  mainly  in  two  classes  of  persons  ;  namely  (i)  In  those 
who  live  in  houses  upon  which  the  rhus  toxicodendron  is  grown  as  a  Virginia 
creeper,  the  nature  of  the  case  being  usually  discovered  from  the  fact  that  the 
patient  is  always  affected  when  at  home,  and  never  when  away  ;  and  (2)  In 
hysterical  patients,  or  in  malingerers,  who  purposely  but  surreptitiously  produce 
the  skin  eruption.  If  the  latter  is  suspected,  it  is  generally  possible  to  place  the 
patient  under  conditions  which  preclude  self-application,  when  the  disappearance 
of  lesions  confirms  the  diagnosis  ;  or  the  actual  vesicant  employed  may  some- 
times be  discovered,  liquor  epispasticus  for  instance,  or  some  other  preparation 


112  BULL.^ 

of  cantharides  ;  croton  oil ;  capsicum  ;  carbolic  acid  ;  m^'labris  ;  iodine  ;  or 
one  of  the  strong  mineral  acids,  especially  nitric  acid. 

The  relationship  of  occupation  to  a  bullous  dermatosis  will  often  become 
obvious  from  the  wa^'  the  skin  trouble  recurs  whenever  an^^  particular  work  is 
resumed  ;  the  list  above  indicates  the  kind  of  occupations  that  are  liable  to 
produce  it  ;  it  should  be  remembered,  however,  that  nearty  aU  these  produce 
bulte  far  more  seldom  than  they  do  a  vesicular  dermatitis. 

Extremelv  oedematous  tissues  are  very  easily  blistered,  and  on  this  account 
one  must  be  char\-  of  diagnosing  anything  but  simple  blisters  when  bullae  develop 
upon  oedematous  legs  or  other  parts  in  association,  for  instance,  with  Bright' s 
disease,  or  in  chronic  heart  cases  with  failing  compensation.  The  same  applies 
to  the  blebs  arising  on  the  skin  of  fractured  limbs,  and  also  in  the  region  of  a 
local  gangrene  ;  or  necrosis  of  the  soft  parts  due  to  such  causes  as  frost-bite,  or 
Raynaud's  disease,  or  scurv'y.  The  diagnosis  in  these  cases  will  nearly  always 
be  clear  enough,  and  so  will  it  be  in  cases  of  simple  blisters  due  to  friction  or 
irritation. 

Having  thus  excluded  all  the  more  or  less  obvious  cases,  there  remain  the 
following  :  pemphigus,  en,-thema  buUosum,  dermatitis  herpetiformis,  erythema 
iris,  epidermolvsis  bullosa,  en,-sipela.s,  impetigo  contagiosa,  iodism,  bromism, 
glanders,  svphilis,  and  s\-ringomyelia.  Of  these,  acquired  syphilis  is  so  very 
seldom  bullous  that  it  would  not  be  diagnosed  unless  there  was  strong  collateral 
evidence  of  the  nature  of  the  complaint,  either  in  the  historj'  or  in  the  other 
clinical  evidence  presented  by  the  patient. 

S\-Tingomyeha  is  ver\'  rare  also,  and  buUae  occur  in  but  a  ver^'-  small  propor- 
tion of  the  cases  ;  should  they  do  so  they  would  attract  attention  from  their 
distribution  being  probably  confined  to  quite  a  local  area,  the  fingers  and  hands 
for  instance,  leaving  the  rest  of  the  person  free.  The  diagnosis  would  be  con- 
firmed bv  finding  cutaneous  sensibility  natural,  though  the  patient  cannot 
distinguish  pain  from  touch,  or  heat  from  cold,  in  the  affected  parts.  The 
cutaneous  affections  of  s^-ringom^-eUa  are  sometimes  known  as  Moi^van's 
disease.  The  lesions  are  due  to  injuries  produced  because  the  skin  is  in- 
sensitive to  things  that  are  painful  enough  or  hot  enough  to  produce  sores 
and  blisters. 

The  patient's  occupation  would  ver^^  likel^^  suggest  the  nature  of  the  complaint 
in  a  case  of  bullous  glanders ;  it  might  actually  be  known  that  a  horse  with, 
which  the  patient  had  had  to  do  was  affected  with  the  complaint.  The  skin 
eruption  is  sometimes  quite  a  late  manifestation  of  a  prolonged  and  obscure 
febrile  illness  when  the  glanders  infection  has  started  internally,  for  instance  in 
the  lungs.  The  Bacillus  mallei  may  be  found  either  in  direct  smears  from  the 
contents  of  the  bullae  themselves,  or  in  cultures  made  from  them.  Bacterio- 
logical methods  afford  the  final  criterion  of  glanders. 

Both  bromides  and  iodides  mav  produce  many  different  t\'pes  of  skin  eruptions. 
The  commonest  by  far  is  that  of  simple  acne  ;  but  in  other  patients  there  may  be,, 
instead  of  acne,  either  a  patch}-  er\-thema  with  cutaneous  infiltration  ;  or  nodular 
swelling  studded  with  yellow  points  from  which  thick  puriform  fluid  can  be 
expressed  ;  or  a  confluent  f uruncular  lesion  ;  or,  finally,  a  true  bullous  eruption  or 
hydroa.  The  latter  is  decidedly  rare,  but  the  possibilit\'  of  its  occurrence  should 
be  borne  in  mind,  and  enquir\-  should  be  made  as  to  an}-  drugs  that  the  patient 
may  be  taking  ;  in  the  case  of  iodides  the  urine  will  give  a  bluish-green  colour 
with  the  guaiacum  test,  though  no  blood  is  present,  and  if  there  is  still  doubt  a 
quantity-  of  urine  may  be  evaporated  down,  and  either  bromine  or  iodine  detected 
by  ordinar\-  chemical  tests.  It  is  noteworthy-  that  bromide  and  iodide  eruptions 
have  been  recorded  in  infants  at  the  breast  when  the  mother  has  been  taking' 
the   drug  without  herself  presenting   an}-  cutaneous   symptoms.      The   causal 


BULL^ 


113 


micro-organism  is  generally  a  staphylococcus,  but  occasionally  it  has  been  found 
to  be  the  Bacillus  pyocyaneus. 

Bullous  impetigo  contagiosa  is  a  variety  of  impetigo.  Fluid  seems  to  accumu- 
late in  the  infected  spots  so  quickly  that  at  first  it  does  not  appear  to  be  purulent 
but  rather  to  take  the  form  of  single  big  vesicles  or  bullae.  These  often  become 
pustular,  and  as  they  dn,'  up  the  crusts  over  them  have  a  characteristic  yellow- 
honey-like  appearance.  The  condition  can  be  diagnosed,  as  a  rule,  from  the 
fact  that  other  parts  of  the  body  present  the  typical  lesions  of  ordinary  impetigo  ; 
there  may  be  other  patients  affected  in  the  same  house  or  school,  and  the  condi- 
tion is  as  readily  curable  by  antiseptic  measures  as  is  impetigo.  There  is  a  very 
rare  and  extremely  grave  disease  described  as  impetigo  herpetiformis  in  pregnant 
women  ;  but  this  seems  to  be  an  aggravated  form  of  dermatitis  herpetiformis 
or  herpes  gestationis  become  purulent  and  contagious.  It  is  found  in  Austria, 
but  not,  apparently,  in  England. 

Erysipelas  as  a  cause  of  bullje  is  well  known,  and  when  blebs  are  present  upon 
the  tjrpical  tender,  slightly  raised,  and  well  demarcated  red  skin  at  the  height  of 
the  affection,  in  association  with  the  constitutional  symptoms  and  pyrexia, 
there  can  seldom  be  any  difficult}^  in  the  diagnosis.  It  is  when  the  erysipelas  is 
subsiding  or  has  subsided,  whilst  the  bulls,  or  the  remains  of  them,  are  still 
obvious,  that  a  difficulty  might  arise.  Streptococci  may  be  detected  bacterio- 
logically. 

If,  on  due  consideration,  all  the  conditions  described  above  can  be  excluded 
and  it  has  been  found  that  the  patient  is  suffering  from  a  disease  of  which  bulls 
with  more  or  less  erythema  are  the  chief  manifestation,  then  the  diagnosis  has 
been  narrowed  down  to  one  or  other  of  the  following  :  pemphigus,  erythema 
bullosum,  dermatitis  herpetiformis,  erythema  iris,  and  epidermolysis  bullosa  ; 
there  is  evidence  to  show  that  these  are  closely  related  in  some  respects,  the 
different  names  applying  to  affections  that  differ  more  in  type  than  kind.  If 
the  patient  develops  bullae  on  various  parts  of  the  trunk  and  limbs  without  any 
erythema,  or  at  any  rate  without  any  erj^thema  until  the  bullae  have  been  present 
a  longer  or  shorter  time,  the  condition  is  then  described  as  pemphigus.  If  the 
bullae  develop,  not  on  normal-looking  skin,  but  upon  places  where  there  has 
already  been  erythema,  associated  with  more  or  less  itching,  or  even  pain,  before 
the  bullae  develop,  and  if  the  whole  eruption  consists  of  this  combined  condition 
of  erythema  and  large  bulls,  the  name  used  to  designate  it  is  erythema  bullosum. 
If  the  bullae  tend  to  dry  up  at  their  central  parts  and  then  to  be  followed  by  a 
secondary  ring  of  vesicles  or  blebs  around  the  original  one,  these  secondary 
vesicles  being  followed  in  turn  by  others  upon  a  yet  larger  ring  outside  them, 
the  condition  is  referred  to  as  herpes  iris  or  as  erythema  iris,  according  as  there 
is  little  or  much  er^-thema  before  the  first  vesicles  or  bulls  appear.  When  the 
bulls  are  apt  to  develop  on  any  part  of  the  body  from  a  degree  of  rubbing  or 
scratching  which  in  the  ordinary  individual  would  be  quite  unlikely  to  produce 
blisters,  this  undue  tendency  to  blister  formation,  from  what  ought  to  be  inade- 
quate causes,  is  spoken  of  as  epidermolysis  bullosa,  a  condition  which  may 
persist  throughout  life  without  necessarily  leading  to  any  other  untow-ard  sym- 
ptoms in  the  patient  ;  it  is  probably  related  to  factitious  urticaria.  Dermatitis 
herpetiformis  is  a  polymorphous  eruption,  of  which  bulls  form  but  a  part  ; 
the  trouble  begins  with  itching  of  the  skin,  and  more  or  less  general  disturbance, 
part  of  which  arises  from  the  loss  of  sleep  entailed  b}'  the  irritation.  In  various 
parts  of  the  body  or  limbs  er^-thematous  and  urticarial  patches  supen.'ene,  some 
of  wtiich  subside  without  further  development,  whilst  upon  others  clusters  of 
vesicles  soon  appear.  Many  of  the  clusters  contain  twenty  or  thirty  vesicles 
upon  a  single  inflamed  base  ;  some,  fewer  vesicles  of  larger  size  ;  whilst  yet 
others,  in  the  place  of  clusters  of  small  vesicles,  develop  into  typical  blebs  varjang 
D  '  S 


314  BULLM 

in  area  from  that  of  a  sixpence  to  that  of  a  half-crown.  No  region  of  the  body  is 
exempt.  The  characters  of  the  lesion  are  precisely  similar  to  those  found  in 
pregnant  women  suffering  from  herpes  gestationis,  but  there  must  be  a  difference 
in  causation,  for  the  latter^  though  it  occurs  with  every  successive  pregnancy  in 
the  same  woman,  remains  in  complete  abeyance  between  the  pregnancies,  w^hilst 
dermatitis  herpetiformis — Diihring's  disease  or  hydroa — may  occur  in  either  sex 
and  at  almost  any  age,  though  it  is  less  common  in  children  than  in  adults.  It 
is  probablj'  due  to  the  action  of  some  poison  circulating  in  the  blood,  derived 
perhaps  from  the  food  in  some  cases  ;  it  is  possible  for  two  persons  to  be  taken 
ill  after  partaking  of  the  same  food,  one  with  acute  gastro-intestinal  symptoms, 
such  as  diarrhoea  and  vomiting  ;  the  other  with  acute  pemphigus  ;  it  looks, 
therefore,  as  if  pemphigus  and  its  allies  may  be  related  to  the  acute  urticaria  that 
is  so  familiar  in  certain  cases  of  shell-fish  poisoning  ;   it  may  be  due  to  ptomaines. 

Any  one  of  the  bullous  dermatoses  may  be  either  acute,  subacute,  or  chronic, 
in  any  of  these  degrees  there  may  be,  practically,  no  constitutional  disturbances 
on  the  one  hand,  or  the  patient  may  be  so  ill,  with  more  or  less  pyrexia  and 
constitutional  disturbances,  as  to  require  to  stay  in  bed ;  while  not  a  few  cases, 
•especially  those  of  the  type  to  which  the  term  pemphigus  can  be  strictly  applied, 
may  prove  fatal.  In  all  the  bullous  dermatoses  the  eruption  may  be  restricted 
to  the  cutaneous  surface  ;  but  they  may  also  occur  upon  the  mucous  membranes, 
especially  of  the  mouth,  palate,  oesophagus,  nose,  colon,  rectum,  and  vagina.  If 
recovery  has  taken  place  upon  one  occasion  there  is  a  decided  tendency  for  subse- 
quent attacks  to  occur. 

Finally,  it  may  be  mentioned  that  although  it  is  often  stated  as  a  general  rule 
that  many  skin  diseases  may  be  associated  with  eosinophilia,  as  a  matter  of  fact 
few  skin  diseases  other  than  the  bullous  dermatoses  produce  any  marked  degree 
of  eosinophilia,  so  that  a  differential  leucocyte  count  may  afford  valuable  dia- 
gnostic evidence.  The  absence  of  eosinophilia  by  no  means  excludes  pemphigus 
or  erythema  buUosum  or  any  other  bullous  dermatosis,  but  the  presence  of 
eosinophilia  in  a  doubtful  case  increases  the  probability  of  the  condition  being 
one  of  these  ;  it  is  noteworthy,  moreover,  that  whereas  the  cells  in  the  contents 
of  the  bullae  themselves  are,  to  a  considerable  extent,  coarsely  granular  eosino- 
phile  corpuscles,  those  which  occur  in  a  blister  produced  artificially  in  the  same 
case  present  no  such  tendency  to  eosinophilia.  Herbert  French. 

BUZZING  IN  THE  EARS.— (See  Tinnitus.) 

CACHEXIA  literally  means  "  a  bad  habit,"  and  is  an  ill-defined  term  used 
to  include  almost  any  depraved  condition  of  the  body  in  which  nutrition  every- 
where is  defective.  Formerly  it  was  synonymous  with  chlorosis.  It  is  generally 
applied  to  patients  who  exhibit  at  the  same  time  progressive  loss  of  weight,  and 
change  of  complexion  in  the  direction  of  sallowness  or  actual  anjemia.  (See 
Weight,  Loss  of  ;  and  Anaemia.) 

The  word  is  generally  prefixed  by  a  qualifying  adjective,  such  as  cancerous 
cachexia,  syphilitic  cachexia,  malarial  cachexia,  tuberculous  cachexia,  the  dia- 
gnosis generally  being  indicated  by  other  symptoms  or  by  the  history.  Other 
varieties  of  cachexia  that  may  be  given  special  mention,  and  which,  if  they  are 
borne  in  mind,  are  not  as  a  rule  difficult  of  diagnosis,  are  C.  splenica,  including 
blood  diseases  such  as  leucocythemia,  in  which  with  progressive  loss  of  weight 
and  anaemia  there  is  enlargement  of  the  Spleen  {q.v.)  ;  C.  utevina,  with  chronic 
non-fatal  lesions  of  the  uterus  or  other  pelvic  organs,  notably  with  leucorrhoea, 
chronic  endometritis,  or  fibroid  tumoiirs  ;  and  often  accompanied  by  brown 
disfiguring  pigmentation  (chloasma  uterinum),  especially  on  the  forehead  and 
round  the  eyes  ;  C.  parasitica,  due  to  infection  by  the  more  serious  intestinal  or 


CAMMIDGE'S     PANCREATIC     REACTION  115 

other  parasites,  especially  Ankylostomum  duodenale,  Bothriocephalus  latus,  Bilhar- 
zia  hcsmatobia,  and  Trichina  spiralis  ;  C.  chlorotica,  a  synonj^m  for  chlorosis  ;  C. 
mercurialis,  attributed  to  the  effects  of  mercury,  though  perhaps  really  due  to 
syphilis,  seeing  that  the  condition  is  commonest  in  tertiary  cases  in  which 
mercury  has  been  given  in  large  quantities  ;  it  was  much  commoner  in  former 
days,  when  iodide  of  potassium  was  not  employed,  and  great  destruction  of  the 
tissues  of  the  legs,  scalp,  palate,  and  other  parts  was  common  ;  C.  exophthalmica, 
the  cachexia  that  is  sometimes  associated  with  exophthalmic  goitre  ;  C.  palustris, 
or  marsh  cachexia,  due  either  to  actual  malaria  or  to  constant  living  in  un- 
healthy, damp  surroundings  ;  C.  alkalina,  the  bad  health  caused  by  taking  large 
quantities  of  alkalies  for  a  long  period,  and  evidenced  by  pallor,  breathlessness, 
emaciation,  and  anaemia  ;  C.  aquosa,  also  called  pica,  and  C.  afrtcana,  a  term 
given  to  an  anaemic  condition  leading  to  serous  effusion,  and  often  accompanied 
by  perversion  of  appetite,  seen  in  hot  climates  and  especially  among  negroes;  it 
has  received  many  names,  such  as  white  tongue,  stomach  disease  of  negroes, 
negro  cachexy,  intratropical  anaemia,  dirt-eating  disease,  and  many  others. 
Doubtless  many  different  disorders  have  been  included  under  this  name,  including 
the  results  of  malaria  or  of  intestinal  worms  ;  C.  renalis,  which  results  from 
prolonged  albuminuria,  especially  in  subacute  tubal  nephritis  ;  C.  scorbutica,  a 
condition  formerly  described  as  associated  with  rickets,  though  more  likely  related 
to  the  infantile  scurvy  of  Barlow,  nutrition  being  impaired,  the  head  and  upper 
part  of  the  body  perspiring  profusely  during  sleep,  anaemia  developing,  and  the 
patient  being  intolerant  of  bed-clothes  owing  to  tenderness  or  actual  painfulness 
of  the  bones  :  there  may  or  may  not  be  bleeding  gums  ;  the  bone  tenderness  is 
thought  to  be  due  to  subperiosteal  haemorrhages  ;  C.  saturnina,  which  results 
from  chronic  lead  poisoning.  Herbert  French 

CAMMIDGE'S  PANCREATIC  REACTION.— The  improved  pancreatic  re- 
action primarily  depends  upon  the  fact  that  when  the  urine  of  a  patient 
suffering  from  pancreatic  inflammation  is  hydrolysed  by  boiling  with  dilute  HCl, 
a  sugar  having  the  reactions  of  a  pentose  is  set  free,  and  may  be  recognized  by 
conversion  into  its  osazone  crystals  by  treatment  with  phenylhydrazine.  A 
golden  yellow  flocculent  deposit  of  flexible  hairlike  crystals  forms,  arranged  in 
microscopic  sheaves,  readily  soluble  in  dilute  sulphuric  acid.  The  appearance 
and  solubility  of  the  crystals  are  very  characteristic,  but  as  glycuronic  acid,  which 
is  set  free  to  a  greater  or  less  extent  in  all  urines  during  the  hydrolytic  process, 
also  forms  a  crystalline  compound  with  phenylhydrazine,  it  is  removed  by 
treating  the  still  acid  urine  with  tribasic  lead  acetate,  after  the  excess  of  hydro- 
chloric acid  has  been  neutralized  with  lead  carbonate.  The  lead  that  goes  into 
solution  has  also  to  be  removed  by  converting  it  into  an  insoluble  sulphide  or 
sulphate  before  the  phenylhydrazine  test  is  applied. 

The  results,  both  of  five  years'  clinical  experience,  and  of  many  animal  experi- 
ments, have  demonstrated  that  a  positive  "  pancreatic  "  reaction  is  strong 
presumptive  evidence  of  a  disturbance  of  function  and  of  active  degenerative 
changes  in  the  pancreas.  In  most  cases  these  are  consequent  on  inflammation, 
either  acute  or  chronic,  but  in  a  few  instances  a  positive  reaction  seems  to  arise 
from  abnormal  physiological  activity.  The  latter  may,  however,  be  neglected 
for  all  practical  purposes,  for  it  is  not  associated  with  symptoms  suggestive  of 
pancreatic  disease. 

It  has  been  pointed  out  repeatedly  that  the  pancreatic  reaction  is  not  patho- 
gnomonic of  pancreatitis,  and  the  writer  must  again  insist  that  the  results  of 
the  test  must  be  considered  in  conjunction  with  the  clinical  symptoms  and  the 
evidence  to  be  obtained  by  a  complete  analysis  of  the  urine  and  faeces.  By 
doing  so  one  can  not  only  obtain  confirmation  of  the  indications  given  by  this 


ii6  CAMMIDGE'S     PANCREATIC     REACTION 

special  method  of  examination,  but  also  infer  the  probable  cause  of  the  changes 
in  the  pancreas,  which  is  a  most  important  point,  for  pancreatitis  is  rarely,  or 
never,  a  primary'  disorder,  but  is  usually  secondary  to  an  ascending  catarrh  from 
the  duodenum,  gall-stones  in  the  common  bile-duct  or  in  the  ampulla  of  Vater, 
invasion  of  the  pancreas  by  a  duodenal  or  gastric  ulcer,  malignant  disease 
either  primary  in  the  pancreas  or  secondary  to  some  other  organ,  back-pressure 
from  disease  of  the  heart  or  lungs,  arteriosclerosis,  alcoholism  and  cirrhosis  of 
the  liver,  sj^hilis,  tubercle,  influenza,  typhoid  fever,  mumps,  etc.,  etc.  In  many 
of  these  the  chnical  signs  and  symptoms  alone  are  sufficient  to  indicate  the 
cause  of  the  pancreatitis,  but  in  others  they  are  so  indefinite  or  obscure  that  it  is 
only  by  considering  the  results  of  a  complete  quantitative  and  qualitative  analysis 
of  the  urine,  and  faeces  also,  that  a  correct  diagnosis  can  be  arrived  at. 

A  single  negative  pancreatic  reaction  does  not  exclude  chronic  pancreatitis,  or 
rather  the  results  of  inflammation  of  the  pancreas,  for  the  reaction  is  only  given 
when  there  are  active  degenerative  changes  in  the  gland  at  the  time  when  the 
urine  is  being  excreted.  Cirrhosis  of  the  pancreas  due  to  past  inflammation  does 
not,  therefore,  cause  a  reaction  after  the  inflammation  has  subsided.  Cancer  of 
the  pancreas  too  is  associated  with  a  positive  reaction  in  only  about  25  per  cent 
of  cases,  the  presence  of  the  growth  being  apparently  unattended  by  any  inflam- 
matory changes  in  the  pancreas  in  the  remaining  75  per  cent. 

Other  points  to  be  noticed  in  examining  the  urine  from  suspected  cases  of 
pancreatic  disease  are  : — 

1.  The  presence  of  calcium  oxalate  crystals  (see  Oxaluria)  in  the  centrifu- 
gahzed  deposit ;  these  are  met  with  in  63  per  cent  of  cases  of  chronic  pancrea 
titis,  or  73  per  cent  if  jaundiced  cases  are  excluded. 

2.  A  pathological  excess  of  urobilin  (see  Fig.  23,  p.  95)  ;  this  is  a  very  constant 
indication  of  cholangitis,  and  a  particularly  useful  sign  of  gall-stones  in  the 
common  bile-duct,  whether  accompanied  by  jaundice  or  not. 

3.  A  well-marked  indican  reaction  :  pointing  to  a  catarrhal  condition  of  the 
intestinal  mucous  membrane,  with  abnormal  putrefactive  changes  in  the  contents 
of  the  intestine,  and  possibly  a  duodenal  or  gastric  ulcer. 

4.  Bile  pigment  in  the  urine  :  showing  that  there  is  some  obstruction  to  the 
free  flow  of  bile  into  the  intestine,  due  to  impacted  gall-stones,  gripping  of  the 
common  bile-duct  by  the  inflamed  head  of  the  pancreas,  which  surrounds  the 
duct  in  62  per  cent  of  cases,  malignant  disease  of  the  head  of  the  pancreas,  or  a 
growth  in  the  common  bile-duct. 

For  the  purposes  of  a  further  differential  diagnosis,  the  results  of  a  qualitative 
and  quantitative  analysis  of  the  faeces  are  most  important.  In  carrying  out  the 
analysis  the  points  to  be  noticed  particularly  are  : — 

1.  The  presence  or  absence  of  stercobilin  ;  in  gall-stone  obstruction,  traces  at 
least  are  nearly  always  met  with,  whereas  in  malignant  disease  of  the  head  of 
the  pancreas,  total  blocking  of  the  duct  is  the  rule,  although  the  soft  growths 
occurring  primarily  in  the  common  duct  usually  allow  some  bile  to  filter  through, 
so  that  traces  of  stercobilin  are  met  with  in  the  faeces. 

2.  The  percentage  of  unabsorbed  fat  :  in  cancer  of  the  pancreas  this  is  always 
very  high,  70  to  80  per  cent  ;  it  is  usually  somewhat  less  in  growths  of  the  common 
duct,  averaging  60  to  70  per  cent,  and  varies  from  a  subnormal  percentage  in 
early  catarrh  of  the  pancreas  to  as  much  as  50  or,  rarely,  even  80  per  cent  in 
advanced  chronic  pancreatitis. 

3.  More  important  still,  however,  is  the  relation  of  the  unsaponified  to  the 
saponified  fats,  for  whereas  the  former  are  in  excess  in  diseases  that  interfere 
with  the  digestive  functions  of  the  pancreas,  such  as  cancer  of  the  gland  and 
advanced  chronic  pancreatitis,  the  latter  predominate  in  obstruction  of  the 
common  duct  by  gall-stones,  without  pancreatitis,   and  in  malignant  growths 


CHARCOT-LEYDEN     CRYSTALS 


117 


not  involving  the  pancreas.  It  must  be  borne  in  mind,  however,  that,  owing 
to  the  abnormal  activity  of  fat-splitting  bacteria  in  the  lower  bowel,  such  as  is 
met  with  in  some  cases  of  intestinal  catarrh,  an  excess  of  saponified  fat  may  be 
found  in  cases  of  chronic  pancreatitis,  where  the  disease  is  due  to  an  infection 
spreading  from  the  duodenum  along  the  pancreatic  ducts.  A  similar  excess  is 
often  met  with  in  early  catarrhal  pancreatitis,  owing  probably  to  an  increased 
flow  of  pancreatic  juice  analagous  to  the  salivation  met  with  in  parotitis. 

4.  Microscopical  examination  of  the  faeces  for  fat  globules,  fatt}-  acid  cr^'stals, 
undigested  muscle  fibres,  connective  tissue,  etc.,  should  not  be  omitted  :  a 
large  excess  of  fat  globules  and  free  fatty  acid  crystals,  with  numerous  isolated 
undigested  muscle  fibres,  pointing  to  cancer  of  the  pancreas  o,r  advanced  cirrhosis 
of  the  gland,  whereas  muscle  associated  with  connective  tissue  points  to  defective 
gastric  digestion. 

5.  An  acid  reaction  of  the  fresh  stool  is  in  favour  of  a  diagnosis  of  pancreatic 
disease  ;   in  simple  gall-stone  obstruction,  the  faeces  are  usually  alkaline. 

6.  Occult  blood,  when  constant^  present  in  the  faeces  (see  p.  94),  is  suggestive 
of  malignant  disease  or,  more  rarel}',  advanced  pancreatitis,  in  which  it  is  now 
well  known  that  there  is  a  haemorrhagic  tendency ;  while  the  discovery  of  blood 
intermittently  points  to  a  gastric  or  duodenal  ulcer,  which  may  be  invading  the 
pancreas  and  setting  up  pancreatitis. 

By  carefully  considering  all  the  facts  thus  obtained,  and  interpreting  them 
in  the  light  of  the  clinical  signs  and  symptoms,  it  is  possible,  not  only  to  diagnose 
correctly  the  existence  of  disease  of  the  pancreas,  but  also  to  arrive  at  a  satis- 
factor)'  conclusion  as  to  its  probable  cause.  Affection  of  the  pancreas  is  much 
commoner  than  is  generally  supposed,  and  many  try'ing  cases  of  chronic  indiges- 
tion, recurring  or  persistent  jaundice,  and  obscure  affections  of  the  upper 
abdomen  would  be  explained,  and  satisfactorily  treated,  if  investigated  as  above. 
Undiagnosed,  and  consequently  untreated,  pancreatitis,  is  probably  the  most 
common  cause  of  diabetes.  If  this  were  more  widely  recognized  much  might 
be  done  to  stay  the  further  increase  of  that  disease.  p.  j .   Cammidge. 

CARDIAC    BRUITS.— (See  Bruits,  Cardiac.) 

CARDIAC  IMPULSE  DISPLACED.— (See   Heart  Impulse   Displaced.) 

CARDIAC  THRILLS. — (See  Thrills,  Precordial.) 

CASTS  IN  THE  URINE.— (See  Albuminuria.) 

CEPHALALGIA.— (See  Headache.)  ^:j^ 

CHARCOT-LEYDEN  CRYSTALS.— Charcot-  Ley- 
den  crystals  were  at  one  time  supposed  to  consist 
of  spermin,  but  now  there  is  considerable  doubt 
as  to  their  exact  chemical  nature.  Their  chief 
importance  from  a  clinical  point  of  view  is  that 
they  are  more  common  in  certain  conditions  than 
in  others.  They  may  be  found  either  in  the 
sputum,  the  blood,  or  in  the  stools. 

The  crystals  themselves  are  of  microscopic  size, 
needing  the  high  power  for  their  detection.  Each 
resembles  a  very  elongated  diamond  {Fig.  26), 
with  clear-cut  edges,  without  colour,  but  with  a 
slightly  yellow  appearance  when  seen  obliquely.  They  stain  with  eosin,  and 
are  soluble  in  hot  water,  in  mineral  acids,  and  in  alkalies,  so  that  for  their 
detection  a  fresh  specimen  is  required. 

In  the  sputum,  they  are  far  more  common  in  asthma  than  under  anv  other 


I^/^.  26. — Charcot-Leyden  crys- 
tals and  leucocytes  under  the 
high  power  of  the  microscope. 
(From  ISledical  Laboratory 
Methods.     Dr.   Herbert  French.) 


ii8  CHARCOT-LEYDEN     CRYSTALS 

circumstances — true  spasmodic  asthma,  such  as  also  gives  rise  to  Curschmann's 
Spirals  [q.v.)  and  eosinophile  corpuscles  in  the  sputum  at  the  same  time. 
As  a  means  of  determining  whether  a  given  case  is  one  of  paroxysmal  dyspnoea, 
cough,  or  bronchitis  on  the  one  hand,  or  true  asthma  complicated  by  bronchitis, 
upon  the  other,  the  detection  of  large  nurabers  of  Charcot-Leyden  crystals  in 
a  fresh  specimen  of  sputum  affords  considerable  evidence  in  favour  of  the 
latter  diagnosis.  Small  numbers  of  the  crystals  may  be  found  in  bronchitis  and 
in  association  with  bronchiectasis,  but  in  true  asthma  their  numbers  may  be 
quite  large. 

The  occurrence  of  Charcot-Leyden  crystals  in  the  blood  is  of  little  diagnostic 
value.  They  are  seldom  if  ever  found  in  fresh  blood  ;  but  when  the  latter  has. 
stood  for  some  time  in  bulk  they  develop,  particularly  in  certain  diseases  in 
which  leucocytes  are  breaking  down  rapidly,  especially  in  cases  of  leukcBvnia. 
Some  authorities  have  tried  to  draw  important  clinical  deductions  from  the 
development  of  these  crystals  in  blood,  but  it  is  doubtful  whether  they  really 
have  any  significance  of  value. 

In  the  stools,  Charcot-Leyden  crystals  have  been  found  in  a  great  variety  of 
diseases,  but  whether  or  not  clinical  deductions  can  be  drawn  from  their  presence 
is  doubtful.  It  is  stated  that,  when  they  abound,  the  patient  is  probably 
suffering  from  an  animal  parasite  ;  but  it  affords  no  indication  of  the  nature  of 
the  parasite  present.  Their  occurrence  should  lead  one  to  examine  the  fasces 
for  parasites  or  their  ova  with  even  greater  care  than  usual. 

Herbert  French. 

CHEST,    BLOODY   EFFUSION  IN When,   on    needling   a   chest    containing 

fluid  in  the  pleural  cavity,  this  fluid  is  found  to  be  obviously  blood-stained, 
the  fact  is  always  very  suggestive  of  one  of  three  things  :  either  the  inflammation 
of  the  pleura  has  been  exceedingly  acute  ;  or  the  chest  has  already  been  tapped 
not  long  previously,  so  that  there  has  been  haemorrhage  into  the  residual  fluid  ; 
or  there  is  malignant  disease  of  the  pleura,  either  primary  or  secondary,, 
carcinoma  or  sarcoma.  The  history  of  the  case  may  at  once  indicate  whether 
the  inflammation  is  very  acute  or  not  ;  the  symptoms  would  have  been  of  short 
duration  and  associated  with  much  pyrexia,  whilst  the  fluid  itself  would  be  of 
high  specific  gravity,  would  contain  a  large  amount  of  albumin,  would  probably 
coagulate  spontaneously,  and  microscopically  would  exhibit  numerous  poly- 
morphonuclear cells  and  lymphocytes,  as  well  as  an  abundance  of  red  corpuscles,, 
but  no  particles  of  growth  in  the  centrifugalized  deposit. 

If  blood  is  found  in  pleuritic  fluid  at  a  second  tapping,  when  it  was  not 
present  at  the  first,  the  fact  is  by  itself  of  little  value  in  difterential  diagnosis,  for 
the  bleeding  has  probably  been  caused  by  the  act  of  paracentesis. 

When  there  is  a  new  growth,  and  the  effusion  contains  obvious  blood  at  a  first 
tapping,  it  is  likely  that  the  symptoms  will  have  been  of  gradual  onset,  there 
will  not  be  marked  pyrexia,  there  may  not  be  signs  of  obstruction  to  a  bronchus 
or  to  the  intrathoracic  veins  ;  but  the  diagnosis  may  be  cleared  up  by  finding 
fragments  of  new  growth  in  the  centrifugalized  deposit.  It  is  of  course  by  no 
means  every  case  of  malignant  disease  affecting  the  pleurae  that  produces  a 
blood-stained  effusion  ;  but  when  the  effusion  is  blood-stained  at  a  first  tapping, 
in  a  case  that  has  not  run  a  very  acute  course,  one  should  be  very  suspicious  of 
new  growth.  In  not  a  few  such  cases  there  have  also  been  comparatively  large 
numbers  of  coarsely  granular  eosinophile  corpuscles  in  the  effusion. 

Herbert  French. 

CHEST,  DEFORMITY  OF.— (See  Deformity  of  the  Chest.) 

CHEST,  PAIN  IN (See   Pain  in  the  Chest.) 


CHEST,     PUS     IN  iig- 


CHEST,  PUS  IN. — When,  on  needling  the  chest,  pus  wells  up  into  the 
exploring  syringe,  it  is  exceedingly  probable  that  the  patient  is  suffering  from 
an  empyema.  Other  lesions  may  simulate  empyema,  however,  and  even  when 
empyema  is  actually  present  it  is  important  not  to  let  the  diagnosis  rest  at 
empyema ;  but  rather  to  regard  it  as  a  symptom  and  try  to  diagnose  its  cause. 
It  by  no  means  follows,  of  course,  that  when  the  exploring  syringe  fails  to  detect 
pus,  an  empyema  is  not  present,  for  sometimes  it  is  situated  either  between 
the  lower  lobe  and  the  diaphragm,  in  front  of  the  lung  or  between  the  lobes,, 
or  in  some  other  position  in  which  it  is  difficult  to  hit  it  off  with  the  needle. 
When  pus  is  found  but  the  amount  is  only  quite  small,  there  may  be  doubt  as  tO' 
whether  it  came  from  an  empyema  outside  the  lung,  from  a  bronchus,  or  an 
abscess  cavity  in  the  lung  substance.  The  nature  of  the  case  may  remain  undecided 
until  a  subsequent  puncture,  or  a  resection  of  a  rib,  conclusively  discovers  intra- 
pleural pus. 

Even  when  pus  wells  up  in  the  exploring  syringe  it  is  sometimes  possible  to- 
mistake  for  empyema  a  collection  of  pus  which  is  below  the  diaphragm.  A 
subdiaphvagmatic  abscess  and  an  abscess  within  the  liver  are  the  two  conditions 
most  liable  to  simulate  empyema  in  this  way.  If,  however,  the  history,  the 
symptoms,  and  the  physical  signs  do  not  serve  to  distinguish  between  these 
different  conditions,  it  will  still  be  clearly  necessary  to  evacuate  the  pus,  and  the 
surgeon's  finger  inserted  through  the  wound  will  be  able  to  feel  whether  the 
diaphragm  is  above  or  below  the  collection.  Even  then  there  is  one  possible 
source  of  error,  namely,  when  there  is  pus  both  above  and  below  the  diaphragm. 
A  subdiaphragmatic  abscess,  secondary  perhaps  to  appendicitis  upon  the  right 
side,  or  to  a  leaking  gastric  ulcer  upon  the  left,  may  have  infected  the  pleura 
through  the  diaphragm,  causing  first  a  serous  and  then  a  purulent  effusion, 
separated  from  that  below  the  diaphragm  merely  by  the  thickness  of  that 
muscle.  It  may  be  very  difficult  indeed  to  be  sure  of  this  condition,  even  at  the 
time  of  operation,  the  nature  of  the  case  not  being  fully  cleared  up  until,  when 
one  of  the  pus-containing  cavities  has  been  evacuated,  the  abnormal  physical 
signs  persist,  and  a  second  collection  of  pus,  above  or  below  the  diaphragm  as 
the  case  may  be,  is  found  at  a  subsequent  exploration.  The  ;r-rays  may  be  of 
considerable  assistance  sometimes  in  showing  whether  the  diaphragm  is  above 
the  pus  or  below  it 

If,  however,  the  physical  signs,  symptoms,  and  the  result  of  needling,  all 
conclusively  prove  that  the  chest  contains  an  empyema,  it  is  still  necessary  to- 
decide  as  far  as  possible  the  nature  of  the  latter.  Its  commonest  cause  is 
pneumococcal  infection,  nearly  always  preceded  by  lobar  pneumonia  in  adults, 
in  children  sometimes  by  bronchopneumonia,  but  not  infrequently  arising 
insidiously.  It  is  probable  that  many  of  the  so-called  latent  empyemata 
of  children  have  really  been  preceded  by  undiagnosed  bronchopneumonia. 
Difficulty  very  often  arises  from  the  fact  that  the  amount  of  pus  present  is  not 
great,  so  that  though  it  compresses  the  lung  sufficiently  to  render  the  alveoli 
airless,  the  bronchial  tubes  still  remain  patent,  and  there  is  no  complete  dullness 
at  the  base  or  wherever  the  empyema  may  be  ;  and  over  the  affected  area  there 
may  be  bronchial  breathing  and  crackling  rales,  instead  of  the  absence  of  breath- 
sounds  and  of  voice-sounds  that  usually  accompanies  empyema  in  adults.  If 
there  is  doubt  as  to  the  nature  of  the  empyema  as  judged  by  the  history, 
bacteriological  examination  of  the  pus  will  often  indicate  its  origin.  The 
commonest  organisms  to  be  found  are  pneumococci,  streptococci,  and  staphylo- 
cocci, though  Bacillus  coli  communis ,  typhoid  bacilK,  and  the  Bacillus  pyocyaneus 
also  occur,  and  it  is  not  improbable  that  other  organisms  also  may  be  present 
in  some  instances.  The  mode  of  infection  is  generally  either  via  the  lung,  or 
from  beneath  the  diaphragm  ;  and  careful  inquiry  into  the  history  and  symptoms 


CHEST,     PUS    IN 


■^vill  generally  indicate  which  of  these  two  paths  has  been  the  more  hkely.  When 
infection  from  any  peritoneal  condition  such  as  appendicitis,  leaking  gastric 
ulcer^  or  sub-diaphragmatic  or  hepatic  abscess,  can  be  excluded,  when  there 
has  been  no  injur}'  to  the  chest  with  broken  rib,  or  a  wound  communicating 
with  the  exterior,  and  when  there  is  nothing  to  indicate  whether  the  infection 
has  succeeded  pneumonia  or  is  itself  pneumococcal,  suspicion  will  arise  that  the 
patient  has,  been  suffering-  from  phthisis,  which  has  caused  a.  pleurisy  which 
was  at  first  non-purulent,  but  which  became  converted  into  an  empyema  as  the 
result  of  secondary  infection  with  pyogenic  organisms,  especially  if  there  is 
a  tuberculous  family  history,  or  if  the  patient  has  himself  been  weakly  for  some 


J^ij^.  27. — .^Kiagram  snowing  tne  mottling  01  the  lung  apices  produced  by  phthisis. 
Posterior  view.        {By  Dr.  A.  C.  Jordan.) 

time.  The  sputum  should  be  examined  ^\'ith  particular  care,  and  Ar-ray 
examination  may  pro\'e  very  helpful ;  for  even  when  the  compression  of  the  lung 
by  empyema  has  led  to  marked  opacitj^  at  the  base,  it  ma}'  still  be  possible  to 
make  out  that  apical  mottling  which  is  almost  pathognomonic  of  phthisis 
(Fig.  27). 

Rarer  causes  of  empyema  than  those  mentioned  above  will  generally  have 
been  accompanied  by  other  symptoms,  or  by  a  history  which  suggests  the  nature 
of  the  individual  case.  Herbert  French. 

CHEST,  SEROUS  EFFUSION  IN.— When  exploratory  needhng  of  the  chest 
discovers  clear  serous  fluid  in  the  pleural  cavity,  it  is  most  important  to  regard 
the  fact  merely  as  a  symptom,  for  there  are  many  different  causes  to  which 
it  may  be  due,  and,  whenever  possible,  one  should  decide  what  is  the  actual 
cause  in  each  particular  case.  In  the  first  place,  the  effusion  may  be  inflam- 
mator}^  or  merely  a  transudate  ;  the  pleuritic  must  be  distinguished  from 
the  pleural  effusion.  Clinical  points  indicating  that  the  effusion  was  inflam- 
matory rather  than  passive  would  be  :  its  being  unilateral,  not  bilateral  and 
symmetrical  ;  not  being  associated  with  a  general  water-logging  of  the  patient  ; 
and  the  non-existence  of  the  more  common  causes  for  passive  effusion, 
particularly  chronic  heart  failure  or  acute  nephritis  with  general  anasarca.. 
Physical,  chemical,  and  microscopical  analyses  of  the  fluid  might  also  serve  to 


CHEST,     SEROUS     EFFUSION     IN 


indicate  whether  the  effusion  was  active  oi*  passive  (see  Ascites).  There  are 
cases,  of  course,  in  which  there  ma}'  be  doubt,  but  it  is  generally  easy  to  deter- 
mine whether  the  effusion  is  due  to  pleurisy  or  not.  Pleural  effusions  net  due  to 
pleurisy  occur  late,  and  the  diagnosis  will  have  been  made  already  from  the 
existence  of  prominent  symptoms  earher  in  the  disease,  for  instance.  Albumin- 
uria    {q.v.),  Orthopncea  [q.v.),  CEdema  {q.v.),  and  so  forth. 

Pleuritic  effusion;  on  the  other  hand,  may  sometimes  be  the  most  prominent 
symptom,  and  it  is  not  always  easy  to  determine  the  cause  of  the  pleurisy. 
It  should  be  an  invariable  rule  to  have  the  effusion  examined  microscopically, 
both  for  cells  and  for  micro-organisms,  and  sometimes  to  have  guinea-pigs 
injected  with  it  in  order  to  see  whether  in  six  weeks'  time  the  inoculated 
animals  have  developed  general  tuberculosis  or  not.  The  commonest  cause  for 
apparently  simple  and  idiopathic  pleuritic  effusion,  is  latent  or  undiagnosed 
tuberculosis  of  the  lung  ;  there  may  be  no  sputum  ;  ;tr-ray  shadows  may  be 
indeterminate  ;  there  may  be  no  abnormal  apical  physical  signs  ;  there  may 
be  too  few  bacilh  for  them  to  be  detected  on  direct  examination  of  the 
deposit,  even  when  it  has  been  most  carefully  centrifugalized,  and  yet  inocu- 
lated guinea-pigs  may  develop  typical  tuberculosis  and  thus  indicate  the  nature 
of  the  pleurisy. 

Intrathoracic  new  growth,  whether  of  the  mediastinum,  lung,  or  pleura,  is 
fortunately  uncommon  ;  but  when  it  occurs,  the  symptoms  and  physical  signs 
to  which  it  gives  rise  are  often  very  difficult  to  interpret.  The  growth  may 
obstruct  a  bronchus  and  give  all  the  physical  signs  of  fibroid  lung,  with  or  with- 
out bronchiectasis  ;  it  may  cause  a  big  mass,  bodily  displacing  the  lungs  and 
heart  ;  it  may  cause  multiple  nodules  which,  unless  they  obstruct  the  superior 
vena  cava  and  produce  obvious  varicose  veins  on  the  chest  wall  or  other 
prominent  symptoms,  may  give  rise  to  no  very  definite  signs  or  symptoms  at 
all  ;  or,  what  is  not  at  all  infrequent,  the  growth  may  lead  to  pleuritic  effusion 
which  may  at  first  seem  to  be  simple,  or  even  be  taken  to  be  tuberculous,  growth 
not  being  suspected  until  the  rapid  recurrence  of  the  eftusion,  repeated 
tappings,  and  rapid  downhill  course  of  the  disease  ultimately  suggest  its 
nature.  Microscopical  examination  of  the  centrifugalized  deposit  of  the 
pleuritic  fluid  sometimes  leads  to  the  detection  of  particles  of  new  growth 
which  clinch  the  diagnosis,  whilst  if  the  fluid  in  a  case  which  is  not  absolutely 
acute,  is  blood-stained  at  a  first  tapping,  this  by  itself  is  highly  suggestive 
of  neoplasm. 

Acute  rheumatism,  particularly  between  the  ages  of  five  and  twenty,  is  not 
an  uncommon  cause  of  pleurisy  with  eflusion.  It  may  occur  when  there  have 
already  been  joint-pains,  or  other  symptoms  of  acute  rheumatism,  such  as  chorea, 
recurrent  tonsilUtis,  pericarditis,  endocarditis  followed  by  valvular  disease,  skin 
affections  such  as  erythema  multiforme,  erythema  nodosum,  pehosis  rheumatica, 
or  subcutaneous  nodules.  In  such  cases  the  diagnosis  is  not  difficult ;  but  it  is 
less  easy  when  the  pleuritic  effusion  is  itself  the  main  symptom  in  the  case. 
The  youth  of  the  patient,  the  absence  of  anaemia  or  of  previous  ill-health  of 
some  duration,  the  absence  of  abnormal  apical  lung  signs,  of  a  family  history 
of  phthisis,  the  presence  of  a  cardiac  bruit,  the  occurrence  of  heart  disease, 
acute  rheumatism,  or  chorea  in  other  members  of  the  same  family,  the  rapid 
onset  of  the  disease,  and  the  almost  equally  rapid  resolution  of  the  effusion, 
even  when  no  particular  treatment  is  adopted,  are  points  in  favour  of  acute 
rheumatism  rather  than  tuberculosis.  When  in  doubt,  the  negative  results  of 
guinea-pig  inoculation  would  point  in  the  same  direction,  and  von  Pirquet's 
skin  reaction  would  be  negative.  There  are,  however,  many  cases  of  pleuritic 
effusion  in  young  people,  in  whom  it  is  impossible  to  allocate  the  cause  either 
to  rheumatism  or  phthisis,  and  such  cases  are  sometimes  spoken  of  as  examples 


CHEST,     SEROUS     EFFUSION    IN 


of  "simple"  pleurisy;  doubtless -most  of  these  are  either  tuberculous  or 
rheumatic,  the  majority  ultimately  proving  to  be  the  former. 

Pneumococcal  lesions  of  thr  lung  generally  produce  pleurisy  ;  lobar  pneumonia 
indeed,  never  occurs  without  it,  though  bronchopneumonia,  even  when  it  is 
pneumococcal,  often  does.  It  is  less  common,  however,  for  pneumococci  to 
cause  a  serous  effusion  than  either  a  dry  pleurisy  or  an  empyema,  although 
pneumococcal  pleuritic  effusion  is  met  with  now  and  then,  the  diagnosis  being 
confirmed  by  the  discovery  of  pneumococci  in  the  fluid.  It  is  even  possible 
for  pneumococcal  pleuritic  effusion  to  occur  without  there  having  been  any 
definite  lobar  pneumonia  or  bronchopneumonia  preceding  it — primary  pneumo- 
coccal pleurisy.  It  is  difficult  to  say  where  pneumococcal  serous  effusion  stops 
and  pneumococcal  empyema  begins,  the  two  merging  into  one  another,  and 
the  same  case  often  exhibiting  clear  fluid  at  one  exploration,  cloudy  fluid  a 
few  days  later,  and  pus  later  still. 

Bright's  disease  may  cause  either  a  passive  effusion  as  the  result  of  heart 
failure  in  chronic  cases  ;  or  a  simple  accumulation  of  oedema  fluid  in  the  pleural 
cavities  without  heart  failure,  in  cases  in  which  the  general  oedema  of  Bright's 
disease  is  extreme  ;  or  actual  pleurisy  with  serous  effusion,  probably  the  result 
of  intercurrent  infection  by  some  low  type  of  organism,  corresponding  with  the 
peritonitis  with  Ascites  {q.v.)  and  with  the  pericarditis  which  may  also  occur  in 
these  cases.  The  diagnosis  will  be  indicated  by  the  Albuminuria  {q.v.),  associated 
with  renal  tube-casts  ;  and  if  there  is  bilateral  effusion  without  universal  oedema, 
but  with  signs  of  heart  failure  in  the  form  of  orthopnoea,  oedema  of  the  legs,  and 
perhaps  ascites,  the  effusion  is  passive  ;  it  belongs  to  the  second  category  if  there 
is  universal  oedema,  as  in  some  cases  of  subacute  nephritis  of  some  standing  ; 
whilst  if  the  effusion  is  inflammatory  it  will  probably  be  unilateral,  or  else  more 
marked  in  one  side  of  the  chest  than  in  the  other.  In  a  few  cases,  an  extensive 
pleuritic  effusion  in  a  middle-aged  or  elderly  person  is  the  very  first  indication 
that  there  is  anything  renal  the  matter,  the  diagnosis  of  red  granular  contracted 
kidney  being  confirmed  by  the  urinary  changes,  big  heart,  ringing  aortic  second 
sound,  high  blood-pressure,  or  by  albuminuric  retinitis. 

Any  of  the  severe  blood  diseases,  particularly  Hodgkin's  disease,  lymphadenoma, 
lymphoma,  lytnphatic  leukemia,  splenomedullary  leukcsmia,  splenic  ancBmia, 
pseudo-leukcsmia  infantum,  and  to  a  less  extent  pernicious  ancemia,  may  give 
rise  to  inflammation  of  any  of  the  serous  membranes,  and  thus  lead  to  ascites, 
pericarditis,  or  pleurisy  with  effusion.  The  latter  is  seldom  an  early  symptom 
in  such  cases,  however,  and  the  diagnosis  will  generally  be  known  already  by 
the  presence  of  pronounced  An/emia  {q.v.),  enlargement  of  the  Lymphatic 
Glands  ((/.w.),  or  enlargement  of  the  Spleen  (5'.z;.),withor  without  pathognomonic 
blood-changes  already  discussed  under  these  various  headings. 

Pleuritic  effusion  may  sometimes  be  secondary  to  infection  of  the  pleurae  from 
inflammatory  changes  below  the  diaphragm  ;  thus  appendicitis  may  lead  to  micro- 
organisms tracking  up  behind  the  ascending  colon  to  reach  the  diaphragm,  there 
perhaps  producing  a  small  subdiaphragmatic  abscess,  or  a  local  inflammation 
which,  stopping  short  of  pus  formation,  ultimately  subsides.  The  bacteria  in 
contact  with  the  lower  surface  of  the  diaphragm  seem  able  to  pass  through  the 
latter  and  infect  the  pleura  without  there  being  any  actual  hole  in  the  diaphragm 
muscle  ;  they  seem  to  pass  through  the  normal  stomata,  and  it  is  noteworthy 
that  passage  of  micro-organisms  in  the  reverse  direction  is  so  rare  as  almost  to 
be  negligible  ;  acute  peritonitis  often  produces  acute  pleurisy,  but  the  latter, 
or  even  empyema,  seldom  produces  peritonitis.  Anj^  inflammatory  mischief 
below  the  diaphragm  may  lead  in  this  way,  sometimes  to  dry  pleurisy, 
sometimes  to  pleuritic  effusion,  and  sometimes  to  empyema.  One  need  not 
enumerate  all  such  causes,  but  they  should  be   borne  in  mind  as  possibilities. 


CHEST,     SEROUS    EFFUSION    IN  123 

There  may  have  been  acute  general  peritonitis,  or  a  more  local  inflammation 
of  the  peritoneum,  tracking  in  the  manner  already  described  in  connection  with 
appendicitis.  This  is  possible  when  there  is  a  leaking  from  a  gastric  or  duodenal 
ulcer  ;  local  infection  from  the  gall-bladder  ;  pyosalpinx  ;  pelvic  peritonitis  due 
to  whatever  cause  ;  perinephric  inflammation  secondary  to  renal  calculus  or 
injury,  or  tuberculosis  of  the  kidney  ;  hepatic  abscess  or  other  inflammatory 
changes  in  or  about  the  liver,  such  as  infective  cholangitis,  suppurative  pyle- 
phlebitis, or  the  softening  and  breaking  down  of  new  growth,  gumma,  or 
hydatid  cyst.  When  the  possibility  of  a  pleuritic  effusion  being  secondary  to 
an  abdominal  lesion  of  some  kind  is  borne  in  mind,  the  diagnosis  of  the  case 
is  generally  indicated,  at  least  approximately,  by  the  preceding  history  and 
symptoms.  If  the  fluid  obtained  smells  as  though  it  were  infected  with  Bacillus 
coli  communis,  this  would  be  an  additional  argument  in  favour  of  some  sub- 
diaphragmatic cause. 

Infarction  of  the  lung,  whether  thrombotic  or  embolic,  is  very  apt  to  be 
associated  with  pleurisy,  the  latter  often  being  dry  ;  but  if  the  infarct  has 
been  extensive,  or  is  due  to  embolism  from  some  septic  source  such  as  a 
lateral  sinus  or  jugular  vein  thrombosis  in  connection  with  otitis  media,  or 
other  similar  lesions  causing  venous  clotting,  the  inflammation  of  the  pleura 
tends  to  go  further  and  produce  an  effusion  which,  at  first  serous,  may  later 
become  purulent.  The  diagnosis  is  sometimes  obvious  ;  but  when  after  an 
operation,  perhaps  for  excision  of  an  inflamed  appendix,  the  patient  a  few 
days  later  develops  pleurisy  with  efl'usion,  it  may  not  occur  to  one  that  a 
possible  explanation  of  the  trouble  is  that  more  than  one  systemic  vein  in  the 
region  of  the  right  iliac  fossa  has  become  inflamed  and  thrombosed,  and  that 
portions  of  the  clot  have  been  detached  and  carried  to  the  lung,  where  multiple 
infected  emboli  have  led  to  pleurisy  and  serous  effusion,  without  going  so  far  as 
to  produce  either  abscess  in  the  lungs  or  empyema.  Should  haemoptysis  occur 
in  such  cases,  as  it  sometimes  does,  phthisis  may  be  feared  ;  but  it  will  be 
excluded  by  the  absence  of  tubercle  bacilli  on  repeated  examination  of  the 
sputum. 

Multiple  serositis  or  polyorrhomenitis  is  a  term  used  to  express  any  condition 
in  which  there  is  recurrent  inflammation  and  serous  effusion  into  more  than  one 
serous  membrane.  It  generally  affects  the  peritoneum,  pericardium,  and  both 
pleurae  either  simultaneously  or  successively.  It  is  not  a  disease  in  itself,  so 
that  the  differential  diagnosis  of  the  cause  of  the  combined  effusions  has  to  be 
made  upon  the  same  lines  as  that  described  for  each  separately.  There  are 
cases  in  which,  even  when  the  patient  dies,  the  precise  nature  of  the  multiple 
serous  inflammations  and  effusions  is  obscure  ;  it  is  very  possible  that  the 
original  microbial  cause  has  disappeared,  leaving  behind  it  so  much  fibrotic 
thickening  of  the  membranes  that  even  the  normal  secretions  are  unable 
to  drain  away  as  fast  as  they  should.  The  result  is,  that  recurrent  tapping 
at  comparatively  short  intervals  becomes  necessary,  and  the  patient  ultimately 
dies  of  exhaustion,  nothing  being  found  post  mortem  except  fibrous  thickening 
of  the  peritoneum,  pericardium,  and  pleurae,  with  more  or  less  extensive  peri- 
hepatitis, perisplenitis,  adherent  pericardium,  and  chronic  mediastinitis.  The 
general  opinion  is  that  the  primary  cause  in  these  cases  has  been  either  acute 
rheumatism  or  tuberculosis.  Sometimes  secondary  malignant  disease  affects 
more  than  one  of  the  serous  membranes  at  the  same  time,  and  produces  a  clinical 
picture  which  at  first  simulates  chronic  simple  polyorrhomenitis  ;  there  are 
generally  symptoms  due  to  the  primary  growth  ;  but  occasionally,  especially  in 
connection  with  diffuse  carcinoma  of  the  stomach — "  indiarubber-bottle  " 
stomach — the  primary  growth  causes  no  symptoms,  and  the  nature  of  the 
multiple  serous  effusions  may  be  obscure  unless  particles  of  new  growth  can  be 


124  CHEYNE-STOKES     RESPIRATION 

detected  in  the  centrifugalized  deposit,  or  secondary  masses  can  be  found  in 
the  hver  or  lymphatic  glands.  The  left  supraclavicular  glands  should  be  care- 
fully examined.  Sometimes  the  diagnosis  is  not  arrived  at  until  a  post-mortem 
examination  is  made. 

Besides  chronic  tuberculous,  rheumatic,  and  mahgnant  polyorrhomenitis,  a 
similar  condition  may  be  due  to  Bright's  disease  or  any  of  the  severe  anaemias  ; 
the  differential  diagnosis  of  the  serous  effusions  to  which  these  may  give  rise  has 
already  been  discussed.  Careful  examination  of  the  blood  and  urine,  together 
with  estimation  of  the  blood-pressure,  examination  of  the  optic  discs,  and  routine 
physical  examination  of  the  various  bodily  systems,  are  essential  before  the 
correct  diagnosis  can  be  arrived  at.  Herbert  French. 

CHEST,  VARICOSE  VEINS  ON (See  Veins,  Varicose  Thoracic.) 

CHEYNE-STOKES  RESPIRATION,  or  periodic  breathing,  consists  in 
the  occurrence  of  a  series  of  inspirations,  beginning  with  a  hardlj^  perceptible 
movement  increasing  to  a  maximum,  and  then  declining  in  force  and  length 
until  they  cease  in  a  period  of  apnoea  of  some  seconds'  duration,  during  which 
the  patient  may  appear  to  be  dead,  but  at  the  end  of  which  a  low  inspiration 
followed  by  one  more  decided,  and  then  others  of  increasing  depth,  mark  the 
beginning  of  a  new  ascending  series  of  inspirations  which  in  their  turn,  when 
the  maximum  has  been  reached,  become  progressively  smaller  again  to  end  in 
another  period  of  apnoea  ;  and  so  on  with  more  or  less  periodicit}^  {I^^g-  28).     The 


vvr---^ 


Fig:  28, — Cheyne-Stokes  Breathing.      A  graphic  record  from  a  case  of  arterial  degeneration 
and  softening  of  the  medulla  oblongata.     The  two  curves  were  completed  in  143  seconds. 

duration  of  each  period  varies  from  half  a  minute  to  two  minutes  or  even  more. 
There  is  a  pecuhar  variety  of  periodic  breathing  in  which,  instead  of  a  waxing 
and  waning  sequence,  only  two  or  perhaps  three  rapid  deep  breaths  are  made 
at  a  time,  with  long  periods  of  apnoea  between  them- — a  variety  of  periodic 
breathing  which  is  sometimes  spoken  of  as  Blot's. 

Periodic  breathing  occurs  during  sleep  both  in  the  very  young  and  in  the 
very  old,  without  there  being  any  actual  disease.  In  other  persons  Cheyne- 
Stokes  breathing  is  generally  a  late  phenomenon,  having  been  preceded  by 
other  symptoms,  particularly  ursemic  or  cardiac,  though  in  a  few  cases  of 
progressive  softening  secondary  to  arterial  degeneration  in  the  medulla  oblongata 
Cheyne-Stokes  respiration  may  be  the  most  saUent  symptom  in  the  case. 

Broadly  speaking,  one  ma}^  classify  the  chief  causes  of  periodic  breathing 
under  headings,  as  follows  : — 

1.  Arterial,  especially  when  there  are  Degenerative  Changes  in  the  Medulla 
Oblongata  : — 

Arterio-sclerosis 

Senile  degeneration,  especially  changes  associated  with  granular  kidney. 

2.  Ursemic,  in  cases  of  : — 


Acute  nephritis 
Chronic  nephritis 
Calculous  disease  of  the  kidney 
Tuberculous     disease     of     the 
kidney 


Ascending  nephritis,  acute  or  chronic 
Cystic  kidneys 
Carcinoma  of  the  kidney 
Sarcoma  of  the  kidney. 


CH  ORDER  125, 

3.  Chronic  Heart  Failure  : — 

Secondary  to  valvular  heart  disease 

Secondary  to  myocardial  degeneration,  especially  fatty  or  fibroid  heart 

Secondary  to  chronic  obstruction  in  the  lungs,  especially  from  emphysema 
and  bronchitis,  and  fibroid  lung 

Failure  associated  with  very  high  systemic  blood-pressure  due  to  arterio- 
sclerosis or  granular  kidney. 

4.  Narcotic  Poisoning,  especially  from 

Morphia  Butyl  chloral  hydrate 

Opium  Veronal 

Chloral  Sulphonal. 

5.  Macroscopic  Lesions  of  the  Brain  or  its  Coverings  :— 

Tuberculous  meningitis 

Suppurative  meningitis 

Posterior-basal  meningitis 

Cerebrospinal  meningitis 

Hydrocephalus 

Tumour  of  the  brain,  especially  of  the  pons  or  medulla 

Hemorrhage 

Softening  of  the  brain  secondary  to  : 

Chronic  arterial  degeneration 

Syphilis  Caisson  disease 

Embolism  General  paralysis 

Acute    specific    fevers,    such    as    pneumonia,    cholera,    diphtheria, 
typhoid  fever,  malaria,  infective  endocarditis".  ^    ■"..  • 

The  differential  diagnosis  of  these' various  conditions  will  be*  indicated  by 
symptoms  and  signs  other  than  the  Ch^syjie-Stpkes .  respiration,  for  the  latter 
will  have  occurred  late  in  the  great  majority  "of  the  cases.  The  urine  will  be 
examined,  the  blood-pressure  measured,  the  physical  signs  of  the  'heart  particu- 
larly noted,  the  retina  examined  for  retinitis,  optic  neuritis,  or  for  choroidal 
tubercles,  and  careful  inquiries  will,  be  made  into  the  history.  ■  Wheye  nqtcotfc 
poisoning  may  be  suspected,  the  gastric  contents  may  be  recovered  and  analyzed, 
bottles  found  under  suspicioxis  circumstances  anay  be  examined -in  .the  same 
way,  or  evidence  of  hypodermic*injections  sought  for  on  the  patient's  body  or  ' 
limbs.  When  Cheyne-Stokes  respiration  occurs  as  the  main  symptom  in  the 
case,  the  great  probability  is  that  there  are  degenerative  changes  in  the  medulla 
oblongata,  nearly  always  secondary  to  arterial  degeneration,  either  senile, 
syphilitic  or  sclerotic.  When  there  have  been  obvious  symptoms  of  some,  other 
kind  before  Cheyne-Stokes  respiration  develops,  the  latter  is  far  more  important 
from  the  prognostic  than  from  the  diagnostic -standpoint.  Herbert  French. 

CHORDEE. — -A  condition  in  which,  during  erection,  the  penis,  instead  of 
remaining  straight,  becomes  curved  like  a  banana,  either  downwards  Or  to  one 
or  other  side.  It  is  nearly  always  due  to  gonorrJieea,  though,  in  rare  cases  it  has 
been  noticed  as  the  result  of  injury  without  gonorrhoea.  The  dift'erential 
diagnosis  will  depend  upon  the  history  and  the  ^xisten(^e  or  otherwise  of 
a  urethral  discharge  containing,  gonococci.  The  cbndition  itself  is  probably 
due  to  inflammatory  effusion  into  one  or  other  corpus  cavernosnm,-or  the  corpus 
spongiosum,  as  the  case  may  be  ;  or,  in  the  absence  of  inflammation,  to 
the  bursting  of  one  or  more  blood-vessels,  with  consequent  blood  extravasation. 
There  are  cases  on  record  in  which  fracture  of  the  penis  has  occurred  during 
resisted  coitus,  the  diagnosis  depending  on  the  history  and  upon  the  obvious 
break  that  is  palpable  in  the  penis  during  erection.  Herbert  French, 


126 


CHYLURIA 


CHYLURIA. — The  passage  of  milky-looking  urine,  due  to  the  admixture  with 
it  of  emulsified  fat,  is  known  as  chyluria.  It  is  not  likely  to  be  mistaken  for 
phosphaturia,  even  when  the  latter,  especially  after  the  largest  meal  of  the  day, 
causes  the  urine  to  be  almost  Hke  thin  milk  from  the  spontaneous  deposition  of 
the  excess  of  phosphates  whilst  the  urine  is  still  in  the  bladder.  The  opacity  in 
the  latter  case  disappears  on  the  addition  of  a  drop  or  two  of  acetic  acid,  whilst 
the  fat  droplets  of  chyluria  do  not  clear  up  with  acids,  are  obvious  under  the 
microscope,  and  may  be  brought  out  still  more  clearly  by  the  use  of  special  fat 
stains,  such  as  osmic  acid,  sudan  III,  or  saffranin.  As  a  rule,  the  urine  coagulates 
on  standing,  and  subsequently  liquefies  again,  when  it  throws  up  a  fatty  scum 
and  deposits  a  sediment.  The  fat  is  most  plentiful  after  meals  which  contain 
fat,  and  the  degree  of  chyluria  consequently  varies  considerably  in  the  same 
patient,  and  may  sometimes  be  almost  absent. 

The  commonest  cause  for  the  symptom  is  infection  hyFilaria  sanguinis  hominis 
in  the  tropics,  adults  being  affected  more  often  than  children,  and  females 
more  often  than  males.  There  may.  or  may  not  be  elephantiasis  at  the  same 
time  ;  the  diagnosis  may  be  suggested  by  eosinophiha  and  confirmed  by  the 
discovery  of  the  embryos  in  the  blood  {Plate  XII,  Fig.  F) . 

Chyluria  may  also  occur,  however,  in 
those  who  have  never  been  abroad,  and  it 
is  sometimes  associated  in  some  way  that 
is  not  yet  fully  understood  with  sub-acute 
nephritis  ;  there  may  be  chylous  ascites  at 
the  same  time.  The  diagnosis  depends 
upon  the  history,  the  general  oedema,  the 
anaemia,  cardiac  hypertrophy,  and  upon 
the  discovery  of  an  abundance  of  albumin 
with  renal  epithelial  cells  and  tube-casts  in 
the  centrifugalized  urinary  deposit,  as  well 
as  fat  droplets  in  the  supernatant  fluid. 

Sonaetimes  chyluria  develops  quite  apart 
from  any  renal  lesion,  either  spontaneously 
or  as  the  result  of  abdominal  injury;  and 
it  has  generally  been  found  in  these  rare 
cases,  that  there  has  been  either  rupture  of 
the  receptaculum  chyli,  or  else  a  blockage 
in  the  thoracic  duct.  The  latter  some- 
times results  in  cases  of  malignant  disease, 
especially  carcinoma  of  some  intra-abdom- 
inal organ.  The  development  of  chyluria 
in  such  cases  would  be  a  late  symptom, 
and  the  diagnosis  would  probably  have 
been  made  already  on  account  of  other 
symptoms,  especially  the  discovery  of  a 
primary  tumour.  It  is  important  not  to 
forget  rectal  and  vaginal  examination,  lest 
the  growth  should  be  pelvic. 

Herbert  French. 
CLAW-FOOT,  pied-en-griffe,  Krallen  der 
Zehen  [Fig.  29),  is  much  less  common  than 
Claw-hand  {q.v.),  but  it  may  arise  from  similar  causes.  The  internal  popliteal 
nerve,  which  supplies  the  interossei  and  lumbricals  of  the  foot  through  its  ex- 
ternal plantar  branch,  is  homologous  to  the  ulnar  nerve  in  the  upper  extremity. 
Its  buried  course  in  the  leg  does  not,  however,  expose  it  to  the  same  chances 


Fig.  2g. — Claw-foot. 


CLAW-HAND  127 


of  injury  as  the  more  superficial  ulnar  nerve,  and  consequently  claw-foot  is 
not  often  the  result  of  trauma.  Disease  or  injury  of  the  first  and  second  sacral 
segments  or  spinal  roots  may  produce  the  characteristic  deformity  of  the  toes, 
in  which  case  there  would  probably  be  disturbances  of  sensibility  in  the  cor- 
responding cutaneous  areas.  In  acute  poliomyelitis  affecting  those  segments, 
the  diagnosis  depends  on  the  history  of  onset,  as  in  the  cases  of  claw-hand  of 
similar  origin.  £.  Farquhar  Buzzard. 

CLAW-HAND,  main-en-griffe,  Krallenhand,  is  the  name  used  to  describe  a 
hand  characterized  by  a  claw-like  p'osition  of  the  lingers  [Fig.  30).  In  such  a 
hand  the  lingers  are  extended  at  the  metacarpo-phalangeal  joints  and  flexed  at 
both  inter-phalangeal  joints.  This  position  of  the  fingers  is  the  result  of  the 
over-action  of  the  extensor  communis  digitorum  and  flexores  digitorum  when 
unopposed  by  the  normal  antagonism  of  the  interossei  and  lumbricales.  It  is  not 
symptomatic  of  any  particular  disease,  but  results  from  any  morbid  condition 
which  produces  atrophic  paralysis  of  the  intrinsic  hand  muscles  so  long  as  the 
long  extensors  of  the  fingers  remain  intact.  Progressive  muscular  atrophy,  ulnar 
paralysis,  syringomyelia,  cervical  pachymeningitis,  acute  poliomyelitis,  peroneal 
atrophy,  and  supernumerary  ribs  are  among  the  conditions  which  may  give  rise 
to  claw-hand  to  a  lesser  or  greater  degree.  In  any  particular  case  the  diagnosis 
of  the  condition  underlying  it  must  depend  on  the  result  of  further  investigation. 


Fig.   30. — Syringomyelic  claw-hand. 

In  progressive  muscular  atrophy,  wasting  of  the  intrinsic  hand  muscles  is  often 
an  early  symptom,  and  a  claw-hand  may  develop  before  the  long  extensor 
muscles  of  the  fingers  have  become  involved  in  the  disease.  All  four  fingers 
are  usually  affected  to  an  approximately  equal  extent,  and  there  is  often  marked 
wasting  of  the  thenar  and  hypothenar  eminences.  When  the  abductor  pollicis 
is  also  involved,  the  thumb  tends  to  come  into  line  with  the  fingers  and  gives 
an  appearance  to  the  hand  resembling  that  of  the  ape  (ape's  hand).  The  flexors 
of  the  wrist  often  become  involved  before  the  extensors,  with  the  result  that 
the  wrist  is  hyperextended,  and  a  "  preacher's  hand  "  results.  The  absence 
of  pain  and  of  all  sensory  disturbance,  the  gradual  onset,  and  the  general 
exaggeration  of  the  deep  reflexes,  serve  to  distinguish  this  condition  from  some 
of  the  other  causes  of  claw-hand. 

In  ulnar  paralysis  the  claw-position  is  more  marked  in  the  ring  and  little 
fingers  than  in  the  middle  and  first  fingers,  owing  to  the  fact  that  the  two  outer 
lumbricals  are  supplied  by  the  median  nerve.  The  adductor  pollicis  is  the  only 
thenar  muscle  to  suffer,  but  the  hypothenar  eminence  is  wasted.      If  the  injury 


CLAU'-HAXD 


to  the  nerve  is  above  the  point  where  it  gives  off  the  branch  to  the  flexor  carpi 
ulnaris,  the  latter  muscle  \yiil  also  be  paralyzed,  and  flexion  of  the  -n-rist  will  be 
carried  out  with  a  leaning  towards  the  radial  side.  In  ulnar  paralysis  the  palsy 
is  limited  to  the  muscles  supphed  by  the  ulnar  ner\-e,  and  there  is  usually  some 
sensory  loss  in  the  area  of  skin  innervated  b}-  the  latter. 

The  claw-hand  of  syringomyelia  [Fig.  30)  resembles  that  of  progressive  mus- 
cular atrophy  in  general  appearance,  and  may  show  the  modifications  to  which 
the  term  "  ape's  hand  "  and  "  preacher's  hand  "  have  been  applied.  The  mus- 
cular atrophy  is  not  limited  to  the  distribution  of  a  single  ner\-e,  but  involves 
the  musculature  inner^-ated  by  the  eighth  cervical  and  first  dorsal  spinal  seg- 
ments, the  segments,  in  fact,  in  which  the  gliosis  frequently  begins.  The  diagnosis 
depends  on  the  presence  of  dissociative  anaesthesia,  trophic  and  vasomotor 
disturbances  such  as  whitlows,  glossy  skin  (peau  lisse),  main  succulente,  and 
is  often  corroborated  bv  the  occurrence  of  oculo-pupillar\-  phenomena,  nystag- 
mus, scoUosis,  and  e\-idence  of  spastic  paralysis  in  the  leg  of  the  same  side. 
Cervical  pachymeningitis  ovly  leads  to  a  claw-hand  when  it  interferes  with 
the  function  of  the  eighth  cervical  and  first  dorsal  anterior  roots  and  leaves 
uninjured  the  sixth  and  seventh  cervical  roots.  The  condition  is  generally 
bilateral  with  some  as\Tnmetr\-,  and  it  is  usually  associated  with  pain  and  ill- 
defined  disturbances  of  sensibility  in  the  two  arms. 

An  acute  poliomyelitis  affecting  the  eighth  cervical  and  first  dorsal  segments, 
and  leaWng  intact  the  sixth  and  seventh  cer\dcal  segments,  is  of  uncommon 
occurrence.  The  history-  of  acute  onset,  with  constitutional  s\-mptoms  such 
as  headache,  fever,  vomiting,  and  con^■ulsions,  affords  a  clue  to  the  diagnosis. 
The  absence  of  sensory-  loss,  and  the  possible  presence  of  atrophic  palsies  in 
other  parts  of  the  body,  form  additional  data  in  these  cases. 

Peroneal  atrophy  is  another  condition  in  which  a  claw-hand  may  develop, 
owing  to  the  slow  progressive  wasting  of  the  intrinsic  hand  muscles.  The 
diagnosis  depends  on  the  s^-mmetrT.-  of  the  affection  and  the  preceding  or  con- 
comitant atrophv  of  the  leg  muscles,  generally  beginning  in  those  supplied  by 
the  peroneal  nerve  (see  Figs.  8  and  9,  p.  71). 

Supernumerary  cervical  ribs  may  lead  to  the  production  of  a  claw-hand  when 
they  cause  neuritic  changes  in  the  trunk  formed  by  the  eighth  cervical  and  first 
dorsal  contributions  to  the  brachial  plexus.  The  muscular  atrophy  is  preceded 
b}^  pain  in  the  arm  and  neck,  and  sometimes  by  vasomotor  changes  and  diminu- 
tion of  the  radial  piilse.  Analgesia  in  the  distribution  of  the  eighth  cervical 
and  first  dorsal-root  areas  may  also  be  detected,  but  the  diagnosis  must  depend 
mainly  on  the  skiagraphic  discovery  of  the  rudimentarj-  ribs. 

E.  Farqiihar  Buzzard. 

CLONUS,  ANKLE.— (See  Axkle-Cloxus.) 

CLUBBED  FINGERS. — This  condition  denotes  bulbous  enlargement  of  the  soft 
parts  of  the  terminal  phalanges,  \^-ith  over-cur\-ing  of  the  nails  both  transversely 
and  lon.gitudinally,  seen  characteristically  in  morbus  cseruleus,  and  also  in  asso- 
ciation M,-ith  fibroid  lung.  It  is  readily  distinguished  from  enlargement  due  to 
bonv  changes,  such  as  those  of  acromegaly  and  pulmona.r\-  osteoarthropathy. 

Minor  degrees  of  clubbing  of  the  fingers  may  occur  with  almost  any  disease  that 
leads  to  persistent  congestion  of  terminal  parts,  such  as  mitral  stenosis,  mitral 
regurgitation,  emphysema,  chronic  bronchitis,  pleurisy  with  effusion,  empyema, 
chronic  phthisis,  some  forms  of  aortic  aneur\-sm,  asthma,  pericarditis,  adherent 
pericardium,  mediastinitis,  or  mediastinal  neoplasm.  In  such  cases,  however, 
the  clubbing  has  to  be  looked  for — it  does  not  thrust  itself  upon  one's  notice  ;  it 
may  also  pass  away  again  when  the  cause  is  removed,  for  instance,  when  an 
empyema  is  cured  by  operation. 


CLUBBED     FINGERS 


129 


Obvious  and  extreme  finger-clubbing  has  only  two  main  causes — con- 
genital heart  disease  with  cyanosis  (Fig.  31),  especially  pulmonary  stenosis 
with  or  without  a  perforated  interventricular  septum ;  and  fibroid  lung, 
especially  if  associated  with  bronchiectasis.  The  distinction  between  these 
two  will  generally  be  obvious.  The  former  dates  from  infancy  and  is  associ- 
ated with  extreme  cyanosis  and  a  loud  pulmonary  systolic  bruit  and  thrill  ; 
the  latter  develops  later  in  life,  is  seldom  associated  with  such  extreme 
cyanosis  except  when  the  patient  is  in  extremis,  and  is  accompanied  by 
displacement  of  the  heart  and  other  signs  of  fibrosis  of  the  lung,  with  or 
without  bronchiectasis. 

Difficulty  may  arise  in  those  rarer  cases  of  congenital  heart  disease  in  which 
there  is  no  bruit — cases,  for  instance,  in  which  the  heart  gives  off  a  single  large 
vessel,  the  place  of  the  pulmonary  arteries  being  taken  by  intercostal  vessels — 


Fig:  31. — Clubbed  fingers  in  a  case  of  congenital  pulmonary  stenosis  with  e.vtreme 

cyanosis. 


but  even  here  the  fact  that  the  lividity  is  out  of  proportion  to  the  dyspnoea, 
and  the  history  that  the  cyanosis  and  the  finger-clubbing  date  from  soon  after 
birth,  afford  immediate  clues  to  the  diagnosis.  Congenital  heart  disease  without 
cyanosis — patent  ductus  arteriosus  for  instance — does  not  give  rise  to  clubbed 
fingers.  In  lung  cases  the  diagnosis  is  either  obvious  from  the  physical  signs  ; 
or  else,  if  the  abnormal  physical  signs  are  so  slight  as  by  themselves  to  suggest 
little  more  than  bronchitis,  the  existence  of  marked  clubbing  of  the  fingers 
is  important  evidence  that  the  lung  trouble  is  much  more  extensive  than 
this,  and  that  there  is  really  much  fibrosis,  and  probably  bronchiectasis,  too 
deep-seated  perhaps  to  permit  of  the  usual  physical  signs  being  detected  at 
the  surface  of  the  chest.  A  moderate  degree  of  clubbing  of  the  fingers  is 
sometimes  observed  in  case's  of  cirrhosis  of  the  liver,  particularly  in  that  type 
which  begins  as  splenic  anaemia — Banti's  disease.  This  suggests  that  the 
changes  in  the  finger  tips  have  a  chemical  as  well  as  a  mechanical  factor  in 
their  causation.  Herbert  French. 

D  9 


I30  CLUB-FOOT     OR     TALIPES 

CLUB-FOOT  OR  TALIPES. — Any  deformity  of  the  foot  not  limited  to  the 
toes  commonly  goes  under  the  name  of  club-foot  or  tahpes.  The  diagnosis  of 
the  dilierent  forms  of  talipes  is  extremelv  difhcult,  owing  to  the  number  of 
causes  and  the  compUcated  nature  of  the  deformities.  It  may  be  -well,  therefore, 
to  define  briefly  the  chief  varieties  of  simple  deformity-. 

1.  Talipes  Equinus. — In  this  condition  the  fore  part  of  the  foot  cannot  be 
raised  to  the  normal  degree.  Any  healthy  adult  is  able,  with  the  knee  straight,  to 
dorsiflex  the  ankle  to  such  an  extent  that  the  baU  of  the  great  toe  is  two  or  three 
inches  higher  than  the  prominence  of  the  heel.  The  degree  of  dorsiflexion  is  even 
greater  in  infants,  but  with  advancing  years  the  movement  becomes  hmited,  so 
that  old  people  may  hardly  be  able  to  dorsiflex  the  foot  beyond  the  right  angle. 

2.  Talipes  Calcaneus, — In  this  condition  the  heel  is  depressed  and  the  fore 
part  of  the  foot  elevated.  Extension  of  the  ankle  is  Hmited,  so  that  the  fore 
part  of  the  foot  may  not  touch  the  ground  in  w-alking. 

3.  Talipes  Valgus. — The  foot  is  everted  and  abducted  at  the  ankle  joint,  so 
that  the  inner  malleolus  is  too  prominent. 

'4.  Talipes  Varus. — The  foot  is  inverted  and  adducted  at  the  ankle  joint,  so 
that  the  outer  malleolus  is  too  prominent.  In  this  condition,  however,  there  is 
more  serious  deformity  at  the  medio-tarsal  joint,  at  which  the  fore  part  of  the 
foot  is  adducted  and  inverted. 

(;).  Talipes  Cavus. — The  arch  of  the  foot  is  too  high  or  hollow.  This  may 
be  due  to  depression  of  the  fore  part  of  the  foot,  of  the  heel,  or  of  both. 

Club-foot  may  be  di^•ided  into  (I)  The  Congenital,    (II)   The  Acquired. 

I.  CoxGEXiTAL   Talipes. 

Congenital  tahpes  is  usually  quite  easy  to  diagnose,  because  of  the  history  of 
the  presence  and  the  nature  of  the  deformity-  at  birth.       There  are  two  chie 
varieties  of  it  :    (a)   Equino-varus  ;    [b]   Calcaneo-valgus. 

Sometimes  the  histor\"  may  be  lacking  or  misleading,  and  the  shape  of  the  feet 
may  have  been  so  altered  by  treatment  or  neglect  that  it  may  be  ver\-  difficult 
to  distinguish  the  condition  from  paralvtic  tahpes,  especially  that  due  to 
paralysis  of  the  lower  neurone.  In  making  the  distinction  it  is  important  to 
remember  that  the  shortening  is  usually  ver\-  much  less  in  congenital  cases,  and 
that  wasting  of  the  muscles,  apart  from  tight  splinting,  is  also  much  less. 
Trophic  ulcers,  and  cold  and  blue  feet,  which  are  common  in  cases  of  paralysis, 
do  not  occur  in  congenital  talipes.  Moreover,  the  toes  are  not  h^^per-extended 
at  the  metatarso-phalangeal  joints,  a  condition  commonly  present  in  paralytic 
talipes.  The  reaction  of  degeneration  is  not  present  in  congenital  cases,  thus 
distinguishing  it  from  tahpes  due  to  comparatively  recent  paralysis  of  the 
lower  neurone.  The  reflexes  are  not  exaggerated,  thus  distinguishing  it  from 
talipes  due  to  paralysis  of  the  upper  neurone.  In  congenital  equino-varus  the 
small  conical  heel  is  nor  only  raised  but  also  turned  inwards  in  a  characteristic 
way,  and  it  is  generally  separated  from  the  inner  aspect  of  the  foot  by  a  deep 
furrow.  There  is  also  a  curious  flattening  on  the  outer  side  of  the  foot,  just  in 
front  of  the  external  maUeolus.  where  the  skin  is  dmipled  and  loose.  There  is 
also  a  furrow  on  the  inner  side  of  the  foot  opposite  the  medio-tarsal  joint.  The 
varus  is  alwavs  worse  than  the  equinus,  whereas  in  paralvtic  cases  the  equinus 
is  usually  worse  than  the  varus.  With  care  the  overstretched  and  therefore 
weak  muscles  can  be  shown  to  be  capable  of  voluntary-  contraction. 

II.  Acquired  Talipes. 

This  condition  may  be  subdi\"ided  as  follows:  (i)  The  parah-tic,  due  to 
{a)  Disease  of  the  upper  neurone  ;  (b)  Disease  of  the  lower  neurone  ;  (c)  Primary- 
muscular    disease  ;    (2)    Postural,   e.g.,  talipes  valgus  ;     (3)   Due    to    fibrosis   of 


CLUB-FOOT     OR     TALIPES  131 

muscle,  with   retraction  ;    (4)   Due  to  bone  disease  ;    (5)   Due  to   joint  disease 
6)   Due  to  contracting  scars  ;    (7)   Due  to  hysteria. 

I.  The  Paralytic. — [a)  In  talipes  due  to  destruction  of  the  upper  neurone  the 
reflexes  are  exaggerated  and  the  plantar  reflex  is  extensor  ;  whereas  in  talipes 
due  to  disease  of  the  lower  neurone  the  reflexes  are  unchanged,  diminished,  or 
lost.  Reaction  of  degeneration  may  be  present  with  lesions  of  the  lower  neurone, 
and  absent  with  lesions  of  the  upper.  Coldness  and  blueness  of  the  feet  are 
only  common  in  lesions  of  the  lower  neurone,  and  the  same  is  true  of  trophic 
ulcers.  The  shortening  and  wasting  are  generally  much  greater  in  lesions  of 
the  lower  neurone,  and  the  distribution  of  the  paralysis  is  much  more  irregular 
than  in  those  of  the  upper.  When  the  disease  of  the  upper  neurone  is  in  the 
brain,  it  is  usual  for  the  arm  as  well  as  the  leg  to  be  paralyzed  (infantile  hemi- 
plegia), or  both  feet  may  be  symmetrically  involved  {congenital  spastic  para- 
plegia). Occasionally  there  may  be  a  cerebral  monoplegia.  In  any  case  the 
deformity  due  to  disease  of  the  upper  neurone  is  almost  characteristic,  and  is 
mostly  equinus,  usually  with  a  little  valgus,  but  occasionally  with  slight  varus  ; 
whereas  when  the  lower  neurone  is  affected  the  deformity  is  nearly  always 
equino-varus  or  talipes  valgus.  In  distinguishing  various  destructive  lesions 
of  the  upper  neurone,  the  history  and  the  nature  of  the  deformity  may  help. 
In  hemiplegia  or  monoplegia  there  may  be  a  history  of  difficult  labour,  with 
delivery  by  forceps,  indicating  injury  to  the  cerebral  cortex,  or  meningeal 
haemorrhage  with  secondary  fibrosis  of  the  motor  area.  The  deformity  may  not 
be  obvious  for  a  year  or  more  after  birth,  and  it  is  usually  first  noticed  when  the 
child  begins  to  walk.  In  other  cases  it  may  be  due  to  thrombosis  of  the  cerebral 
veins  following  measles  or  influenza,  or  to  rupture  of  some  of  the  cortical  veins 
during  whooping-cough  or  violent  fits  of  passion.  Congenital  spastic  paraplegia 
is  distinguished  by  its  symmetry,  by  the  amount  of  spasm  as  shown  by  the 
unexpected  degree  of  flexion  of  the  ankles  that  can  be  produced  by  firmly 
pressing  upwards  the  fore-parts  of  the  feet.  Moreover,  there  is  usually  some 
mental  incapacity,  and  often  the  history  of  nervous  disease  in  the  family.  When 
the  lesion  is  in  the  spinal  cord,  there  may  be  a  history  of  spinal  injury  or  the 
evidence  of  spinal  caries,  or  of  growth  causing  a  spastic  paraplegia.  In  amyo- 
trophic lateral  sclerosis  there  are  signs  of  paralysis  and  wasting  of  the  upper 
limbs.  Friedreich's  disease^  or  hereditary  ataxy ^  is  an  occasional  cause  of  talipes 
equinus  or  equino-varus.  It  can  be  recognized  by  the  inco-ordination,  the 
nystagmus,  the  slurring  of  speech,  the  age  of  onset,  which  is  usually  about  six 
to  nine  years,  the  absence  of  knee-jerk,  and  the  hallux  erectus. 

{b).  Lesions  of  the  lower  neurone  may  be  in  the  cord  (infantile  paralysis),  or  in 
the  Cauda  equina  (spina  bifida),  in  the  lumbo-sacral  cord  or  sacral  plexus  (e.g., 
carcinoma  of  the  rectum),  or  in  the  peripheral  nerves  (peripheral  neuritis,  injured 
sciatic  nerve,  or  Tooth's  neuro-muscular  paralysis).  Infantile  paralysis  results 
from  acute  anterior  poliomyelitis,  and  is  distinguished  by  its  irregular  distribution, 
reaction  of  degeneration,  and  its  vasomotor  and  trophic  lesions.  It  is  frequently 
possible  to  show  that  the  patient  is  unable  to  use  certain  muscles  or  groups  of 
muscles,  especially  the  anterior  tibial  and  peroneal  group.  It  is  quite  unusual 
for  the  paralysis  to  be  limited  to  the  leg  ;  the  thigh  is  often  affected  to  some 
extent,  and  often  the  opposite  leg.  It  is  important  to  examine  for  spina  bifida  ; 
talipes  due  to  this  is  not  necessarily  symmetrical  ;  one  foot  may  be  involved 
more  than  another,  and  the  deformity  is  often  progressive.  I  have  seen  several 
cases  of  talipes  calcaneo-valgus  associated  with  it,  and  also  pure  cavus,  and  one 
very  bad  case  of  equino-varus  of  one  foot,  and  equino-valgus  of  the  other.  The 
foot  may  drop  in  peripheral  neuritis  due  to  diphtheria,  lead  poisoning,  or 
alcoholism.  In  each  of  these  conditions  there  is  other  evidence  of  the  disease. 
In  many  cases  of  growth  in  the  pelvis  the  foot  may  drop  owing  to  invasion  of  the 


132  CLUB-FOOT     OR     TALIPES 

sacral  plexus  by  the  growth,  which  may  be  either  sarcoma  of  the  pelvis  or 
carcinoma  of  the  rectum.  Wounds  of  the  thigh,  or  the  pressure  of  tight  splints 
in  the  treatment  of  fracture,  or  the  forcible  extension  of  a  contracted  knee,  may 
lead  to  paralysis  of  the  sciatic  nerve,  especially  of  its  external  popliteal  branch. 
This  may  lead  to  talipes  equino- varus.  A  similar  deformity  may  follow  injury 
of  the  lumbar  spine  with  secondary  haemato-rhachis,  or  growth  anywhere  in  the 
course  of  the  sciatic  nerve.  I  have  known  it  follow  the  use  of  a  Hodgen  extension 
apparatus.  Tooth's  neuro-muscular  paralysis  (Figs.  8  and  9,  p.  71)  causes  paresis 
of  the  anterior  tibial  and  peroneal  muscles,  with  talipes  equino-varus  and  marked 
cavus,  and  deformity  of  the  toes.  It  may  be  distinguished  from  infantile 
paralysis  by  the  symmetrical  affection  of  both  feet,  by  the  wasting  of  the  thenar 
eminences,  and  the  history  of  similar  deformity  in  the  family,  and  from  the 
primary  muscular  dystrophies  by  the  occurrence  of  reaction  of  degeneration. 

(c).  Primary  Muscular  Disease. — In  primary  muscular  paratysis  (see  Atrophy, 
Muscular)  talipes  may  be  developed  late  in  the  disease  ;  but  as  a  rule  the  patients 
do  not  live  long  enough  for  the  deformity  to  become  a  striking  feature  of  their 
condition.  The  family  history  assists  the  diagnosis,  and  in  the  pseudo-hyper- 
trophic  form  there  is  the  characteristic  way  in  which  the  patient  raises  himself 
from  the  supine  position  by  rolling  into  the  prone  position,  and  then  lifting 
himself  on  his  toes  and  hands,  and  working  his  hands  up  the  fronts  of 
the  thighs. 

2.  Postural. — Acquired  talipes  valgus  may  be  due  either  to  posture  or  to 
paralysis  of  the  tibiales  muscles.  When  a  patient  attempts  to  adduct  and  invert 
the  fore-part  of  the  foot,  the  tendons  of  these  muscles  can  be  seen  to  stand  out 
when  they  are  not  paralyzed.  The  foot  may  be  forced  into  a  cramped  position 
by  tight  boots,  and  a  form  of  talipes  cavus  may  thus  develop,  with  marked 
deformity  of  the  toes,  which  are  hyper-extended  at  the  metatarso-phalangeal 
joints  and  flexed  at  the  others.  This  condition  must  not  be  confounded  with 
a  similar  one  due  to  paralysis  of  the  small  muscles  of  the  foot,  especially  of  the 
interossei  and  lumbricales. 

3.  Fibrosis  and  Contracture  of  tlie  Muscles  of  the  Calf. — Very  rarely  the 
calf  muscles  may  contract  as  a  result  of  an  ischaemia  analogous  to  that  occurring 
in  the  fore-arm,  and  leading  to  contracture  of  the  wrist  and  fingers  (Volkmann's 
contracture).  The  same  condition  may  develop  as  a  result  of  cellulitis  of  the 
calf  muscles,  often  associated  with  compound  fracture  of  the  leg,  or  with  acute 
necrosis  of  the  tibia.  In  all  these  conditions  it  is  important  to  prevent  the 
development  of  talipes  equinus. 

4.  Bone  Disease. — Injury  or  inflammation  of  the  tibia  near  the  epiphysial 
lines  in  youth  may  lead  either  to  arrest  or  over-growth  of  the  affected  bone. 
This  is  not  uncommonly  a  cause  of  talipes,  which  can  be  recognized  if  care 
be  taken  to  make  comparative  measurements  and  ;v-ray  examinations  of 
the  bones. 

5.  Joint  Disease. — In  fractures  into  the  ankle  joint,  such  as  Pott's  and 
Dupuytren's  fractures,  a  very  bad  form  of  talipes  equino- valgus  may  form  unless 
care  be  taken  to  correct  the  deformity  and  to  keep  the  ankle  moving.  Talipes 
equinus  may  arise  as  a  result  of  the  maltreatment  of  sprains,  and  it  may  also 
follow  arthritis  of  the  ankle,  either  septic  or  tuberculous,  unless  care  be  taken  to 
keep  the  joint  dorsi-flexed  during  treatment. 

6.  Contracting  Scars. — Occasionally  talipes  equinus  follows  severe  burns  or 
lacerations  of  the  skin  of  the  leg  or  foot.  The  diagnosis  is  usually  obvious 
enough  from  the  scars.  There  may  be  some  wasting  of  the  muscles  from  want 
of  growth  of  the  limb  from  disuse. 

7.  Hysteria. — Hysterical  club-foot  may  be  suspected  from  the  associated 
symptoms  and  confirmed  by  the  absence  of  any  change  in  the  electrical  reactions, 


COLIC  133 

by  the  variation  of  the  deformity,  and  the  disproportionate  amount  of  spasm, 
which  passes  off  during  sleep  and  under  an  anaesthetic. 

Finally,  it  is  to  be  remembered  that  if  a  normal  muscle  is  left  in  one  position 
over  a  long  period  with  its  points  of  origin  and  insertion  unduly  approximated, 
it  may  presently  be  found  to  be  impossible  to  lengthen  it  out  properly  again  ; 
it  is  in  this  way  that  contractures  of  muscles  are  apt  to  occur  during  the  course 
of  long  febrile  illnesses — enterica  for  instance — when  the  patient  may  remain 
curled  up  in  bed  for  weeks.  If  the  limbs  are  passively  extended  and  flexed  each 
day,  no  contracture  results,  but  it  sometimes  happens  that  the  neglect  of  this 
precaution  is  followed  by  persistent  contracture  of  what  had  hitherto  been 
normal  muscles,  and  one  of  the  likely  results  of  this  is  club-foot. 

R.   P  Rowlands. 

COLIC. — This  is  a  word  often  used  verj-  loosely  for  any  severe  abdominal 
pain  which  tends  to  wax  and  wane  in  intensity.  Such  pain  may  be  associated 
with  disease  in  almost  any  one  of  the  abdominal  viscera,  and  the  word  colic  is 
actually  applied  quite  commonly  to  the  pain  caused  by  the  passage  of  a  calculus 
down  the  bile-duct  (biliary  colic)  or  the  ureter  (renal  colic).  The  name  "  mucous 
colic  "  is  also  used  by  some  writers  for  the  disease  usually  known  as  muco- 
membranous  colitis.  It  is  better,  however,  to  restrict  the  term  colic,  used 
without  a  qualifying  adjective,  to  pain  caused  by  contraction  of  the  intestine, 
of  a  cramp-like  nature,  caused  bjr  local  irritation  or  by  general  poisoning,  in 
the  absence  of  any  organic  disease  of  the  bowel.  Diagnosis  therefore  mainly 
consists  (i)  In  excluding  such  organic  affections;  and  (2)  In  ascertaining, 
so  far  as  possible,  the  cause  of  the  local  spasm. 

I.  In  order  to  exclude  organic  disease  a  careful  examination  of  the  whole 
abdomen  is  needed,  as  well  as  observation  of  the  general  condition  of  the  sufferer. 
It  must  be  remembered  that  in  simple  colic  there  may  be  vomiting,  sweating, 
and  some  degree  of  collapse  owing  to  the  severity  of  the  pain.  The  patient's 
temperature  is  not,  however,  usually  raised  ;  the  abdominal  walls  move  freely 
on  respiration  ;  and  there  is  little  or  no  local  tenderness,  pressure  being  often 
a  relief  to  the  pain,  so  that  the  sufferer  tends  to  press  his  abdomen  against  a 
pillow  or  other  support.  Though  the  face  exhibits  an  expression  of  pain,  there 
is  not  the  pinched,  anxious  facies  so  characteristic  of  grave  abdominal  troubles ; 
and  the  patient  is  likely  to  throw  himself  about  instead  of  lying  still  as  in  such 
conditions  as  peritonitis  or  intestinal  obstruction.  The  pulse  is  not  often 
markedly  affected  :  it  may  even  be  unduly  slow,  but  in  nervous  subjects  the 
anxiety  and  pain  may  cause  some  rise  in  its  frequency. 

It  will  be  convenient  to  enumerate  the  different  affections  which  may  give 
rise  to  abdominal  pain  liable  to  be  called  colic  by  patients.  These  are  :  Acute 
intestinal  obstruction,  intussusception,  appendicitis,  and  possibly  even  perfora- 
tive peritonitis  ;  colitis  and  ulcerative  diseases  of  the  colon  ;  malignant  disease 
of  the  intestine  ;  pancreatic  disorders,  acute  and  chronic  ;  gastric  pain, 
especially  that  encountered  in  cases  of  pyloric  obstruction  ;  intestinal  neuralgia, 
and  referred  pains  in  spinal  caries  and  in  cases  of  pressure  by  tumours  or 
aneurysms  ;  gastric  and  intestinal  crises  in  locomotor  ataxy  ;  and  renal  and 
biliary  colic. 

Taking  the  diagnostic  features  separatel}'  : — 

Rise  of  temperature  above  100°  F.  will  indicate  the  existence  of  some  inflam- 
matory affection,  such  as  appendicitis.  The  possibility  of  thoracic  disease, 
such  as  pneumonia  or  diaphragmatic  pleurisy,  causing  abdominal  pain,  must 
be  borne  in  mind  ;  but  such  pain  is  not  really  colicky  in  character.  (See  Pain, 
Abdominal.) 

Vomiting  that  is  repeated  and  severe  does  not  occur  in  simple  colic.  It 
suggests  the  existence  of  intestinal  obstruction,  if  the  temperature  of  the  patient 


134  COLIC 

is  normal  or  subnormal,  or  of  some  form  of  peritonits  if  there  be  fever.  In  the 
former  condition,  a  faecal  odour  may  be  noted  in  the  vomit  ;  in  the  latter,  large 
quantities  of  fluid  may  be  brought  up  with  little  effort  ;  but  these  signs  occur 
late  in  the  course  of  these  conditions  (see  Vomiting).  The  colicky  pains 
associated  with  gastric  dilatation  due  to  pyloric  obstruction  are  likely  to  end 
with  the  expulsion  of  a  large  quantity  of  foul  fermenting  material.  The 
dilatation  of  the  stomach  may  be  ascertained  by  noting  the  existence  of 
splashing  in  the  organ  when  the  fingers  are  "  dipped  "  sharply  in  the  epigastric 
region  ;  by  eliciting  an  increased  area  of  tympanitic  resonance  ;  by  observing  the 
peristaltic  movements  of  the  hypertrophied  walls  of  the  stomach,  as  seen  by 
inspection  of  the  abdomen  ;  by  discovery  in  the  vomit  of  food  taken  some  days 
previously,  as  well  as  of  organisms  of  fermentation  (torulse  and  sarcinae),  the 
vomited  matter  being  generally  foul  and  frothy  ;  and  by  examination  with 
the  AT-rays  after  exhibition  of  a  bismuth  meal. 

Tenderness  and  rigidity  of  the  abdominal  wall  are  usually  absent  in  colic. 
When  conjoined,  they  point  to  affection  of  the  peritoneum  ;  tenderness  alone 
indicates  disease  of  some  viscus,  as  in  colitis,  when  it  is  found  along  the  course 
of  the  colon,  in  intestinal  or  gastric  ulceration,  and  so  forth. 

Slight  fullness  of  the  abdomen  may  exist  in  cases  of  colic,  but  it  is  usually 
inconspicuous  ;  more  often  the  abdominal  walls  may  appear  retracted.  Con- 
siderable degrees  of  distention  indicate  some  organic  trouble,  such  as  cirrhosis 
of  the  liver,  intestinal  obstruction,  or  peritonitis. 

A  contracted  portion  of  bowel  may  sometimes  be  felt  in  cases  of  colic.  This 
must  be  distinguished  from  an  actual  tumour  or  inflammatory  mass,  and  from 
the  elongated  swelling  felt  in  intussusception.  The  spasmodically  contracted 
gut  of  colic  is  of  small  diameter,  and  may  be  felt  to  relax  as  the  pain  subsides 
and  to  harden  again  with  a  fresh  exacerbation. 

Constipation  is  the  rule  in  patients  suffering  from  colic,  and  if  a  motion  is 
passed  it  is  small  and  hard.  The  appearance  of  diarrhcea  will  point  to  some 
affection  of  the  bowel,  such  as  colitis.  In  mucous  colitis,  which  is  associated 
with  severe  pain,  hard  scybala  may  be  passed  along  with  casts  of  the  intestine 
or  large  shreds  of  mucus.  The  rolls  of  this  substance  may  resemble  segments 
of  tape-worm,  but  can  easily  be  floated  out  if  placed  in  water.  The  appearance 
of  any  blood  per  anum  will  show  that  something  more  than  mere  colic  is  present 
(see  Blood  per  Anum). 

Intestinal  neuralgia  may  be  difficult  to  distinguish  from  colic,  as  both  are 
alike  functional  disorders  without  organic  disease.  Neuralgia  is  likely  to  occur 
in  an  anaemic,  ill-nourished  person  ;  it  arises  without  obvious  exciting  cause, 
and  may  recur  at  the  same  time  of  the  day  with  some  regularity.  The  pain 
has  not  the  cramp-like  character  of  colic,  but  is  aching,  boring,  or  darting.  It 
is  a  very  rare  disorder. 

The  gastric  or  intestinal  crises  of  locomotor  ataxy  may  be  indistinguishable 
from  colic,  except  by  recognition  of  the  other  symptoms  of  the  disease — absence 
of  knee-jerks,  with  ataxy,  and  Argyll  Robertson  pupils. 

In  children,  who  are  specially  liable  to  suffer  from  attacks  of  colicky  pain 
due  to  indiscretions  in  diet,  it  is  important  to  bear  in  mind  the  possibility  of 
appendicitis,  on  the  one  hand,  as  a  cause  of  abdominal  pain,  and  on  the  other 
of  Pott's  disease,  which  may  give  rise  to  pain  referred  to  the  front  of  the  abdomen. 
Examination  of  the  spine  in  these  latter  cases  may  reveal  the  existence  of 
rigidity  and  tenderness,  and  perhaps  some  prominence  of  one  or  more  vertebral 
spines. 

Appendicular  Colic This  term  is  sometimes  applied  to  attacks  of  pain  in  the 

right  iliac  fossa.  Their  association  with  disease  of  the  appendix  is  doubtful. 
Appendicitis  may  subsequently  ensue,  but  it  is  as  likely  that  the  original  attacks 


COLIC 135 

may  have  been  due  to  colitis  (typhlitis),  which  afterwards  spread  to  the  appendix, 
as  that  this  organ  was  at  fault  throughout.  Unless  the  signs  of  appendicitis 
are  present — pain,  vomiting,  fever,  tenderness  and  rigidity  of  the  muscles  in 
the  right  iliac  fossa — the  condition  cannot  be  recognized  with  certainty.  In 
all  cases  of  doubt  as  to  the  cause  of  colicky  pains,  an  examination  per  rectum 
is  advisable  ;  it  may  reveal  the  presence  of  inflammation  in  the  appendicular 
region,  or  of  an  intussusception,  in  quite  unsuspected  cases. 

Biliary  Colic. — The  passage  of  a  calculus  down  the  bile-ducts  gives  rise  to 
severe  and  even  agonizing  pain  in  the  right  hypochondrium.  It  is  of  a  colicky 
character,  but  it  is  apt  to  be  more  intense  than  that  of  simple  colic.  It  may 
be  accompanied  by  vomiting,  sweating,  and  collapse.  Shivering  is  frequently 
seen,  and  if  present  is  suggestive  of  this  trouble.  The  pain  is  likely  to  pass 
round  into  the  right  side  and  to  the  angle  of  the  right  scapula  ;  it  may  even  be 
referred  to  the  tip  of  the  right  shoulder.  If  the  calculus  lodge  in  the  common 
bile-duct,  jaundice  will  result.  Its  depth  will  vary  with  the  degree  of  obstruction, 
and  while  the  colic  lasts  it  is  not  likely  to  be  very  intense.  Palpable  enlargement 
of  the  gall-bladder  is  quite  exceptional  in  cases  of  gall-stones.  Actual  proof 
of  the  cause  of  the  colic  may  sometimes  be  obtained  by  finding  a  stone  in  the 
faeces,  which  may  be  done  by  passing  them  through  a  coarse  sieve,  under  a 
current  of  water.  Attacks  of  gall-stone  colic  are  liable  to  recur,  and  a  history 
of  previous  illness  of  the  same  kind  may  aid  in  the  diagnosis.  Women  are 
rather  more  subject  to  gall-stones  than  men,  and  fat  subjects  suffer  more  than 
thin.     The  malady  is  most  often  encountered  in  middle  life. 

Pancreatic  Colic,  due  to  passage  of  a  calculus  along  one  of  the  ducts  of  the  gland 
may  occur,  but  can  scarcely  be  diagnosed.  It  is  characterized  by  severe,  deeply 
seated  pain  in  the  epigastrium,  sometimes  extending  to  the  back  and  loins. 
Exactly  similar  attacks  of  pain  occur  in  chronic  pancreatitis,  and  may  be 
accompanied  by  shivering,  or  actual  rigors.  Intense  jaundice  may  also  be  seen 
in  this  malady,  and  an  enlarged  gall-bladder  can  usually  be  felt.  The  condition 
can  only  be  recognized  when  there  are  present  other  signs  of  pancreatic  disease — 
wasting,  pigmentation  of  the  skin,  and  the  passage  of  bulky,  offensive  stools, 
containing  large  quantities  of  fat.  Chemical  examination  may  show  that  much 
of  this  fat  is  neutral  (unaltered)  fat,  with  less  than  the  usual  proportion  of  fatty 
acids  (p.  116).  Microscopical  examination  may  reveal  the  presence  of  unaltered 
meat-fibres  in  the  motions.  The  urine  may  contain  sugar,  and  Cammidge's 
Test  (q.v.)  may  be  applied  to  it,  though  the  trustworthiness  of  this  reaction  is 
not  yet  established. 

Renal  Colic. — The  distinguishing  features  of  the  passage  of  a  calculus  down 
the  ureter  are  similar  to  those  of  biliary  colic,  but  the  pain  starts  in  one  loin 
and  radiates  downwards  to  the  thigh  and  to  the  testicle  in  the  male,  to  the 
labium  majus  in  the  female.  The  urine  may  contain  blood,  and  also  epithelium 
from  the  pelvis  of  the  kidney  and  from  the  ureter.  Frequency  of  micturition 
is  often  marked,  but  the  quantity  of  urine  may  be  small  ;  it  may  even  be 
temporarily  suppressed.  If  the  calculus  become  impacted  in  the  ureter,  a 
swelling  may  subsequently  appear  in  the  loin,  due  to  the  formation  of  a  hydro- 
nephrosis. The  pain  may  cease  suddenly  when  the  stone  passes  into  the  bladder. 
The  ;\;-ra3^s  are  of  considerable  value  in  detecting  the  concretion,  provided  the 
bowels  be  empty  so  that  shadows  due  to  scybala  can  be  avoided. 

The  pain  due  to  the  presence  of  a  calculus  in  the  kidney  can  hardly  be  mistaken 
for  colic,  but  occasionally  the  symptoms  of  this  condition  may  precede  an  attack 
of  renal  colic.  A  history,  therefore,  of  pain  in  the  loin,  frequency  of  micturition, 
and  the  appearance  of  blood  in  the  urine,  may  help  in  the  diagnosis  of  the  latter 
condition.  Tuberculous  disease  of  the  kidney,  in  which  the  symptoms  may  be 
very  similar,  though  apt  to  be  accompanied  by  more  wasting  and  by  evening 


136  COLIC 

pyrexia,  may  give  rise  to  colicky  attacks  if  blood-clots  or  caseous  masses  lodge 
in  the  ureter.     Pus  and  tubercle  bacilli  may  be  found  in  the  urine. 

2.  A  diagnosis  of  the  cause  of  the  colic  is  also  necessary.  Its  principal  causes 
are  indigestible  food,  alcoholic  excess,  and  lead-poisoning.  This  last  should  be 
eliminated  first.  It  is  characterized  by  the  great  severity  of  the  pain,  by  the 
obstinate  constipation  which  accompanies  it,  by  the  anaemic  appearance  of  the 
patient,  and  by  the  presence  of  a  blue  line  along  .the  margin  of  the  gums,  though 
the  absence  of  the  blue  line  in  a  patient  whose  teeth  and  gums  have  been  kept 
clean  does  not  exclude  plumbism.  Lead  may  be  found  by  chemical  examination 
of  the  urine,  but  usually  only  in  minute  traces.  There  will  usually  be  a  history 
of  some  occupation  involving  contact  with  lead — painting,  glazing,  type-setting, 
or  manufacture  of  some  compound  of  lead  ;  but  the  possibility  of  poisoning 
by  drinking-water  or  by  beer  which  has  stood  in  contact  with  leaden  pipes  must 
be  remembered — the  latter  especially  in  potmen.  The  part  played  by  alcohol  in 
inducing  colic  can  only  be  inferred  from  the  appearance  of  the  patient  and  such 
signs  as  tremor  of  the  hands,  furred  tongue,  pharyngitis,  and  so  forth.  In  cases 
due  to  indigestible  food,  a  history  of  the  consumption  of  fried  fish,  shell-fish,  pork, 
raw  fruit,  or  other  suspicious  matter  may  be  obtained.  The  pain  is  more  likely 
to  move  along  the  course  of  the  colon  than  to  remain  fixed  in  the  centre  of  the 
abdomen  or  at  some  special  point,  as  it  usually  does  in  lead  colic.  In  infants, 
colic  may  be  caused  by  hard  curds  of  milk,  and  be  indicated  by  drawing  up  of 
the  legs  and  screaming.  In  older  children,  unripe  apples,  plum-stones,  and 
similar  delicacies  are  often  the  source  of  the  trouble,  and  fruit-stones  may  be 
discovered  subsequently  in  the  motions.  w.  Cecil  Bosanquet. 

COLOUR  BLINDNESS.— (See  Vision,  Defects  of.) 

COMA  is  a  state  of  unnatural,'  heavy,  deep  and  prolonged  sleep,  often  accom- 
panied by  slow  stertorous  or  irregular  breathing,  and  frequently  ending  in  death. 
It  may  be  due  to  a  large  number  of  different  causes,  which  may  be  classified  into 
two  main  groups,  nam.ely  :  {A)  Cases  in  which  coma  is  not  a  prominent  symptom 
early  in  the  malady,  but  only  in  a  late  stage,  when  the  nature  of  the  disease  has 
already  been  suggested  by  other  symptoms  ;  and  {B)  Cases  in  which  coma  comes 
on  early  and  may  be  the  most  prominent  feature  of  the  case. 

Group  A  includes — 

1.  Certain  Severe  Fevers  in  which  coma  may  occur  as  a  terminal  phenomenon  : 

Typhus  fever  Yellow  fever 

Typhoid   fever  Blackwater  fever 

Cholera  Malignant  malaria. 

Dysentery  I 

2.  Acute  Inflammatory  Lesions  of  the  Brain  or  the  Cranial  Meninges  : 

Suppurati\'e  meningitis  Epidemic    cerebrospinal    menin- 

Tuberculous  meningitis  [  gitis,  or  spotted  fever 

Posterior  basal  meningitis         !  Acute  encephalitis. 

3.  Certain  Less  Acute  Lesions  of  the  Central  Nervous  System  : 


Cerebral  tumour 
Cerebral  abscess 
Post-epileptic  state 


General    paralysis   of   the  insane 
Disseminated  sclerosis 
Syphilis  of  the  brain. 


4.  Diseases  in  which  General  Metabolism  is  probably  at  fault  : 


Uraemia 
Diabetes 
Cholaemia 


Addison's  disease 
Raynaud's  disease. 


COMA 


137 


Group  B  includes  the  following  conditions — 

The  Results  of  Head  Injury  : 

Concussion  j 

Compression  by  meningeal 

hsemorrhage  | 

Vascular  Lesions  of  the  Brain  : 

Embolism 
Haemorrhage 


Depressed  fracture 
Fracture    of    the     base 
skull. 


of    the 


The  Acute  Effects  of  Drugs,  particularly  : 
Alcohol  Carbon  monoxide 


Thrombosis  :  (a)  arterial,  (fo)  of 
a  venous  sinus  such  as  the 
superior  longitudinal. 


Trional 
Tetronal 
Bromides 

Chloroform    and    other 
anaesthetics. 


6. 


7- 


Excessive  cold. 

Duodenal  bleeding 
Intestinal  bleeding 
Ruptured  aneurj'sm. 


Opium  Absinthe 

Morphia  Chloral  hydrate 

Carbolic  acid  Veronal 

Oxalic  acid  Sulphonal 

The  Chronic  Effects  of  Drugs  or  Chemicals,  especially  plumbism  leading  to  : 

Saturnine  encephalopathy. 
The  Effects  of  Extremes  of  Temperature  : 

Heat  stroke  | 

Excessive  Loss  of  Blood  from  : 

Ruptured  tubal  gestation  ' 

Post-partum  haemorrhage 

Haemoptysis  1 

Haematemesis  I 

Hysterical  Trance. 

Although  it  is  generally  possible  to  make  a  broad  distinction  betAveen  the  two 
groups  enumerated  above,  it  is  necessary  perhaps  to  point  out  that  some  con- 
ditions which  usually  give  rise  to  other  symptoms  before  they  produce  coma, 
sometimes  pass  unrecognized  until  coma  supervenes.  This  apphes,  for  example, 
to  certain  cases  of  diabetes  mellitus,  uraemia,  suppurative  meningitis,  or  cerebral 
abscess  or  tumour  ;  whilst,  conversely,  some  conditions  which  usually  exhibit 
coma  early,  may  not  do  so  until  after  there  have  been  other  symptoms  to  indicate 
the  nature  of  the  case.  It  is  not  necessary  to  enter  into  the  differential  diagnosis 
of  those  conditions  in  which  other  prominent  symptoms  have  preceded  coma. 

When  coma  is  either  the  first  or  the  most  prominent  sj'mptom  in  the  case, 
however,  it  is  very  important  to  arrive  as  near  the  correct  diagnosis  as  may  be 
at  the  earliest  possible  moment,  for  any  given  case  is  to  be  relegated  to  one  or 
other  of  the  following  four  classes,  which  differ  from  one  another  radically  as 
regards  treatment : — 

1.  Cases  in  which  immediate  trephining  is  required,  for  instance  for  meningeal 
haemorrhage. 

2.  Cases  in  which  active  treatment  by  lavage  of  the  stomach  or  bj-  the 
administration  of  antidotes  is  required,  as  in  opium  or  other  poisoning. 

3.  Cases  in  which  active  medicinal  or  phvsical  treatment  is  required  : 
for  instance,  diabetic  coma  requiring  the  administration  of  alkalies,  or  uraemia 
requiring  venesection,  and  so  forth. 

4.  Cases  in  which  absolute  rest  is  indicated,  especialh'  in  cerebral  haemorrhage. 
When  investigating   a   case,    notice    first  whether   there   is   any  evidence   of 

unilateral  paralysis  :  the  pupils  may  be  markedly  unequal,  one  cheek  may  be 
more  puffed  out  on  expiration  then  the  other,  one  arm  or  leg  may  fall  more  hmply 
than  the  other  ;  there  may  be  differences  between  the  two  knee-jerks  or  the  two 
plantar  reflexes.     There  may  be  conjugate  deviation  of  the  eyes.     If  there  is 


138  COMA 

distinct  evidence  of  unilateral  paresis  or  paralysis,  there  is  almost  certainly  a 
cranial  or  intracranial  lesion,  either  haemorrhage,  embolism,  fracture,  tumour, 
abscess,  or  thrombosis.  Next,  examine  the  head  with  particular  care  to  see  if 
there  are  any  signs  of  injury  ;  the  presence  of  a  scalp  wound  or  even  of  a 
fracture  does  not  of  course  prove  that  this  is  the  primary  cause  of  the  coma, 
for  the  patient  may  have  become  unconscious,  from  a  cerebral  hsemorrhage  for 
example,  and  in  falling  may  have  struck  his  head,  in  which  case  the  injury  is  due 
to  the  coma,  and  not  the  coma  to  the  injury.  Some  of  the  very  greatest 
difficulties  in  diagnosis  arise  on  this  account,  particularly  when  the  patient  has 
previously  taken  sufficient  alcohol  for  his  breath  to  smell  of  it,  and  to  suggest 
that  he  is  drunk.  Careful  observation  for  several  hours  may  be  required  before 
the  diagnosis  can  be  settled,  and  even  then  errors  are  sometimes  unavoidable.  A 
clear  history  is  generally  lacking,  but  if  it  is  available  it  often  assists  materially 
in  deciding  the  nature  of  the  case.  The  ears  and  nose  should  be  examined 
with  particular  care  to  see  whether  cerebrospinal  fluid  or  blood  is  coming  from 
either,  as  an  indication  that  there  is  a  fracture  at  the  base  of  the  skull  ;  and 
blood  coming  forward  into  the  subconjunctival  tissue  may  afford  evidence  in 
the  same  direction. 

Cerebral  hcBmorrhage  is  much  more  common  in  an  elderly  than  in  a  young  person, 
whilst  the  reverse  is  true  of  embolism.  The  latter  may  occur  instantaneously, 
whilst  haemorrhage  produces  coma  rather  more  gradually  ;  and  thrombosis, 
syphilitic  or  otherwise,  often  leads  to  hemiplegia  so  gradually  that  no  coma 
occurs.  The  presence  of  albuminuria  with  casts,  with  a  high  blood-pressure  as 
measured  instrumentally  ;  the  history,  in  an  elderly  man,  of  ajprevious  seizure 
of  a  similar  kind  with  definite  hemiplegia,  especially  if  there  is  also  an  enlarged 
heart  with  a  lumpy  first  sound  at  the  impulse,  or  perhaps  a  local  systolic  bruit 
there,  and  soft  systolic  aortic  bruit  with  a  ringing  aortic  second  sound,  would 
all  indicate  cerebral  haemorrhage,  associated  with  defective  arteries  and  perhaps 
with  granular  kidney.  Albuminuric  retinitis  should  be  looked  for.  Strong 
evidence  in  favour  of  cerebral  embolism  would  be  afforded  by  a  previous 
history  of  acute  rheumatism  and  the  existence  of  a  presystolic  or  other  bruit 
indicative  of  organic  mitral  or  aortic  disease,  especially  if  there  has  been  any 
pyrexia,  progressive  anaemia,  enlargement  of  the  spleen,  infarction  elsewhere,  or  a 
tendency  to  purpura,  epistaxis,  or  other  bleeding  suggesting  that  fungating 
endocarditis  has  developed  upon  the  top  of  a  chronic  valvular  lesion. 

Supposing  there  is  no  evidence  of  a  unilateral  paralysis,  it  does  not  immediately 
follow  of  course  that  none  of  the  above  conditions  are  present ;  one  form  of 
cerebral  haemorrhage  in  particular  that  may  cause  no  unilateral  paralysis  is 
pontine  hcBmorrhage  ;  this  might  be  suggested  at  once  by  the  very  small, 
almost  pin-point  pupils,  though  similar  pin-point  pupils  may  be  due  to  opium 
poisoning.  The  thermometer  affords  a  means  of  diagnosis  between  these,  for 
opium  poisoning  leads  to  a  subnormal  temperature,  whilst  haemorrhage  into  the 
pons  Varolii  rapidly  causes  the  temperature  to  rise  even  to  the  point  of  hyper- 
pyrexia. 

The  diagnosis  of  other  varieties  of  coma  due  to  poisoning  can  seldom  be  arrived 
at  accurately  unless  the  circumstances  of  the  case  either  allow  of  an  analysis  of 
the  gastric  contents,  or  else  point  to  the  patient  having  ta,ken  an  over-dose  of 
one  of  the  drugs  mentioned  in  the  above  list,  either  accidentally  or  with  suicidal 
intent.     The  bottle  may  be  found  near  the  patient. 

Coma  due  to  poisoning  by  carbon  monoxide  is  generally  obvious  at  once  ; 
the  patient  has  a  peculiar  bright  cherry-red  colour  ;  it  is  impossible  to  convert 
the  carboxyhaemoglobin  in  his  blood  into  reduced  haemoglobin  by  the  ordinary 
ammonium  sulphide  method  ;  and  there  is  generally  direct  evidence  of  the  mode 
of  poisoning,   such  as  the   fact  that  the  patient  is  found   in  a  room  with  the 


COMA  139 

windows  shut  and  the  gas  turned  on,  or  has  been  subjected  to  the  fumes  of  slow 
combustion  from  a  stove,  brazier,  limekiln,  or  some  other  fire  which  has  been 
burning  with  an  insufficient  supply  of  oxygen. 

Saturnine  encephalopathy  is  very  variable  in  its  symptoms  ;  it  may  take  the 
lorm  of  epileptiform  convulsions  ;  more  or  less  dementia  ;  continued  coma  ;  acute 
mania  ;  indeed,  its  multiformity  is  one  of  its  chief  features.  The  occupation  of 
the  patient  may  point  to  the  diagnosis  forthwith  in  some  cases,  or  there  may 
be  a  blue  line  upon  the  gums  or  other  signs  of  lead  poisoning.  Not  infre- 
quently, however,  the  nature  of  the  case  gives  rise  to  much  perplexity  before 
the  diagnosis  is  ultimately  made.  One  method  of  arriving  at  the  latter  is  to 
collect  an  abundance  of  urine,  evaporate  it  to  dryness,  and  apply  the  tests  for 
lead  to  the  residue.  The  case  is  apt  to  be  mistaken  for  either  cerebral  haemor- 
rhage, cerebral  tumour,  or  general  paralysis  of  the  insane.  Optic  neuritis  may  be 
directly  due  to  plumbism,  and  this  makes  the  differential  diagnosis  still  more 
difficult,  unless  there  is  clear  collateral  evidence  of  lead  poisoning. 

Coma  due  either  to  heat  stroke  or  to  exposure  to  excessive  cold  is  generally 
indicated  by  the  collateral  evidence,  especially  as  regards  the  temperature  of 
the  patient's  surroundings,  or  his  having  been  exposed  to  very  strong  sun's 
rays  when  at  work.  The  chief  difficulty  will  be  to  make  certain  that  there  is 
not  any  vascular  lesion  of  the  brain.  When  there  is  doubt,  the  course  of  the  case 
may,  however,  indicate  its  nature,  heat-stroke  generally  recovering  rapidly,  or 
ending  fatally  with  hyperpyrexia  ;  but  sometimes,  even  in  a  fatal  case,  the 
diagnosis  may  remain  in  doubt  until  a  post-mortem  examination  has  been  made. 

Acute  encephalitis  is  a  disease  of  children  rather  than  of  adults  ;  its  general 
symptoms  are  those  of  acute  meningitis  ;  the  patient  becomes  unconscious 
more  rapidly,  however,  than  is  usual  with  the  latter,  and  yet,  notwithstanding 
the  apparent  severity  of  the  illness,  recovery  may  occur,  either  within  a  few 
days  or  a  week  or  two.  The  diagnosis  rests  upon  the  course  and  recovery,  for 
in  the  earlier  stages  it  will  nearly  always  have  been  regarded  as  acute  meningitis. 
The  same  applies  to  acute  thrombosis  of  the  superior  longitudinal  sinus,  the 
diagnosis  between  which  and  acute  encephalitis  or  meningitis,  is  generally  one 
of  opinion  only,  unless  operative  measures  are  resorted  to,  or  a  post-mortem 
examination  made.  Optic  neuritis,  as  well  as  headache,  vomiting,  and  general 
convulsions,  occur  in  all  three. 

General  paralysis  of  the  insane  does  not  as  a  rule  give  rise  to  coma  and  epilepti- 
form convulsions  until  the  nature  of  the  case  has  already  been  indicated  by  the 
mental  and  physical  changes — particularly  the  ideas  of  grandeur,  the  loss  of 
highest  cerebral  control  in  one  way  or  another,  the  changes  in  disposition,  and 
the  inability  to  perform  the  finer  movements  required  for  writing,  dancing, 
playing  the  piano  or  violin,  painting,  and  so  forth,  in  which  the  patient  may  at 
some  time  previously  have  been  an  adept.  Occasionally,  however,  notwith- 
standing some  alterations  in  the  mental  character,  the  diagnosis  of  general 
paralysis  may  not  have  entered  one's  mind  in  a  given  case  until  a  sudden  syncopal 
seizure,  with  or  without  convulsions,  attracts  particular  notice  to  it.  It  is  not 
impossible  that  such  a  case  may  even  then  be  mistaken  for  one  of  severe  cerebral 
haemorrhage,  and  it  may  be  treated  as  such  until  it  is  found  that  the  coma, 
severe  though  it  may  have  been,  rapidly  passes  off  in  a  way  that  would  not 
have  been  the  case  had  it  been  a  haemorrhage  of  corresponding  severity.  The 
recurrence  of  these  attacks  will  make  the  diagnosis  certain,  even  if  it  remains  in 
doubt  for  a  time,  and  it  is  stated  that  examination  of  the  cerebrospinal  fluid 
for  excess  of  small  lymphocytes  or  for  Wassermann's  serum  reaction  will  serve 
to  clinch  the  diagnosis  in  most  cases. 

Severe  hcemorrhage  other  than  cerebral  as  a  cause  for  coma  is  usually  indicated 
at  once  by  the  sudden  extreme  blanching,  not  only  of  the  patient's  cheeks,  but 


I40  COMA 

also  of  his  lips  and  mucous  membranes.  The  pulse-rate  rises  to  loo,  120,  or  even 
150,  according  to  the  amount  of  blood  that  has  been  lost ;  if  there  has  been 
external  evidence  of  the  haemorrhage,  the  differential  diagnosis  will  be  arrived  at 
as  discussed  under  such  headings  as  H.^matemesis,  Hemoptysis,  Metrorrhagia, 
etc.  If  the  bleeding  has  been  internal  in  a  healthy  person,  the  commonest  cause 
is  duodenal  ulcer  in  a  man,  pelvic  hasmatocele  or  ruptured  tubal  gestation  in 
a  woman ;  similar  blanching  in  cases  of  typhoid  fever  would  point  to  intestinal 
bleeding.  The  coma  in  such  cases  comes  on  suddenly,  but  it  does  not  long  remain 
profound.  It  is  often  preceded  by  amaurosis,  and  may  be  accompanied  by 
epileptiform  convulsions,  so  that  acute  urjemia  may  be  simulated. 

When  an  aortic  aneurysm  ruptures  either  into  a  bronchus,  the  oesophagus, 
trachea,  stomach,  or  bowel,  the  amount  of  blood-loss  seldom  leads  to  coma,  but 
rather  to  sudden  death ;  sometimes,  however,  when  the  bleeding  is  into  some 
closed  space  such  as  the  mediastinum  or  retroperitoneal  tissue,  the  blood-escape 
is  checked  to  some  extent,  and  acute  blanching  with  coma  precedes  further 
bleeding  and  death.  Rupture  of  an  aortic  aneurysm  into  the  pericardium  causes 
sudden  death  before  the  amount  of  blood  lost  has  been  sufficient  to  produce 
marked  blanching. 

Hysterical  or  functional  trance  is  an  affection  of  young  women,  and  it  is  not 
very  common  ;  the  diagnosis  is  arrived  at  by  a  process  of  exclusion,  and  until  the 
case  has  been  watched  for  some  time,  its  nature  may  not  be  obvious,  unless  there 
have  been  other  hysterical  symptoms  previously.  It  is  a  dangerous  diagnosis  to 
make  until  every  other  possible  cause  for  coma  has  been  considered  and  satis- 
factorily excluded,  for  it  is  not  difficult  to  jump  to  the  conclusion  that  coma  in  a 
girl  or  young  woman,  really  arising  perhaps  from  a  cerebral  tumour  or  abscess, 
is  due  to  a  neurosis.  It  is  most  important  to  examine  the  optic  discs  with 
great  care,  lest  there  should  be  optic  neuritis,  the  latter  never  being  functional. 

Herbert  French. 

CONJUNCTIVITIS. — (See  Eye,  Acute  Inflammation  of.) 

CONSTIPATION 

I.— CHRONIC    CONSTIPATION. 

In  normal  individuals  the  indigestible  residue  of  a  meal  reaches  the  descending 
colon  in  less  than  sixteen  hours,  and  in  defaecation  all  the  contents  of  the  large 
intestine  beyond  the  splenic  flexure  are  excreted.  Consequently  some  of  the 
residue  of  a  meal  taken  eight  hours  after  defsecation  should  be  excreted  at  the 
next  defaecation  in  individuals  whose  bowels  are  opened  every  twenty-four 
hours.  If,  however,  the  bowels  are  only  opened  on  alternate  mornings — a 
condition  which  is  not  necessarily  pathological — forty  hours  instead  of  sixteen 
would  elapse  before  some  of  the  residue  of  the  meal  would  be  excreted.  Constipa- 
tion may  therefore  be  defined  as  a  condition  in  which  none  of  the  residue  of  a 
meal,  taken  eight  hours  after  defcecation,  is  excreted  within  forty  hours. 

In  doubtful  cases  constipation  thus  defined  can  be  recognized  by  giving 
three  charcoal  lozenges  with  some  food  eight  hours  after  defaecation  ;  if  a 
blackened  stool  is  not  passed  within  the  next  forty  hours,  the  patient  must  be 
regarded  as  constipated.  The  abnormal  action  of  the  bowels  in  constipation 
may  manifest  itself  in  three  different  ways  : — 

1.  DefcBcation  may  occur  with  insufficient  frequency.  A  daily  action  of  the 
bowels  is  merely  a  matter  of  convenience,  and  many  people  in  perfect  health 
only  defaecate  once  in  two  or  three  days.  As  a  rule,  however,  an  individual 
may  be  regarded  as  constipated  if  his  bowels  are  not  opened  at  least  once  in 
forty-eight  hours. 

2.  The  stools  may  be  insufficient  in  quantity  and  a  certain  amount  of  fcBces  is 
retained,  although  the  bowels  may  be  opened  once  daily  or  more  often.    This  condition 


CONSTIPA  TION 


141 


(cumulative  constipation)  can  be  differentiated  readily  by  the  charcoal  test 
from  that  in  which  the  bowels  are  properly  emptied,  but  the  faeces  are  very 
small  in  quantity  owing  to  the  diet  or  to  the  unusually  active  absorptive  power 
of  the  intestines. 

3.  The  bowels  may  be  opened  daily,  yet  the  fcsces  are  hard  and  dry,  owing  to 
prolonged  retention  before  excretion  ;  the  deficient  quantity  of  water  in  the 
stools  also  renders  them  less  bulky  than  normal.  The  stools  may  be  similar  in 
character  when  an  excessive  quantity  of  fluid  is  lost  by  other  channels,  as  in 
diabetes.  By  means  of  the  charcoal  test  it  is  easy  to  determine  whether  con- 
stipation is  also  present. 


After  the  diagnosis  of  constipation  has  been  made,  it  is  necessary  to 
determine  its  cause.  The  first  essential  is  to  distinguish  between  two  great 
classes  of  constipation  :  that  in  which  the  passage  through  the  intestines 
is  delayed,  whilst  defaecation  is  normal — Intestinal  Constipation  ;  and  that 
in  which  there  is  no  delay  in  the  arrival  of  faeces  in  the  pelvic  colon,  but  their 
final  excretion  is  not  adequately  performed — Pelvi-rectal  Constipation  or 
Dyschezia. 

A. — Diagnosis    between    Intestinal  Constipation   .^nd   Dyschezia. 

A  rectal  examination  should  be  made  in  the  morning,  after  an  attempt  has 
been  made  to  open  the  bowels  without  the  assistance  of  medicine,  enemata, 
or  suppositories.  If  more  than  a  very  small  quantity  of  faeces  is  found  in  the 
rectum,  dyschezia  may  be  diag- 
nosed. If  the  rectum  is  almost 
or  quite  empty,  the  constipation 
must  be  due  to  delay  in  the 
passage  through  the  intestines, 
except  in  the  uncommon  cases 
of  dyschezia  in  which  there  is 
inability  to  pass  fasces  from  the 
pelvic  colon  into  the  rectum. 
The  latter  condition  can  be 
recognized  on  rectal  examina- 
tion, if  the  pelvic  colon  is  felt 
through  the  front  wall  of  the 
rectum  to  be  filled  with  solid 
faeces  ;  the  presence  of  faeces  in 
the  pelvic  colon  can  also  be 
proved  if  a  sigmoidoscopic  ex- 
amination is  made  at  once  with 
out  further  preparation  of  the 
patient  by  washing  out  his 
bowels. 

At  the  same  time  the  abdomen 
should  be  palpated.  If  scybala 
are  felt  in  any  part  of  the  colon, 
intestinal  constipation  must  be 
present.     This  is,  however,  not 

necessarily  the  case  if  faeces  are  felt  in  the  iliac  or  pelvic  colon,  as  the 
rectum  in  dyschezia  may  be  so  full  of  faeces  that  retention  occurs  secondarily 
in  the  pelvic  colon  and  rectum  ;  such  a  condition  would  be  recognized  by  the 
rectal  examination. 

When  a  patient  feels  that  there  is  something  in  his  rectum  which  he  cannot 


Fi^:  32. — Habitual  Constipation.  Twenty-four  hours 
after  bismuth  breakfast.  No  bismuth  has  reached 
beyond  the  first  two  inches  ot  the  transverse  colon. 
Subsequent  examinations  showed  that  a  similar  delay 
occurred  along  the  whole  of  the  large  intestine. 


142 


CONSTIPA  TION 


expel  at  all,  or  that  after  defgecation  the  relief  is  incomplete,  dyschezia  is  probabl3' 
present.  The  absence  of  this  symptom  does  not  exclude  the  possibility  of 
dyschezia,  as  the  rectum  is  often  so  insensitive  in  such  cases  that  no  sensation 
is  experienced,  even  when  it  is  filled  tightly  with  faeces. 

The  frequent  passage  of  very  small  pieces  of  hard  faeces  (fragmentary' 
constipation),  or  the  occurrence  of  pseudo-diarrhoea — in  which  small  fluid  stools, 
sometimes  containing  hard  fragments  of  faeces,  are  passed,  although  the  charcoal 
test  shows  the  presence  of  constipation — are  both  symptoms  suggestive  of 
dyschezia. 

Some  indication,  which  is  not,  however,  absolutely  reliable,  can  be  obtained 
from  the  results  of  previous  treatment.  Patients,  who  have  found  that  diet  and 
mild  aperients  readily  give  them  relief,  are  probably  suffering  from  intestinal 
constipation.  Those  who  have  obtained  better  results  with  enemata,  and 
particularly    with    suppositories,  probabl}^    have    dyschezia.     Dyschezia    is    of 

course  also  present  in  those 
patients  who  have  to  dig  out 
the  faeces  from  the  rectum  with 
their  fingers. 

Examination  with  the  x-rays 
is  the  only  method  by  which 
the  two  classes  of  constipation 
can  be  separated  with  absolute 
certainty,  and  by  which  the 
predominant  condition  can  be 
discovered  in  cases  in  which 
both  are  present  together.  Two 
ounces  of  bismuth  oxychloride 
mixed  with  porridge  or  bread 
and  milk  are  taken  at  breakfast, 
and  observations  are  made  at 
intervals  during  the  next  two 
or  three  daj^s  of  the  shadow 
produced  on  the  fluorescent 
screen.  The  colon  should  be 
emptied  as  completely  as  possi- 
ble by  aperients  and  enemata 
for  two  or  three  days  before  the 
examination,  and  if  the  bowels 
have  not  opened  naturally  on 
the  morning  of  the  bismuth 
breakfast,  an  enema  should  be 
given  at  once.  During  the  period 
of  observation  no  aperients  or  enemata  should  be  given,  and  the  patient 
should  be  allowed  to  continue  his  usual  occupation  and  to  take  his  ordinary 
diet,  in  intestinal  constipation,  delay  is  observed  in  the  passage  through 
some  part  or  all  of  the  colon,  and  occasionally  the  small  mtestine  ;  in  dyschezia 
there  is  no  delay  in  the  intestines,  but  the  act  of  defaecation  does  not  empty 
the  pelvic  colon  and  rectum  completely  {Figs.  32,  33). 

B. — Diagnosis   of    the    Cause    of    Intestinal"  Constipation. 

Intestinal  constipation  may  be  due  to  (i)  The  motor  activity  of  the  intestines 
being  deficient  ;  or  (2)  The  force  required  to  carry  the  fcBces  to  the  pelvic  colon 
being  excessive.  In  the  first  group  of  cases  aperients  are  generally  much 
more  effective  than   in  the  second  ;    in  the  latter  there  may  be  a  history  that 


Fig.  33. — Dyschezia.  Twenty-four  hours  after  bis- 
muth breakfast.  All  the  bismuth  has  collected  in  the 
dilated  pelvic  colon  and  rectum,  except  traces  which 
remain  in  the  transverse  colon.  In  spite  of  this  the 
patient  felt  no  desire  to  defeecate. 


CONSTIPA  TION 


143 


purgatives  are  producing  less  effect  than  formerly,  or  that  they  now  completely 
fail  to  act,  but  that  enemata  still  give  a  more  or  less  satisfactory  result.  The 
increased  activity  of  the  intestines  in  their  attempt  to  respond  to  the  excessive 
demands  in  the  second  class  often  leads  to  colic. 

I.   Deficient  Motor  Activity  may  be  due  to  : — • 

(a).  Weakness  of  the  Intestinal  Musculature  (Atonic  Constipation). 

When  constipation  has  existed  from  infancy,  especiall}''  if  it  is  present  in 
several  members  of  the  family,  it  is  likely  to  be  due  to  congenital  hjrpoplasia  of 
the  intestinal  musculature. 

Constipation  developing  gradually  as  old  age  is  approaching,  is  generally  due 
in  part  to  senile  intestinal  hypoplasia. 

When  constipation  occurs  in  chlorotic  girls,  in  cachectic  conditions,  in  rickets, 
and  in  fevers,  it  may  generally  be  assumed  to  be  due  to  weakness  of  the  intes- 
tinal musculature,  secondary  to  these  conditions. 

When  the  abdomen  is 
constantly  distended  and 
tympanitic,  and  the  patient 
complains  of  attacks  of  colic, 
which  are  relieved  by  the 
passage  of  flatus,  it  may  be 
assumed  that  the  constipa- 
tion is  due,  in  part  at  least, 
to  the  incapacitating  effect 
of  distention  on  the  intestinal 
musculature.  The  Flatu- 
lence (q.v.)  may  be  primary, 
or  it  may  be  secondary  to  the 
constipation,  in  which  case 
some  other  cause  of  the  con- 
dition must  be  looked  for. 

The  constipation  of  fat 
people  is  due  in  part  to 
the  inefhciency  of  the  intes- 
tinal musculature  resulting 
from  fatty  infiltration. 

In  all  these  conditions  the 
atony  of  the  colon  can  be 
recognized  with  the  ;ir-rays  by 
its  abnormally  large  lumen 
in  addition  to  the  slow  pass- 
age of  faeces  {Figs.  34  and  35). 

(b).  Deficient  Reflex  Activity  of  the  Intestines. 

Insufficient  Stimulation  of  Intestinal  Movements. — Careful  enquiry  should  be 
made  into  the  patient's  diet  and  habits,  as  many  cases  are  due  to  too  little 
food  being  taken,  or  to  the  food  containing  too  little  mechanical  or  chemical 
peristaltic  stimulants,  and  some  are  due  to  deficient  exercise.  Other  cases 
result  from  a  "  greedy  colon,"  the  absorption  of  food  being  unusually  complete. 
In  spite  of  enough  food  of  a  sufficiently  stimulating  character  being  taken,  and 
in  spite  of  the  fact  that  the  abdomen  is  retracted  and  no  accumulation  of  faeces 
can  be  felt  in  either  the  colon  or  the  rectum,  yet  a  very  deficient  quantity  of 
faeces  is  excreted.  This  is  the  type  of  case  in  which  benefit  results  from  the  use 
of  agar-agar  or  petroleum.  In  constipation  due  to  an  unsuitable  diet  or  to  a 
greedy  colon,  the  stools  are  generally  small,  dark,  and  dry,  and  smell  less  strongly 


Fig-.  34. — Diagram  of  the  normal  large  intestine.  The 
numbers  represent  the  hours  after  a  bismuth  breakfast  at  which 
the  different  parts  of  the  colon  are  reached.  C,  Ca;cum  ; 
AC,  Ascending  colon;  HF,  Hepatic  flexure;  SF,  Splenic 
flexure  ;  DC.  Descending  colon  ;  IC,  Iliac  colon  ;  PC,  Pelvic 
colon;    R,   Rectum;    U,  Umbilicus;    P,  Pelvis. 


144 


CONSTIPA  TION 


than  normal.  In  oesophageal  and  pyloric  obstruction  constipation  is  always 
present  owing  to  the  small  quantity  of  food-residue  which  reaches  the  colon. 
The  other  symptoms  generally  prevent  a  mistake  in  diagnosis  being  made  ; 
but  occasionally  in  pyloric  obstruction  the  patient  complains  of  nothing  but 
some  slight  indigestion  or  weakness  in  addition  to  the  constipation.  The 
passage  of  a  stomach-tube  twelve  hours  after  a  large  meal,  when  the  stomach 
should  be  completely  empty,  and  an  ;i;-ray  examination,  will  clear  up  the 
diagnosis  in  doubtful  cases. 

Deficient  Sensibility  of  the  Intestinal  Mucous  Membrane. — This  is  the  probable 
cause  of  the  constipation  when  there  is  a  history  of  excessive  tea-drinking 
or  of  the  long-continued  use  of  large  doses  of  aperients  ;  it  is  also  partly  respon- 
sible for  the  constipation  associated  with  catarrhal  colitis — in  which  excess  of 
mucus  is  passed  with  the  stools — whether  this  is  primary  or  a  result  of  constipa- 
tion of  other  origin. 

Depression  of  the  Nervous  System. — In  neurasthenic,  hypochondriac,  and  insane 

patients,  the  condition  of  the 
nervous  system  is  the  chief 
cause  of  the  constipation  which 
is  almost  invariably  present  ; 
but  an  improper  diet  is  gener- 
ally an  additional  factor. 

(c).  Inhibition  of  the  Motor 
Activity  of  the  Intestines. 

This  group  of  cases  can  often 
be  recognized  by  the  fact  that 
sedatives,  such  as  opium  and 
belladonna,  give  relief,  whilst 
purgatives  are  required  in  un- 
usually large  doses,  and  pro- 
duce an  unusual  amount  of 
colic  unless  given  with  a  seda- 
tive. The  x-rays  show  that 
the  small  intestine  as  well  as 
the  colon  is  traversed  slowly  ; 
this  is  unusual  in  other  forms 
of  constipation  {Fig.  36).  In- 
hibition may  be  direct,  central, 
or  reflex. 

Direct     Inhibition    in     Dead 

Poisoning. — The    diagnosis    is 

siTggested    by   the    occupation   of   the   patient,    a  blue   line    on   his   gums,  the 

presence  of  anaemia  and  sometimes  of  arteriosclerosis  and  granular  kidney,  or 

a  previous  history  of  colic  or  lead  palsy. 

Central  Inhibition. — A  history  of  a  recent  shock,  annoj'ance,  or  worry  is 
obtained. 

Reflex  Inhibition. — Constipation  is  a  frequent  symptom  of  painful  diseases 
of  abdominal  and  pelvic  viscera,  other  than  the  intestines  themselves.  It  can 
then  be  cured  only  by  treating  the  primary  condition,  so  that  it  is  essential  to 
ascertain  the  cause  of  the  pain.  Constipation  is  particularly  liable  to  result 
from  disease  of  the  vermiform  appendix,  female  genital  organs,  stomach, 
duodenum,  and  gall-bladder. 

{d).  Irregular  Spasmodic  Contraction  of  the  Intestine:  Spastic  Constipation  : 
Enterospasm. 

When  constipation  is  associated  with  pain,  especially  if  the  pain  comes  on  in 


P'g-  35.  —  Post-dysenteric  atony  and  paresis  of  the 
colon.  Compare  the  lumen  of  the  colon  and  the  slow 
passage  of  feeces  through  it  with  Fig^.  34. 


CONSTIPA  TION 


145 


attacks,  during  which  the  difficulty  with  the  bowels  is  increased,  the  possibility 
that  it  is  due  to  spasm  of  the  colon  must  be  considered.  The  pain  is  situated 
in  the  course  of  the  large  intestine,  most  frequently  in  the  iliac  and  pelvic  colon, 
but  occasionalh'  in  other  parts.  The  affected  parts  of  the  colon  can  generally 
be  felt  as  a  contracted,  tender 
cord,  in  which  scybala  may  be 
detected  and  the  narrow  lumen 
can  be  recognized  with  the  ;v-ray3 
[Fig.  37).  When  the  pain  is  in 
the  right  iliac  fossa,  appendicitis 
may  be  simulated  ;  the  long 
duration  of  the  attacks  without 
any  p}"rexia,  the  occasional  his- 
tory of  similar  pain  on  the 
opposite  side,  and  the  contracted 
condition  of  the  ascending  colon 
and  sometimes  of  the  caecum 
(though  in  other  cases  the  csecum 
may  be  distended  and  tympan- 
itic), are  distinctive  features  of 
spastic  constipation.  When  the 
pain  is  in  the  left  side,  a  tumour 
of  the  descending  or  iliac  colon 
may  be  suspected  :  the  long 
history,  the  absence  of  visible  or 
palpable  peristalsis  and  of  dis- 
tention above  the  contracted 
part,  and  the  absence   of   occult 

blood  from  the  stools,  are  points  which  distinguish  spastic  constipation  from 
cancer  of  the  colon.  In  cases  of  spastic  constipation  the  stools  should  always 
be  examined  for  the  presence  of  mucus,  as  the  spasm,  especially  when  it  occurs 

in  neurotic  women,  is  often 
only  a  symptom  of  muco- 
membranous  colitis,  shreds  or 
membranes  of  coagulated  mucus 
being  passed  by  the  patient. 

2. — Constipation  due  to 
Excessive  Force  required 
to  carry  the  f.^ces  to  the 
Pelvic  Colon  may  be  due  to  : 
[a).  Obstruction  by  Faeces. 
Dry,  hard  f^ces,  which  re- 
quire abnormally  strong  peri- 
stalsis to  carry  them  to  the 
pelvic  colon,  result  from  :  (i) 
Insufficient  consumption  of 
water — a  common  cause  of  con- 
stipation in  women  ;  (ii)  Ex- 
cessive loss  of  water  by  other 
channels — one  cause  of  the 
constipation    of    diabetics,    and 

a  possible  cause  in  individuals  who  perspire  freely  and  are  only  constipated  in 

hot  weather. 


J'/g^.  36. — Constipation  due  to  lead  poisoning.  The 
passage  through  the  small  intestine  as  well  as  the 
colon  is  slow,  owing  to  the  inhibitory  action  of  the 
splanchnic  nerves. 


■FiS^.  37. — Constipation  with  muco-membranous  colitis, 
showing  spasm  of  descending  and  iliac  colon. 


146 


CONSTIPA  TION 


(b).  Narrowing  of  the  Intestinal  Lumen. 

Organic  stricture.  Unless  this  is  due  to  a  palpable  tumour,  it  may  be  very- 
difficult  to  distinguish  from  constipation  due  to  less  serious  causes.  More  or  less 
colic  is  generally  present,  and  its  situation  often  gives  a  clue  to  the  localization 
of  the  obstruction.  An  ^r-ray  examination  should  be  made  :  the  shadow  of  the 
colon  is  soon  visible  as  far  as  the  seat  of  the  obstruction,  beyond  which  no  bis- 
muth passes  for  a  considerable  time.  Sometimes  the  actual  narrowing  of  the 
intestine  can  be  observed  {Fig.  38). 

Non-malignant  strictures  of  the  colon  are  rare.  If  there  is  a  history  of  tuber- 
culous or  dysenteric  ulceration,  the  possibility  of  obstruction  due  to  cicatrization 
should  be  considered,  though  this  is  a  very  unusual  occurrence.       Hyperplastic 

tuberculous  infiltration  of  the 
intestine,  especially  of  the 
caecum,  causes  obstruction,  but 
the  tumour  present  is  clinically 
indistinguishable  from  cancer. 
Obstruction  to  the  iliac  or 
pelvic  colon  may  follow  the 
pericolitis  which  results  from 
the  formation  of  diverticula  in 
old  people  who  have  long 
suffered  from  constipation.  This 
condition  may  also  be  indistin- 
guishable from  a  growth,  but 
the  possibility  should  be  borne 
in  mind  in  the  case  of  elderly 
patients  with  a  tumour  in  the 
iliac  or  pelvic  colon,  where  there 
is  a  long  history  of  constipation  : 
the  sigmoidoscope  may  help  in 
the  diagnosis.  If  a  vesico-colic 
fistula  develops  in  association 
with  chronic  constipation,  it 
should  be  remembered  that 
pericolitis  •  due  to  ulceration  of 
diverticula  is  a  more  frequent 
cause  of  this  condition  than 
cancer. 

Organic  stricture  of  the 
colon  is  most  commonly  due 
to  cancer.  The  possibility  of 
cancer  should  always  be  considered  when  an  individual  above  the  age  of 
forty,  whose  bowels  have  been  regular  previously,  develops  constipation  of 
increasing  severity  without  change  of  diet  or  habits,  or  when  a  patient,  who 
is  habitually  constipated,  becomes  more  so  without  obvious  reason.  The  con- 
stipation is  at  first  intermittent  and  may  alternate  with  diarrhoea  ;  drugs  become 
steadily  less  effective,  and  enemata,  which  at  first  give  greater  relief  than  drugs, 
also  lose  their  effect  slowly.  A  tumour  is  palpable  in  less  than  half  the  cases  ; 
it  may  vary  in  size,  and  even  disappear  after  the  bowels  have  been  opened  well, 
because  a  mass  of  faeces  may  become  impacted  above  a  cancerous  stricture 
which  is  itself  impalpable.  Hence,  although  the  presence  of  a  tumour  is  an 
important  aid  in  diagnosis,  its  absence  or  disappearance  does  not  exclude  the 
possibility  of  cancer  ;  only  when  its  disappearance  under  treatment  is  accom- 
panied by  complete  and  lasting  cure  of  all  symptoms,  can  cancer  be  excluded. 


/•'/X.  •  .  —  ^l.iaLjr.Lin  showing  incomplete  intestinal 
obstruction,  due  to  cancer  of  ascending  colon.  Taken 
nine  hours  after  a  bismuth  meal.  C,  Caecum;  T,  The 
palpable  tumour,  marked  out  with  a  wire  placed  on  the 
patient's  abdomen  ;  AC,  Strictured  ascending  colon  ; 
TC,  Transverse  cqlon  ;  A,  Appendix,  which  is  rarely  seen 
so  clearly;  U,  Umbilicus,  marked  by  a  coin;  IC.  Iliac 
crest.  Skiagram  by  Dr.  A.  C.  Jordan.,  reproduced  by 
permission  from  "The  Archives  of  the  Roentgen  Ray." 


CONSTIPA  TION 


147 


The  tumour  is  hard,  and  cannot  be  altered  in  shape  by  pressure,  as  is  the  case 
with  fascal  tumours.  Slight  attacks  of  colic  occur  frequently,  but  they  are  not 
often  severe  until  the  obstruction  is  almost  complete  ;  the  colic  may  be  accom- 
panied by  visible  and  palpable  peristalsis  and  spasmodic  contractions  of  the 
intestine.  The  latter  is  a  most  important  sign,  as  it  never  occurs  in  colic 
associated  with  lead-poisoning  or  colitis,  and  very  rarely  with  obstruction  due 
to  fsecal  impaction.  Progressive  loss  of  weight  and  strength,  anorexia,  and 
anaemia  are  late  -symptoms,  and  it  is  important  to  make  a  correct  diagnosis 
before  they  have  appeared.  The  obvious  presence  of  blood  in  the  faeces  is  an 
important  symptom,  but  it  is  often  absent.  Much  more  frequently  traces 
are  found  which  are  only  recognizable  by  chemical  tests.  In  the  absence  of 
haemorrhoids  and  of  haemorrhage  from  the  mouth,  throat,  or  nose,  the  presence 
of  "  occult  "  blood  in  the  fasces  is  strong  evidence  that  ulceration  is  present  in 
the  stomach  or  intestines  ;  when  symptoms  pointing  to  gastric  or  duodenal 
ulcer  and  gastric  carcinoma 
are  absent,  and  constipation  is 
present,  a  suspicion  of  cancer 
of  the  intestine  receives 
important  confirmation.  In 
doubtful  cases  a  sigmoidoscopic 
examination  should  be  made, 
as  cancer  is  much  more  com- 
mon in  the  rectum  and  pelvic 
colon — which  alone  can  be 
investigated  by  this  method — 
than  in  any  other  part  of  the 
intestine. 

A  kink  of  the  colon  is  a 
very  unusual  cause  of  consti- 
pation. It  is  sometimes  partly 
responsible  for  the  constipa- 
tion which  is  almost  always 
present  in  visceroptosis  [Fig. 
39),  and  it  should  be  suspected 
when  an  attack  of  localized 
peritonitis,  due  particularly  to 
disease  of  the  female  genital 
organs,  appendicitis,  or  leak- 
age from  a  gastric  or  duodenal 
ulcer,  is  followed  by  constipa- 
tion.    An    x-r2t.Y    examination 

should,  however,  always  be  made  before  advising  surgical  interference,  as,  in 
the  vast  majority  of  cases,  even  if  adhesions  are  present  they  have  nothing  to 
do  with  the  obstruction.  The  ;ir-rays  show  whether  the  delay  takes  place  in 
the  neighbourhood  of  the  supposed  adhesions,  and  the  presence  or  absence  of 
adhesions  can  also  be  ascertained  by  seeing  how  movable  the  colon  is,  and 
whether  the  two  limbs  of  the  various  flexures  can  be  separated  from  each  other. 

Whatever  may  be  the  primary  cause  of  Hirschsprung' s  disease  (wrongly 
called  "congenital  idiopathic  dilatation  of  the  colon"),  it  is  probable  that  a 
kink  is  produced  after  the  dilatation  has  reached  a  certain  degree  by  the  over- 
hanging of  the  dilated  part  of  the  colon  over  the  undilated  section  {Fig.  40). 
There  is  always  a  history  of  constipation  dating  from  the  first  few  months  of 
life,  although  sometimes  the  bowels  may  be  opened  daily  but  insufficiently. 
Soon  after  birth  the  abdomen  becomes  greatly  enlarged,  the  size  varying  from 


Jiig;.    39. — Skiagram    taken    by    Dr.    A.    C.    Jordan, 
showing  ptosis  of  csecum  and  transverse  colon. 


148 


CONSTIPA  TION 


time  to  time.     The  outline  of  the  distended  colon  can  be  seen,  and  peristalsis 
is  often  visible.     The  abdomen  finally  becomes  enormous ;   it  is  then  tense  and 

tympanitic.  Attacks  of  obstruction 
are  liable  to  occur,  and  death  takes 
place  most  frequently  between  the 
ages  of  three  and  eight. 

When  a  large  abdominal  tumour 
is  present,  constipation  may  be 
produced  by  its  pressure  on  the 
colon. 

Chronic  intussusception  may  give 
rise  to  symptoms  similar  to  those 
produced  by  a  stricture  ;  attacks 
of  colic  accompanied  by  visible  peri- 
stalsis occur  with  increasing  frequency 
and  severity,  and  they  are  often 
brought  on  by  food  or  aperients. 
An  intussusception  should  be  sus- 
pected under  these  circumstances 
when  a  sausage-shaped  tumour  is 
palpable,  especially  if  blood  and 
mucus  are  passed  at  frequent  inter- 
vals. In  one-third  of  the  cases,  the 
apex  of  the  intussusception  can  be 
felt  on  rectal  examination. 


Pi^.  40.  —  Colon  in  a  case  of  Hirschsprung's 
Disease.  AC,  Ascending  colon  ;  TC,  Transverse 
colon;  DC,  Descending  colon;  I C,  Iliac  colon; 
PC,  Loop  of  pelvic  colon  ;  R,  Rectum.  The  dotted 
lines  represent  the  costal  margins. 


C. — Diagnosis    of    the    Cause   of   Dyschezia. 

Dyschezia  is  due  to  a  want  of  proper  proportion  between  the  power  of 
expelling  the  faeces  from  the  pelvic  colon  and  rectum,  and  the  force  required  to 
do  this  completeh'.  It  may  therefore  be  due  to  (i)  Inefficient  DefcBcation  ;  or 
(2)  An  Obstacle  to  efficient  Defcecation. 

I.     Inefficient  Defjecation  may  be  due  to  : — 

(a).  Weakness  of  the  Voluntary  Muscles  of  Defaecation. 

This  should  always  be  suspected  when  constipation  dates  from  pregnancy, 
or  is  associated  with  ascites,  large  abdominal  tumours,  or  great  obesity. 
It  is  often  easy  to  ascertain  the  condition  of  the  abdominal  muscles  by 
simple  palpation  in  the  horizontal  position  ;  the  discovery  of  a  movable 
kidney  or  a  dropped  liver  would  also  suggest  that  the  abdominal  muscles 
are  weak.  The  patient  should  next  be  told  to  raise  her  head  from  the  couch  ; 
the  recti  muscles  contract  and  their  strength  can  be  ascertained,  and  any 
separation  between  them  recognized.  Finally,  the  patient  should  be  examined 
standing  up  ;  bulging  of  the  abdomen  below  the  umbilicus  {Fig.  41)  shows 
that  visceroptosis  is  present  and  that  the  abdominal  muscles  are  weak.  The 
patient  often  complains  of  abdominal  discomfort,  which  is  relieved  by  lying 
down  or  by  pressing  the  lower  part  of  the  abdomen  upwards. 

In  all  cases  in  which  a  woman,  whose  bowels  have  previously  been  regular, 
becomes  constipated  after  the  birth  of  a  chUd,  the  condition  of  the  pelvic  floor 
should  be  investigated,  as  well  as  that  of  the  abdominal  wall.  The  anus  is 
normally  slightly  retracted  ;  the  retraction  is  increased  and  the  anus  moves 
slighth'  forward  when  the  levator  ani  muscles  are  contracted  by  making  the 
movement  which  is  required  when  it  is  attempted  to  restrain  a  commencing 
defaecation.  If  thej^  are  weak,  the  retraction  in  the  condition  of  rest  is  absent 
or  diminished,  and  on  contracting  the  levator  ani  muscles,  the  retraction  and 


CONSTIPA  TION 


149 


forward  movements  are  slight  or  absent.  On  straining,  the  whole  perineum 
projects  much  further  than  it  should  do,  and  in  severe  cases  the  uterus  may  be 
more  or  less  prolapsed  :  in  such  cases  no  further  evidence  is  required  to  show 
that  the  dyschezia  is  partly  due  to  weakness  of  the  levator  ani  muscles. 

When  constipation  is  present  in  asthmatic  or  very  emphysematous  people, 
it  is  partly  due  to  the  fact  that  the  great  rise  in  intra-abdominal  pressure  required 
in  defaecation  cannot  be  produced  by  contracting  the  diaphragm,  as  the  latter 
is  already  almost  as  low  as  it  can  go. 

(fe).  Habitual  Disregard  of  the  Call  to  Delsecation. 

When  dyschezia  is  not  associated  with  weakness  of  the  muscles  of  the 
abdominal  wall  or  pelvic  floor,  the  history  will  generally  show  that  it  has 
resulted  from  habitual  disregard  of  the 
call  to  defaecation — a  very  common 
cause  in  girls,  and  a  not  uncommon  one 
in  schoolboys  and  business  men,  who 
allow  themselves  too  little  time  between 
getting  up  and  beginning  the  day's 
work.  The  call  is  often  neglected  also  if 
for  any  reason  defaecation  is  painful. 

[c).  Unfavourable  Posture  during  Defae- 
cation. 

Enquiry  should  be  made  as  to  the 
height  of  the  seat  in  the  water-closet,  as 
when  this  is  too  high  it  is  impossible  to 
assume  the  proper  crouching  position, 
and  defeecation  may  consequently  be 
inefficient. 

Weakness  of  the  voluntary  muscles  of 
defaecation,  habitual  disregard  of  the 
call,  and  the  assumption  of  an  unsuit- 
able position  during  the  act,  all  lead  to 
the  same  results — the  loss  of  the  defaeca- 
tion reflex,  and  atony  and  paresis  of  the 
musculature  of  the  pelvic  colon  and 
rectum.  The  loss  of  the  defaecation  reflex 
is  shown  by  the  fact  that  the  patient 
never  experiences  a  desire  to  defaecate, 
even  when  examination  shows  that  the 
rectum  is  full  of  faeces.  The  atony  of 
the  rectum  is  shown  by  its  abnormally 
large   size   and   the  very  slight   resistance 

offered  when  the  finger  presses  upon  its  walls  ;  the  atony  of  the  pelvic  colon  is 
shown  by  the  abnormally  large  shadow  it  forms  when  examined  with  the  ^r-rays 
[Fig.  33,  p.  142).  The  paresis  of  the  pelvic  colon  and  rectum  is  shown  by  the 
patient's  inability  to  defaecate  by  an  effort  of  will,  when  the  rectum  isfvdlof  faeces. 

{d).  Primary  Weakness  of  the  Defaecation  Reflex. 

This  is  sometimes  the  cause  of  constipation  in  infants  ;  it  is  probably  the 
case  when  defaecation  occurs  immediately  if  the  natural  stimulus  is  exaggerated 
by  the  mechanical  effect  of  the  introduction  of  a  finger  into  the  rectum,  or  by  the 
combined  mechanical  and  chemical  effect  of  the  introduction  of  a  piece  of  soap. 

{e).  Organic  Nervous  Diseases. 

When  constipation  occurs  in  the  course  of  organic  nervous  diseases,  such  as  tabes 
dorsalis,  myelitis,  or  meningitis,  it  is  due  to  disturbance  in  the  defaecation  centre 
in  the  lumbo-sacral  cord  or  the  tracts  connecting  it  with  the  brain.      When 


Fig.   41. — Visceroptosis. 


I50  CONSTIPATION 


constipation  and  difficulty  in  micturition  appear  simultaneously,  the  possibility 
of  some  organic  nervous  disease,  such  as  tabes,  should  be  considered,  even  if 
no  other  symptoms  are  present. 

(/).  Hysteria. 

When  dyschezia  occurs  in  hysterical  individuals,  it  is  often  due  to  the  patient 
having  suggested  to  himself  that  he  cannot  open  his  bowels  at  all,  or  unless  he 
takes  a  purgative  or  an  enema.  The  diagnosis  can  be  confirmed  hy  the  result 
of  treatment  :  if  such  a  patient  can  be  persuaded  after  a  thorough  examination 
that  there  is  really'  no  reason  whate^'er  why  he  should  not  obtain  a  dail^r  action 
of  the  bowels  without  artificial  aid,  he  will  have  no  difficult}^  in  curing  himself 
at  once. 

2.     Obstacles  to  Efficient  Def.ecation  may  be  due  to  : — 

{a).  Hard   and  Bulky  Fseces. 

When  the  faeces  are  abnormally-  hard  as  a  result  of  intestinal  constipation  or 
of  the  excessive  loss  of  fluid  from  diarrhoea,  haemorrhage,  or  other  cause,  the 
force  required  to  expel  them  maj^  be  so  great,  especially  if  the}^  are  bulky,  that 
dyschezia  results.  This  condition  can  be  recognized  easily  hy  a  rectal  examina- 
tion, which  shows  that  faeces  of  abnormal  hardness  are  impacted  in  the  rectum. 

[b).  Spasm   of  the   Sphincter    Ani. 

^■^^len  defaecation  is  painful,  it  is  rendered  difficult  as  well  as  painful  hy  reflex 
spasm  of  the  sphincter  ani.  The  anal  canal  and  rectum  should  be  examined 
after  the  introduction  of  a  cocaine  suppository-,  or — if  necessarj^ — under  a  general 
anaesthetic,  so  that  any  local  cause  of  the  pain,  such  as  an  anal  ulcer  or  inflamed 
haemorrhoids,  may  be  discovered.  In  the  absence  of  these,  the  genito-urinary 
organs  should  be  examined  thoroughlj^  for  reflex  causes  of  spasm. 

(c).  Organic  Stricture   of  the   Rectum   and   Anus. 

In  every  case  of  constipation  a  digital  examination  of  the  rectum  should  be 
made,  and  in  cases  of  doubtful  origin  the  rectum  and  pelvic  colon  should  be 
examined  with  a  proctoscope  and  sigmoidoscope.  Congenital  narrowness  of  the 
anal  canal  is  easHj^  recognized  ;  it  is  a  rare  condition,  but  may  give  rise  to  no 
symptom  until  several  years  after  the  child  is  born.  Fibrous  stricture  of  the 
rectum  is  an  occasional  cause  of  dyschezia,  especially  in  women ;  it  is  never  due 
to  s\-philis,  but  results  from  an  inflammatory  infiltration  of  the  submucous 
tissue,  secondary  to  infection  of  an  abrasion  of  the  mucous  membrane.  The 
condition  is  generally  painful,  and  often  associated  Avith  active  inflammation  and 
ulceration  ;  it  can  be  distinguished  readily-  from  malignant  stricture  b}^  means  of 
the  proctoscope.  Cancer  of  the  rectum  or  pelvic  colon  is  a  common  cause  of 
dyschezia  ;  when  constipation  deA-elops  after  the  age  of  forty  without  anj^  obvious 
cause,  especiall}-  if  it  is  accompanied  by  a  sense  of  fullness  in  the  rectum  and  of 
incomplete  relief  after  defaecation,  b3^  loss  of  weight  and  strength,  or  b}^  dis- 
charge of  mucus  and  blood,  the  possibility  of  cancer  of  the  rectum  should  alwaj^s 
be  considered,  and  a  thorough  examination  made. by  the  finger  and  proctoscope 
or  sigmoidoscope. 

{d).  Pressure   on   the   Rectum  from   Without. 

Pressure  on  the  pehic  colon  and  rectum  by  a  gravid  uterus  alwa3^s  produces 
some  dyschezia.  Apart  from  this,  the  possibility  of  a  pelvic  tumour,  such  as 
distended  tubes,  cancer  and  fibroid  of  the  uterus,  and  ovarian  tumours,  should  be 
remembered  in  dyschezia  occurring  in  women,  especialty  if  there  is  a.ny  pelvic 
pain.  The  presence  of  a  retroverted  but  otherwise  normal  uterus  cannot  be 
regarded  as  a  sufficient  explanation  of  dA'schezia. 

{e).  Invagination, 

When  a  constipated  patient,  whose  general  health  is  so  good  that  cancer 
seems  improbable,  complains  that  after  defaecation  he  feels  as  if  something  were 


CONSTIPATION  151 

still  present  in  the  rectum,  especially  if  mucus  and  occasionally  a  little  blood  is 
passed,  the  dyschezia  may  be  due  to  the  obstruction  caused  by  the  invagination 
of  the  mucous  membrane  of  the  upper  part  of  the  rectum  into  the  lower  part. 
The  condition  is  generally  associated  with  lumbar  pain.  On  digital  examination 
the  invaginated  mucous  membrane  can  be  felt,  especially  when  the  patient 
strains. 

II.— ACUTE    CONSTIPATION. 

Acute  constipation  may  be  (i)  Due  to  acute  intestinal  obstruction;  or  (2)  A 
symptom  of  (a)  some  general  disease,  or   {b)  some  other  acute  abdominal  disease. 

I.     Acute    Intestinal    Obstruction. 

A.  The  following  points  help  in  the  distinction  between  acute  intestinal 
obstruction  and  severe  cases  of  acute  constipation  of  other  origin  : — 

(i).  Visible  and  palpable  peristalsis  or  stiffening  of  the  intestines  is  never 
present  except  in  obstruction. 

(11).  Vomiting  is  never  fseculent,  except  occasionally  at  a  very  late  stage,  in 
non-obstructive  cases. 

(Hi).  In  other  conditions  the  constipation  is  incomplete  : — 

{a).  Flatus,  and  even  a  small  quantity  of  faeces,  may  be  passed  spontaneously. 

(6).  A  purgative  may  give  a  result  ;  it  is,  however,  very  unwise  to  administer 
purgatives  in  such  cases,  but  frequently  the  patients  have  already  tried  them 
on  their  own  responsibility. 

(c).  A  rectal  examination  should  always  be  made.  In  organic  Intestinal 
obstruction  the  rectum  is  empty  ;  if  it  contains  faeces  there  may  be  obstruction 
due  to  faeces,  but  It  is  exceedingly  rare  for  this  to  produce  symptoms  at  all  com- 
parable in  severity  with  those  due  to  acute  obstruction.  With  this  exception, 
the  presence  of  any  quantity  of  faeces  would  show  that  there  was  no  intestinal 
obstruction. 

(d).  In  doubtful  cases  two  enemata  should  be  given,  with  an  Interval  of 
an  hour  :  the  first  generally  brings  away  a  certain  amount  of  faeces,  even  if 
obstruction  is  complete  ;  the  second  only  results  in  the  passage  of  faeces  or  flatus 
if  there  is  no  complete  obstruction  or  if  the  obstruction  is  very  high  in  the  small 
intestine.  If  there  is  complete  obstruction,  the  second  enema  is  either  retained 
or  escapes  unaltered  and  with  abnormally  small  force. 

B.  Before  considering  any  other  possibility,  all  the  hernial  apertures  should 
be  examined,  even  in  the  absence  of  local  pain,  as  a  strangulated  hernia  gives 
all  the  signs  of  acute  intestinal  obstruction. 

C.  The  following  points  should  then  be  considered  in  determining  the  cause 
of  the  acute  Intestinal  obstruction  : — 

(1).  Age. — Intestinal  obstruction  in  the  new-born  is  almost  invariably  due  to  a 
congenital  malformation  :  as  this  is  generally  in  the  rectum,  the  latter  should  be 
examined  first,  and  only  aftet  it  has  been  found  to  be  normal  should  the 
possibility  of  congenital  obstruction  In  the  duodenum  or  ileum  be  considered. 
In  infants  the  common  cause  of  intestinal  obstruction  is  intussusception  ;  at 
a  somewhat  older  age  obstruction  may  arise  in  connection  with  a  Meckel's 
diverticulum  ;  but  In  children  and  young  adults  the  most  common  cause  is 
obstruction  by  bands  or  adhesions  resulting  from  local  peritonitis,  due  to 
appendicitis,  tuberculous  peritonitis,  or  caseous  mesenteric  glands.  Acute 
obstruction  occurring  In  an  Infant  or  child  under  ten  years  of  age,  in  whom 
there  is  a  history  of  constipation  and  abdominal  distention  dating  from  soon 
after  birth,  is  most  probably  due  to  Hirschsprung's  disease.  After  the  age  of 
forty  the  possibility  of  cancer  of  the  colon  should  always  be  remembered,  and 
in   fat   patients,  especially   women,  obstruction    by    gall-stones.       In    patients 


CONSTIPATION 


over  sixt\-  acquired  diverticula  of  the  colon  are  likely  to  give  rise  to  symptoms 
and  signs  which  are  generally  mistaken  for  cancer. 

(ii).  History. — A  previous  attack  of  appendicitis,  or  a  history  of  tuberculous 
peritonitis  or  of  inflammatoni-  pelvic  disease  in  females,  suggests  the  possibHitv 
of  obstruction  by  bands  or  adhesions  ;  the  same  diagnosis  should  be  considered 
if  the  patient  has  some  weeks  or  months  before  had  a  strangulated  hernia 
reduced.  A  history-  of  biliary  colic  or  of  the  less  striking  s^nnptoms  which  may 
result  from  cholelithiasis  indicates  that  obstruction  may  be  due  to  impaction  of 
a  gall-stone.  "\Mien  acute  obstruction  follows  a  period  of  increasing  constipa- 
tion in  middle-aged  patients,  cancer  is  probablv  present. 

(ui).  State  of  the  Bowels. — ^The  passage  of  blood  and  mucus  without  any  faeces 
is  ver^-  suggestive  of  an  intussusception.  In  older  patients  it  may  be  due  to 
cancer.  The  passage  of  stools  during  the  early  stages  in  spite  of  other  evidence 
of  obstruction,  indicates  that  the  latter  is  situated  in  the  small  intestine. 

(iv).  Abdominal  E-vamiviation. — 

(«).  Distention. —  Great  distention  generally  means  that  the  obstruction  is 
in  the  colon  :  if  it  is  present  very  soon  after  the  onset  of  sjinptoms,  it  is 
probably  due  to  cancer  or  vol\"ulus  ;  if  it  has  been  present  to  a  less  extent 
for  some  time  before  the  onset  of  acute  sj-mptoms,  a  growth  is  likelj' ;  but 
if  it  has  de\"eloped  ver\-  acutely,  a  volvulus  is  more  probable.  In  infants  and 
smaU  children  great  distention  suggests  Hirschsprung's  disease,  if  the  abdomen 
is  t\Tiipanitic  ;  if  it  is  partially  dull,  and  if  free  fluid  or  irregular  masses 
are  present,  tuberculous  peritonitis  is  the  probable  diagnosis.  Well-marked 
distention  in  both  flanks  suggests  origin  in  the  pelvic  colon  or  rectum  ;  if 
in  the  right  flank  only,  in  the  hepatic  flexure  or  transverse  colon  ;  if  the 
flanks  are  comparatively  undistended,  and  the  central  part  of  the  abdomen  is 
most  affected,  the  obstruction  is  likely  to  be  in  the  fleum  or  the  caecum  ;  distention 
is  slight  when  the  obstruction  is  in  the  duodenum  or  jejunum. 

(6).  Visible  Peristalsis  and  Stiffening  of  the  Intestine. — ^The  position  and  direc- 
tion of  %-isible  peristalsis  and  the  position  of  stiffening  coils  of  intestine  may  show 
the  localization  of  the  obstruction.  \\Tien  a  series  of  more  or  less  parallel  con- 
tracting coils  is  \"isible  in  the  central  part  of  the  abdomen,  the  obstruction  is  in 
the  smaU  intestine  ;  if  it  appears  to  culminate  in  the  right  iliac  fossa,  this  is 
likely  to  be  the  seat  of  disease.  Stiffening  of  a  length  of  intestine,  which  can 
be  seen  to  rise  up  and  felt  to  harden,  most  often  occurs  in  the  colon,  and  especially 
when  there  is  a  g^o^vth  near  its  lower  end.  The  most  marked  peristalsis  and 
stiffening  occur  when  acute  obstruction  is  a  sequel  of  chronic  obstruction  ;  they 
may  be  completely  absent  in  verj^  acute  primarj^  cases. 

(c).  Tumour. —  The  diagnosis  of  intussusception  can  be  made  with  certainty 
only  when  the  characteristic  sausage-shaped  tumour  situated  somewhere  in  the 
course  of  the  colon  is  felt.  In  acute  obstruction  due  to  cancer,  the  tumour  is 
often  not  palpable,  as  it  is  generally  hidden  by  the  dilated  intestine.  But  large 
tumours  are  sometimes  felt,  especially  when  present  in  the  right  or  left  iliac 
fossa  :  the  former  are  generally  due  to  cancer  of  the  caecum,  the  latter  to  cancer 
of  the  iliac  colon  and  inflammaton,*  thickening  round  acquired  diverticula — a 
condition  which  may  closely  simulate  cancer.    Gall-stones  can  hardly  ever  be  felt. 

(v).  Rectal  Examination. — A  growth  of  the  rectum  can  be  recognized  easily,  and 
sometimes  a  growth  of  the  pelvic  colon  can  be  felt  through  the  front  wall  of  the 
rectum.  In  infants,  the  end  of  an  intussusception  may  be  felt  in  the  lumen  of 
the  rectum,  and  more  frequently  the  tumour  can  be  felt  on  bimanual  examination. 
Obstruction  due  to  pelvic  adhesions  can  often  be  recognized  by  the  presence  of 
tender  masses  and  the  lixit\-  of  some  of  the  pelvic  viscera.  The  presence  of 
more  than  traces  of  faeces  in  the  rectum  in  cases  of  undoubted  obstruction 
indicates  that  its  situation  is  probablj-  high  up  in  the  small  intestine.     A  very 


CONTRACTIONS  153 


ballooned  rectum  suggests  obstruction  high  up  in  the  rectum  or  in  the  pelvic 
colon,  but  this  is  not  an  invariable  rule. 

(vi).  Pain. — When  the  pain  is  localized,  or  moves  in  a  definite  direction  to 
reach  its  greatest  severity  at  a  certain  point,  the  latter  is  likely  to  be  near  the 
seat  of  the  obstruction.  When  the  pain  is  situated  in  the  middle  line,  the 
obstruction  is  probably  in  the  small  intestine  if  it  is  above  the  umbilicus,  and  in 
the  colon  if  below. 

(vii).  Vomiting. — The  more  frequent  the  vomiting  and  the  earlier  the  onset  of 
faeculent  vomiting,  the  higher  in  the  intestine  is  the  obstruction  likely  to  be. 
It  is  most  severe  in  small  intestine  obstruction  due  to  bands  or  internal  hernia  ; 
its  onset  is  later  and  its  occurrence  less  frequent  and  sometimes  only  after  food 
in  cases  of  growth  and  vohailus. 

(viii).  Borboyygmi  are  sometimes  most  marked  over  the  seat  of  the 
obstruction. 

(ix).  Shock  and  Collapse  are  more  marked  the  higher  the  obstruction.  They 
are  also  much  greater  when  obstruction  is  accompanied  by  strangulation  owing 
to  bands  or  hernia  than  when  strangulation  is  absent,  as  with  gall-stones  and 
cancer. 

2.    Symptomatic. 

In  Acute  General  Diseases.  —  Constipation  beginning  acutely,  is  a  frequent 
symptom  of  a  large  variety  of  acute  infective  and  other  diseases.  It  is  never 
so  severe  that  it  cannot  be  overcome  by  purgatives  or  enemata,  and  the  other 
symptoms  are  so  much  more  striking  in  the  majority  of  cases  that  the  presence 
of  constipation  has  little  influence  in  forming  a  diagnosis. 

In  Acute  Abdominal  Conditions. — Constipation  is  a  prominent  symptom  in 
most  acute  abdominal  conditions.  Other  symptoms  are  often  so  well  marked 
that  the  question  of  intestinal  obstruction  hardly  arises.  Thus,  the  diagnosis 
can  generally  be  made  by  the  early  tenderness  and  rigidity,  its  localization,  and 
the  early  pyrexia  in  acute  peritonitis  due  to  appendicitis  or  the  perforation  of 
an  ulcer  ;  the  characteristic  situation  and  radiation  of  the  pain  in  renal  and 
biliary  colic,  and  the  frequent  haematuria  in  the  former  and  jaundice  in  the  latter  ; 
the  presence  of  a  tumour  when  an  ovarian  cyst  is  twisted  ;  the  melaena  and 
occasional  hsematemesis,  and  the  presence  of  a  primary  disease  in  the  heart  or 
abdomen  in  mesenteric  embolism  and  thrombosis  respectively.  Some  cases  of 
acute  pancreatitis  are  clinically  almost  indistinguishable  from  intestinal  obstruc- 
tion, but  flatus  is  generally  passed  ;  there  may  also  be  a  history  of  biliary  colic, 
and  the  patient  is  generally  fat,  middle-aged,  and  alcoholic.  The  diagnosis  is 
seldom  made  with  certainty  until  the  typical  fat-necrosis  is  seen  on  opening 
the  abdomen.  In  lead  colic  the  constipation  is  not  absolute,  and  the 
occupation  of  the  patient  and  the  blue  line  on  the  gums  suggest  the  correct 
diagnosis.  Arthur  F.   Hertz. 

CONTRACTIONS,  Athetotic,  Choreiform,  Fibrillar,  Spasmodic,  and  Tetanic- 
are  all  to  be  defined  for  present  purposes  as  involuntary  and  painless  contrac- 
tions occurring  in  the  voluntary  muscles.  From  Contractures  {q.v.)  they  may 
be  distinguished  by  their  short  duration,  longer  or  shorter  intervals  in  which 
the  affected  muscles  are  relaxed  occurring  between  the  separate  contractions. 
From  cramps  they  differ  by  being  painless,  or  comparatively  so,  and  also  by 
their  short  duration.  But  in  many  cases  it  is  impossible  and  also  unnecessary 
to  draw  any  hard-and-fast  line  showing  where,  for  example,  tetanic  contractions 
cease  and  tetanic  cramps  begin.  In  all  cases  the  occurrence  of  the  contractions 
mentioned  above  may  be  taken  to  indicate  some  disease  of  the  nervous  system, 
usually  organic  but  sometimes  functional. 


154 


CONTRACTIOXS 


Athetotic   ContractioxSj    Athetosis,   or   Mobile   Spasm. 

Athetosis  is  a  form  of  involuntary  movement  affecting  the  fingers,  hands,  and 
A\Tists  most  often  ;  less  often  the  toes  and  feet,  and  in  rare  instances  the  face. 
It  is  usually  unilateral,  but  in  exceptional  cases  bilateral — the  "  double 
athetosis  "  of  French  neurologists.  The  movements  are  spontaneous  and 
incessant,  and  may  even  continue  while  the  patient  is  asleep  ;  in  other  instances 
they  tend  to  cease,  but  are  started  anew  or  exaggerated  when  voluntary  move- 
ment is  attempted.  In  the  hand,  the  movements  consist  of  a  succession  of  slow 
and  serpentine  flexions,  extensions,  h\'perextensions,  and  lateral  motions,  all 
combined  to  cause  the  fingers  and  thumb  to  execute  the  most  curious  and 
complex  clutching  or  spreading  movements  [Fig.  42).  The  vcrist  is  held  more  or 
less  flexed  ;  the  fingers  may  move  about  together,  or  wander  each  individually. 
Analogous  movements  are  observed  when  athetosis  occurs  in  the  lower  extremity, 
or   the   mouth   and   face.        Xo   great  regularity   characterizes  the  motions   of 

athetosis,  and  as  a  rule  they  are 
steady  rather  than  violent.  In  all 
cases,  a  large  amount  of  voluntary 
control  over  the  affected  parts  is 
retained  ;  mobile  spasm  must  be 
attributed  to  varpng  degrees  of 
central  irritation  of  muscles  that 
are  incompletely  paralyzed  and 
somewhat  spastic. 

Primary,  idiopathic,  or  primitive 
athetosis  is  a  rare  disease  of  child- 
hood or  of  adult  life,  in  which  bi- 
lateral athetotic  contractions  first 
make  their  appearance  in  a  pre- 
viously healthy  person,  either  for 
no  particular  reason,  or  after  a 
chill  or  a  ner\-ous  shock.  It  may 
or  may  not  be  associated  ^\'ith 
epilepsy  or  insanit}'-.  This  form  of 
athetosis  appears  not  to  be  con- 
nected with  any  definite  changes  in 
the  nervous  system,  and  so  is  to 
be  distinguished  from  all  other  con- 
ditions in  which  athetosis  is  seen. 
Athetosis  is  common  in  the  various  spastic  paraplegias  of  infants  and  children, 
which  may  be  either  congenital  or  acquired  :  Congenital  cerebral  diplegia,  also 
known  as  Little's  disease  when  the  legs  are  the  part  chiefly  affected,  is  a  condition 
in  which  the  nervous  structures  suffer  from  an  inherited  taint  (alcoholism, 
syphilis,  insanity),  and  either  fail  to  develop  proper h',  or  degenerate  earl}-  in 
hfe.  The  onset  of  Little's  disease  is  gradual,  and  usuallj^  early,  but  it  may  be 
delayed  until  the  child  is  as  much  as  six  or  eight  years  old.  The  patient  is  found 
to  be  backward  or  mentally  deficient,  probably  unable  to  walk,  and  afilicted 
with  bilateral  spastic  paralysis.  The  paralysis  may  affect  the  legs,  the  legs  and 
arms,  or  even  the  whole  bod}',  and  may  be  more  marked  and  more  spastic  on 
one  side  of  the  body  than  on  the  other  ;  speech  is  defective,  optic  atrophy 
common,  and  the  gait  is  clumsy  and  stiff,  "  cross-legged  "  or  "  scissor."  In- 
voluntary movements  occur  in  the  affected  members,  and  are  athetotic  or 
choreiform  ;  tremor  or  intention-tremor  may  also  be  niet  with  not  in- 
frequently. 


Fi£^.  42. — The  hand  in  athetosis. 


CONTRACTIONS  155 


Although  it  may  not  appear  for  some  years  after  birth,  this  form  of  cerebral 
diplegia  is  really  a  congenital  disorder  ;  and  it  is  to  be  distinguished,  for  reasons 
connected  with  its  pathological  anatomy  and  etiology,  from  certain  other  forms 
of  spastic  paralysis  in  infants  and  children  that  may  closely  resemble  it  from 
a  clinical  point  of  view.  These  are  the  acquired  cevebral  paralyses  of  infants,  the 
spastic  infantile  hemiplegias,  monoplegias,  diplegias,  triplegias,  paraplegias, 
that  result  from  more  or  less  localized  cerebral  inflammations  or  haemorrhage 
occurring  at  birth  or  in  infancy.  Porencephaly ,  or  the  occurrence  of  lacuna  in 
the  tissues  of  the  cortex  or  brain,  may  be  found  in  either  the  congenital  or  the 
acquired  cerebral  paralyses  ;  it  is  really  a  post-mortem-room  term,  and  requires 
no  special  consideration  here.  The  acquired  spastic  paraplegias  fall  into  two 
categories,  according  to  their  etiology  : — 

1.  Birth  palsies  :  due  to  meningeal  or  cortical  hsemorrhage  caused  by  prolonged 

labour  or  the  use  of  instruments.     Many  of  these  infants  have  been 
born  prematurely. 

2.  Acquired  palsies  :    due  to — 

Encephalitis    occurring  after   an   acute   specific    fever,    or   suppurative 
in  origin. 

Polio-encephalitis,  the  cerebral  analogue  of  acute  poliomyelitis  in  the 
anterior  cornua  of  the  cord. 

Cerebral   embolism. 

Cerebral  or  meningeal  haemorrhage  or  thrombosis. 
The  birth  palsies  are  due  to  injuries  received  in  the  process  of  birth,  and  the 
rupture  of  meningeal  or  cerebral  blood-vessels,  with  the  escape  of  blood  ;  they 
develop  at  once,  and  the  history  of  the  case  should  make  diagnosis  easy.  The 
diagnosis  of  the  exact  cause  of  an  acquired  spastic  paralysis  in  an  infant  or  child 
may  be  less  easy.  The  paralysis  due  to  encephalitis  generally  appears  during 
the  first  two  or  three  years  of  life,  but  may  come  on  at  almost  any  age.  Cerebral 
thrombosis  in  children,  is  said  to  happen  oftenest  at  about  the  age  of  six. 
Cerebral  embolism  is  likely  to  be  seen  in  infants  or  children  with  acquired  heart- 
disease,  the  embolus  being  derived  from  vegetations  on  the  mitral  or  aortic 
valves,  or  from  thrombi  that  have  formed  in  backwaters  of  the  dilated  left 
auricle  or  ventricle.  These  infantile  hemiplegias  or  diplegias  are  of  sudden 
onset,  and  are  characteristically  spastic.  Athetotic  movements,  with  or  without 
choreiform  contractions,  trophic  lesions,  and  tremors,  are  common  in  the  affected 
limbs  ;  the  children  often  grow  up  to  exhibit  mental  defect,  imperfect  speech, 
or  epilepsy.  As  a  rule,  the  face  is  less  involved  than  the  arm  or  leg,  and  the 
athetotic  movements,  confined  to  the  affected  parts,  may  not  be  developed  until 
years  after  the  occurrence  of  the  original  cerebral  lesion. 

Post-hemiplegic  athetosis,  which  cannot  be  sharply  marked  off  from  post- 
hemiplegic chorea  (see  p.  157),  is  an  uncommon  sequela  of  hemiplegia  in  the 
adult ;  but  common — being  seen  in  about  a  third  of  the  cases — in  the  congenital 
and  acquired  hemiplegias  just  considered.  In  the  adult,  it  occurs  oftenest  when 
the  lesion  is  situated  near  the  posterior  part  of  the  internal  capsule  or  the  optic 
thalamus.  These  athetotic  movements  of  the  extremities  have  been  described 
already  ;  in  the  adult,  they  may  be  combined  with  choreiform  contractions 
involving  the  whole  arm  and  shoulder,  and  the  face.  The  diagnosis  should  not 
be  difficult,  as  the  history  of  a  stroke  will  be  obtained  and  the  physical  signs  of  a 
hemiplegia  will  be  present. 

Choreiform    Contractions. 

These  are  similar  to  the  contractions  seen  in  chorea.  They  are  involuntary 
and  inco-ordinated  movements,  purposive  in  character,  but  aimless  and 
ineffective    in    performance.       They    are    jerky,   rapid,    and    highly    irregular  • 


156  CONTRACTIONS 


groups  of  muscles  are  successively  put  into  action,  as  if  the  original  intention 
were  given  up,  or  changed,  as  soon  as  the  complex  movement  began.  They  may 
affect  one  side  of  the  body  only,  or  both. 

When  mild,  choreiform  movements  amount  to  no  more  than  excessive 
fidgetiness,  involving  perhaps  only  the  hands  and  arms,  or  the  hands,  arms,  and 
face,  in  ^vriggling  and  grimacing.  When  severe,  they  give  the  patient  no  rest ; 
he  is  tossed  about,  perhaps  with  the  utmost  violence,  by  combined  but  irregular 
contractions  in  which  any  of  the  voluntary  muscles  may  participate.  Choreiform 
contractions  bear  no  resemblance  to  tremors,  whether  coarse  or  fine.  From 
intention-tremors  they  are  distinguished  by  the  facts  that  they  continue  when 
the  patient  is  at  rest,  that  they  are  purposive,  and  resemble  ordinary  voluntary 
movements  misapplied.  From  ataxia  they  are  distinguished  by  occurring  at 
rest  as  well  as  on  attempted  movement ;  the  muscular  contractions  of  ataxia 
are  merely  inco-ordinated,  apparently  ill-designed  and  clumsily  executed,  types 
of  normal  movements. 

Choreiform  contractions  are  seen  in  the  following  conditions  : — 

Chorea,  chorea  minor,  acute  chorea,  or  St.  Vitus's  dance 

Chronic  degenerative  or  Huntington's  chorea 

Chorea  major  or  pandemic  chorea 

Hysteria 

Pre-hemiplegic  chorea 

Post-hemiplegic  chorea 

Congenital  and  acquired  spastic  paralyses  of  infants 

Cortical   sclerosis 

Chorea  electrica  (Henoch). 
Chorea,  chorea  minor,  acute  chorea,  or  5^.  Vitus's  dance,  is  an  acute  disease  of 
childhood  or  adolescence,  commoner  in  girls  than  boys,  and  closely  connected  with 
a  history  or  a  family  history  of  rheumatism,  and  with  rheumatic  endocarditis. 
It  may  also  occur  in  adults  in  connection  with  pregnancy,  when  it  is  sometimes 
of  a  severe  type  and  may  run  on  into  insanity.  The  movements  may  be  confined 
to  one  side  of  the  body — hemichorea — or  may  affect  both  sides  ;  the  muscles 
are,  in  general,  weak,  speech  may  be  interfered  with,  respiration  is  often  jerky, 
and  the  patient  is  often  unduly  irritable  and  emotional.  Except  in  the  severest 
cases  of  chorea,  the  movements  cease  during  sleep  ;  the  disease  tends  to  recovery 
in  the  course  of  perhaps  two  or  three  months. 

Mild  cases  of  chorea,  in  which  the  face  is  most  affected,  may  present  a  certain 
resemblance  to  the  more  chronic  and  quite  unconnected  disorder  known  as 
habit-spasm,  habit-chorea,  or  convulsive  tic  (see  Spasmodic  Contractions,  p  159). 
A  facial  tic  is  controlled  for  a  time  by  strong  efforts  of  the  will,  whereas  the 
facial  movements  of  chorea  will  usually  be  increased  by  the  concentration  of 
the  attention  on  them  ;  the  facial  movements  of  chorea  are  irregular,  representing 
a  succession  of  various  purposive  but  uncompleted  actions,  while  the  facial  tic 
consists  in  the  repetition  of  a  single  definite  and  purposive  movement  originally 
designed,  no  doubt,  to  give  relief  to  some  local  irritation. 

Chronic,  degenerative,  or  Huntington's  chorea  is  a  rare  hereditary  disease 
coming  on  at  the  age  of  thirty  or  forty,  associated  with  slow  and  difficult 
speech  and  with  insanity.  The  involuntary  movements  are  slower  and  more 
ataxic  than  those  of  acute  chorea,  and  can  often  be  suppressed  for  a  time  by 
exercise  of  the  will.  They  affect  the  extremities  and  face,  are  continuous,  cease 
during  sleep,  and  are  accentuated  by  excitement,  so  that  at  first  sight  acute 
chorea  may  be  imitated  fairly  closely.  The  diagnosis  between  this  chronic 
chorea  and  an  acute  chorea  that  had  become  chronic,  as  sometimes  happens, 
would  turn  on  the  family  history,  mental  symptoms,  age  at  onset,  and  the 
course  of  the  disease.     Chronic  chorea  is  incurable,  and  may  take  twenty  years 


CONTRACTIONS  157 


or  more  to  run  its  course  ;  mental  failure  occurs  early,  and  is  progressive ; 
and  a  family  history  of  chronic  chorea  can  always  be  obtained. 

Chorea  major,  or  pandemic  chorea,  is  an  epidemic  hysterical  manifestation 
occurring  in  the  more  emotional  races  of  Europe  under  the  influence  of  religious 
excitement.  Choreiform  movements  are  among  the  less  conspicuous  of  its  motor 
phenomena,  and  it  need  not  be  considered  further,  for  it  is  unknown  to  the  more 
phlegmatic  Northern  races. 

In  hysteria  the  motor  phenomena  are  notoriously  protean.  Should  a  hysterical 
patient  have  had  chorea  herself,  or  should  she  have  had  the  opportunity  of 
observing  it  in  others,  she  may  reproduce  its  characteristic  movements  with  the 
greatest  accuracy.  The  diagnosis  here  may  be  very  difficult  for  a  time,  particu- 
larly if  the  patient's  previous  history  be  not  known,  and  hysteria  not  suspected. 
The  hysterical  patient's  temperament  will  probably  lead  her  to  develop  other 
signs  or  symptoms  that  will  suggest  the  true  diagnosis  in  these  cases  ;  such  as 
tremors,  paralyses,  contractures,  hemi-anssthesia,  anaesthesia  of  the  stocking 
and  glove  distribution,  exaggeration  of  the  deep  reflexes,  or  attacks  of  hysterics. 
Remission  of  the  choreiform  movements  and  of  the  local  symptoms  generally 
may  occur  when  the  hysterical  patient  thinks  she  is  no  longer  under  observation, 
or  when  her  attention  is  diverted  elsewhere.  In  a  word,  the  hysterical  patient 
simulating  chorea  or  hemichorea,  is  likely  to  overdo  the  part. 

Choreiform  movements  may  occur  in  connection  with  hemiplegia  in  two 
forms.  Pre-hemiplegic  chorea  has  been  recorded  in  a  few  cases,  twitchings  or 
even  choreiform  movements  being  initiated  in  the  limbs  of  one  side  of  the  body 
shortly  before  the  onset  of  an  apoplectic  stroke.  Post-hemiplegic  chorea  is 
commoner,  and  is  more  often  seen  in  children  than  in  adults.  After  a  hemiplegia, 
more  or  less  muscular  spasm  and  movements  of  one  kind  or  another  are  habitually 
seen  on  the  affected  side  of  the  body.  In  many  patients  these  movements  take 
the  form  of  tremors,  flne  or  coarse  ;  in  others  they  are  athetotic  ;  in  others  again 
they  are  ataxic,  occurring  only  when  voluntary  movements  are  attempted  ;  and 
in  yet  others  they  are  choreiform.  Which  of  these  forms  of  muscular  contraction 
is  likely  to  occur  in  any  given  case  it  is  impossible  to  say  ;  they  are  all  due  to 
combinations  of  cerebral  irritation,  muscular  spasm,  and  muscular  paralysis, 
mixed  together  in  varying  proportions. 

The  choreiform  movements  occurring  in  the  spastic  paraplegias  of  infants 
and  children,  conditions  that  have  been  more  vaguely  described  as  cortical 
scleroses  on  the  strength  of  their  post-mortem  appearances,  are  to  be  regarded  as 
variants  of  the  athetotic  contractions  already  considered  above.  Henoch's 
chorea  electrica  is  considered  below  :  it  is  the  muscles  of  the  neck  and  shoulder 
that  are  chiefly  involved  in  this  rare  disorder. 

Fibrillar    Contractions. 

Fibrillar  contractions  of  the  muscles,  or  fascicular  muscular  twitchings,  are 
small  spontaneous  contractions  visible  on  the  surfaces  of  muscles,  rhythmical 
or  irregular,  involving  not  the  whole  muscle,  but  only  single  muscular  bundles 
in  it.  They  may  be  confined  to  a  few  of  the  bundles,  or  may  occur  irregularly 
in  any  of  the  bundles  composing  a  muscle.  They  are  almost  always  too  small 
and  feeble  to  produce  any  visible  movements  at  the  joints.  These  muscular 
flickerings  are  increased  in  fatigue,  and  when  the  muscle  is  mechanically 
stimulated.  Similar,  but  coarser,  twitchings  may  be  seen  in  normal  muscles 
when  they  are  over-fatigued,  or  on  exposure  to  cold. 

The  finest  fibrillar  contractions  are  said  to  occur  only  in  cases  of  organic 
disease  in  the  central  nervous  system.  They  are  seen  most  freely  in  muscles 
that  are  degenerating  or  undergoing  atrophy,  or  are  shortly  about  to  atrophy, 
as  the  result  of  disease  in  the  lower  motor  neuron  ;    they  cease  to  appear  when 


158  CONTRACTIONS 


the  muscle  is  much  wasted.  They  are  most  evident  in  the  extremities  and 
tongue,  and  no  doubt  are  due  to  irritation  of  motor  nerve-cells  in  the  cord  or 
bulb  that  are  hyper-excitable  because  they  are  degenerating. 

From  a  diagnostic  point  of  view,  fibrillar  contractions  are  important,  because 
for  practical  purposes  they  do  not  occur  in  the  myopathies  or  primary  muscular 
dystrophies  that  are  due  to  lesions  in  the  muscles  themselves  and  not  in  the 
spinal  cord.  In  only  a  few  recorded  cases  have  these  fibrillations  been  seen  in 
cases  of  myopathy  where  lesion  of  the  central  nervous  system  could  be  excluded. 
Neurologists  and  myologists  have  devoted  much  attention  to  primitive  myopathy, 
with  the  result  that  it  has  become  burdened  with  a  highly  elaborate  classification 
and  nomenclature.     Thus  the  condition  generally  has  been  described  as — 

Primary   progressive   myopathy 

Progressive   muscular  dystrophy   (Erb) 

Idiopathic  muscular  atrophy  and  hypertrophy 

Primitive  progressive  myopathy 

Muscular  dystrophy 

Myopathy. 
Special  forms  of  it  have  been  raised  to  the  dignity  of  "  types,"  the  chief  of 
which  are  the — 

Simple  atrophic  (Erb) 

Pseudo-hypertrophic 

Juvenile  (Erb) 

Facio-scapulo-humeral  (Landouzy  and  Dejerine) 

Distal   (Gowers) 

Myotonia  atrophica 

Mixed  and  transitional 

(Leyden   and  Moebius) 
(Zimmerlin). 
Distinctions  between  these  various  forms  must  be  sought  in  special  manuals. 
Their  importance  for  present  purposes  consists  in  this — that  fibrillary  contractions 
may  occur  as  a  rare  exception  in  most  of  them. 

Contrariwise,  fibrillar  contractions  are  habitually  observed  in  the  course  of 
the  progressive  muscular  atrophies  of  neuropathic  origin,  variously  known  under 
such  names  as — 

Chronic  anterior  poliomyelitis 

Amyotrophic  lateral  sclerosis  (Charcot) 

Progressive  bulbar  paralysis 

Progressive  muscular  atrophy 

Toxic  degeneration  of  the  lower  motor  neuron 

Werdnig-Hoffmann  progressive  muscular  atrophy  of  infants, 
according  to  their  special  characters.  In  all  of  these,  the  lower  motor  neurons 
are  primarily  at  fault,  exhibiting  slow  or  rapid  degeneration  ;  in  many  cases 
the  upper  motor  neurons  are  also  affected,  either  simultaneously,  or  before  or 
after  the  lower.  As  a  rule,  no  cause  for  the  degeneration  can  be  discovered  ; 
but  many — perhaps  a  half — of  the  patients  have  previously  had  acute  polio- 
myelitis. Occurring  in  infants  or  children,  this  neuropathic  muscular  atrophy 
is  generally  of  the  Werdnig-Hoffmann  type,  affecting  the  legs  first,  and  spreading 
upwards  to  the  body  and  arms  ;  the  hands  and  feet  are  affected  late,  and  the 
deep  reflexes  vanish.  The  condition  may  at  first  sight  resemble  rickets,  but  in 
rickets  there  is  no  real  muscular  atrophy,  the  deep  reflexes  are  retained,  and 
fibrillar  contractions  do  not  occur.  It  may  be  indistinguishable  from  one  of  the 
primary  myopathies  considered  above  ;  but  the  occurrence  of  fibrillar  contrac- 
tions would  make  the  diagnosis  of  neuropathic  muscular  atrophy  the  more 
probable. 


CONTRACTIONS  159 


In  adults  the  disease  may  conform  to  one  of  several  types,  according  to  the 
distribution  of  the  atrophy.  In  some  instances,  the  lower  motor  neurons  of 
the  hand,  arm,  and  neck  are  attacked,  when  the  Claw-hand  {q.v.)  may  result  ; 
in  others,  the  lower  extremities  may  first  show  the  degeneration.  Charcot's 
amyotrophic  lateral  sclerosis  is  characterized  by  spasticity  of  the  legs  combined 
with  atrophy  of  the  muscles  of  the  hands  and  arms.  In  making  the  diagnosis 
of  neuropathic  muscular  atrophy,  it  must  be  remembered  that  the  onset  is 
gradual,  that  fibrillar  conti-actions  are  present,  that  the  atrophy  proceeds  pari 
passu  with  the  loss  of  power,  and  that  sensation  and  the  sphincters  are  not 
involved.  The  electrical  changes  in  the  muscles  are  of  assistance,  too,  the 
partial  Reaction  of  Degeneration  [q.v.)  being  exhibited  ;  the  nerves  react 
normally  to  faradism,  and  to  galvanism  so  long  as  there  are  muscle  fibres  left  to 
respond  to  the  stimulation,  while  the  muscles  react  sluggishly,  and  A.C.C  is  often 
greater  than  K.C.C. 

Bulbar  paralysis  is  due  to  lesions  of  the  medulla  oblongata,  and  the  nerves 
mainly  affected  are  the  motor  part  of  the  fifth,  the  seventh  (facial),  the  eleventh 
(spinal  accessory)  and  twelfth  (hypoglossal).  In  other  cases,  ophthalmoplegia 
is  observed  as  well.  It  is  only  in  the  chronic  cases  of  bulbar  paralysis  that 
fibrillar  contractions  are  seen,  and  they  are  particularly  well  shown  in  the  tongue, 
which  has  been  described  as  looking  "  like  a  bag  half  full  of  worms."  The  main 
symptoms  will  be  difficulty  in  articulation,  phonation,  mastication,  and,  most 
of  all,  in  swallowing. 

Spasmodic    Contractions. 

In  general  parlance,  the  epithet  "  spasmodic  "  implies  suddenness  and  short 
duration.  These  characteristics  are  not  implied  by  the  word  as  it  is  used 
clinically.  Hence  it  is  necessarj^  to  distinguish  between  spasmodic  contractions 
or  muscular  spasms  of  three  kinds,  according  as  they  are  : — (i)  Short  and 
single — the  muscular  twitch  ;  (2)  Short  and  repeated — clonus  or  clonic  spasms  ; 
(3)  Tetanic — commonly  and  improperly  known  as  tonic  spasms  ;  these  are 
long-sustained. 

I.  Single  Spasmodic  Contractions  of  a  muscle  or  group  of  muscles,  over  in 
a  fraction  of  a  second,  may  occur  in  normal  persons  who  are  suffering  from  great 
fatigue,  overwork,  or  nervous  exhaustion.  For  no  apparent  reason,  and  fre- 
quently just  as  the  person  is  going  off  to  sleep,  a  sudden  violent  twitch  in  one 
or  more  of  the  limbs  occurs,  and  wakes  him  up.  In  other  cases  these  sudden 
starts  may  occur  when  the  patient  is  resting  by  day.  In  abnormally  nervous 
or  excitable  patients  such  sudden  spasms  are  more  frequently  seen,  and  often 
result  from  some  sudden  and  unexpected  sensory  impression — a  sound,  sight, 
or  touch.  The  diagnosis  of  such  spasms  in  nervous  or  jumpy  patients  should 
not  be  difficult,  the  affection  being  very  chronic,  and  no  doubt  familiar  to  the 
patient  and  the  patient's  entourage.  Coming  on  suddenly,  this  jumpiness  may 
be  a  minor  sign  of  various  nervous  disorders,  such  as  hysteria,  acute  chorea, 
delirium  tremens,  general  paralysis.  Graves'  disease,  and  so  forth. 

Single  twitches  of  muscles  or  of  groups  of  muscles,  form  the  outstanding 
featm-e  of  the  simpler  forms  of  a  series  of  affections  known  as  habit  spasms  or 
spasmodic  tics.  A  habit  spasm  consists  in  the  involuntary  repetition  of  some 
ordinary  co-ordinated  purposive  act.  In  many  instances,  the  tic  was  at  first 
a  natural  reflex  act,  designed  to  allay  some  transient  irritation.  Thus  a  blinking 
tic  may  have  been  initiated  by  the  pain  caused  by  a  foreign  body  in  the  eye,  or 
conjunctivitis  ;  a  sniffing  tic  by  some  temporary  itching  about  the  nares  ;  a 
shoulder-shrugging  tic  by  some  irritation  of  the  neck  due  to  a  tight  or  rough 
collar.  By  voluntary  repetition  such  an  act  ultimately  becomes  automatic, 
when  it  is  spoken  of  as  a  habit  spasm  or  tic.     These  motor  tics  exist  in  great 


i6o  CONTRACTIONS 


variety,  oftenest  affecting  the  face,  less  often  the  jaws,  neck,  or  limbs  ;  they  are 
so  common  as  to  escape  comment  in  their  minor  manifestations — mannerisms 
and  stereotyped  acts — being  set  down  merely  to  "  individualit5^"  Most  tics 
can  be  controlled  by  mental  effort  with  some  distress,  are  increased  by  emotion, 
cease  during  sleep,  and  are  curable  only  with  great  difficulty  when  well  established. 
In  all  cases,  the  patient  is  supposed  to  exhibit  a  certain  psychical  weakness. 

More  violent  and  shock-like  muscular  spasms  are  seen  in  the  rare  condition 
known  as  myoclonus  or  paramyoclonus  multiplex.  Mj^oclonic  movements  are 
particularly  sudden  and  violent,  occurring  bilaterally,  or  first  on  one  side  of 
the  body  and  then  on  the  other  ;  they  are  painless,  but  may  give  rise  to  much 
inconvenience  by  their  violence.  They  are  increased  by  eraotion  and  cease 
during  sleep.  They  may  be  single,  but  more  often  are  clonic,  repeated  perhaps 
fifty  or  a  hundred  times  in  a  minute.  In  paramyoclonus  multiplex  there  are 
no  mental,  sensory,  or  sphincter  changes.  In  hysteria,  myoclonus  is  excep- 
tionally seen,  and  is  accompanied  by  other  hysterical  manifestations.  In 
certain  rare  forms  of  epilepsy,  the  so-called  myoclonic  epilepsy,  these  parox^^smal 
asynchronous  bilateral  lightning-like  movements  have  been  recorded  ;  the 
diagnosis  will  be  easy  here,  as  the  patient  exhibits  the  phenomena  of  major 
epilepsy — loss  of  consciousness,  relaxation  of  the  sphincters,  etc. — in  addition 
to  the  sudden  and  forcible   mj^oclonic  movements. 

In  certain  cases  of  minor  epilepsy  or  petit  mal,  the  affection  may  take  the 
form  of  spasmodic  twitches  of  the  muscles  of  a  limb,  or  of  the  face. 

2.  Clonic  Spasmodic  Contractions,  clonic  spasms,  or  clonus,  are  in  realitj^ 
interrupted  tetanic  contractions,  consisting  in  the  rhythmical  and  more  or  less 
rapid  repetitions  of  the  single  brief  muscular  spasm  or  twitch.  A  typical  clonus 
of  muscles  in  the  arms  or  legs  may  often  be  produced  in  health  by  the  adoption 
and  maintenance  of  some  strained  position.  Thus  ankle-clonus  is  soon  produced 
if  a  normal  person  sits  in  a  chair  and  strains  the  heels  up  while  the  toes  are  held 
pressing  on  the  floor.  Such  clonus  is  physiological,  being  due  to  heightening  of 
the  muscle  tone  or  normal  state  of  tonic  muscular  contraction  by  the  application 
of  mechanical  tension  to  the  calf  muscles. 

Pathologically,  clonic  spasms  are  typically  seen  in  the  second  or  clonic  stage 
of  major  epilepsy,  where  they  succeed  the  initial  tetanic  (or  tonic)  stage.  Here 
they  are  universal  and  bilateral  as  a  rule,  although  one  side  of  the  bodj'  may  be 
more  involved  than  the  other,  or  the  arms  more  than  the  legs.  Consciousness 
is  lost,  and  the  sphincters  are  often  relaxed  in  the  second  stage  of  epilepsy  ;  very 
similar  convulsive  seizures  may  be  met  with  in  patients  with  chronic  nephritis 
[urcBmic  convulsions)  and  in  pregnant  women  (eclampsia).  The  clonic  stage  of 
epilepsy  may  be  imitated  unconsciously  by  patients  with  hysteria,  or  frankly 
mimicked  by  the  malingerer.  In  hysteria  the  onset  of  the  fit  is  gradual,  not 
sudden  ;  consciousness  is  impaired,  not  lost ;  the  pupil  reacts  to  light,  and  is 
not  immobile  as  in  epilepsy  ;  screaming  and  purposive  movements  occur 
throughout,  and  the  fit  is  often  protracted  ;  the  sphincters  are  not  relaxed,  and 
the  tongue  is  not  bitten.  The  malingerer  is  red  and  heated  by  the  effort  of 
producing  the  clonic  spasms,  his  consciousness  is  fully  preserved,  and  he  reacts 
at  once  to  the  application  of  painful  stimuli  that  leave  the  epileptic  unmoved. 
Both  the  hysterical  patient  and  the  malingerer  show  quivering  of  the  ej'elids, 
and  are  likely  to  resist  attempts  to  open  the  eyes. 

Mild  and  limited  clonic  spasms  of  a  few  muscular  groups,  without  loss  of 
consciousness  and  lasting  for  only  a  few  seconds,  may  be  seen  in  patients  with 
major  epilepsy,  and  are  often  described  by  them  as  "warnings."  Such  attacks 
are  identical  with  those  of  minor  epilepsy.  In  certain  patients  they  seem  to  be 
to  some  extent  under  control,  so  that  their  threatened  onset  can  be  prevented 
if  the  patient  can  sit  or  lie  down,  for  e.xample,  or  can  press  on  or  con.strict  the 


CONTRACTIONS  i6i 


limb  in  which,  the  spasms  are  about  to  appear.  The  diagnosis  of  hystero- 
epilepsy  is  sometimes  made  in  these  patients  ;  but  the  term  is  not  a  good  one, 
and  is  often  misleading. 

In  Jacksonian  epilepsy,  clonic  convulsions  occur  without  loss  of  consciousness  ; 
they  are  usually  unilateral,  starting  in  some  given  muscle  and  spreading  thence 
until  both  limbs  or  half  the  body  are  convulsed.  Transient  paresis  from 
exhaustion  may  be  noted  afterwards  in  the  affected  muscles.  In  severe  or  long- 
established  cases  the  whole  body  may  be  convulsed,  or  a  tetanic  stage  may  occur 
after  the  clonus  ;  in  these  instances  consciousness  may  be  lost.  Jacksonian  or 
focal  epilepsy  may  result  from  any  form  of  local  irritation  of  the  motor  cortex — 
trauma,  haemorrhage,  new  growth,  the  effects  of  syphilis,  chronic  inflammation. 
It  leads  in  the  long  run  to  paresis  and  atrophy  of  the  affected  muscles. 

As  the  names  imply,  myoclonus  and  paramyoclonus  multiplex  exhibit  tj^ical 
clonic  contractions.  The  clonus  occurs  in  single  muscles  or  muscle-groups, 
such  as  the  biceps  and  supinator  longus,  the  quadriceps  femoris  and  semi- 
tendinosus  ;  rarely  in  the  face  :  up  to  loo  contractions  a  minute  may  occur. 
Henoch's  chorea  electrica  is  the  same  as  myoclonus.  It  is  said  that  animals  from 
which  the  parath^Toid  glands  have  been  removed  may  exhibit  identical  spasms. 
For  the  diagnosis  of  myoclonus,  see  above.  Clonic  spasms  of  the  neck-muscles, 
particularly  the  sternomastoids,  are  common  in  torticollis  or  wry-neck. 

3.  Tetanic  Contractions,  tetanic  or  the  so-called  tonic  spasms.  Physio- 
logists and  clinicians  both  make  use  of  the  tAvo  terms  "  tetanic  "  and  "  tonic," 
but  unfortunately  employ  them  in  different  senses.  Physiological  "  tetanus  " 
is  the  apparently  steady  state  of  muscular  contraction  exhibited  by  the  voluntary 
muscle  at  work,  maintained  by  the  fusion  of  separate  muscular  twitches  or 
spasms  due  to  a  rapid  succession  of  nervous  (or  other  similar)  stimuli.  It  may 
be  seen  in  a  single  muscle  or  in  many  together.  Clinically,  however,  "  tetanus  " 
or  "  tetanic  contractions  "  have  come  to  be  associated  with  pain,  besides  being 
of  some  dviration,  and  the  terms  are  used  only  when  a  large  number  of  muscles 
are  simultaneously  involved  ;  tetanus  of  a  single  muscle  is  referred  to  clinically 
as  a  cramp  (q-V.).  To  the  physiologist,  the  normal  resting  muscle  is  already  in 
a  state  of  "  tonic  contraction,"  and  exhibits  "  tonus."  This  muscle-tone  is 
maintained  partly  by  local  or  peripheral  stimulation  (mechanical  tension,  the 
venosity  of  the  blood,  drugs  such  as  digitalis  or  veratria)  ;  and  partly  by  nervous 
impulses  that  reach  the  muscles  more  or  less  continuously  from  the  motor  neurons 
of  the  central  nervous  system.  This  central  element  of  muscular  tonus  is  really 
of  reflex  origin  and  due  to  posture,  the  maintenance  of  the  erect  attitude  ;  the 
motor  impulses  descending  in  answer  to  ascending  impulses  received  by  the 
central  nervous  system  from  the  muscles  and  joints  concerned.  But  the  clinician 
applies  the  terms  "  tonus  "  and  "  tonic  contractions  "  to  the  severe  and 
pathological  muscular  contractions  seen,  for  example,  in  the  iirst  stage  of  major 
epilepsy,  which  are  physiologically  and  scientifically  speaking  tetanic,  not  tonic. 
This  clinical  misuse  of  the  word  "  tonic  "  is,  of  course,  well  established  and  time- 
honoured,  but  only  serves  to  promote  confusion.  The  terms  "  tonic  spasm  " 
and  "  tonic  contraction  "  should  be  reserved  for  states  of  muscle-tone  that  are 
raised  only  within  physiological  limits,  and  are  not  pathological.  The  contrac- 
tions or  spasms  that  the  clinician  calls  "  tonic  "  are  almost  always  pathological, 
and  in  the  interests  of  uniformity  should  be  described  as  "  tetanic,"  not  "  tonic." 
Exaggerated  states  of  physiological  tone  and  the  milder  degrees  of  pathologically 
heightened  muscular  tonicity  are  described  clinically  as  spastic  states  or 
spasticity,  falling  short  of  tetanus  in  degree,  and  differing  from  both  tetanus 
and    cramp   by  being  painless.     They    are    detailed    under   the    heading    CoN- 

TR.\CTURES    {q.'O.). 

Tj'pical  tetanic  (or  tonic)  spasms  are  seen  in  tetanus.     Here  the  patient  has 


i62  CONTRACTIONS 


become  infected  by  Bacillus  tetani  {Plate  XII,  Fig.  T),  through  some  known  or 
unknown  wound.  He  first  notices  stiffness  of  the  neck  and  jaws;  soon,  increasing 
tetanic  spasm  of  the  muscles  of  mastication  brings  on  trismus  or  lockjaw.  Spasm 
of  the  facial  muscles  next  brings  on  the  painful  grin  known  as  the  nsMS  sardonicus, 
and  presently  paroxysmal  tetanic  spasms  of  great  violence  occur  in  practically  all 
the  voluntary  muscles.  If  the  spasms  are  strongest  in  the  extensors  of  the  back, 
the  body  is  arched  backwards  till,  perhaps,  the  heels  touch  the  head  (opistho- 
tonus). If  the  flexors  contract  most  powerfully,  the  body  is  bent  forwards 
(emprostho tonus) ;  in  some  cases  the  body  remains  straight  and  stiff  (orthotonus) 
when  the  flexors  and  extensors  are  balanced.  These  acutely  painful  paroxysms 
last  for  perhaps  a  few  seconds,  and  recur  at  varying  intervals  on  any  kind  of 
stimulation  ;  they  may  cause  death  by  asphyxia  or  heart-failure.  In  the 
intervals  between  these  severe  paroxysms,  a  milder  but  still  painful  tetanic  (the 
so-called  tonic)  contraction  of  the  muscles  is  maintained  ;  or,  in  milder  cases, 
nothing  more  than  an  exaggerated  physiological  muscle-tone  may  be  observed 
between  whiles.  In  mild  or  chronic  cases  of  tetanus,  the  signs  and  symptoms 
■will  be  far  less  severe  than  those  described  above  ;  but  trismus  and  painful 
muscular  contractions  will  still  occur.  In  some  chronic  cases,  the  chief  sign  may 
be  a  recurring  but  transient  risus  sardonicus,  perhaps  with  some  stiffness  of  the 
neck  ;  not  a  few  of  these  patients  have  been  treated  for  habit-spasm  or  hysterical 
grimacing  for  a  time,  until  the  suspicion  of  tetanus  arose,  or  spread  of  the  tetanic 
spasms  to  the  trunk-muscles  made  the  diagnosis  more  obvious.  The  diagnosis 
of  tetanus  may  have  to  be  made  in  other  instances  from  impacted  wisdom  tooth 
or  from  muscular  rheumatism,  which  may  cause  stiff-neck  but  is  hardly  likely 
to  set  up  trismus  ;  or  from  spinal  meningitis,  in  which  there  is  fever,  while  the 
tetanic  spasms  occur  on  exertion,  and  do  not  primarily  affect  the  muscles  of  the 
jaws,  and  great  pain  is  felt  on  moving  the  head  and  neck. 

The  spasms  of  tetanus  must  be  distinguished  from  those  of  strychnine  poisoning. 
In  this,  trismus  is  absent  or  occurs  very  late,  the  extremities  are  first  and  most 
markedly  affected,  the  muscles  are  quite  relaxed  between  the  paroxysms,  and 
the  symptoms  develop  rapidly — within  an  hour  or  two  of  the  administration  of 
the  drug.  In  tetany  the  distribution  and  duration  of  the  tetanic  contrac- 
tions should  suffice  to  prevent  any  confusion  with  tetanus.  In  hydrophobia 
there  should  be  a  history  of  a  bite  by  some  animal,  most  often  a  dog  ;  mental 
symptoms  are  prominent,  and  the  spasms  affect  the  muscles  of  respiration  and 
deglutition  most,  while  trismus  is  absent.  In  hysteria  a  patient  may  exhibit 
trismus,  tetanic  spasms,  and  opisthotonus  ;  but  no  true  picture  of  tetanus 
will  be  presented,  and  no  doubt  abundant  evidences  of  hysteria  will  be  found 
on  examination  of  the  patient,  or  will  develop  if  the  case  be  kept  under 
observation.  •  a.  J.  J  ex-Blake. 

CONTRACTURES — are  lasting  bodily  deformities  resulting  from  a  great 
variety  of  causes.  For  clinical  purposes  they  may  be  roughly  divided  into  two 
classes,  according  as  they  are  (i)  Active,  or  (2)  Passive.  The  division  between 
the  two  is  not  sharp,  as  active  contractures  when  long  established  tend  to 
become  passive. 

I.   Active  Contractures  :   resulting: — • 

(a).   From  lesions  of  the  upper  motor  neuron  : 

Cortical  lesions  Subacute  combined  degeneration 

Hemiplegia  Lateral  sclerosis 

Friedreich's  ataxia  Spastic  ataxia 

Myelitis  Spastic  paraplegia 
Transverse  lesions  of  the  cord 


CONTRACTURES  163 


{b).  F/om  lesions  of  the  lower  motor  neuron  : 
Acute    poliomyelitis  Neuritis 

Chronic  poliomj-elitis  Trauma  of  nerves 

Progressive  muscular  atrophy 

(c).  From  disuse  : 

Hysteria  Torticollis 

2.  Passive  Contractures  :   seen  in  : — 

Late  stages  of  the  active  contractures 

Local  organic  diseases  of  the  bones,  joints,  muscles,  fasciae,  etc. 

I.  Active  or  Spastic  Contractures. — In  these,  certain  groups  of  muscles  are 
thrown  into  a  permanent  state  of  contraction,  or  else  the  balance  of  power 
between  antagonistic  sets  of  muscles  is  upset.  In  either  case  bodil}^  deformity 
(iiexion,  extension,  curvature)  results  ;  but  the  deformity  can  be  redressed 
temporarily  either  by  steadily  maintained  mechanical  traction,  or  by  the  forcible 
electrical  stimulation  of  the  weaker  set  of  the  antagonistic  muscles  involved. 
In  passive  contractures,  on  the  other  hand,  no  amount  of  electrical  or  other 
stimulation  avails  to  correct  the  deformity,  nor  can  the  application  of  force 
without  rupture  of  the  tissues. 

Active  contractures  must  be  distinguished  from  certain  other  forms  of  muscular 
contractions,  particularly  cramps  and  tetanic  (or  so-called  tonic)  contractions 
or  spasms  of  the  voluntary  muscles.  Cramps  may  resemble  contractures 
by  their  relatively  long  duration  ;  thus  the  cramps  of  tetany  have  been  known 
to  persist  for  days  and  even  weeks.  But  pain  is  a  constant  feature  of  cramp, 
whereas  it  has  no  connection  at  all  with  contractures  per  se.  Tetanic  contractions 
of  muscles  (see  Contractions) — commonly  called  tonic  by  the  misuse  of  a  word 
that  already  has  a  definite  and  different  physiological  meaning — resemble  cramps 
by  being  painful,  and  differ  from  them  only  by  being  more  generalized.  The 
normal  resting  muscle  is,  physiologically  speaking,  in  a  constant  state  of  tonic 
contraction,  and  exhibits  a  certain  reflex  tone  or  tonus  (muscle-tone)  due  to  the 
combined  action  of  two  factors,  one  local  and  one  nervous.  The  local  or 
peripheral  component  is  inherent  in  the  muscle-tissue,  and  may  be  increased 
by  such  influences  as  mechanical  tension  of  the  muscle-fibres,  augmented  venosity 
of  the  blood,  the  action  of  drugs  like  digitalis  or  veratria.  The  nervous  or  central 
factor  consists  of  efferent  nerv'ous  impulses  from  the  motor  neurons,  sent  down 
no  doubt  in  response  to  afferent  impulses  coming  up  from  the  muscles  and  joints, 
and  determined  largely  in  man  by  the  habitual  maintenance  of  the  erect  posture. 
Any  muscular  spasm,  rigidity,  or  spasticit}^  set  up  by  increase  of  this  normal 
tone  within  physiological  limits,  may  properly  be  referred  to  as  a  condition 
of  tonic  contraction.  But  when  a  spasticity  is  pathological,  as  are  all  the 
"  tonic  contractions  "  of  the  clinician,  it  should  no  longer  be  referred  to  as  a 
state  of  tonic  contraction,  especially  as  it  corresponds  satisfactorily  with  the 
physiological  "  tetanic  contraction  "or  "  tetanus."  A  typical  pathological 
spasticity  or  active  contracture  is  seen  in  Sherrington's  "  decerebrate  rigidity," 
the  extensor  spasm  observed  in  the  limbs  of  the  cat  or  rabbit  after  removal 
of  the  cerebral  hemispheres  and  basal  ganglia.  This  rigidity  lasts  for  several 
days,  and  is  due  to  the  removal  of  the  inhibitory  impulses  normally  reaching 
the  cord  from  the  cortex  and  thalamus.  A  similar  rigidity,  though,  of  course, 
with  a  different  distribution,  is  seen  in  such  disorders  as  hemiplegia,  cortical 
losses,  lateral  sclerosis,  Friedreich's  ataxia,  subacute  combined  degeneration, 
and  transverse  lesions  of  the  cord. 

The  active  contractures  following  hemiplegia  or  cortical  lesions  in  the  motor 
area  are  confined  to  the  affected  side  of  the  body,  and  should  not  be  difficult  to 
diagnose.     Gowers   described   three   varieties  of  rigidity   after   hemiplegia,    but 


164  CONTRACTURES 


only  the  last  of  these  is  usually  described  as  a  contracture  :  (i)  Initial  rigidity, 
present  at  the  outset  and  lasting  only  for  a  few  hours  ;  (2)  Early  rigidity, 
beginning  within  a  few  days  of  the  stroke  and  lasting  for  a  week  or  a  few  weeks, 
possibly  due  to  the  irritation  of  blood-clot  at  the  site  of  the  cerebral  lesion  ; 
(3)  Late  rigidity  or  contracture,  first  appearing  several  weeks  or  months  after 
the  stroke,  and  due  to  the  fact  that  while  all  the  muscles  are  spastic,  certain 
groups  of  them  are  stronger  than  their  antagonists.  Thus  the  thumb  is  flexed 
and  pressed  into  the  palm  ;  the  fingers  are  clenched  ;  the  wrist  and  elbow  are 
flexed,  the  forearm  is  pronated,  and  the  arm  is  adducted.  The  thigh  is  adducted, 
the  knee  extended ;  the  heel  is  drawn  up,  the  foot  inverted,  and  a  characteristic 
spastic  gait  results.  The  deep  reflexes  are  increased  on  the  hemiplegic  side, 
where,  too,  ankle-clonus  and  Babinski's  extensor  reflex  can  be  obtained.  The 
lapse  of  years  converts  these  active  contractures  into  passive,  as  has  been  noted 
already,  in  consequence  of  structural  changes  in  the  muscles  and  fasciae,  and 
in  the  joints. 

Contractures  are  highly  characteristic  of  the  congenital  and  the  acquired 
cerebral  diplegias  or  hemiplegias  due  to  cortical  lesions,  cortical  sclerosis,  or 
porencephalus  (see  Contractions,  Athetotic).  The  patients  show  bilateral 
spastic  paralysis  ;  one  side  is  sometimes  more  severely  affected  than  the  other. 
If  the  legs  only  are  affected,  the  condition  is  known  as  Little's  disease,  and  the 
gait  is  "  cross-legged  "  or  "  scissor,"  the  feet  being  pointed  and  inverted,  and  the 
thighs  adducted.  Kyphosis  is  often  seen,  and  the  arms,  if  involved,  are  held 
in  the  position  of  a  hemiplegic  arm  (see  above).  In  the  acquired  cases  the 
spastic  paresis  is  oftener  unilateral  than  bilateral  ;  the  nutrition  of  the  affected 
limb  suffers  conspicuously,  and  its  growth  is  retarded  and  incomplete. 

In  Friedreich' s  disease,  a  familial  disorder  beginning  usually  between  the  ages  of 
seven  and  seventeen,  and  seen  oftenest  in  males,  characterized  by  ataxia,  inten- 
tion-tremor, nystagmus,  and  hesitating  or  syllabic  speech,  active  contracture  sets 
up  scoliosis  or  scoliokyphosis,  pes  varus  or  equino-varus,  and  "main  bote" — an 
analogous  deformity  of  the  hand  with  hyperextension  of  the  terminal  phalanges. 
These  contractures  are  partly  due  to  muscular  atrophy,  partly  (in  the  case  of 
the  foot)  to  overuse  of  certain  muscles  in  attempts  at  equilibration  ;  the  heel 
is  drawn  up,  the  dorsum  of  the  foot  arched,  the  sole  hollowed  out,  the  toes  flexed 
at  the  interphalangeal  joints  and  hyperextended  at  the  metatarsophalangeal  ; 
hypertrophy  of  the  prominent  extensor  longus  hallucis  has  been  found. 

In  subacute  combined  degeneration,  in  which  may  be  included  lateral 
sclerosis  if  the  degeneration  mainly  affects  the  upper  motor  neurons,  there  wfll 
be  contractures.  The  earliest  symptoms  are  connected  with  sensation  ;  but  the 
patient,  usually  an  anaemic  adult  in  the  second  half  of  life,  presently  develops 
spasticity  in  his  legs.  The  limbs  tend  to  draw  up  as  he  lies  in  bed,  from  flexor 
spasm  ;  the  gait  becomes  spastic,  and  walking  is  soon  impossible — the  condition 
becoming  one  of  spastic  paraplegia.  The  deep  reflexes  are  increased,  and 
Babinski's  sign  is  present  ;  segmental  areas  of  anaesthesia  can  be  made  out,  and 
control  over  the  sphincters  is  weakened.  After  some  months,  this  spastic  stage 
gives  place  to  flaccidity,  control  over  the  sphincters  is  lost,  and  the  patient 
rapidly  runs  down  hill.  In  cases  of  transverse  myelitis  or  transverse  lesions  of 
the  cord,  spasticity  with  increased  deep  reflexes,  loss  of  sensation,  and  loss  of 
control  over  the  sphincters  is  the  rule.  The  diagnosis  is  facilitated  by  the  fact 
that  no  symptoms  occur  in  parts  of  the  body  innervated  from  above  the  cord 
lesion  ;  at  the  level  of  the  lesion  there  is  evidence  of  nerve-irritation  (girdle 
pain,  hyperaesthesia) .  In  these  cases  the  flexors  of  the  leg  overpower  the 
extensors  ;  the  limbs  draw  themselves  up  again,  sooner  or  later,  as  often  as  they 
are  extended  for  the  patient. 

So  far,  the  active  contractures  considered  have  all  been  due  to  lesions  of  the 


CONTRACTURES  165 


upper  motor  neuron.  A  second  class  contains  those  resulting  from  lesions 
of  the  lower  motor  neuron  and  the  subsequent  muscular  atrophy.  These 
conti'actures  arise  either  from  the  unbalanced  action  of  the  muscles  that  normally 
antagonize  those  that  have  atrophied,  or  from  late  shrinkage  of  the  paralyzed 
muscles  themselves  ;  and  a  spinal  curvature  may  come  on  from  the  adoption 
of  some  posture  that  facilitates  locomotion  or  the  occupations  of  life  when  the 
spinal  muscles  are  intact. 

Acute  and  chronic  poliomyelitis,  neuritis,  and  lesions  of  the  nerves  have 
to  be  discussed  in  this  connection.  Acute  poliomyelitis,  or  infantile  paralysis, 
begins  suddenly  with  malaise,  pains,  and  an  acute  febrile  attack  ;  the  flaccid 
paralysis  appears  early,  and  contractures  begin  to  show  themselves  within 
a  few  months,  as  a  rule.  The  limbs  are  most  involved,  isolated  muscles 
or  groups  of  muscles  being  paralyzed  ;  and  it  should  be  noted  that  the 
parah^sis  is  distributed  in  accordance  with  the  nuclear  grouping  of  the 
muscles  in  the  anterior  cornual  regions  of  the  cord.  Sensation  is  affected  only 
in  the  rarest  instances.  If  many  muscles  in  a  limb  are  paralyzed,  its  growth 
is  much  impaired.  Contractures  are  common  in  chronic  poliomyelitis  and 
the  various  forms  of  progressive  muscular  atrophy  of  neuropathic  origin  (see 
Contractions,  Fibrillar),  the  hands  and  feet  being  mainly  involved,  with 
the  production  of  various  forms  of  club-foot  and  claw-hand.  All  the  muscles 
are  involved  together,  and  there  is  no  selection  of  certain  groups  for  paralysis 
as  is  the  case  in  acute  poliomyelitis.  In  addition,  fibrillar  contractions  can  be 
seen  in  the  degenerating  muscles,  provided  that  they  are  not  too  thickly  covered 
with  subcutaneous  tissue.  The  onset  is  insidious,  and  the  disease  occurs  most 
often  in  middle  age  ;  the  commonest  type  is  that  in  which  the  hands  are  first 
and  most  involved,  but  in  other  cases  the  legs,  and  in  others  the  upper  arm  and 
shoulder,  first  give  evidence  of  the  disease.  Contractures  are  seen  occasionally 
in  alcoholic  neuritis  of  the  motor  type,  and  more  frequently  in  arsenical  neuritis, 
talipes  equinovarus  or  flexor  contracture  of  the  wrist,  with  excessive  muscular 
hypersesthesia,  being  noted  ;  such  deformities  are  rare  in  other  forms  of  neuritis, 
such  as  those  due  to  lead,  diabetes,  influenza,  diphtheria,  etc.  For  example, 
secondary  contracture  of  the  muscles  on  the  affected  side  in  Bell's  facial  paralysis 
may  occur,  and  gives  rise  to  the  impression  that  the  sound  side  of  the  face  is 
paralyzed  while  the  face  is  at  rest,  for  the  face  as  a  whole  is  pulled  over  to  the 
affected  side  :  on  voluntary  movement,  however,  the  healthy  side  will  be  found 
to  move  normally,  while  the  paralyzed  side  remains  comparatively  still. 
Contractures  usually  follow  severe  trauma  of  nerves,  unless  satisfactory  healing 
of  the  wound  and  regeneration  of  the  nerve-trunks  take  place. 

Active  contractures  from  disuse  may  occur  in  otherwise  healthy  subjects  who 
for  any  reason  may  have  been  kept  too  long  in  one  position.  Patients  who 
have  lain  on  their  backs  in  bed  for  long  periods  may  have  a  temporary  talipes 
equinus  when  they  get  up — an  active  contracture  due  to  the  weight  of  the 
bedclothes  resting  on  the  toes  and  keeping  the  feet  extended.  Fractured  or 
injured  limbs  that  have  been  splinted  and  kept  too  long  in  one  position,  often 
exhibit  active  contractures  when  the  splints  are  removed  (e.g.,  Volkmann's 
ischaemic  contracture  of  the  forearm,  Fig.  43).  In  some  cases,  the  contracture 
is  due  to  fixation  of  the  muscles,  tendons,  or  muscle-sheaths  by  inflammatory 
products  that  have  become  organized,  in  others  to  adhesions  or  bony  deposits 
that  have  formed  themselves  in  or  about  the  joints,  while  in  others  mere  disuse, 
without  inflammatory  changes,  may  be  supposed  to  underlie  these  contractures  : 
all  of  these  would  be  avoided  by  the  timely  use  of  massage  and  movement. 

Paralyses  occur  in  perhaps  25  per  cent  of  all  patients  with  hysteria,  in  two 
main  types  :  the  rarer  flaccid,  the  commoner  spastic,  and  often  marked  enough 
to  produce  active  contracture.     In  hysterical  contracture  the  affected  muscles 


1 66 


CONTRACTURES 


are  not  wasted  except  in  severe  cases  of  long  duration  ;  the  deep  reflexes  are 
increased  ;  ankle-clonus  may  be  present ;  but  Babinski's  sign  in  all  probability 
is  never  observed.  The  limbs  are  most  affected  (hemi-,  mono-,  or  paraplegia), 
less  often  the  muscles  of  the  face,  e^-elids,  lips,  or  tongue.  Certain  attitudes 
are-lhighlj'  characteristic  of  hysterical  spastic  paralyses  ;  the  elbows,  ^msts, 
and  fingers  are  kept  flexed,  the  arms  are  adducted  ;  the  hip  and  knee  are  extended, 
and  the  foot  is  held  in  a  position  of  talipes  equinovarus ;  ptosis  mav  be  seen,  from 

spasm  of  the  orbicularis ;  torticollis  from 
contracture  of  the  sternomastoid.  In  the 
less  severe  cases,  the  stiffness  and  paresis 
are  neither  complete  nor  marked  enough 
for  the  condition  to  be  referred  to  as  a 
contracture.  In  all  instances  the  deform- 
ity produced  is  the  result  of  active  mus- 
cular spasm,  and  in  the  severe  cases  it 
cannot  be  overcome  by  exercise  of  the 
patient's  will,  galvanization,  or  by  the 
application  of  mechanical  force.  The 
contracture  often  persists  during  sleep, 
and  is  abolished  only  bj^  deep  anaesthesia 
— a  character  distinguishing  h^'sterical 
contractures  from  those  due  to  organic 
disease.  Hysterical  contractures  often  last 
for  months,  or  even  years:  and  in  cases  of 
long  standing,  muscular  atrophy  and 
structural  changes  about  the  joints  may 
establish  permanent  passive  contracture 
from  disuse.  Highly  characteristic  of 
h^'sterical  contracture  is  the  patient's  use 
of  antagonistic  muscles  to  prevent  passive 
or  active  correction  of  the  deformity  ex- 
hibited. If,  for  example,  the  arm  is  semi- 
flexed by  contractmre  of  the  biceps,  the 
triceps  can  be  felt  to  contract  and  resist 
the  movement  when  the  attempt  is  made 
to  flex  the  arm  fmrther.  A  similar  con- 
traction of  the  triceps  can  be  felt  or  seen 
if  the  patient  is  asked  to  bend  the  joint 
for  herself  ;  with  the  result  that  the  joint 
remains  unmoved,  although  all  signs  of 
great  effort  to  bend  the  arm  ma3^  be 
displayed.  Pain  and  tenderness  in  the 
contracted  muscles  are  usuall}'  found  ; 
and  other  hj^sterical  stigmata  such  as 
hemiansesthesia,  paraesthesia,  cla\Tis  or 
globus  hystericus,  and  the  hysterical 
temperament  generall}^,  will  not  be  want- 
ing. Special  forms  of  hysterical  contracture  may  give  rise  to  great  trouble  in 
diagnosis  by  imitating  definite  conditions  or  diseases.  Thus  a  painful  "  hys- 
terical hip  "  or  "  hysterical  knee  "  may  pass  on  from  surgeon  to  surgeon,  until 
one  is  found  to  operate  upon  the  normal  joint  for  tuberculous  arthritis  ;  hys- 
terical spasm  of  some  of  the  abdominal  muscles  may  lead  to  the  diagnosis  of 
pregnancy  even  in  rovalties  in  search  of  an  heir,  when  the  condition  is  one  of 
pseudocj'esis  ;    hysterical  contracture  of  muscles   in  the  neck  or  shoulder  may 


f/g-.  43. — Volkinann's  ischaemic  paralysis 
following  the  use  of  an  anterior  splint  for 
fracture  of  the  bones  of  the  forearm.  Note 
the  clenched  fingers  and  the  trophic  sore  on 
the  forefinger.  (Reproduced  by  permission 
from  a  paper  by  Mr.  R.  P.  Rowlands  in  the 
Guy's  Hospital  Gazette. ) 


CONTRACTURES  167 


be  diagnosed  as  new  growth,  the  palpable  tumour  vanishing  only  when  the 
patient  has  been  anaesthetized  and  is  on  the  operating-table  awaiting  incision. 

Torticollis,  which  may  be  regarded  as  a  functional  disease,  and  is  a  form  of 
tic,  is  characterized  in  its  later  stages  by  contracture  of  the  affected  muscles  of 
the  neck.  Its  clonic  variety  is  easy  to  diagnose  ;  but  where  the  spasms  are 
tetanic  (or  tonic)  rather  than  clonic,  the  diagnosis  must  be  made  from  such 
conditions  as  cervical  caiies,  rheumatic  myositis,  or  deep  inflammation  in  the 
glands  of  the  neck.  Congenital  torticollis  dates  from  birth,  usually  affects  the 
right  sternomastoid  muscle,  and  is  often  associated  with  facial  asymmetry — when 
it  is  perhaps  due  to  congenital  defect  of  the  centres  in  the  bulb.  The  face  is 
smaller  on  the  side  of  the  affected  sternomastoid. 

2.  Passive  Contractures  are  those  due  to  affections  of  the  bones,  joints, 
or  soft  tissues,  that  mechanically  obstruct  correction  of  the  deformities  they 
produce.  The  contracted  limbs  can  only  be  straightened  by  surgical  measures, 
or  by  manipulations  severe  enough  to  rupture  the  obstructions. 


-/■VV  44. — Dupuytren's  Contracture. 

Passive  contractures  often  result  from  long  continuance  of  the  active  con- 
tractures considered  above,  by  a  gradual  process  of  transition  :  these  will 
not  be  considered  further. 

Passive  contractures  may  result  from  the  most  varied  local  organic  diseases 
of  the  affected  parts.  Dupuytren  s  Contracture  of  the  palmar  fascia,  leading  to 
deformity  of  the  little  and  ring  fingers  [Fig.  44)  is  so  characteristic  that  it 
can  seldom  be  mistaken.  It  is  prone  to  occur  in  gouty  subjects  and  in  those 
who  use  the  palms  of  their  hands  most,  as  in  the  case  of  coachmen  and  those 
who  use  spades,  etc.  In  diseases  of  the  joints,  such  as  rheumatism,  rheumatoid 
arthritis,  spondylitis  deformans,  tuberculosis,  gonorrhoea,  etc.,  the  patient  may 
lie  in  bed  or  go  about  for  weeks  or  months  in  some  bent  or  contorted  position 
that  involves  the  minimum  of  discomfort;  ankylosis  of  the  affected  joints  often 
results,  from  the  gi'owth  of  adhesions,  ecchondroses,  or  exostoses  in  and  about 
the  edges  of  the  joints,  that  permanently  limit  their  range  of  movement.  Corres- 
ponding shortening  will  take  place  in  the  muscles  that  are  relaxed,  and  a  passive 


CONTRACTURES 


contracture  results.  The  growth  of  a  tumour  in  or  about  a  joint  may  produce 
identical  results.  Traumatic  or  inflammatory^  lesions  about  the  muscles  or  their 
tendons  may  establish  inflammatory  products  locally  that  permanently  limit  the 
movements  of  these  structures.  Large  superficial  scars  due  to  extensive  burns 
or  losses  of  skin  and  the  superficial  tissues,  being  composed  mainly  of  fibrous 
tissue,  maj"  contract,  and  so  bring  about  marked  contractures  (see  Fig.  45). 


Fig.  45. — Cicatricial 


contracture  after  a  burn.       (From  Professo 
hitroduction  to  Su}-gc?y.) 


Rutherford  Morison's 


The  diagnosis  of  the  cause  of  a  passive  contracture  will  obviously  depend  upon 
the  results  of  the  physical  examination  of  the  affected  part,  and  upon  the  success 
with  which  a  true  history  of  the  onset  and  course  of  the  case  can  be  elicited. 

A.  J.  J  ex-Blake. 

CONVULSIONS,  or  CONVULSIVE  SEIZURES,  are  paroxysms  of  involuntary 
muscular  contractions.  They  may  be  divided  into  two  classes,  according  as 
they  are  local  or  general ;  local  convulsions  have  been  considered  under  the  heading 
Contractions,  Spasmodic  {q.v.),  and  the  following  account  will  deal  mainly 
with  general  convulsions.  The  general  convulsions  without  loss  of  consciousness 
that  constitute  Rigors  are  described  under  that  heading  {q.v.)  ;  with  this 
exception,  general  convulsions  are  almost  always  accompanied  by  loss  of  con- 
sciousness, excepting  in  some  few  cases  of  partial  epilepsy  and  of  hysteria. 

In  most  cases  of  convulsions,  both  sides  of  the  body — face,  neck,  arms,  trunk, 
and  legs — are  convulsed  equally.  But  it  sometimes  happens  that  though 
their  cause  is  apparent!}^  a  general  one,  the  movements  are  unilateral  or  are 
much  more  marked  on  one  side  of  the  body  than  the  other  ;  for  present  purposes 
such  convulsions  may  still  be  termed  general.  Usually  convulsions  are  clonic, 
less  often  tetanic  or  tonic. 

"  Fits  "  may  be  defined  roughly  as  any  sudden  paroxysms  or  seizures  occurring 
in  the  course  of  any  disease.  In  common  usage,  however,  a  "  fit  "  is  a  convulsive 
fit,  or  fit  of  convulsions,  and  if  unqualified,  the  term  usually  means  an  epileptic 
fit,  but  not  always. 

Certain  clinical  features  are  common  to  almost  all  convulsive  seizures  in 
which  consciousness  is  lost.  If  the  onset  is  sudden,  as  it  usually  is,  the  patient 
is  apt  to  fall  down  and  injure  himself  unless  already  recumbent.  If  the  muscles 
of  the  mouth  and  jaws  are  involved  and  saliva  is  freely  secreted,  the  mouth 
foams  ;   if  the  tongue  or  cheeks  are  bitten,  the  foam  becomes  stained  with  blood. 


CONVULSIONS 


169 


Clenching  of  the  jaws  will  make  the  breathing  laboured,  stertorous,  and  ineffec- 
tual. If  the  muscles  of  respiration  are  greatly  affected,  much  cyanosis,  with 
congestion  of  the  face,  neck,  and  exposed  parts,  will  be  observed.  The  convulsive 
movements  are  typically  clonic,  limited  in  range,  purposeless,  and  accompanied 
by  more  or  less  rigidity.  If  the  rigidity  is  marked,  the  amplitude  of  the  move- 
ments will  be  correspondingly  reduced,  so  that  the  condition  may  even  become 
one  of  stiffness  and  tetanic  (or  so-called  tonic)  spasm.  It  is  characteristic  of 
epilepsy  that  the  fit  should  consist  of  a  brief  tetanic  stage  followed  by  a  longer 
stage  of  clonus.  Control  over  the  organic  reflexes  of  micturition  and  defaecation 
is  often  lost,  with  the  result  that  the  bladder  and  rectum  may  be  emptied  involun- 
tarily. As  a  rule  the  reflexes  cannot  be  obtained  while  the  convulsions  last, 
and  are  lost  or  diminished  for  some  hours  after  they  are  over,  or  are  unequal 
on  the  two  sides  of  the  body.  When  the  fit  is  over  and  the  patients  have  re- 
covered consciousness  they  often  complain  of  headache  and  lassitude,  showing 
diminished  sensibility  to  all  impressions,  mental  hebetude,  and  great  sleepiness. 
Less  often,  the  patient  becomes  excited  or  terrified  after  a  fit,  or  even  maniacal, 
and  he  may  also  exhibit  automatism  for  hours  or  even  days  ;  in  none  of  these 
conditions  will  he  be  responsible  for  his  actions.  The  duration  of  general  con- 
vulsions is  commonly  to  be  measured  in  seconds  or  minutes  ;  but  in  severe 
cases  they  may  go  on  for  hours  if  untreated,  and  in  the  status  epilepticus  may 
last  for  days  with  only  brief  intermissions.  Prolonged  convulsions  due  to  any 
cause  may  raise  the  temperature  several  degrees  ;  when  they  are  unilateral, 
the  temperature  is  raised  more  on  the  affected  side  than  on  the  other.  Albu- 
minuria after  a  fit  is  very  common,  and  may  last  for  a  day  or  two  ;  it  is  in  no 
way  evidence  that  the  fit  was  due  to  renal  disease  and  uraemic  in  character. 

The  morbid  conditions  in  which  local  or  partial  convulsions,  and  in  rarer 
instances  general  convulsions  also,  occur  without  loss  of  consciousness,  have  been 
sufficiently  considered  under  Contractions,  Spasmodic  {q.v.),  but  for  the  sake 
of  clearness  may  be  recapitulated  : — 


Fatigue 

Nervous  exhaustion 

Habit  spasm 

Spasmodic  tic 

Myoclonus 

Hysteria 


Jacksonian  epilepsy 

Chorea  electrica  (Henoch) 

Tetany 

Tetanus 

Hydrophobia 

Strychnine  poisoning 

Malingering. 

The    convulsions    commonly  accompanied    by  loss  of   consciousness    will    be 
considered  here  under  the  following  heads  : — 

I.  General  Convulsions  of  Infants  and  Children,  seen  in  : — 


Hereditary  syphilis 
Congenital  heart  disease 
Cerebral  paralysis 
Onset  of  acute  fevers 
Meningitis 


Drug  poisoning 

Enlarged  thymus 

Idiocy 

Rickets 

Epilepsy,  minor  and  major. 


2.  General  Convulsions  of  Adolescents  and  Adults,  seen  in  :- 


Epilepsy,  minor  and  major 
Jacksonian  epilepsy 
Epileptiform  convulsions — 

Uraemia 

Pregnancy 

Severe  heart  disease 

Asphyxia 

Stokes-Adams'  disease 


Cerebral  lesions  : — 

Apoplexy 

Meningitis 

Intracranial  growth 
General  paralysis 
Chronic  alcoholism 
Cerebral  syphilis 
Hysteria 
Malingerins:. 


170  CONVULSIONS 


Epilepsy,  major  and  minor 
Jacksonian  epilepsy 
Disseminated  sclerosis. 


3.  Unilateral  Convulsions,  seen  in  : — 
Apoplexy 

Intracranial  growth 
Meningitis 

I.  General  Convulsions  of  Infants  and  Children. — Among  the  commonest  of 
all  convulsive  seizures  are  those  occurring  in  children  of  tender  age,  known  as 
infantile  convulsions.  The  sexes  are  affected  equally  ;  about  a  third  of  the  cases 
take  place  during  the  first  year  of  life,  two-thirds  during  the  first  two  years  ; 
and  they  are  rare,  apart  from  epilepsy,  after  the  age  of  five  or  six.  They  are 
of  more  serious  import  in  infants  under  six  months  than  in  older  children, 
and  also  in  ansemic  and  weakly  infants.  In  hereditary  syphilis  convulsions  often 
prove  fatal  during  the  first  few  weeks  of  life.  For  the  rest,  in  about  half  the 
patients  rickets  is  the  predisposing  cause  ;  in  many  of  the  others  some  local 
irritation,  such  as  inflammation  of  the  gums  in  dentition,  diseases  of  the  nose  or 
ears,  the  presence  of  irritating  food  or  worms  in  the  intestine,  renal  or  vesical 
calculus,  or  phimosis,  can  be  found ;  while  convulsions  at  the  onset  of  acute 
infectious  diseases,  such  as  scarlet  fever,  pneumonia,  measles,  whooping-cough,  or 
during  their  course,  and  in  nephritis,  are  not  infrequent.  Overdosing  with  drugs 
— strychnine,  atropine,  santonin,  morphia,  etc. — or  with  alcohol,  may  bring  on 
convulsions.  Fright  and  over-strong  emotions  are  included  among  the  causes 
of  infantile  convulsions  ;  how  far  inheritance,  the  neurotic  or  neuropathic 
taint,  is  responsible  for  them  is  uncertain.  They  occur  in  children  with  enlarge- 
ment of  the  thymus  gland,  the  so-called  status  lymphaticus,  and  in  these  not 
infrequently  a  fit  has  a  fatal  issue.  Finally,  it  must  be  remembered  that 
in  any  child  they  may  be  early  evidence  of  epilepsy,  or  of  organic  disease  of  the 
brain.  Their  diagnosis  demands  a  very  careful  examination  of  the  child,  and 
also  of  its  diet  and  the  hygiene  of  its  daily  life.  They  may  be  due  to  congenital 
heart  disease,  when  there  will  be  enlargement  of  the  heart,  a  cardiac  murmur  or 
naurmurs,  and  some  degree  of  cyanosis.  In  children  with  organic  disease  of 
the  brain  {porencephalus,  congenital  or  acquired  cerebral  paralysis,  spastic  para- 
plegia, etc.)  there  will  be  paralysis,  spasm,  and  muscular  atrophy,  and  probably 
mental  defect.  If  the  convulsions  are  due  to  the  onset  of  some  acute  infectious 
disorder,  they  will  come  on  suddenly  in  a  child  previously  well,  and  will  be 
accompanied  by  high  fever  and  followed  by  the  characteristic  rash  ;  a  history 
of  exposure  to  infection  is  often  unobtainable.  Similar  convulsions  and  fever 
may  occur  in  meningitis,  usually  towards  the  end  of  the  disease.  They  are 
not  rare  in  whooping-cough,  particularly  in  rachitic  infants,  being  precipitated 
by  the  asphyxia  resulting  from  the  whooping,  and  not  rarely  causing  death. 
The  diagnosis  of  fits  due  to  drugs  or  alcohol,  taken  either  by  the  child,  or  by  the 
mother  if  the  child  is  being  suckled,  will  depend  upon  obtaining  an  adequate 
history  of  the  case.  In  what  way  enlargement  of  the  thymus  brings  about  con- 
vulsions is  not  known  ;  the  condition  is  fortunately  rare,  and  is  hardly  ever 
diagnosed  during  life.  The  fits  occurring  in  hydrocephalus  and  the  various 
degrees  of  mental  defect  need  only  be  mentioned. 

It  is  to  rickets  that  one  must  look  for  the  explanation  of  most  convulsions 
occurring  between  the  ages  of  three  months  and  four  or  five  years.  The  nervous 
system  is  unstable  in  all  young  children,  the  power  of  cerebral  inhibition  not 
being  acquired  for  several  years.  In  rickets  this  instability  is  much  increased, 
and  finds  expression  in  irritability,  fits  of  screaming,  restlessness,  the  inability 
to  sleep  well  at  night,  and  in  the  more  serious  troubles  of  tetany,  laryngismus 
stridulus,  and  convulsions.  Any  child  with  fits  should  be  scrutinized  for  evidence 
of  rickets — for  exaggerated  curvatures  in  the  long  bones,  the  rickety  rosary, 
a  Harrison's  sulcus  on  the  sides  of  the  chest,  the  large  and  bulging  rickety  head, 


CONVULSIONS  171 


thinness  of  the  hair  on  the  back  of  the  head  (due  to  head-rolling),  a  tumid  and 
flaccid  abdomen,  lateness  in  the  closure  of  the  anterior  fontanelle,  and  general 
muscular  debility.  Enquiry  should  be  made  for  other  symptoms  common  in 
rickets  that  will  come  under  the  observation  of  the  mother  or  nurse — tenderness 
of  the  bones  and  skull  on  handling  and  washing,  head-rolling  due  to  tenderness 
of  the  skull,  much  sweating  about  the  head  in  sleep,  broken  slumber,  proneness 
to  gastro-intestinal  upsets,  constipation  and  mucous  stools  or  constipation 
alternating  with  diarrhoea,  unusual  liability  to-  coryza  and  bronchitis  (or 
"  catching  cold  ").  The  feeding  and  hygiene  of  the  child  must  be  gone  into  : 
in  low  life,  rickets  is  mainly  due  to  deficiency  of  fat  and  protein  in  the  diet,  with 
excess  of  carbohydrate  food,  whereas  in  high  life  the  diet  is  more  likely  to  err  by 
lack  of  freshness  due  to  too  careful  sterilization  or  to  the  use  of  patent  foods  ; 
rickety  children  all  suffer  from  want  of  enough  exposure  to  fresh  air  and  sun- 
shine. But  if  rickets  is  the  main  predisposing  cause  of  infantile  convulsions, 
it  must  be  remembered  that  they  are  actually  brought  on  by  some  secondary 
exciting  cause,  such  as  a  gastro-intestinal  disturbance  with  diarrhoea  or  vomiting, 
or  reflex  irritation  of  an}-  sort.  Whether  dentition  is  in  itself  enough  to  account 
for  convulsions  is  extremel}^  doubtful,  although  that  "  teething-fits  "  do  occur  is 
one  of  the  things  that  every  woman  knows. 

Epilepsy  is  one  of  the  last  causes  of  infantile  convulsions  that  should  be 
thought  of,  except  when  the  fits  occur  for  the  first  time  in  tolerably  healthy 
children  more  than  three  or  four  years  old.  A  bad  family  historj'  of  fits  or 
of  insanit}^  in  the  parents  or  the  brothers  and  sisters  would  make  epilepsy  more 
probable  ;  so  would  the  occurrence  of  an  aura  before  the  fit,  and  the  division  of 
the  -fit  into  a  tonic  and  a  clonic  stage,  with  biting  of  the  tongue  or  cheeks.  The 
repetition  of  fits  for  which  there  is  no  local  or  general  cause,  such  as  those 
described  above,  would  be  in  favour  of  epilepsy,  particularly  if  they  extended 
over  a  long  period  of  time.  But  one  fit  undoubtedly  facilitates  the  occurrence 
of  another  soon  afterwards,  so  that  the  recurrence  of  convulsions  for  a  few  days 
or  weeks  in  a  rickety  child  is  not  enough  to  justify  the  diagnosis  of  epilepsy. 

2.  General  Convulsions  of  Adolescents  and  Adults. — The  convulsions  of  epilepsy, 
including  both  the  major  and  the  minor  forms,  are  very  variable  in  extent 
and  duration.  In  the  minor  degrees,  or  petit  nial,  there  is  usually  brief  tonic 
or  tetanic  spasm,  with  loss  of  consciousness,  but  without  clonus  or  con- 
vulsions. In  severer  cases  this  is  known  as  tetanoid  epilepsy,  a  tetanic  spasm 
convulsing  the  patient  for  some  seconds,  or  even  for  a  minute  or  two,  with  great 
risk  of  death  by  asphyxia.  In  partial  epilepsy  the  convulsions  are  confined  to 
part  of  the  body — the  face,  perhaps,  or  the  arms  and  face.  Midway  between 
minor  and  major  epilepsy  Gowers  places  '^  epilepsia  media,  in  which  there  is 
muscular  spasm  of  tonic  character,  without  the  clonic  spasm  which  follows  when 
the  tonic  spasm  is  more  severe."  In  major  epilepsy  the  typical  picture  is  as 
follows  :  after  experiencing  an  aura  or  warning  of  some  sort  for  a  few  seconds, 
the  patient  is  seized  with  a  general  tetanic  spasm,  cries  out,  and  falls  to  the 
ground,  this  tetanic  or  tonic  stage  lasting  for  from  five  to  thirty  seconds.  This 
then  gives  place  to  the  clonic  stage,  or  convulsions,  with  foaming  at  the  mouth, 
and  clonic  jactitations  that  are  often  unequal  on  the  two  sides  of  the  body. 
After  a  few  minutes  the  clonus  dies  away  and  the  patient  is  left  comatose  or 
stupefied,  with  a  headache  that  is  slept  off  in  the  course  of  the  next  few  hours. 
Consciousness  is  always  lost  in  true  epilepsy  ;  the  extent  and  duration  of  the 
convulsions,  however,  are  highly  variable.  The  fits  of  Jacksonian  epilepsy 
are  rarely  generalized  ;  the  condition  is  considered  below.  In  true  epilepsy  there 
is  no  known  organic  lesion  of  the  brain  ;  the  loss  of  consciousness  and  the 
convulsions  are  due  to  some  unknown  functional  disturbance  of  its  action.  But 
apparently  identical  fits  may  occur  in  the  course  of  a  number  of  diseases  in 


172  CONVULSIONS 


which  organic  lesions  are  present,  either  in  the  brain  or  elsewhere,  and  to  these 
the  name  epileptiform  convulsions  is  given.  They  are  seen  most  often  in  urcBmia, 
in  which  the  kidneys  are  severely  diseased  and  toxaemia  results  ;  the  patient 
exhibits  the  characteristic  picture  of  advanced  renal  disease,  with  headache, 
high  blood-pressure,  hypertrophied  heart,  albuminuria,  probably  retinal 
changes,  and  anaemia.  It  must  not  be  forgotten  that  transient  albuminuria 
is  commonly  present  after  fits  due  to  any  cause  whatever.  In  the  intervals 
between  uraemic  convulsions  the  patient  may  remain  unconscious. 

The  convulsions  occurring  in  connection  with  pregnancy  are  known  as  eclamptic 
Ms,  the  condition  as  eclampsia.  The  majority  of  such  convulsions  come  on 
before  labour,  some  during  labour,  and  15  or  20  per  cent  during  the  first  week 
after  parturition  ;  any  fits  occurring  after  this  are  probably  due  to  some  cause 
— -uraemia,  for  example — other  than  pregnancjr  or  parturition.  In  many  cases 
the  fits  occur  suddenly  and  without  any  warning,  or  after  no  more  than  a  brief 
period  of  headache  or  restlessness,  or  after  vomiting.  Eclampsia  appears  to  be 
an  auto-intoxication  accompanied  by  a  profound  disturbance  of  the  protein 
metabolism  ;  its  primary  cause  is  to  be  sought  in  the  placenta,  and  it  is  brought 
about  by  the  increased  activity  of  the  placental  and  other  proteolytic  enzymes. 
Its  diagnosis  can  rarely  be  a  matter  of  difficulty.  There  is  nearly  always 
albuminuria,  and  some  observers  regard  puerperal  eclampsia  as  one  variety  of 
uraemia. 

EpileptiforiTi  convulsions  may  occur  in  severe  heart  or  lung  disease,  and, 
indeed,  in  the  terminal  stages  of  many  disorders,  due  in  part  to  asphyxia,  in 
part  to  toxaemia.  Like  certain  obstinate  infantile  convulsions,  they  may  often 
be  stopped  by  the  administration  of  oxygen  to  breathe. 

In  Stokes-Adams'  disease,  epileptiform  or  apoplectiform  convulsive  seizures 
occur  from  time  to  time,  no  doubt  due  to  the  asphyxia  and  cerebral  anaemia 
resulting  from  temporary  cessation  of  the  heart's  action.  The  pulse  is  habitually 
slow  in  this  disorder,  beating  about  thirty  times  to  the  minute  ;  the  cardiac 
auricles,  on  the  other  hand,  beat  at  the  normal  rate.  The  patients  are  usually 
arteriosclerotic  people  in  the  second  half  of  life  ;  if  they  are  seen  in  their  con- 
vulsions, the  diagnosis  of  apoplexy  will  probably  be  made,  only  to  be  corrected 
later  when  it  is  found  that  the  attack  leaves  no  paralysis  or  paresis  behind  it, 
that  similar  seizures  have  occurred  before,  and  that  the  pulse  is  slow. 

General  convulsions  due  to  direct  irritation  or  to  disease  of  the  brain  may 
occur  in  a  large  number  of  cerebral  lesions,  whether  these  are  unilateral  or  bilateral, 
though,  of  course,  most  commonly  in  the  latter  case.  In  most  of  these  there 
will  be  other  well-marked  signs  or  symptoms  of  disease,  especially  optic  neuritis,- 
that  should  suffice  to  clear  up  the  diagnosis.  Such  convulsions  may  be  seen  in 
meningeal,  subdural,  or  arachnoid  hcBmorrhage  ;  in  meningitis  due  to  the  B. 
tuberculosis,  Weichselbaum's  meningococcus,  or  other  microbes  ;  in  cerebritis, 
or  inflammation  of  the  brain  ;  in  congenital  anomalies  of  the  brain  such  as 
porencephalus,  hydrocephalus,  and  the  abnormalities  met  with  in  idiots  and 
mentally  defective  children  generally ;  and  in  cerebral  or  cerebellar  abscess, 
tumour,  or  aneurysm,  when  sufficient  growth  has  taken  place  to  raise  the  intra- 
cranial pressure  generally.  In  another  group  may  be  placed  those  cases  in 
which  extensive  degenerative  changes  have  taken  place  in  the  brain  ;  fits  are 
common  in  the  second  and  third  stages  of  general  paralysis  of  the  insane,  when 
other  signs,  such  as  defective  memory  and  judgment,  grandiose  ideas,  inequality 
or  reflex  immobility  of  the  pupils,  blurred  speech,  tremors  of  the  tongue  and 
face,  loss  or  exaggeration  of  the  deep  reflexes,  and  muscular  weakness  may  be 
looked  for  ;  in  the  insanity  of  chronic  alcoholism,  with  its  tremors  and  inco- 
ordination, its  marked  sensory  perversions,  and  its  paramnesia  or  illusions  of 
memory  ;     and  in  cerebral  syphilis,  where  the  lesions  may  be  either  vascular, 


CONVULSIONS  173 


gummatous,  meningeal,  diffuse,  or  a  combination  of  any  or  all  of  these,  and  the 
main  sjmiptoms  are  headache,  insomnia,  attacks  of  aphasia  and  hemiplegic  or 
epileptifonn  convulsions,  paralysis  of  cranial  nerves,  and  in  addition  dementia 
in  the  diffuse  cases.  Chronic  plumbism  may  produce  cerebral  symptoms  of 
the  most  varied  kind  {saturnine  encephalopathy) ,  from  simple  headache  to  acute 
mania,  and  amongst  the  phenomena,  convulsions  of  epileptiform  type  may  be 
prominent.  The  diagnosis  is  based  upon  the  history,  the  occupation,  the  other 
symptoms  of  lead  poisoning,  and  perhaps  upon  analysis  of  the  urine. 

Lastly  must  be  mentioned  the  general  convulsions  of  the  hysterical  and  of 
malingerers.  In  hysteria,  the  fits  are  noisy  and  protracted  performances,  the 
movements  are  more  or  less  purposive  and  quite  unlike  clonus  ;  the  patient 
becomes  red  in  the  face  rather  than  blue  or  white  ;  consciousness  is  not  lost, 
attempts  to  open  the  eyes  are  resisted,  pressure  into  the  supra-orbital  notch 
causes  withdrawal  of  the  head,  the  sufferer's  hand  is  withdrawn  if  pressure  is 
made  between  a  nail  and  its  matrix  ;  the  sphincters  are  not  relaxed,  and  the 
tongue  or  cheeks  are  rarely  bitten.  The  convulsions  are  brought  on  by  some 
emotional  upset,  and  tend  to  cease  when  unsympathetically  received.  The 
malingerer  may  display  no  little  art  and  skill  in  his  convulsions,  which  are 
modelled  on  those  of  epilepsy  ;  here  again,  the  sufferer  is  red  in  the  face  rather 
than  blue,  although  he  may  breathe  stertorously,  and,  with  the  help  of  a  little 
soap,  foam  at  the  mouth  ;  consciousness  is  not  lost,  the  corneal  reflex  is  present, 
the  head  and  hand  are  withdrawn  from  painful  impressions  ;  the  sphincters 
are  not  relaxed  ;  perspiration  is  usual  ;  it  is  said  that  in  epilepsy,  if  the  hands 
are  clenched,  the  thumb  is  buried  in  the  palm,  whereas  the  malingerer  clenches 
it  outside  the  fingers  ;  and  on  the  detection  of  its  character,  the  simulated  fit 
ends  as  suddenly  as  it  began. 

3.  Unilateral  Convulsions.  —  The  convulsions  in  apoplexy  are  habitually 
limited  to  one  side  of  the  body.  The  onset  of  apoplexy,  more  often  gradual 
than  sudden,  is  generally  preceded  by  headache,  dizziness,  and  tingling  or  weak- 
ness in  some  part  of  the  body  ;  and  it  is  more  marked  in  cerebral  haemorrhage 
than  in  embolism  or  thrombosis.  The  loss  of  consciousness  comes  on  earlier 
and  persists  longer  in  cerebral  haemorrhage  than  in  the  other  two  conditions  ; 
in  all  cases  where  it  occurs — 50  to  75  per  cent — it  is  brought  about  by  cerebral 
anaemia.  When  the  convulsions  are  prominent  the  case  is  described  as  one  of 
epileptiform  apoplexy.  The  diagnosis  of  apoplexy  is  discussed  under  Coma 
[q.v.)  ;  it  is  sufficient  to  say  that  cerebral  hcBmorrhage  is  commoner  in  middle- 
life,  in  persons  with  high  blood-pressure  and  hypertrophied  hearts,  and  in  the 
subjects  of  arteriosclerosis  ;  cerebral  embolism  is  associated  with  endocarditis 
or  intracardiac  thrombosis,  and  occurs  oftenest  in  young  patients  with  heart- 
disease  ;  cerebral  thrombosis  is  seen  in  syphilitic  patients,  and  in  those  with 
vascular  disease,  and  is  characteristically  of  slow  onset  after  premonitory 
warnings. 

In  cerebral  abscess  and  cerebral  tumour  convulsions  are  not  very  common, 
and  usually  appear  only  after  the  diagnosis  has  been  made  clear  by  the  occurrence 
of  such  cardinal  symptoms  as  headache,  vomiting  on  change  of  position,  optic 
neuritis  (choked  disc),  and  localizing  signs  pointing  to  intracranial  tumour. 
But  it  may  happen  that  an  epileptiform  fit  with  unilateral  or  bilateral  convul- 
sions is  the  first  sign  that  anything  is  wrong,  or  at  any  rate  maj^  be  the  first 
thing  that  makes  the  patient  consult  a  medical  man.  The  headache  that  follows 
a  convulsive  seizure  is  likely  to  be  very  severe  and  prolonged  if  the  fit  is  due  to 
intracranial  new  growth  or  abscess,  and  vomiting  and  choked  disc  will  probably 
be  observed,  with  localizing  signs.  Of  the  two,  cerebral  abscess  is  the  more 
likely  in  patients  with  chronic  suppurative  disease  of  the  ear  or  nose,  or  of  the 
facial  and  frontal  sinuses.     Meningitis — especially  tuberculous   meningitis  in  its 


174  CONVULSIONS 


later  stages — often  exhibits  unilateral  or  bilateral  convulsions  ;  squint  and 
other  local  paralyses,  more  or  less  coma  or  mental  apathy,  gastro-intestinal 
symptoms,  Cheyne-Stokes  breathing,  and  irregularity  of  the  pulse  and  tem- 
perature, are  likely  to  be  noted  in  these  cases. 

The  unilateral  convulsions  of  J acksonian  epilepsy  are  rarely  difficult  to  diagnose. 
The  patient  usually  gives  a  history  of  head  injury,  and  often  a  cranial  scar  or 
irregularity  is  to  be  found.  There  is  no  loss  of  consciousness  during  the  attack, 
except  in  very  severe  and  inveterate  cases  ;  usually  only  one  limb  is  involved, 
and  an  aura  of  some  sort  usually  precedes  the  convulsions,  which  exhibit  a 
characteristic  "  spread  " — ^beginning  in  a  single  muscle  or  group  of  muscles, 
and  spreading  thence  to  the  muscles  whose  cortical  areas  of  representation 
adjoin  that  of  the  muscle  first  involved.  In  Jacksonian  epilepsy  there  is 
almost  always  an  irritative  lesion  of  the  motor  cortex  or  its  immediate  vicinity, 
due  to  trauma,  syphilitic  meningitis,  or  new  growth  ;  paresis  or  paralysis  of 
the  affected  muscles  follows  the  convulsions,  and  in  the  course  of  time  becomes 
marked.  The  "  spread  "  is  frequently  characteristic  ;  if  the  face  is  involved 
first,  the  arm  follows,  and  then  the  leg  ;  if  the  hand  is  attacked  first,  the  con- 
vulsions spread  up  the  arm,  then  to  the  face,  last  to  the  leg.  In  the  severer 
cases,  where  the  whole  side  of  the  patient  is  convulsed,  consciousness  is  lost, 
and  then  the  convulsions  may  become  bilateral. 

It  is  not  often  that  unilateral  convulsions  occur  in  epilepsy  or  infantile  con- 
vulsions, or  epileptiform  convulsions,  and  when  they  do  there  is  a  danger  lest 
the  diagnosis  of  apoplexy  or  some  focal  organic  lesion  of  the  brain  be  made. 
There  is  nothing  in  the  character  or  distribution  of  the  convulsions  in  these 
cases  that  enables  a  diagnosis  to  be  made,  and  it  is  only  after  they  are  over,  and 
when  it  is  found  that  no  evidence  of  organic  cerebral  mischief  is  left  behind,  that 
their  functional  nature  can  be  established.  They  are  not  followed  by  any 
permanent  paresis,  paralysis,  or  atrophy  of  the  muscles  on  the  affected  side. 
It  must  be  remembered  that  unilateral  convulsions,  the  so-called  "  apoplecti- 
form "  convulsions,  may  occur  exceptionally  in  a  number  of  the  conditions 
detailed  under  Group  2. 

In  disseminated  sclerosis,  hemiplegic  apoplectiform  attacks  like  those  seen  in 
general  paralysis  are  not  rare,  often  accompanied  by  aphasia.  These  attacks 
are  both  transient  and  recurrent.  The  patients  are  likely  to  exhibit  other 
evidences  of  disseminated  sclerosis — a  childish  and  optimistic  mental  attitude, 
optic  atrophy,  nystagmus,  impaired  articulation,  intention  tremor,  undue 
muscular  fatigability  ;  the  deep  reflexes  are  commonly  increased,  Babinski's 
extensor  plantar  reflex  is  present,  sensation  is  but  little  affected,  and  control 
over  the  sphincters  is  rarely  lost  until  late  in  the  disease.  A.  J.  J  ex-Blake. 

CORYZA.— (See  Discharge,  Nasal.) 

COUGH. — Cough  is  a  signal  that  something  is  irritating  a  branch  of  the  vagus 
nerve  or  the  cough  centre,  and  is,  in  fact,  nature's  effort — often  ill  directed — to 
remove  that  something.  Hence,  to  diagnose  the  cause  of  a  cough  it  is  necessary 
to  know  the  branches  of  the  vagus  ;    they  are  as  follows  : — 

1.  A  small  meningeal  branch,  of  no  interest  as  causing  cough,  though  it  may 
possibly  account  for  vomiting  in  meningitis. 

2.  Arnold's  branch  to  the  ear — a  cause  of  cough,  though  a  rare  one,  due  to 
affections  (wax,  eczema,  etc.)  of  the  external  ear. 

3.  Pharyngeal  branch — a  frequent  source  of  cough. 

4.  Superior  laryngeal  branch — sensory  to  base  of  tongue,  larynx,  etc.,  the 
most  frequent  source  of  cough,  with  or  without  visible  changes. 

5.  Inferior  laryngeal  branch — motor  for  action  of  coughing,  not  a  cause  of 
cough,  but  of  inefficiency  and  other  peculiarities  in  the  act  of  coughing. 


COUGH  175 

6.  Cardiac  branches — indirect  causes  through  circulatory  failure. 

7.  Pulmonary  branches — concerned  in  the  cough  of  gross  pulmonary  or 
pleural  diseases. 

S  and  9.  (Esophageal  and  pericardial  branches — possible  but  most  rare  causes. 
10.  Gastric  branches — occasionally  dyspepsia  causes  a  cough. 
The  irritants  to  which  the  surfaces  of  the  distribution  of  these  nerves  are 
exposed  may  be  classified  into  : — 

1.  Foreign  bodies,, e.g.,  dust,  food,  tobacco  smoke,  etc. 

2.  Excess  of  natural  secretion. 

3.  Pressure  and  inflammation. 

4.  Acute  or  chronic  simple  debility  or  increased  irritability,  e.g.,  after 
influenza,  etc. 

In  dealing  with  the  treatment,  there  is  no  better  division  of  coughs  than  into 
those  which  are  helpful  and  those  which  are  not,  and  the  same  division  is  most 
useful  in  arriving  at  a  diagnosis  of  the  cause  of  a  cough,  for  if  the  cough 
succeeds  in  its  object — the  removal  of  the  offending  material — we  can  see,  or 
at  least  enquire  about,  its  nature,  and  this  will  at  once  give  a  strong  clue  to 
the  locality  of  the  irritable  point,  and  very  possibly  also  to  the  morbid  process 
going  on.  Hence  the  first  questions  to  ask  a  patient  with  a  cough  are  :  "  Do 
you  bring  anything  up  ?  "     "  What  do  you  bring  up  ?  " 

Cough  without  Expectoration. — If  the  answer  to  the  first  question  be,  "  No, 
the  cough  is  just  a  troublesome  dry  cough  with  no  expectoration  at  all,"  we  at 
once  begin  to  think  of  some  of  the  purely  reflex  coughs  produced  by  an  irritant 
which  the  cough  itself  is  powerless  to  remove,  and  though  we  may  very  often 
make  a  short  cut  to  a  diagnosis  by  other  means  of  investigation,  or  observation 
of  the  general  condition,  the  following  routine  should  be  followed  if  no  prominent 
clue  offers  itself : — 

1.  Examine  the  external  ear  for  wax,  eczema,  etc.,  although  this  is  a  com- 
paratively rare  cause  of  cough,  except  in  the  special  experience  of  aurists.  - 

2.  Enquire  whether  any  ordinary  irritant,  such  as  tobacco  smoke,  etc.,  brings 
it  on  ;  this,  of  course,  at  once  raises  the  suspicion  that  the  nasopharynx  or 
larynx  is  unduly  sensitive,  and  should  lead  to  a  careful  examination  of  the 
region,  whereupon  a  cause  may  be  detected  directly,  such  as  chronic  inflammation 
of  any  sort,  or  a  long  pendulous  uvula,  somewhat  oedematous,  or  showing  other 
signs  of  acute  inflammation.  Conditions  of  undue  irritability  without  anything 
to  see  occur  after  influenza  or  whooping-cough,  and  indeed  remain  long  after  the 
acute  trouble  has  passed  away  from  the  regions  ;  therefore  enquiry  must  be 
made  for  some  such  illness.  Such  a  cough  is  often  seen  when  convalescents  go 
into  a  cold  bedroom,  or  get  into  cold  sheets  at  night. 

3.  Ask  the  patient  to  cough  voluntarily  ;  the  curious  barking  or  rough  cough 
of  laryngitis  and  of  pressure  on  the  trachea  from  aneurysm  or  growth,  also  the 
very  striking  cough  of  paralysis  of  the  vocal  cords,  at  once  betray  themselves. 

4.  Examine  the  chest  carefully  for  heart  disease  or  early  phthisis  ;  the  cough 
of  both  these  conditions  is  commonly  dry  ;  so  too  is  the  cough  of  the  early 
hours  of  an  oncoming  bronchitis  or  pneumonia,  but  these  can  scarcely  fail  to 
give  other  indications. 

5.  If  no  cause  reveals  itself  by  now,  the  stomach  must  be  thought  of,  and  its 
functional  and  physical  conditions  enquired  into  and  examined,  and  only  after 
negative  results  from  all  these  enquiries  and  procedures  may  we  think  of  a 
simple  hysterical  cough. 

Cough  with  Expectoration. — Expectoration  generally  makes  the  task  of  dia- 
gnosis much  easier,  and  from  the  simple  inspection  of  a  spittoon  it  is  frequently 
possible  to  make  an  almost  complete  diagnosis  of  a  case  :  the  very  sticky 
sputum  of   any  acute    inflammation   in  its  early  stages,   the   rusty  sputum  of 


176  COUGH 

pneumonia,  the  stink  of  abscess  or  gangrene  of  the  lung  and  of  bronchiectasis, 
the  nummulation  of  phthisical  sputa,  the  frothy  sputum  of  bronchitis,  are  very 
commonly  quite  typical  and  unmistakeable.  Small  blood-clots  make  us 
apprehensive  of  early — but  well-marked — phthisis,  or  of  pharyngeal  conditions  ; 
streaks  of  blood  point  to  acute  laryngitis  or  bronchitis  ;  profuse  haemoptysis 
almost  diagnoses  acute  phthisis  in  the  absence  of  signs  of  an  aneurysm  or  growth. 
Pus  is  a  factor  common  to  all  inflammations  of  mucous  membranes,  and  there- 
fore in  itself  is  of  but  little  diagnostic  value,  though  its  quantity,  colour,  and 
odour  may  be  very  suggestive  of  abscess  or  excavation,  or  of  an  hepatic  abscess 
ruptured  into  the  lung,  of  gangrene,  or  stinking  empyema.  With  hepatic  abscess 
the  sputum  sometimes  has  an  almost  pathognomonic  anchovy-sauce  appearance. 

In  any  case  of  cough  with  sputum  it  is  wise  to  have  a  microscopical  examination 
of  the  latter,  particularly  for  tubercle  bacilli. 

The  Age  of  the  Patient. — In  babies  and  quite  young  children  most  of  the  more 
unusual  causes  of  cough  can  be  at  once  excluded  on  the  mere  fact  of  age,  but 
the  presence  of  a  foreign  body  in  the  larynx  is  one  of  the  unusual  ones  to  be 
remembered,  especially  if  the  cough  has  come  on  suddenly  in  the  midst  of  health. 
Bronchitis,  bronchopneumonia,  tubercle,  pneumonia,  whooping-  cough,  and 
diphtheria,  are  far  and  away  the  most  common  causes  in  these  young  subjects, 
and  owing  to  the  absence  of  expectoration  they  do  not  reveal  their  presence 
without  careful  examination  of  the  chest  and  throat.  From  infancy  to  middle 
life,  the  age  of  the  patient,  gives  but  little  assistance  in  determining  the  dia- 
gnosis ;  but  about  middle  age  chronic  bronchial  troubles,  quiet  pleurisies, 
growths,  aneurysms,  etc.,  become  increasingly  obtrusive,  giving  rise  to  a 
persistent  cough,  and  only  careful  routine  examination  of  the  chest  will  reveal 
their  presence.  An  enlarged  caseous  gland  may  be  thought  of  in  youth,  but  I 
doubt  if  it  can  ever  be  diagnosed  certainly. 

How  long  have  you  had  the  cough  ?  Much  information  may  be  derived  from 
the  answer  to  this  question,  for  a  cough  that  has  only  lasted  a  few  days,  but 
in  that  time  has  become  sufhciently  severe  to  cause  the  patient  to  seek  advice, 
is  practically  certain  to  belong  to  the  group  caused  by  acute  trouble,  easily 
detectable  when  the  chest  is  carefully  examined  ;  whereas,  on  the  contrary,  a 
cough  that  has  lasted  some  months,  and  yet  seems  to  the  patient  uncertain  in 
its  causation,  is  very  likely  to  be  due  to  some  of  the  obscurer  conditions,  pressures 
of  aneurysms  or  glands,  etc.,  which  need  care  to  discover.  The  Rontgen  rays 
are  of  considerable  value  in  detecting  thoracic  aneurysms  and  new  growths,  and 
they  are  also  of  service  in  demonstrating  phthisical  and  other  lesions  in  many 
cases  ;  skiagraphic  evidence  must  never  be  relied  upon  by  itself,  however  ;  it 
should  always  be  interpreted  in  terms  of  the  other  clinical  data  and  physical  signs. 

When  does  the  cough  come  on  ?  A  cough  in  the  morning  only,  is  suggestive  of 
bronchial  catarrh  with  slight  accumulation  of  secretion  during  sleep.  A  cough 
on  getting  into  bed  suggests  laryngeal  irritability  or  a  long  pendulous  uvula  ; 
but  one  that  wakes  the  patient  after  he  has  gone  to  sleep  makes  one  apprehensive 
of  phthisis,  in  the  absence  of  other  indications  of  obvious  acute  chest  changes. 
A  cough  on  exertion  suggests  heart  weakness,  and  in  determining  the  presence  of 
this,  the  finest  discrimination  is  required  in  auscultation,  for  these  are  typically 
the  cases  of  morbus  cordis  without  a  bruit  in  which  frequency  of  rhythm  and 
good  differentiation  of  the  first  and  second  sounds  are  all  important  for  a 
diagnosis.  Shortness  of  breath  will  generally  be  a  marked  symptom  associated 
with  the  cough  in  these  cases  (see  Breath,  Shortness  of). 

Has  the  voice  altered  since  the  cough  appeared  ?  Laryngeal  inflammations  or 
paralysis  of  a  vocal  cord  are  suggested  by  an  affirmative  answer,  and  the  larynx 
must  be  carefully  examined,  the  more  carefully  the  more  nearly  the  patient  is 
approaching  to  the  period  of  life  when  growths  are  more  common. 

Fred.  J .  Smith. 


CRAMPS  177 

CRACKLING,  EGG-SHELL — This  is  a  condition  closely  allied  to  Crepitus 
{q.v.)  ;  if  subcutaneous  emphysema,  arthritis,  and  tenosynovitis  can  be  excluded, 
it  is  nearly  always  a  symptom  either  of  osteosarcoma,  if  it  occurs  in  connection 
with  a  long  bone,  or  of  hydrocephalus  or  craniotabes  in  the  case  of  the  occipital 
or  other  cranial  bones.  The  ;ir-rays  may  often  assist  the  diagnosis  ;  if  there  is  a 
tumour  connected  with  the  end  of  a  long  bone  which  exhibits  egg-shell  crackling 
with  or  without  pulsation,  it  is  almost  certainly  an  osteosarcoma. 

Herbert  French. 
CRAMPS. — These  are  involuntary  tetanic  muscular  contractions  accompanied 
by  sharp  pain  in  the  voluntary  muscles  involved.     Temporary  paralysis  of  move- 
ment,   partial   or   complete,   is  often   associated  with   cramp.     Similar  painful 
spasms  of  the  involuntary  muscles  are  referred  to  as  colic. 

In  most  instances,  cramps  result  from  over-exevtion  of  the  affected  muscles. 
The  cramp  comes  on  at  once,  or  after  a  short  delay,  or  when  the  attempt  is  next 
made  to  use  the  muscles  involved.  The  most  striking  example  of  this  is 
swimmer's  cramp  ;  in  this  the  victim  is  suddenly  overtaken  by  painful  spasm 
and  paralysis  of  the  muscles  of  the  leg  or  legs,  or  of  the  legs  and  arms.  If  in 
deep  water  he  is  likely  to  drown  unless  help  is  speedily  forthcoming.  Similar 
but  less  extensive  cramps  are  not  rarely  experienced  by  persons  taking  part 
in  the  more  violent  of  outdoor  games — football,  hockey,  lacrosse,  etc.  In 
these,  any  particularly  sudden  or  violent  muscular  effort  may  be  followed 
by  cramp  in  one  or  more  of  the  thigh-  or  calf-muscles.  Cramps  of  the 
legs  are  not  rare  in  rowing  men,  whose  pleasure  it  is  to  perform  very  heavy 
muscular  work  while  seated  in  positions  of  great  confinement  and  constraint. 
Ballet-dancers  who  are  constantly  on  tip-toe  are  very  prone  to  cramps  in  the 
calves  of  the  legs.  Certain  people  seem  to  have  a  great  proclivity  to  cramp, 
which  seems  to  return  with  less  and  less  provocation  the  more  often  it  is 
experienced.  The  diagnosis  of  cramps  due  to  over-exertion,  directly  associated 
as  they  are  with  a  definite  history  of  muscular  strain,  should  not  be  difficult. 
They  rarely  become  so  severe  as  to  prevent  their  victims  from  continuing  to 
take  part  in  the  occupations  that  provoke  their  occurrence. 

It  is  quite  otherwise,  however,  with  patients  who  are  afflicted  with  the 
so-called  professional  cramps  or  occupation  neuroses,  that  result  from  chronic 
strain  and  over-use  of  certain  groups  of  muscles.  They  occur  in  such  persons 
as  writers,  typists,  telegraph  operators,  compositors,  painters,  tailors,  seam- 
stresses, dairymaids  (from  milking  cows),  pianists,  flute-players,  violinists, 
'cellists,  drummers,  blacksmiths,  cigarette-rollers,  and  so  forth.  In  all  these 
employments,  the  muscles  of  the  arms,  forearms,  or  fingers  are  in  constant 
and  special  employment.  If  they  are  overworked,  they  may  become  the  seat 
of  cramps  and  aching  pains — professional  cramps — as  soon  as  they  are  used  ; 
their  movements  lose  their  delicacy,  and  become  inco-ordinated  and  spasmodic. 
A  fine  tremor  is  very  commonly  to  be  observed  in  the  affected  linab. 

It  is  probable  that  over-use  alone  is  not  enough  to  set  up  these  cramps. 
Anxiety,  ill-health,  local  injury  or  disease,  and  the  inheritance  of  a  neurotic 
temperament,  all  contribute  to  the  establishment  of  professional  cramps.  These 
cramps  have  also  been  recorded  in  other  occupations,  and  as  affecting  other 
groups  of  muscles  :  in  treadler's  cramp  the  hamstring  muscles  and  glutei  are 
affected  ;  in  cornet  player's  the  tongue,  in  watchmaker's  the  orbicularis  oculi, 
may  be  attacked.  As  a  rule,  the  diagnosis  of  a  professional  cramp  is  not  hard, 
but  it  is  necessary  to  make  sure  that  neither  organic  nervous  disorder  nor  local 
disease  is  present.  Thus  the  physical  signs,  though  hardly  the  symptoms, 
of  writer's  cramp  may  be  present  in  such  diseases  as  paralysis  agitans,  dissemin- 
ated sclerosis,  tabes,  general  paralysis  ;  brachial  neuralgia  might  simulate  the 
neuralgic  forms  of  occupation  neurosis,  but  it  is  free  from  cramps.  Again, 
D  12 


178  CRAMPS 

affections  of  the  joints  or  of  the  tendons  at  the  wrists,  such  as  chronic  rheumatism, 
rheumatoid  arthritis,  tenosynovitis,  tuberculous  infection,  may  all  give  rise  to 
pain  in,  and  interfere  with  the  movements  of,  the  hand.  Again,  writer's  cramp 
may  be  so  much  feared  by  nervous  patients,  that  their  right  hand  may  become 
so  stiff,  or  weak,  or  painful,  that  they  can  no  longer  write  :  objective  signs  of 
the  cramp,  however,  are  lacking  in  such  cases,  which  are  cured  by  the  re- 
establishment  of  the  patient's  self-confidence. 

Cramps  are  the  main  feature  of  tetany,  a  disease  characterized  by  the  occurrence 
of  paroxysmal  or  continued  tetanic  spasms  of  the  extremities  (see  Fig.  i,  p.  3), 
and  increased  excitability  of  the  nerves  and  muscles  to  electrical  or  mechanical 
stimulation.  Tetany  occurs  in  many  different  conditions,  and  at  any  age.  In 
infants  and  young  children  it  is  a  complication  of  rickets  and  improper  feeding. 
In  children  it  may  result  from  acute  gastro-intestinal  disorders,  either  with  or 
without  diarrhoea  and  vomiting.  Epidemics  of  tetany  in  young  adults,  probably 
resulting  from  food-poisoning,  have  been  described  as  occurring  on  the  Con- 
tinent, though  not,  apparently,  in  Great  Britain.  In  nursing  women,  tetany 
may  follow  prolonged  lactation  ;  or  it  may  develop  during  pregnancy  and  recur 
in  successive  pregnancies.  It  may  result  from  the  removal  of  too  much  or  all 
of  the  thyroid  gland  in  either  sex  ;  this  may  be  regarded  either  as  a  consequence 
of  thyroid  insufficiency,  or  as  evidence  of  parathjrroid  insufficiency,  for  there 
can  be  no  doubt  that  the  parathyroid  glands  are  lost  when  the  bulk  of  the 
thyroid  is  removed.  Tetany  complicates  a  certain  proportion  of  the  cases  of 
gastrectasis,  occurring  whether  the  dilated  stomach  has  been  washed  out  or  no. 
A  few  instances  are  on  record  in  which  tetany  followed  the  acute  specific  fevers, 
enteric  fever,  or  poisoning  by  chloroform,  lead,  or  ergot.  In  fine,  it  may  be 
said  that  tetany  is  usually  due  to  acute  or  chronic  digestive  troubles,  the  painful 
spasms  being  evidence  of  the  absorption  of  some  toxin  from  the  gastro-intestinal 
tract  in  most  cases.  The  cramps  of  tetany  are  mainly  in  the  extremities  and 
paroxysmal  ;  they  may  continue,  however,  for  hours  or  days,  and  are  very 
painful.  During  the  spasms,  the  fingers  are  extended  at  the  terminal  and  flexed 
at  the  metacarpophalangeal  joints  and  pressed  together,  while  the  thumb  is 
adducted  and  flexed  into  the  palm,  so  that  the  so-called  "  accoucheur's  hand  " 
is  produced.  The  wrist  and  elbow  are  flexed,  the  arms  being  usually  folded 
over  the  chest  ;  exceptionally  the  elbow  may  be  stiffly  extended.  The  toes  are 
drawn  together  and  flexed,  the  foot  is  arched  and  turned  inwards,  and  the  ankles 
and  knees  are  held  extended.  Usually  only  the  limbs  are  involved  ;  but  in 
severe  cases,  cramps  occur  in  the  face,  neck,  and  even  the  trunk,  when  respiration 
may  be  seriously  embarrassed.  The  rigid  muscles  are  very  tender  to  the  touch. 
Three  special  signs  are  present  in  the  intervals  between  the  attacks  of  tetany, 
and  are  valuable  in  diagnosis  :  these  are  Trousseau's  sign,  or  reproduction 
of  the  paroxysm  by  compression  of  the  nerves  or  blood-vessels  supplying  the 
affected  parts  ;  Erb's  sign,  or  hyperexcitability  of  the  motor  nerves  to  electrical 
currents  (o'5  to  2-0  milliamperes)  ;  and  Chvostek's  sign,  or  reproduction  of  the 
spasm  in  the  facial  muscles  by  tapping  either  on  the  muscles  themselves  or  on 
the  facial  nerve.  Tetany  must  be  diagnosed  from  tetanus,  in  which  the  spasms 
begin  in  the  head  and  neck,  while  trismus  is  an  early  symptom  ;  and  from 
strychnine  poisoning,  where  the  spasms  are  clonic  rather  than  tetanic,  and 
affect  the  whole  body  and  not  the  extremities  primarily  or  principally.  In 
the  carpo-pedal  spasms  of  rickety  children  or  of  infants  with  severe  gastro- 
intestinal catarrh,  the  cramps  are  similar  to  those  of  tetany,  but  are  transient, 
and  perhaps  affect  the  hands  only,  or  the  hands  and  arms.  Such  spasms  may 
justly  be  regarded  as  identical  with  those  of  mild  tetany.  Hysterical  tetany 
occurs,  and  is  to  be  distinguished  from  true  tetany  by  its  association  with  other 
hysterical  stigmata  on  the  one  hand,  and  on  the  other  by  the  absence  of  Trousseau's 


CURSCHMANN'S     SPIRALS  179 

and  Chvostek's  signs.  Hysterical  tetany  may  also,  perhaps,  be  distinguished  by 
its  failure  to  respond  to  the  exhibition  of  calcium  salts  ;  the  most  recent  view 
of  true  tetany  regards  it  as  the  expression  of  the  hyperexcitability  of  the  nerve- 
cells  due  to  lack  of  calcium  salts,  and  connects  it  with  the  parathyroid  glands 
by  supposing  that  they  control  the  calcium-metabolism  of  the  body. 

Reference  may  again  be  made  to  the  fact  that  cramps  are  prone  to  occur  in 
patients  debilitated  by  the  acute  fevers  or  enteric  fever  ;  severe  cramps  in  the 
legs  and  arms  are  often  a  highly  troublesome  feature  of  the  convalescence  from 
cholera.  In  many  chronic  diseases  nocturnal  cramps  may  give  rise  to  no  little 
distress,  or  may  interfere  seriously  with  sleep  :  in  gout,  chronic  Bright's  disease, 
alcoholic  neuritis,  and  almost  any  chronic  wasting  disorder,  complaint  of  cramp 
is  not  infrequent.  But  in  such  instances  more  serious  signs  or  symptoms  of 
disease  will  no  doubt  have  made  themselves  evident.  A.  J.  J  ex-Blake. 

CREPITUS  is  a  term  generally  used  to  denote  the  grating  or  crackling  sensation 
and  noise  produced  when  two  ends  of  a  broken  bone  grate  together.  It  is  the 
most  conclusive  sign  of  a  fracture  ;  but  it  causes  the  patient  so  much  pain  that, 
whenever  the  x-rays  can  be  employed,  attempts  to  obtain  crepitus  should  not  be 
made  with  any  vigour.  Apart  from  fracture  of  a  bone,  crepitus  is  also  to  be  felt 
and  heard  in  joints  affected  by  dendritic  synovitis,  or  still  more  so  in  cases  of 
osteo-arthritis  ;  the  term  "  silken  crepitus  "  has  been  used  for  the  sensation  felt  on 
moving  such  a  joint,  comparable  to  the  rubbing  together  between  the  fingers  of 
two  pieces  of  stout  silken  ribbon.  Tenosynovitis,  especially  around  the  flexor 
tendons  at  the  wrist,  may  also  produce  a  very  marked  feeling  of  crepitus, 
especially  in  cases  where  the  tendon  sheaths  contain  melon-seed  bodies. 

When  there  is  an  enlargement  of  a  bone  without  fracture,  and  when  on  palpation 
a  feeling  of  crepitus  or  egg-shell  crackling  is  obtained,  it  is  an  indication  that  the 
tumour  is  a  rarefying  osteosarcoma,  which  may  sometimes  be  felt  to  pulsate 
also.  The  diagnosis  may  be  assisted  by  the  use  of  the  ;tr-rays  (see  figures  in 
article  on  Swelling  on  a  Bone). 

Rarefaction  of  the  bones  of  the  skull,  either  as  the  result  of  syphilitic  lesions 
in  adults,  or  of  hydrocephalus  or  craniotabes,  especially  in  the  occipital  region 
of  congenital  syphilitic  and  rickety  infants,  may  make  the  skull  bones  so  thin 
that  they  readily  bend  on  pressure,  and  sometimes  the  result  is  a  sensation  of 
crepitus.     The  diagnosis  is  generally  obvious. 

Quite  apart  from  bony,  arthritic,  or  synovial  changes,  a  characteristic  feeUng 
of  crepitus  may  be  felt  beneath  the  skin  when  gas  or  air  has  accumulated  in  the 
subcutaneous  tissues  as  the  result  of  surgical  Emphysema  (q.v.).     Herbert  French 

CROSSED   PARALYSIS.— (See  Hemiplegia.)  ^,. 

CRUSTS  ON  THE   SKIN.— (See  Scabs.) 
CUD-CHEWING.— (See  Merycism.) 


CURSCHMANN'S   SPIRALS  consist  of   a  highly  re- 
fractile  central    fibre,    and   a   sinuous   wavy  sheath  of  T^v;?-  46- -Curschmanns 

mucus  {Fig.  46).     They  may  be  half  an  inch  in  length,         spirals      from     asthmatic 
but  they  are  very  slender.     Thev  occur  in  the  sputum         ^'""'JT  fTV'''  . 
of  patients  suffering  from  true  spasmodic  asthma,  and  Methods,    Dr.    Herbert 

they    may    be    associated   with   eosinophile    corpuscles  French.) 

and  Charcot-Leyden  crystals.  They  are  best  seen  in  fresh  sputum,  and  are 
pretty  objects  ;  but  their  diagnostic  significance  is  very  hmited,  first  because 
they  are  so  often  absent  in  cases  of  undoubted  asthma,  and  secondly  because 
they  have  been  found  in  bronchiolitis  without  asthma.     They  seem  to  be  casts 


1 80  C  URSCHMA  NN'  S     SPIRA  LS 

of  the  finest  bronchioles.  It  is  probable  that^  if  there  were  doubt  as  to  whether 
a  given  case  were  one  of  primary  emphysema  and  bronchitis,  or  of  spasmodic 
asthma  that  had  led  to  emphysema  and  bronchitis,  the  occurrence  of  t^-pical 
Curschmann's  spirals  would  point  to  the  latter.  There  are,  however,  other 
means  of  arriving  at  the  same  conclusion,  particularly  the  historj^,  the  age  at 
which  the  first  attack  began,  and  the  presence  or  absence  of  Eosinophilia  [q.v.) 

Herbert  French. 

CURVATURE,  SPINAL — In  the  diagnosis,  the  first  thing  is  to  distinguish 
between  lateral  and  antero-posterior  deformities  ;  but  in  a  good  many  cases 
scoliosis  or  lateral  curvature  is  complicated  by  antero-posterior  deformity, 
kyphosis,  or  lordosis  as  well,  and  in  a  few  instances  of  angular  kj^phosis  due 
to  caries,  there  is  some  lateral  deviation,  Avhich  is  generally  much  more  abrupt 
than  is  the  curve  of  scoliosis.  A  good  way  of  demonstrating  lateral  curvature 
is  to  pencil  the  skin  over  the  spinal  processes. 

Lateral    Curvature. 

The  following  are  the  most  important  causes  of  lateral  curvature  : — 

1.  Inequality  in  the  lengths  of  the  lower  limbs. 

2.  Weakness  of  the  muscles  of  the  back  associated  with  bad  habits  of  standing 
or  sitting. 

3.  Carrying  heavy  weights  with  one  arm  or  on  one  shoulder. 

4.  Rickets. 

5.  Paralysis  of  the  muscles  of  the  back,  as  in  infantile  paralysis,  peripheral 
neuritis,  especiall}^  that  following  diphtheria,  and  some  of  the  muscular 
dystrophies. 

6.  Shrivelling  of  one  side  of  the  chest  as  the  result  of  empyema  or  fibroid  lung. 

7.  Wry-neck,  or  other  causes  of  asymmetry  of  the  head  and  shoulders,  such 
as  Sprengel's  shoulder. 

8.  Hysteria. 

Inequality  of  the  lengths  of  the  lower  limbs  is  one  of  the  commonest  causes  of 
lateral  curvature  ;  therefore  it  is  very  important  to  find  out  at  once  if  the  legs 
are  equal.  The  most  reliable  and  easy  method  of  determining  this  is  to  get  the 
patient  to  stand  up  with  both  knees  straight  and  without  resting  a  hand  upon 
anything.  The  observer  then  stoops  in  front  of  the  patient  and  places  his 
thumbs,  with  their  extremities  upwards,  exactly  upon  the  prominence  of  each 
anterior  superior  spine.  The  eye  can  then  detect  the  slightest  difference  in  the 
level  of  the  two  spines.  This  method  is  far  more  reliable  than  measmrement 
from  the  anterior  superior  spines  to  the  malleoli.  Moreover,  the  latter  method 
does  not  show  the  shortening  that  is  due  to  the  fiexion  and  adduction  of  the 
hip  joint.  Further,  the  foot  may  be  fixed  in  a  position  of  talipes  equinus,  which 
may  make  a  short  limb  apparently  longer  than  its  fellow,  so  that  the  anterior 
spine  on  the  corresponding  side  may  be  elevated.  When  the  anterior  spines 
are  on  a  different  level,  the  body  leans  towards  the  lowest  spine,  but  in  order  to 
maintain  the  erect  position,  the  upper  part  of  the  body  becomes  flexed  to  the 
opposite  side.  Thus,  the  spine  in  the  lumbar  region  develops  a  curve  with  its 
convexity  to  the  side  of  the  short  limb.  Lateral  curvature  due  to  a  shortened 
limb,  in  its  early  stages,  is  at  once  corrected  by  compensating  the  shortened 
limb,  and  it  also  disappears  when  the  patient  sits  on  a  flat  level  surface.  In 
the  absence  of  inequality  of  the  limbs,  muscular  weakness  is  by  far  the  most 
common  cause  of  lateral  curvature.  The  spine  does  not  become  straight  when 
the  patient  sits  on  a  flat  level  surface  ;  but  in  the  early  stages  of  the  deformity 
the  shape  can  be  somewhat  corrected  by  muscular  effort. 

Asymmetry   of  the   chest  following    upon    empyema  or   fibroid   lung  is  easily 


CURVATURE,     SPINAL  i8i 

detected.  The  shrivelled  side  is  generally  less  resonant  on  percussion,  and 
there  are  other  signs  of  pulmonar}^  disease. 

Scoliosis  secondar\-  to  wry-neck  is  usually  slight,  and  limited  to  the  spinal  and 
dorsal  regions.  In  growing  youths  the  carrying  of  heavy  weights  with  one  arm 
or  upon  one  shoulder  is  a  common  and  important  cause  of  scoliosis,  and  it  is 
therefore  necessary  to  go  into  the  question  of  occupation  and  habits.  For 
instance,  nursery-maids  and  butchers'  boys  are  very  apt  to  develop  lateral 
curvature  as  the  result  of  carrying  burdens  upon  the  right  arm. 

The  lateral  curvature  due  to  rickets  is  recognized  by  the  unusually  early  onset, 
during  the  first  or  second  year,  and  the  signs  of  rickets  in  other  parts,  especially 
thickening  of  the  lower  end  of  the  radius.  The  direction  of  the  primary  curve 
is  sometimes  explained  by  the  pressure  of  the  arm  of  the  nurse  who  carries  the 
baby  too  exclusively  on  one  arm.  Actual  paralysis  of  the  spinal  muscles  is  a 
rare  cause  of  scoliosis,  and  is  to  be  recognized  by  the  wasting  of  the  spinal  muscles, 
especially  when  this  is  more  marked  on  one  side.  The  sinking  of  the  muscles 
due  to  rotation  of  the  spine  must  not  be  mistaken  for  wasting.  There  is  usually 
paralysis  of  other  muscles,  especially  those  of  the  leg.  Scoliosis  is  often  seen  in 
the  various  primary  muscular  atrophies,  and  in  Friedreich's  hereditary  ataxy. 

Peripheral  neuritis  as  a  cause  is  nearly  always  due  to  diphtheria  or  sore  throat. 
The  history  may  indicate  this,  or  there  may  have  been  other  post-diphtheritic 
paralyses,  notably  that  of  the  soft  palate^  with  nasal  voice  and  regurgitation  of 
fluid  through  the  nose.  Cultivations  should  be  taken  from  the  throat,  and  the 
Klebs-Loffler  bacillus  (Plate  XII,  Fig.  L)  may  be  found  if  sought  early  enough. 
Occasionally  the  abdominal  muscles  may  also  be  paralyzed  in  these  cases,  and 
this  is  a  contributory  cause  of  the  curvature. 

Antero-Posterior  Curvatures. 

These  may  take  the  form  of   (i)   Kyphosis,   (2)  Lordosis. 

I.  Kyphosis,  or  "  hump-back,"  means  a  bending  forwards  of  the  upper  part 
of  the  back  on  to  the  lower.  The  curve  may  be  (a)  Angular,  and  limited  to  a 
small  portion  of  the  back ;  or  it  may  be  {b)  Diffuse,  or  even  general,  extending 
from  the  coccyx  to  the  cranium. 

[a)  Angular  Kyphosis. — The  causes  of  angular  kyphosis  are  : — (i)  Tuberculous 
caries  of  the  vertebrae  ;  (ii)  Growth  of  the  spine  ;  (iii)  Hydatid  disease  of  the 
vertebrae. 

(i).  Caries  is  by  far  the  commonest  cause,  and  it  is  very  important  to  recognize 
the  disease  before  the  deformity  becomes  well  marked.  Unfortunately,  it  may 
be  treated  for  a  long  time  as  stomach-ache  or  intercostal  neuralgia,  because  the 
pain  is  referred  to  the  abdomen  and  the  intercostal  regions.  During  its  active 
stages  it  is  easy  to  recognize  it  from  its  classical  symptoms  and  signs.  The 
patient  avoids  all  jerky  movements,  walks  with  a  stooping  gait,  and  grasps  with 
the  hands  any  convenient  article  of  furniture.  The  spine  is  tender  on  percussion, 
also  on  pressure  upon  the  head  or  shoulders.  Local  rigidity  of  the  back  is 
noticed  when  the  patient  attempts  to  stoop.  In  later  cases,  paralysis  of  the 
legs  may  complicate  the  deformity.  In  the  quiescent  stages,  the  diagnosis  is 
based  on  the  characteristic  local  deformity  and  rigidity.  Skia.grams,  especially 
those  taken  from  side  to  side,  may  afford  material  help  by  showing  evidence 
of  destruction  of  the  bodies  of  the  vertebrae.  In  some  cases,  lateral  curvature 
may  complicate  or  follow  caries,  and  then  the  diagnosis  is  not  easy.  The  disease 
may  have  affected  the  bodies  of  the  vertebrae  unev-enly,  leading  to  some  lateral 
deviation,  which  is  usually  rather  abrupt  and  associated  with  the  local  rigidity 
characteristic  of  caries. 

(ii).  Growth  of  the  spine  is  a  rare  cause  of  angular  curvature.  Rapidly 
developed  curvature  in  a  patient  after  middle  age  may  be  due  to  secondary 


I82 


CURVATURE,     SPINAL 


carcinoma  in  the  bodies  of  the  vertebras,  and  bearing  this  possible  cause  in  mind, 
the  surgeon  should  go  carefully  into  the  history,  and  examine  every  possible 
source  of  primary  carcinoma,  particularly  the  breast.  Primary  or  secondary 
sarcoma  may  also  lead  to  deformity  of  the  spine,  and  in  some  cases  an  ;i;-ray 
examination  may  give  evidence  of  the  development  of  new  bone  in  the  growth, 
or  of  the  absorption  of  the  vertebrae. 

(iii) .  Hydatid  disease  is  a  very  rare  cause  of  spinal  curvature,  and  it  is  usually 
not  limited  to  the  spine. 


J^Jg:  47. — Osteitis  deformans  in  a  man. 


J^/g:  48. — Osteitis  deformans  in  a  woman. 


(6).  Diffuse  Kyphosis. — The  back  maj^  be  bent  forwards  in  a  uniform  curve 
extending  from  the  coccyx  to  the  cranium.  This  variety  is  common  in  rickets, 
owing  to  the  premature  assumption  of  the  sitting  position  when  the  bones  are 
soft  and  the  muscles  of  the  back  are  weak.  When  the  patient  is  lying  prone,  the 
deformity  can  easily  be  corrected  by  raising  the  legs.  Moreover,  there  are  other 
signs  of  rickets,  such  as  enlargement  of  the  lower  end  of  the  radius,  beading  of 
the  ribs,  and  delay  in  the  eruption  of  teeth.  A  similar  deformity  arises  from 
muscular  weakness  due  to  other  causes,  such  as  idiocy  and  congenital  spastic 
paraplegia.     In  all  of  these  there  is  an  entire  absence  of  rigidity  of  the    spine. 


CURVATURE,     SPINAL 


183 


An  extensive  and  uniform  curve,  affecting  the  cervico-dorsal  region  is  common 
during  adolescence,  and  is  due  to  muscular  weakness,  lazy  habits,  and  the  carry- 
ing of  heavy  weights.  In  its  early  stages  the  deformity  is  easily  reducible,  and 
as  a  rule  is  compensated  by  a  marked  lordosis  in  the  lumbar  region,  and  some 
tilting  backwards  of  the  occiput.  It  is  often  associated  with  lateral  curvature, 
and  in  some  cases  may  be  partly  due  to  shortness  of  sight.  The  condition  is 
distinguished  from  caries  by  the  diffuseness  of  the  curvature,  the  absence  of 
pain  and  local  tenderness,  and  the  comparative  suppleness  of  the  back. 

Kyphosis  due  to  spondylitis  deformans  or  to  osteitis  deformans  {Figs.  47  and  48) 
is  of  a  more  uniform  character  without  complicating  lordosis,  and  the  deformity 
is  irreducible.  There  is  generally  evidence  of  the  disease  in  other  parts,  such  as 
osteo-arthritis,  or  the  bending  of  the  legs,  and  increase  of  the  size  of  the  head, 
which  are  due  to  osteitis  deformans.  Porters  carrying 
heavy  weights  on  the  upper  part  of  the  back,  prema- 
turely develop  the  kyphosis  which  is  usually  associated 
with  old  age.  They  frequently  have  a  bursa  over  the 
seventh  dorsal  spinous  process. 

2.   Lordosis,  Hollow-Back This    deformity   is    only 

common  in  the  lumbar  and  lower  dorsal  region.  The 
natural  hollow  of  the  loin  is  exaggerated,  and  usually 
there  is  either  primary  or  compensatory  kyphosis  in  the 
cervico-dorsal  region  {Fig.  49).  Lordosis  is  rarely 
primary,  but  it  may  be  so  in  the  early  stage  of  lumbar 
or  lumbo-dorsal  caries  in  children,  when  the  real  cause 
of  the  deformity  is  apt  to  be  overlooked.  The  abdomen 
is  very  prominent,  and  the  back  is  not  only  hollow,  but 
rigid  and  tender.  Pressure  upon  the  head  also  causes 
pain  in  the  back.  In  some  cases  the  deformity  is 
exaggerated  by  induration  or  suppuration  in  the  psoas 
muscle,  which  complicates  this  disease.  Lordosis  is  not 
uncommonly  due  to  weakness  or  paralysis  of  the  muscles 
of  the  back  {Fig.  49).  It  is  particularly  important  to 
look  for  other  evidence  of  primary  muscular  dystrophy. 
The  upper  part  of  the  back  is  then  thrown  backwards  to 
facilitate  the  maintenance  of  the  erect  position.  Lordo- 
sis is  often  secondary  to  the  flexion  of  hip  disease, 
which  must  not  be  overlooked.  Limitation  of  move- 
ment— especially  of  rotation  of  the  hip  joint — and 
wasting  of  the  thigh,  serve  to  demonstrate  the  existence 
of  this  disease.  Lordosis  and  the  waddling  gait  may 
be  the  first  indications  of  congenital  dislocation  of  the 
hip.      In   this   condition,  which  is  almost   confined   to 

the  female  sex,  the  erect  position  is  maintained  only  by  throwing  the  shoulders 
backwards  to  an  unusual  degree  in  order  to  bring  the  trunk  in  a  line  with  the 
heads  of  the  femora,  which  are  dislocated  backwards.  The  suspicion  of  con- 
genital dislocation  of  the  hip  may  be  confirmed  by  skiagraphy,  by  the  gliding 
movements  of  the  head  of  the  femur  upon  the  pelvis,  the  unnatural  width  of  the 
hips,  the  hollow  appearance  of  Scarpa's  triangle,  and  by  palpation  of  the  head 
of  the  femur  upon  the  dorsum  ilii  when  the  thigh  is  flexed,  strongly  adducted, 
and  inverted.  Contortionists  usually  have  a  good  deal  of  lordosis  owing  to  the 
unnatural  suppleness  of  the  lumbar  spine  and  the  elongation  of  the  hamstrings. 
In  all  these  conditions,  the  back  is  supple,  and 'can  be  restored  to  its  natural 
shape  by  placing  the  patient  in  the  supine  position  and  flexing  the  thighs. 

R.  P.  Rowlands. 


Fig.  49. 
Myopathic  lordosi.s. 


1 84 


CYAXOSIS,     EXTREME 


CYANOSIS,  EXTREME. — Extreme  cyanosis,  blueness,  or  lividitv,  is  generally 
most  marked  in  the  face  ;  next  most  clearh'  in  the  extremities,  especiallj'  the 
hands,  feet,  ears,  and  penis  ;  and  least  marked  in  the  trunk.  Cases  in  which  it 
is  a  prominent  symptom  maj*  be  divided  into  t:\vo  main  groups  according  as  the 
cyanosis  was  present  at  or  soon  after  birth,  or  occurred  later  in  the  hfe  of  a  patient 
Avho  was  originally  quite  free  from  it.  Congenital  cyanosis  of  extreme  degree 
is  nearlj-  always  due  to  malformation  of  the  heart,  particularly  pulmonary  stenosis 
(Fig.  50).  Patent  septum  ventriculorum  may  also  produce  the  symptom,  though 
not  in  so  marked  a  degree,  whilst  patent  ductus  arteriosus,  when  it  occurs  by 
itself,  is  generally  not  associated  with  cyanosis  at  all.  These  three  conditions 
ail  give  rise  to  loud  universal  bruits,  of  which  that  due  to  pulmonary  stenosis 
is  pureU'  systolic,  with  its  maximum  intensitj^  in  the  second  left  intercostal 
space  close  to  the  sternum  ;  that  due  to  patent  septum  ventriculorum  is  also 
sj-stolic,  but  has  its  maximum  intensity  lower  down  the  sternum,  usuall}^  between 

the  tivo  third  spaces  or  fourth  ribs  ; 
whilst  the  bruit  of  patent  ductus  arterio- 
sus is  not  purely  systoUc,  but  continues 
through  both  systole  and  diastole,  with 
its  maximum  intensity  at  the  time  of  the 
second  sound,  and  it  is  best  heard  in  the 
third  left  intercostal  space,  about  half 
an  inch  out  from  the  sternum  ;  all  these 
bruits  may  or  may  not  be  accompanied 
b}-  a  corresponding  thrill,  the  latter 
generally  being  least  marked  with  patent 
septum  ventriculorum.  Extreme  Club- 
bing OF  THE  Fingers  [q.v.)  and  of  the 
toes  accompanies  the  cyanosis  in  most 
cases  [Fig.  31,  p.  129).  In  addition  to 
these  three  tj^es  of  congenital  heart 
disease,  there  are  other  cases  in  which 
extreme  cj-anosis,  with  or  without  club- 
bing of  the  fingers,  occurs  without  any 
definite  bruits,  and  the  diagnosis  of  the 
nature  of  the  lesion  can  only  be  guessed 
at.  There  may  or  maj^  not  be  trans- 
position of  the  great  vessels  or  of  the 
\'iscera  at  the  same  time.  Sometimes 
there  is  a  single  large  vessel,  the  pul- 
monary artery  coming  off  from  the 
aorta  ;  or  there  may  be  only  one  ventricle,  or  a  single  auricle.  It  is  almost 
impossible  to  decide  between  the  various  possible  lesions,  unless  there  is  one  of 
the  definite  bruits  just  described.  Anomalous  cases  seldom  survive,  but  some 
cases  of  pulmonary  stenosis  or  patent  septum  ventriculorum  survive  to  adult  life, 
and  patent  ductus  arteriosus  often  gives  little  inconvenience  to  the  patient  at  all. 
It  is  to  be  remembered  that  patent  foramen  ovale  is  quite  undiagnosable,  that  it 
causes  no  sj'mptoms,  and  is  present  in  a  large  percentage  of  normal  people. 

Cyanosis  developing  in  children  or  adults  who  have  hitherto  been  healthy, 
is  generally  due  either  to  laryngeal  obstruction,  to  lung  lesions,  cardiac  failure, 
obstruction  to  the  superior  vena  cava,  or  to  some  alteration  of  the  blood  itself,  such 
as  is  found  in  splenomegahc  polycythaemia,  methaemoglobinaemia,  sulph-haemo- 
globinaemia,  or  the  later  stages  of  diseases  associated  with  extreme  loss  of  fluid 
from  the  tissues,  especially  cholera  maligna.  The  differential  diagnosis  is  usually 
easy  up  to  a  certain  point.     The  fact  of  laryngeal  obstruction  is  generally  obvious 


^'M-  5^- — -■^  case  of  morbus  coeruleus  :  con- 
genital pulmonary  stenosLs  with  extreme 
c^'anosis. 


CYANOSIS,     EXTREME  185 


from  the  stridor,  and  from  the  way  in  which  the  larynx  moves  forcibly  up  and 
down  with  respiration.  The  cause  of  the  obstruction  may  be  less  easy  to  deter- 
mine. In  a  child,  a  digital  examination  of  the  back  of  the  mouth  should  not  be 
omitted,  lest  there  be  a  post-pharyngeal  abscess  or  a  foreign  body  ;  in  the  absence 
of  this,  the  most  probable  cause  is  diphtheria  ;  though  it  may  be  difficult  to 
diagnose  forthwith  between  laryngitis  with  intermittent  spasm,  laryngismus  stridulus, 
acute  obstructive  laryngitis,  and  diphtheria.  Swabbings  should  be  taken  from  the 
throat  as  far  back  as  possible,  and  examined  bacteriologically.  The  Klebs-Loffier 
bacillus  of  diphtheria  {Plate  XII,  Fig.  L)  may  be  found  on  direct  examination  of 
films  stained  by  Neisser's  method  ;  but  sometimes  they  cannot  be  found  until 
cultivations  have  been  made,  and  this  takes  upwards  of  twenty-four  hours. 
If  there  has  been  no  obvious  cause  for  catarrhal  laryngitis,  such  as  the  inhala- 
tion of  irritant  gases  or  a  recent  attack  of  acute  bronchitis  affecting  the  large 
tubes,  it  is  better  to  assume  that  the  condition  is  diphtheria  until  it  is  proved 
not  to  be  so.  The  occurrence  of  other  cases  in  the  same  house,  or  in  the 
neighbourhood,  may  assist  the  diagnosis.  In  an  older  person,  acute  suffocative 
laryngitis  due  to  pneumococci  or  streptococci  is  associated  with  an  extreme 
cyanosis  of  rapid  onset.  Tracheotomy  is  necessary,  and  the  diagnosis  is  arrived 
at  upon  bacteriological  grounds.  It  is  difficult  to  inspect  the  vocal  cords  in  a 
child  ;  but  in  an  adult  this  is  easier,  and  direct  examination  serves  to  distinguish 
between  acute  or  ulcerative  lesions  of  the  larynx  and  laryngeal  paralysis ;  the, 
latter  sometimes  the  result  of  syphilitic  degeneration  of  part  of  the  vagal 
centre  in  the  medulla,  is  apt  to  produce  bilateral  abductor  paralysis  with  adductor 
spasm,  which  may  come  on  acutely  and  simulate  acute  asphyxia  from  a  foreign 
body.  Tuberculous,  syphilitic  or  malignant,  variolous,  leprous,  lupoid,  and  trau- 
matic ulceration  of  the  larynx,  may  any  of  them  become  acutely  infected  by 
inflammatory  organisms,  and  lead  to  comparatively  sudden  and  severe  laryngeal 
stenosis  with  acute  cyanosis  ;  the  diagnosis  will  depend  in  part  upon  the  history, 
bacteriological  examination,  and  direct  examination  of  the  vocal  cords.  Bright' s 
disease  has  sometimes  caused  similar  symptoms,  due  to  acute  oedema  of  the 
larynx,  and  potassium  iodide  may  do  the  same  in  those  who  are  particularly 
prone  to  iodism.  Knee-jerks  should  be  tested,  and  the  pupils  examined,  lest 
acute  attacks  of  dyspnoea  with  cyanosis  simulating  laryngeal  obstruction,  are 
due  to  the  laryngeal  crises  of  locomotor  ataxy.  , 

Growths  of  the  lung,  particularly  if  they  give  rise  to  pleuritic  effusion  or  to 
obstruction  of  a  bronchus,  may  cause  progressive  cyanosis  ;  the  diagnosis  is  not 
as  a  rule  easy  in  the  earlier  stages,  but  if  there  is  evidence  of  progressive  inter- 
ference with  the  structures  within  the  thorax,  with  ultimate  stenosis  of  the 
superior  vena  cava,  and  the  results  of  this,  namely,  oedema  of  the  face  and  arms, 
together  with  cyanosis  of  these  parts  out  of  proportion  to  any  similar  change 
in  the  legs,  the  diagnosis  lies  between  growth,  aneurysm,  and  mediastinal  fibrosis. 
The  ;v-rays  will  sometimes  be  of  material  assistance  in  deciding. 

Phthisis,  in  the  later  stages,  particularly  when  it  advances  rapidly  and  leads 
to  generalised  caseous  bronchopneumonia,  causes  extreme  cyanosis  in  some 
instances.  The  diagnosis  will  generally  have  been  made  long  previously,  from 
the  symptoms,  such  as  haemoptysis,  cough,  and  wasting  ;  from  the  abnormal 
physical  signs  which  started  at  the  apices  of  the  lungs  and  were  progressive  ; 
and  from  the  discovery  of  tubercle  bacilli  and  elastic  fibres  in  the  sputum. 

Pneumothorax  [q.v.),  when  it  comes  on  suddenly  in  a  patient  who  has  had  no 
symptoms  hitherto,  leads  to  acute  dyspnoea  and  cyanosis,  which  presently  pass 
off  ;  the  physical  signs  are  pathognomonic,  and  the  cause  is  generally  tubercle. 

Embolism  of  the  lung,  if  the  artery  occluded  is  of  large  size,  may  cause  sudden 
death  so  rapidly  that  the  patient  hardly  has  time  to  become  cyanosed  ;  when 
the  embolus  blocks  a  smaller  vessel,  lividity,  dyspnoea,  intrathoracic  pain,  and 


1 86  CYANOSIS,     EXTREME 

haemoptysis  are  the  most  prominent  symptoms  ;  the  diagnosis  is  suggested  by 
the  suddenness  of  the  onset  in  a  case  in  which  there  is  a  cause  for  embohsm^ 
particularly  either  thrombosis  of  a  vein  such  as  the  femoral  or  iliac,  or  a  recent 
surgical  operation  in  the  neighbourhood  of  a  large  vein  such  as  those  in  the 
abdomen,  or  otitis  media  with  a  possibiUty  of  lateral  sinus  thrombosis,  or  a  cardiac 
lesion  such  as  infective  endocarditis  of  the  right  side  of  the  heart.  There  may  be 
no  abnormal  phj^sical  signs  at  all ;  but  when  the  embolus  is  large,  it  generally 
results  in  an  infarct  which  may  be  detected  by  the  impairment  of  percussion 
note,  the  deficient  vesicular  mumaur,  and  the  development  of  a  rub  over  it. 

In  childhood,  the  commonest  lung  affection  to  produce  extreme  cyanosis  is 
bronchopneumonia  ;  the  diagnosis  is  generally  obvious,  though  it  is  not  alwaj^s 
easy  to  determine  whether,  in  a  case  in  which  there  is  some  evidence  of  laryngitis 
at  the  same  time,  the  cyanosis  is  due  mainl}^  to  the  laryngeal  obstruction  or  to  the 
intra-pulmonarjr  lesions.  Each  may  cause  extreme  sucking  in  of  the  intercostal 
spaces  and  convulsive  movements  of  the  chest  as  a  whole ;  but  the  best  measure 
of  the  degree  of  larnygeal  obstruction  is  the  violence  of  the  up-and-down  move- 
ments of  the  larjmx  itself.  There  may  or  may  not  be  empyema  associated  with 
bronchopneumonia ;  but  the  degree  of  cyanosis  will  not  help  to  distinguish 
between  these  two  ;  exploratory^  needling  of  the  chest  will  probably  be  resorted 
to  when  there  is  sufiicient  clinical  ground  for  supposing  that  empj^ema  may  be 
present.  Severe  bronchitis  and  emphysema  in  middle  age  often  lead  to  very 
severe  cj^anosis  and  orthopnoea,  owing  no  doubt  to  the  failure  of  the  right  side 
of  the  heart  to  w'hich  the  lung  trouble  gives  rise.  The  over-distended  condition 
of  the  chest,  its  great  girth,  its  small  difference  between  maximum  inspiratory 
and  maximum  expiratory  girths,  the  deficiency  of  the  vesicular  murmur,  the  occur- 
rence of  sibilant  or  sonorous  rhonchi  all  over,  and  perhaps  non-consonating  rales 
at  the  bases,  w^ould  indicate  the  diagnosis,  particularly  if  the  patient  has 
inelasticity  of  the  skin  of  the  back  of  the  hands,  and  has  suffered  from  similar 
attacks  for  some  years  past,  especially  in  the  winter.  The  chief  difficulty  will  be 
to  determine  whether  the  cause  of  the  cyanosis  is  pulmonary  or  cardiac  (see 
below).  Lobar  pneumonia,  as  a  cause  of  acute  cyanosis,  is  diagnosed  chiefly  by 
a  historj'  of  sudden  onset,  the  continuance  of  pyrexia  for  a  week  or  ten  days 
and  ending  by  crisis,  the  rapid  respiration-rate  in  proportion  to  the  temper- 
ature, the  viscid  rust}'  character  of  the  sputum,  and  the  herpes  labiaUs. 
Sometimes  the  diagnosis  is  made  when  no  abnormal  physical  signs  can  be 
detected  ;  but  if  over  a  large  portion  of  a  lobe  there  is  at  the  same  time  impair- 
ment of  note,  with  bronchial  breathing,  bronchophony,  pectoriloquy,  without 
rales  at  the  height  of  the  malady,  but  with  fine  crepitations  at  the  beginning  of 
the  attack,  and  with  redux  crepitations  as  the  bronchial  breathing  disappears 
after  the  crisis,  the  diagnosis  will  be  obvious,  especially  if  during  the  fever  there 
is  a  great  deficiency  or  complete  absence  of  chlorides  from  the  urine. 

Asthma  is  sometimes  ver^^  difficult  to  distinguish  from  bronchitis  and  emphy- 
sema, because  it  ultimately  gives  rise  to  both  the  latter.  It  may  produce 
extreme  cj^anosis  during  an  attack. 

Cardiac  causes  for  extreme  cyanosis  include  any  of  the  conditions  which  lead 
to  chronic  failure  of  the  right  side  of  the  heart.  These  may  be  classed  into  one  or 
other  of  four  main  groups,  nameh''  :  primary  valvular  disease  of  the  heart  ;  affection 
of  the  muscle  of  the  heart  or  pericardium  ;  failure  of  the  heart  as  the  result  of 
chronic  lung  lesions,  especially  emph^^sema,  bronchitis,  fibroid  lung  and  bronchi- 
ectasis ;  and  cardiac  failure  when  the  heart  is  unable  to  maintain  the  high  blood- 
pressure  due  to  granular  kidney  or  arteriosclerosis.  When  a  late  stage  in  the 
failure  of  compensation  has  been  reached,  it  is  often  difficult  to  determine 
whether  the  primary  condition  is  kidney,  heart,  lungs,  or  arteries  ;  the 
differential  diagnosis  between  these  is  con.sidered   on  page  i8. 


CYSTINURIA 


Cyanosis  due  to  splenomegalic  polycythemia  is  slowly  progressive,  and  the 
diagnosis  is  arrived  at  by  finding  in  the  patient  a  big  spleen  with  Poly- 
CYTH.^MiA  (q.v.),  and  no  other  very  definite  lesion. 

Cyanosis  due  to  inspissation  of  the  blood  as  the  result  of  loss  of  fluid  from  the 
tissues  in  fevers,  such  as  cholera,  dysentery,  yellow  fever  or  tj^phus,  is  a  late 
symptom  in  a  disease  that  will  generally  have  been  diagnosed  upon  other 
grounds. 

MethcBinoglobincBmia  and  sulph-hcBnioglobincBmia  are  diseases  which  have 
been  grouped  together  under  the  term  enterogenous  cyanosis.  Both  are  exceed- 
ingly rare.  The  tint  of  the  skin  is  distinctive,  and  by  itself  suggests  the 
diagnosis,  being  altogether  different  from  that  of  ordinary  cyanosis,  and  yet 
not  to  be  mistaken  for  pigmentarj^  affections  such  as  Addison's  disease,  argyria, 
ochronosis,  or  haemochromatosis.  There  is  no  polyc;^^h3emia.  The  diagnosis  is 
established  by  spectroscopic  examination  of  the  patient's  blood,  a  suitabh" 
diluted  specimen  exhibiting  a  well-defined  absorption  band  in  the  red  [Fig.  22, 
p.  95)  in  addition  to  the  two  bands  of  oxyhsemoglobin  between  the  D  and  E 
lines  [Fig  17,  p.  95)  ;  the  distinction  between  sulph-hasmoglobin  and  methsemo- 
globin  is  not  easy  except  in  the  hands  of  experts  in  blood  chemistry  and 
spectroscopy.  Some  cases  arise  without  any  obvious  external  cause,  and  are  to 
be  distinguished  from  cases  in  which  the  blood-changes  are  directly  attribut- 
able to  the  effect  of  taking  chlorate  of  potash,  anihne  derivatives,  and  possiblv 
other  drugs.  Herbert  French. 

CYSTINURIA  is  the  term  used  to  indicate  the  presence  of  cystin  (Cj,H,.  NSO._,) ., 
in  the  urine.  The  urine  is  usualty  pale,  turbid,  and  oily  in  appearance  when 
passed,  of  a  sUghtly  acid  reaction,  with  a 
pleasant  aromatic  odour  resembling  sweetbriar  ; 
after  standing,  alkaline  decomposition  may 
take  place,  with  the  formation  of  sulphuretted 
hydrogen  and  a  change  in  colour  from  yellow 
to  green.  It  forms  a  light-j^ellowish  deposit, 
which  on  microscopical  examination  is  seen  to 
consist  of  colourless  hexagonal  plates  [Fig.  51). 
The  condition  is  hereditary,  and  mereh'  indi- 
cates a  pecuUarit^^  of  metabolism.  The  crystals 
have  occasionally  given  rise  to  calcuh,  which 
are  of  a  light  fawn  colour  when  first  passed  or 
removed,  changing  to  green  when  they  are 
exposed  to  the  air.     Cj^stin  is  not  dissolved  on 

heating  the  urine  or  by  adding  acetic  acid,  but  ^^^Ir-si-— Cystin  crystal  (high  power), 
it    is    by    mineral    acids    and     by    ammonia  ; 

from  the  latter  it  can  be  recovered  by  evaporation  :  a  chemical  test  that 
has  been  recommended  is  to  boil  some  urine  with  acetate  of  lead  and  caustic 
potash  ;  if  cystin  be  present,  a  dark  precipitate  should  form,  as  the  result  of 
the  formation  of  lead  sulphide.  The  best  evidence  of  the  condition,  however, 
is  the  discovery  of  the  typical  crystals  in  the  urine  microscopically. 

Herbert  French. 

DEAFNESS. — This  is  the  most  constant  sjmiptom  of  disease  of  the  ear.  It 
may  be  present  in  one  or  both  ears,  and  may  vary  from  a  slight  deficiency, 
which  may  be  unnoticed  by  the  patient,  to  a  complete  loss  of  hearing.  The 
cau.ses  of  defective  hearing  are  many.  In  some  cases  it  can  be  easily  relieved  ; 
in  others  the  prognosis  may  be  absolutely  hopeless. 

The  organ  of  hearing  consists  of  two  main  parts.  The  first  is  a  conducting 
portion  consisting  of  the  external  ear — external  auditor}'  meatus,  tvmpanum. 


DEAFNESS 


drum  and  ossicles — the  function  of  \vhich  is  to  collect  the  sound  waves  and 
transmit  the  vibrations  to  the  endolymph  of  the  internal  ear.  The  second 
portion  contains  the  labyrinth,  consisting  of  cochlea,  vestibule,  and  semi- 
circular canals,  in  which  are  situated  the  terminations  of  the  auditory  nerve. 
Deafness  maj'  be  caused  bj'  some  lesion  either  of  the  conducting  portion  of 
the  auditory  apparatus,  or  of  the  internal  ear,  which  contains  the  receptive 
mechanism.  The  latter — known  as  labyrinthine  or  nerve  deafness — is  the  more 
serious  and  usually  the  more  severe,  but  the  former  is  much  the  more  common. 
Rarely,  deafness  maj-  be  due  to  some  disease  of  the  auditory  nerve  or  to  some 
tumour  of  the  brain  involving  the  fibres  of  the  nerve  in  their  intracerebral 
course. 

Tests  for  Hearing. — In  the  examination  of  a  deaf  patient,  a  careful  investi- 
gation of  the  sense  of  hearing  is  necessar}-,  for  two  reasons  :  (a)  To  estimate 
the  severity  of  the  deafness  ;  (b)  To  ascertain  whether  the  lesion  is  situated  in 
the  conducting  apparatus,  or  in  the  labjTinth  or  auditor}^  nerve.  Before  carry- 
ing out  these  tests  it  is  well  to  examine  the  external  auditory  meatus  with  a 
speculum,  to  make  sure  that  the  deafness  is  not  due  to  the  presence  of  a  plug 

of  cerumen,  in  which  case  elaborate 
hearing  tests  are  unnecessary.  The 
following  are  the  tests  usually 
applied  : — 

1.  The  Whispered  Voice  Test. — 
This  consists  essentially  in  noting 
the  distance  at  which  whispered 
words  are  heard.  Vowel  sounds 
are  usually  heard  better  than  con- 
sonants. The  examiner  must  culti- 
vate a  whisper  of  uniform  intensity, 
and  the  patient's  eyes  should  be 
covered  to  avoid  the  possibility  of 
"lip  reading."  Each  ear  must  be 
tested  separately',  the  other  external 
auditory  meatus  being  covered  by 
a  finger. 

2.  The  Watch  Test. — Here,  the 
distance  is  measured  at  which  the  ticking  of  a  watch  is  heard.  The  same 
precautions  must  be  taken  as  in  the  voice  test.  The  observer  must  first 
measure  the  distance  at  which  it  can  be  heard  by  a  normal  person.  Suppose 
this  to  be  30  in.,  and  the  patient  hears  it  at  a  distance  of  12  in.  The  patient's 
hearing  is  then  described  as  i=-.  Instead  of  a  watch,  Politzer's  acoumeter 
{Fig.  52),  an  instrument  which  produces  a  uniform  tapping  sound,  may 
be  used. 

3.  Tuning-fork  Tests  are  of  the  greatest  importance,  since  it  is  chiefly  by  these 
that  labyrinthine  or  nerve  deafness  can  be  distinguished  from  deafness  due  to 
a  lesion  of  the  external  or  middle  ear.  In  the  latter  case,  the  sound  waves  are 
obstructed  on  their  way  to  the  receptive  apparatus,  and  cannot  be  heard  when 
the  fork  is  near  to,  but  not  in  contact  with,  the  ear  ;  whilst,  if  the  base  of  the 
fork  is  applied  to  the  mastoid  process,  forehead,  or  chin,  the  vibrations  are  readily 
heard,  because  thej'  are  now  convej^ed  to  the  normal  receptive  mechanism  directly 
through  the  bone.  In  nerve  or  lab\Tinthine  deafness,  on  the  other  hand,  though 
the  vibrations  are  transmitted  by  the  bone,  the  sound  is  heard  poorly  or  not  at 
all,  for  the  receptive  apparatus  is  at  fault  and  is  unable  to  respond  properly 
to  the  stimulus  of  the  sound  waves,  whether  they  reach  it  via  the  external  and 
middle  ear,  or  through  the  bone. 


s  acoumeter. 


DEAFNESS 


The  tuning-fork  used  should  be  one  which  vibrates  256  times  per  second  (C^). 
It  should  have  a  flat  foot-piece  {Fig.  53),  so  that  it  can  be  applied  conveniently 
to  the  bone,  and  it  may  with  advantage  be  fitted  with  a  contrivance  to 
prevent  the  occurrence  of  overtones.  In  addition,  tuning-forks  vibrating  64 
times  per  second  and  1028  times  per  second  should  be  at  hand,  for  testing  the 
perception  for  high  and  low  tones.  In  an  elaborate  investigation,  still  higher 
pitched  tuning  forks  may  be  necessary.  The  following  are  special  tests  used 
in   testing-bone  conduction  in  a  deaf  patient : — 

1.  Rinne's  Test. — The  tuning-fork  is  struck  lightly,  and 
the  flat  foot-piece  is  held  steadily  against  the  rnastoid  pro- 
cess. Directly  the  patient  ceases  to  hear  the  sound,  he 
raises  his  hand,  and  the  fork  is  then  held  close  to  the 
external  auditory  meatus.  If  the  sound  is  heard  again,  the 
result  is  positive  ;  if  it  is  inaudible,  the  result  is  negative. 
The  test  may  also  be  carried  out  by  holding  the  fork  opposite 
the  external  auditory  meatus  first,  and  then,  when  it  is  no 
longer  audible,  applying  it  to  the  mastoid.  A  useful  modifi- 
cation of  this  test  is  for  the  examiner  to  wait  until  the  fork 
is  no  longer  heard  by  the  patient  through  the  mastoid,  and 
then  to  transfer  it  to  his  own  mastoid.  In  this  way  the 
bone  conduction  of  the  patient  is  compared  with  the  bone 
conduction  of  a  normal  individual. 

2.  Weber's  Test. — This  is  especially  useful  in  unilateral 
deafness.  The  vibrating  fork  is  applied  by  the  flat  foot-piece 
to  the  middle  of  the  forehead.  The  patient  is  then  asked  in 
which  ear  the  sound  is  heard  best.  If  the  deafness  is  in  the 
external  or  middle  ear,  the  sound  will  be  best  heard  on  the 
deaf  side  (positive) ;  if  due  to  a  lesion  of  the  internal  ear  or 
auditory  nerve,  it  will  be  heard  in  the  good  ear  (negative). 
Great  care  has  to  be  exercised  in  this  test  to  get  the  correct 

reply  from  the  patient,  as  there  is  often  unwillingness  to  admit  hearing  in  the 
affected  ear. 

3.  Gelle's  Test. — The  air-pressure  is  increased  in  the  external  auditory  meatus 
by  means  of  a  Siegle's  speculum.  The  vibrating  fork  is  then  applied  to  the 
mastoid,  or  to  the  middle  of  the  forehead.     In  a  normal  person,  bone  conduction 

is  diminished.  When  it  is  un- 
affected it  is  generally  considered 
that  the  foot  of  the  stapes  is 
fixed. 

The    hearing    of    high    or    low 

tones    is    ascertained    by    using 

tuning-forks  of  a  rapid  or  low  rate 

of    vibration.       Galton's  whistle 

{Fig.    54),    which  produces   very 

high   notes,  is  also  used  for  this 

purpose. 

To    sum   up,   labyrinthine   deafness  is   indicated    when    bone    conduction    is 

diminished  markedly,  i.e.,  when  Rinne's  test  is  positive  and  Weber's  is  negative. 

Generally   speaking,   in    this   form   of  deafness   the  perception   of  high-pitched 

sounds  is  diminished. 

Deafness  due  to  some  error  in  the  conducting  apparatus  is  indicated  when 
bone  conduction  is  good,  i.e.,  when  Rinne's  test  is  negative  and  Weber's  positive. 
There  is  also  likely  to  be  poor  perception  of  low-pitched  notes. 

In  carrying  out  these  tests,  however,  it  must  be  remembered  that,  in  a  patient 


§'.  53. — Tuning-fork 
with  foot-piece._ 


Galton's  whistle. 


igo  DEAFNESS 

over  fifiA",  bone  conduction  is  normally'  diminished,  so  that  the  tests  are  often 
inconclusive  in  an  elderly  patient. 

Deafness  due  to  a  Lesion  of  the  Sound-conducting  Apparatus. — ^WTien  this  is 
the  case,  the  external  ear  or  middle  ear  may  be  at  fault.  An  examination  with 
the  speculum  -w-ill  readily  reveal  the  presence  of  a  plug  of  cerumeyj,  polypi,  or  a 
foreign  body,  such  as  a  mass  of  -wool,  which  is  not  infrequently  inserted  and 
forgotten  b}-  the  patient. 

The  cause  of  middle-ear  deafness  ^^-Ql  be  diagnosed  by  considering  other 
symptoms  which  may  be  present,  such  as  pain  and  tinnitus,  together  \\-ith  an 
examination  of  the  t^-mpanic  membrane,  and  of  the  nose  and  naso-pharynx. 
Deafness  is  more  or  less  marked  in  all  inflammatory  diseases  of  the  iniddle  ear, 
acute  or  chronic,  suppurative  or  nonsuppurative.  It  must  be  remembered  that 
there  is  not  necessarily  a  correspondence  between  the  intensity-  of  the  deafness 
and  the  abnormal  appearance  of  the  membrane.  The  latter  may  be  destroyed 
and  hearing  may  remain  fairly  good,  while  with  a  small  perforation,  or  in  chronic 
non-suppurative  otitis  media,  the  deafness  may  be  very  profound. 

Catarrh  of  the  Eustachian  tube,  or  obstruction  to  this  passage  by  the  presence  of 
adenoids  or  enlarged  tonsils,  is  a  common  cause  of  deafness,  especially  in  children. 

In  some  cases  of  middle-ear  deafness,  especially  in  otosclerosis,  where  the 
foot-plate  of  the  stapes  is  fixed,  the  patient  may  hear  ordinary  speech  better 
in  a  noisy  place  than  in  a  quiet  room.     This  is  known  as  paracusis  Willisii. 

In  disease  of  the  conducting  apparatus,  the  patient,  though  deaf,  not  infre- 
quently hears  his  own  voice  very  loudly,  and  also  noises  in  the  nasopharynx 
such  as  occur  on  swallowing.     This  is  known  as  autophonia. 

HypercBsthesia  acustica  is  a  term  applied  when  sounds  produce  an  actual 
painful  sensation  in  the  ear.  It  may  be  present  in  acute  inflammation  of  the 
middle  ear,  fevers,  and  migraine. 

In  Nerve  or  Labyrinthine  Deafness  it  is  of  the  greatest  importance  to  ascertain 
the  cause  of  the  trouble.  It  may  be  due  to  a  lesion  of  the  auditory  nerve  itself, 
-which  may  be  involved  in  a  growth  of  the  temporal  bone,  or  may  show  degenera- 
tive changes  in  locomotor  ataxy.  It  may  also  result  from  a  definite  intra- 
cranial lesion  such  as  a  tumour  of  the  mid-brain  or  pons.  A  diagnosis  in  these 
cases  will  be  made  from  the  coexistence  of  other  nervous  sxTiiptoms  associated 
with  cerebral  tumour. 

In  lab}-rinthine  deafness  the  following  actual  pathological  changes  have  been 
found  : — 

1.  Degenerative  changes  in  the  organ  of  Corti. 

2.  Haemorrhages. 

3.  Organized  inflammatory  products. 

4.  Some  cases  are  probably  due  to  a  rise  in  pressure  in  the  endolymph. 
The  follo%ving  are  the  chief  causes  of  lab^•rinthine  deafness  : — 

1.  Extension  from  disease  of  the  middle  ear,  suppurative  (pyo-lab}Tinthitis) 
or  non-suppiurative  (occasionally  in  otosclerosis). 

2.  Apoplectic  deafness  or  ^Meniere's  disease,  which  may  be  due  to  haemor- 
rhage or  a  sudden  rise  of  intracranial  pressure. 

3.  Following  the  specific  infectious  fevers,  especially  mumps,  tut  also 
influenza,    t^-phoid,    measles,   scarlet  fever,   and   others. 

4.  Sj'philis.  In  the  acquired  disease,  deafness  ma^"  occur  almost  at  any 
stage.  The  onset  is  usually  sudden,  and  may  have  ah  the  characters  of  Meniere's 
disease.     The  trouble  is  usually  unilateral. 

In  congenital  s\-philis  the  trouble  usually  begins  between  the  ninth  and 
sixteenth  years.  Eustachian  obstruction  and  retracted  membranes  are  fre- 
quently present,  but  the  deafness  progresses  and  is  lab}.Tinthine  in  character. 
Other  signs  of  congenital  5}-philis  wiU  be  present  to  assist  in  the  diagnosis. 


DEFORMITY     OF     THE     CHEST  191 

5.  In  Bright's  disease,  leukaemia,  pernicious  and  other  anaemias.  A  haemor- 
rhage is  frequently  the  cause  of  the  trouble  here. 

6.  Certain  drugs  cause  transient  deafness  of  labyrinthine  character  :  notably 
quinine,  and  sodium  salicylate  ;  possibly  alcohol  and  tobacco.  Mercury  and 
lead  also  are  stated  to  cause  deafness  sometimes. 

7.  Traumatic.  Labyrinthine  deafness  may  follow  blows,  falls,  or  fracture 
of  the  base  of  the  skull. 

8.  Occupations,  such  as  caisson  workers,  or  workers  in  a  continuous  loud 
noise  (boiler-makers'  deafness). 

9.  In  certain  diseases,  such  as  meningitis,  especially  cerebrospinal  meningitis  ; 
and  occasionally  in  epilepsy. 

Deafness  may  also  occur  in  hysterical  individuals.  This  may  usually  be 
recognized  by  the  manner  and  aspect  of  the  patient,  and  by  the  absence  of  any 
abnormal  physical  signs  on  examination. 

Lastly,  it  must  be  remembered  that  deafness  is  occasionally  complained  of 
by  a  malingerer.  In  this  case  the  fraud  is  usually  exposed  by  contradictory 
replies  to  hearing  tests  with  the  eyes  bandaged,  or  by  speaking  into  the  chest- 
piece  of  a  bimanual  stethoscope  with  the  tube  to  the  sound  ear  plugged  with 
wool.  The  probability  is  that  the  patient  will  say  he  hears  words  spoken  into 
the  stethoscope,  but  on  removing  this  and  covering  the  sound  ear  with  the 
finger,  he  will  say  that  he  hears  nothing.  Philip  Turner. 

DEFORMITY  OF  THE  CHEST.— In  considering  the  differential  diagnosis  of 
alterations  in  the  form  of  the  chest,  it  must  be  remembered  that  there  are  many 
slight  deviations  from  its  typical  form  which  are  not  produced  by  disease.  A 
long  narrow  chest  {alar  chest),  or  one  flattened  anteriorly  {flat  chest)  is  often  found 
in  persons  predisposed  to  phthisis ;  but  these  also  occur  in  individuals  who  are 
never  affected  by  this  disease.  A  long  neck  and  sloping  shoulders  are  also 
associated  with  this  condition,  while  a  short,  thick  neck  with  high  shoulders  is 
found  in  persons  subject  to  apoplexy. 

The  alterations  in  the  form  of  the  chest  which  may  result  from  disease  are  very 
numerous,  and  are  best  considered  under  the  following  headings  : — 

(i).   Deformities  the  result  of  rickets  ; 

(2).  General  changes  in  the  form  of  the  chest  :  (a)  The  barrel-shaped,  {b)  Uni- 
lateral enlargement,    (c)   Unilateral  shrinking  ; 

(3).  Local  changes  :    (a)  Bulging,    (b)  Retraction. 

1.  Rickets. — The  following  deformities  of  the  chest  in  an  infant  are  due  to 
rickets.  The  chest  is  somewhat  pear-shaped  on  transverse  section,  and  a  long 
vertical  groove  is  often  seen  on  each  side  of  the  sternum.  Beading  of  the 
sternal  ends  of  the  ribs  takes  place,  giving  rise  to  the  rickety  rosary.  The 
pigeon  chest,  in  which  the  ribs  are  flattened  on  each  side  in  front,  so  that  the 
sternum  becomes  unusually  prominent,  making  the  chest  appear  somewhat 
triangular  on  transverse  section,  is  always  due  to  rickets  {Fig.  57).  Harrison's 
sulcus,  which  is  a  horizontal  groove  in  the  lower  part  of  the  rickety  chest,  is 
due  to  the  sinking  in  of  the  ribs  above  the  attachment  of  the  diaphragm.  This 
groove  is  exaggerated  because  the  lower  ribs  are  pushed  out  by  the  increase 
in  size  of  the  abdominal  viscera.  All  these  deformities  of  the  chest  are  usually 
associated  with  other  signs  of  rickets  in  the  child,  which  make  the  diagnosis  easy. 

2.  General  Changes. — {a).  The  Barrel-shaped  Chest  is  found  in  patients  suffering 
from  pulmonary  emphysema  {Fig.  59).  The  chest  is  enlarged  in  all  directions, 
and  gives  the  appearance  which  is  assumed  by  the  normal  chest  only  after  deep 
inspiration.  The  an tero- posterior  diameter  is  greatly  increased.  The  shoulders  are 
higher  than  in  health,  and  the  intercostal  spaces  are  enlarged  and  bulging,  while 
the  dorsal  curve  of  the  spine  is  exaggerated  and  the  back  rounded.     The  move- 


192 


DEFORMITY     OF     THE     CHEST 


ments  of  the  chest  during  respiration  are  extremely  restricted  on  account  of  the 
rigidity  of  the  costal  ligaments,  which  become  ossified.  There  is  very  little 
expansion  of  the  chest  during  inspiration,  but  there  is  elevation  of  the  chest  as  a 
whole.  The  epi-sternal  fossa  is  deep,  the  clavicles  stand  out  prominently  unless 
the  patient  is  stout,  and  the  neck  appears  abnormally  short.  The  apex  beat  of 
the  heart  cannot  be  felt,  as  it  is  covered  by  the  lung.  Vocal  fremitus  is  diminished. 
On  percussion,  the  note  over  the  lungs  is  hyper -resonant,  the  cardiac  dullness  is 
greatly  diminished  and  often  obliterated,  and  the  upper  level  of  the  hepatic 
dullness  is  lowered.  The  breath-sounds  upon  auscultation  are  enfeebled,  and 
expiration  is  markedly  prolonged.  If  bronchitis  be  present  also,  adventitious 
sounds  are  heard,  especially  sonorous  and  sibilant  rhonchi,  and  coarse  bubbling 
rales.  The  heart-sounds  are  obscured,  the  pulmonary  second  sound  is  accen- 
tuated, and  there  are  signs  of  engorgement  of  the  right  side  of  the  heart. 


^./"^^ 

~^^ 

[2% 

2V^     \ 

\~-- 

's/ 

Fi,s;.  55. — Rickety  chest — 
child,  aged  15  months. 


Fig.  57. — Pigeon  chest — 
child,  aged  14  months. 


Fig.  56. — Normal  adult  chest. 


i-''^-' ~^=*1 

// 

U      5Vz 

^ 

^^    \ 

1                  , 

\                          ; 
\  *                         1 

^^ 

1 1 
/ 1 

/   ; 

\  \                        1 

* 

/    / 

\^                   , 

y  J 

x:—-;'- 

_^-' 

},'ig_  58.— Fibrosis  of  the  left  lung— man,  Fig.  59.— Emphysematous  chest, 

aged  30  years. 

Cyrtometric  Tracings  of  Various  Forms  of  Chest 

Transverse  sections  of  various  forms  of  chest  at  the  level  of  the  sterno-xiphoid  articulation,  reduced 
from  cyrtometric  tracings.  The  dotted  lines  indicate  the  natural  shape  at  the  same  age.  The  figures 
represent  the-  measurements  in  inches.     (Sawyer's  Physical  Signs,   igo8.) 


Whenever  any  loss  of  symmetry  in  the  two  sides  of  the  chest  is  found,  the 
vertebral  column  must  be  carefully  examined,  as  the  alteration  may  be  due  to 
a  spinal  curvature. 

(5).  A  Unilateral  Enlargement  of  the  chest  can  be  produced  by  an  extensive 
pleuritic  effusion,  a  large  empyema,  pneumothorax,  and  when  an  intrathoracic 
tumour  affects  the  greater  part  of  one  side  of  the  chest.  The  cause  of  the  enlarge- 
ment is  ascertained  by  the  physical  examination  ;  thus,  with  pleuritic  effusion, 
either  serous  or  purulent,  the  movements  of  the  affected  side  during  respiration 
are  restricted,  while  those  of  the  opposite  side  are  exaggerated.  Dullness  is 
found  over  the  effusion,  while  above  the  effusion  the  percussion  note  is  usually  of 
higher  pitch  than  normal,  and  often  skodaic.     Vocal  fremitus  and  resonance  are 


DEFORMITY     OF     THE     CHEST  193 

absent  over  the  dull  area,  and  the  breath-sounds  are  diminished  or  absent. 
.Egophony  may  be  present  at  the  upper  level  of  the  fluid,  most  frequently  in  the 
neighbourhood  of  the  inferior  angle  of  the  scapula.  The  lung  is  compressed  by 
the  effusion,  so  that  the  breath-sounds  are  frequently  tubular  at  the  upper  level 
of  the  fluid.  The  presence  of  the  fluid  is  further  confirmed  by  finding  the  heart 
pushed  over  to  the  opposite  side,  and  the  liver  depressed  when  the  right  pleura 
is  involved.  When  a  pneumothorax  is  present,  there  is  usually  a  history  of  a 
sudden  onset,  accompanied  by  a  severe  pain  in  the  chest.  The  affected  side  does 
not  move  as  freely  as  the  other  with  respiration.  The  heart  is  displaced  towards 
the  opposite  side,  and  vocal  fremitus  and  resonance  are  diminished  or  absent. 
The  note  over  a  pneumothorax  may  be  resonant,  provided  the  distention  is  not 
great  ;  but  if  the  distention  is  excessive,  and  the  cavity  contains  serum  or  pus, 
in  addition  to  air  the  note  is  usually  dull  or  greatly  impaired  at  the  base  of 
the  lung,  with  hyper-resonance,  but  absence  of  breath-sounds  above.  When 
much  fluid  is  present,  the  note  changes  considerably  with  the  position  of  the 
patient.  Signs  of  compression  of  the  lung  are  present  as  in  pleuritic  effusion. 
The  metallic  tinkling  of  Laennec  is  heard  over  a  pneumothorax,  and  coughing 
is  generally  required  for  its  production.  It  resembles  the  sound  which  occurs 
when  "  a  drop  of  water  falls  on  the  surface  of  a  fluid  contained  in  a  half-filled 
decanter."  The  bell  sound  or  the  "  bruit  d'airain  "  is  very  characteristic  of  a 
pneumothorax.  To  hear  it,  auscultation  is  performed  over  a  portion  of  the 
pneumothorax,  and  a  coin  is  placed  on  another  portion  and  is  struck  with  a 
second  coin  ;  the  sound  has  a  ringing  metallic  quality  like  that  of  the  tinkling 
of  a  small  bell,  or  like  the  ring  that  accompanies  hammering  upon  a  blacksmith's 
anvil.  Hippocratic  succussion  may  also  be  obtained  when  the  observer's  ear 
is  applied  to  the  chest,  while  the  patient's  body  is  shaken  or  jolted. 

(c) .  Shrinking  of  the  whole  of  one  side  of  the  chest  is  due  to  contraction  of  one 
lung,  either  as  the  result  of  a  previous  compression  by  a  large  pleuritic  effusion, 
and  especially  by  an  empyema,  or  on  account  of  fibrosis  of  the  lung  (Fig.  58).  The 
history  of  the  patient  often  indicates  clearly  the  cause  of  the  contraction  of  the 
lung  ;  a  large  effusion  may  have  been  aspirated,  or  an  empyema  may  have  been 
drained  by  surgical  means,  leaving  the  scar  of  the  operation.  In  other  cases,  the 
empyema  may  have  burst  into  the  lung,  and  there  may  be  a  history  of  a  large 
amount  of  pus  having  been  expectorated.  With  fibrosis  of  the  lung,  the  affected 
side  is  retracted  and  shrunken,  the  intercostal  spaces  are  very  narrow,  and  the 
ribs  may  even  overlap.  The  shoulder  is  lower  on  the  affected  side,  and  the 
vertebral  column  is  deviated  towards  the  diseased  lung.  The  heart  is  drawn  over 
to  the  affected  side,  in  which  there  is  very  little  movement  during  respiration.  If 
the  left  lung  be  affected,  the  heart  wfll  be  less  covered  by  lung  than  normally, 
and  so  there  may  be  a  large  area  over  which  cardiac  pulsation  is  visible.  The 
note  over  the  contracted  lung  is  dull,  while  on  the  opposite  side  it  is  hyper- 
resonant.  The  breath-sounds  are  deficient  or  absent,  and  may  be  tubular  or 
cavernous,  while  at  the  base  there  are  numerous  coarse  bubbling  rales,  especially 
if  there  is  bronchiectasis.  Vocal  fremitus  may  be  decreased  or  exaggerated. 
The  expectoration  is  generally  copious,  semi-purulent,  and  often  foetid.  There 
is  often  marked  clubbing  of  the  tips  of  the  fingers. 

3.  Local  Changes. — {a).  Bulging  of  any  portion  of  the  chest  wall  may  occur,  and 
be  difficult  of  diagnosis.  Sometimes  its  cause  is  quite  obvious,  as  when  an 
empyema  points  externally.  Even  this  is  sometimes  mistaken  for  a  localized 
abscess  of  the  chest  wall,  but  a  careful  examination  reveals  the  fact  that  a 
large  empyema  is  present.  Local  bulging  and  deformity  are  very  common  in 
rickets.  In  pulmonary  emphysema,  bulging  is  often  present  in  the  supra- 
clavicular and  infraclavicular  regions.  Bulging  may  also  be  due  to  an  intrathoracic 
tumour,  to  an  aneurysm  of  the  aorta,  and  to  a  tumour  or  abscess  of  the  chest  wall. 

D  13 


194  DEFORMITY     OF     THE     CHEST 

The  most  common  situation  on  the  chest  wall  for  an  aneurysmal  swelling  is  to 
the  right  of  the  sternum  in  the  first,  second,  and  third  intercostal  spaces.  An 
aneurj^sm  may  erode  the  upper  part  of  the  sternum  and  so  produce  a  swelling 
there,  while  in  rare  instances  it  may  produce  a  prominence  on  the  left  of  the 
sternum.  A  bulging  to  the  left  of  the  vertebral  column  may  be  due  to  an 
aneurysm  of  the  descending  thoracic  aorta.  The  expansile  character  of  the 
pulsation  which  occurs  in  these  situations  proves  the  existence  of  an  aneurysm. 
A  tumour  or  abscess  of  the  chest  wall  may  occur  in  any  situation.  The  praecordia 
becomes  prominent  in  children  in  cases  of  pericardial  effusion,  or  when  the  heart 
is  enlarged,  and  the  situation  of  the  prominence  indicates  at  once  its  cardiac 
origin.  An  enlargement  of  the  liver  may  also  produce  a  prominence  of  the  ribs 
under  which  it  lies.  A  hepatic  abscess,  a  subdiaphragmatic  abscess,  or  an 
emp3^ema,  sometimes  point  over  the  lower  part  of  the  chest  in  front,  while  a 
psoas  abscess  may  point  over  the  lower  ribs  posteriorly.  A  prominence  over 
the  spinal  column  in  the  dorsal  region  may  be  due  to  spinal  caries,  or  to  a 
malignant  new  growth  of  the  spine.  An  angular  curvature  of  the  spine  is  most 
commonly  due  to  spinal  caries,  and  any  swelling  which  is  associated  with  it 
may  be  produced  by  an  abscess  arising  from  the  disease.  Bulgings  which  give 
an  impulse  on  coughing,  and  which  wax  and  wane  with  respiration,  suggest 
hernia  of  the  lung,  sometimes  of  considerable  size,  in  marasmic  children  suffering 
from  whooping-cough,  or  in  emaciated  phthisical  subjects  with  incessant  cough. 
{b) .  Retraction  or  localized  shrinking  of  the  chest  wall  occurs  in  any  condition 
in  which  there  is  a  portion  of  lung  contracted  by  disease.  When  present  over 
one  or  both  apices  of  the  lungs,  as  shown  by  retraction  in  the  supra-  and  infra- 
clavicular regions,  it  is  nearly  always  due  to  phthisis,  active,  latent,  or  healed. 
It  is  also  found  in  fibroid  conditions  of  the  lungs  which  are  not  tuberculous.  After 
the  absorption  of  a  pleuritic  effusion  or  the  removal  of  the  pus  from  an  empyema, 
the  lung  is  sometimes  unable  to  expand,  and  a  local  shrinking  of  the  chest  wall 
occurs  in  consequence.  j ,  e.  H.  Sawyer. 

DELIRIUM. — Sydenham's  Dictionary  defines  delirium  as  raving,  which  does 
not  help  us  much  in  diagnosis,  for  it  draws  no  distinction  between  the  casual 
delusions  of  a  chronic  lunatic  while  these  are  being  verbally  expressed,  and  the 
same  delusions  being  verbally  expressed  by  a  patient  severely  ill  with  delirium 
tremens  or  typhoid  fever.  The  definition  is,  however,  comparatively  immaterial, 
for  in  practical  medicine  the  point  to  be  decided  is  what  has  caused  a  given 
mental  obfuscation,  and  not  the  particular  form  it  may  take. 

An  overwhelmingly  large  proportion  of  such  cases  occur  in  the  course  of 
some  well-known  disease,  commonly  pyrexial,  and  beyond  the  fact  that  the 
condition  itself  in  such  diseases  is  a  symptom  of  somewhat  serious  import,  nothing 
need  be  said  as  regards  the  diagnosis.  There  are,  however,  a  few  prognostic 
points  worthy  of  mention  in  connection  with  such  cases.  Thus,  in  typhoid  during 
the  height  of  the  fever,  in  measles,  and  in  scarlet  fever,  the  delirium  is  commonly 
in  proportion  to  the  pyrexia  in  its  violence,  and  can  usually  be  controlled  by 
controlling  the  pyrexia,  if  necessary  ;  in  the  later  stages  of  typhoid,  a  low  mutter- 
ing delirium  is  of  very  serious  import.  In  pneumonia,  on  the  other  hand,  some 
degree  of  delirium  is  an  almost  constant  factor,  no  matter  what  the  temperature 
may  be,  and  its  significance  depends  upon  the  previous  (alcoholic)  history  of  the 
patient,  upon  the  violence  or  severity,  and  duration  or  persistence  of  the  mental 
phenomena,  which  cause  proportionate  exhaustion.  In  rheumatic  fever  (unless 
due  to  salicylates,  vide  infra)  delirium  is  of  extremely  grave  significance,  being 
commonly  associated  either  with  hyperpyrexia  or  with  definite  intracranial 
inflammation,  neither  of  which  is  at  all  common.  In  influenza,  too,  it  is  a 
symptom  causing  great  anxiety. 


DELIRIUM  195 

The  difficulties  of  diagnosis  arise  chiefly  when  we  are  called  to  a  case  of 
delirium  of  which  we  have  no  previous  knowledge,  where  in  fact  our  services 
are  sought  primarily  because  the  patient  has  "gone  off  his  head  and  is  talking 
nonsense,"  and  we  must  consider  to  what  different  factors  this  may  be  due. 
The  following  table  embraces  causes  ordinarily  met  with. 

These  may  first  be  divided  into  those  cases  in  which  changes  in  the 
brain-cells  are  the  primary  cause,  and  those  in  which  some  poison  circulating 
in  the  blood  is  the  primary  cause  of  the  altered  brain  function  ;  this  is 
practically  accurate,  though  theoretically  it  is  conceivable  that  the  first  class 
is  really  due  to  the  second  cause.  The  second  group  may  be  subdivided 
according  to  whether  the  poison  is  developed  in  the  body  {a)  by  its  own 
activities,  or  {b)  by  microbic  agency,  or  whether  it  is  due  to  some  definite 
chemical  poison  introduced  into  the  body  from  without.  Thus  in  tabular 
form  we  have  : — 

Delirium  due  to  intrinsic  brain-  (     Mania  or  lunacy  in  all  its  forms. 

cell  changes  or  to  pure  nerve  -.      Pain,  occasionaily  so  severe  as  to  produce  it. 
influences.  i     Shock,  ditto. 

/      Uraemia.  ' 

T^  1-  ■         J        ,  •  ■  ■  Diabetes. 

Delirmm  due  to  poison  arismg  {  Anaemia 

in  the  body  (autogenetic).        ",  poiycythaemia  ? 

V  Impending  death  from  any  cause. 


-ni„i;„-„^      ^,  „     4-       „•„    1,-  Fevers  of   any  and   everv  kind,  known   and 

Delirium     due     to     microbic      I  ,  ^      xu  ■'  ■£.  ■       u- 

unknown     as    to    their    specific     microbic 

origin. 

Belladonna,    hyoscyamus,    and    their    allies 

alcohol  and  other  less  common  intoxicants, 

i-i„i;r,-„™  A„r.  j.^  „u„^;„.,i  „       J.    I  anaesthetizing  substances,   and    hvpnotics. 

Delirium  due  to  chemical  agents  i  t      j  j       ^u  i.  1  '  •       n 

^         ^  Lead,      and     other     metals     occasionally. 

Exceptionally,  it    arises   from    almost   any 

poison    or   drug,    most    typically,   perhaps, 

from  artificial  salicylate  of  sodium. 


activities. 


introduced  from  without. 


Like  all  other  complete  tables  of  diagnostic  problems,  the  difficulties  are  much 
greater  on  paper  than  in  practice,  for  in  almost  every  case  there  is  some  one 
overwhelming  and  outstanding  fact  in  the  history  which  settles  the  matter 
off-hand.  It  is  well,  however,  to  have  some  fixed  order  of  procedure  laid  down, 
which  may  take  the  following  lines  : — 

1.  Make  strict  enquiries  as  to  anything  unusual  having  been  lately  taken  or 
applied.  Medicines  containing  belladonna,  drops  put  into  the  eyes,  or  some 
strange  or  unusual  vegetable  eaten,  are  the  most  likely  things. 

2.  Enquire  as  to  the  recent  health  of  the  individual  bearing  on  the  urinary 
secretion,  anaemia,  etc.  ;  also  enquire  about  incidents  that  might  have  caused 
shock,  and  incidents  suggestive  of  a  simple  idiopathic  mental  disorder. 

3.  Take  the  temperature  ;  if  materially  raised  it  suggests  some  form  of 
microbic  influence,  although  in  some,  such  as  rabies,  the  pyrexia  may  not  be 
great. 

4.  Note  the  pupils  :  if  dilated  and  fixed,  they  suggest  belladonna  or  perhaps 
alcohol — delirium    tremens    can    hardly    occur    without    a    definite    history    of 

soaking,"  or  an  accident ;  contracted  and  immovable  pupils  suggest  uraemia  ; 
unequal  pupils,  general  paralysis  of  the  insane. 

5.  Test  the  urine  ;  this  will  go  far  in  clearing  up  urinary  causes.  Further 
details  must  be  sought  under  the  appropriate  headings. 

6.  Note  the  skin,  whether  dry  or  sweating,  whether  flushed  or  pale  ;  in  poison- 
ing by  belladonna,  etc.,  it  is  often  dry  and  flushed  ;  if  connected  with  other 
dangerous  chemical  poisons,  it  is  commonly  pale  and  sweaty.         Fred.  J .  Smith. 


196  DIACETURIA 


DIACETURIA — or  the  passage  of  diacetic  acid  in  the  urine — occurs  under 
precisely  similar  circumstances  to  Acetonuria  {q.v.).  It  only  remains  to 
mention-  the  following  clinical  test  for  diacetic  acid  : — 

To  one  inch  of  urine  in  a  test-tube  add  liquor  ferri  perchloridi  (B.P.)  drop  by 
drop.  For  a  moment  a  white  precipitate  of  iron  phosphate  forms,  and  then,  if 
aceto-acetic  acid  be  present,  the  liquid  becomes  deep  purple-red,  this  colour 
being  discharged  on  warming. 

If  carbolic  acid,  salol,  salicin^  or  salicylates  are  being  taken,  the  urine  contains 
phenyl  compounds  which  give  a  similar  reaction  with  ferric  chloride,  but  when 
the  colour  is  due  to  these  it  does  not  disappear  on  warming.  Herbert  French 

DIARRHCEA. — Diarrhoea  is  a  symptom  which  may  be  due  to  many  different 
causes  which  it  is  important  to  differentiate  if  possible.  It  is  convenient  in  the 
first  place  to  divide  cases  into  the  two  groups  :    (i)  Acute,  and  (2)   Chronic. 

1.  Acute. — The  history  is  of  great  importance.  It  may  elicit  some  indiscretion 
of  diet  (the  eating  of  unripe  fruit,  etc.) ,  or  the  consumption  of  some  toxic  article 
of  food  {ptomaine  poisoning).  In  such  cases  vomiting  is  often  present  as  well. 
In  toxic  cases  there  is  great  depression,  and  a  feeble  and,  perhaps,  irregular 
pulse. 

If  there  be  fever,  one  should  think  of  an  infective  cause,  such  as  summer 
diarrhoea  (in  children),  typhoid  fever,  or  dysentery.  In  the  case  of  typhoid, 
enlargement  of  the  spleen  is  an  early  confirmatory  sign,  but  is  sometimes  absent  ; 
spots  should  also  be  looked  for.  The  presence  of  leucopenia  may  be  of  help, 
and  the  pulse-rate  is  low  in  proportion  to  the  temperature.  The  agglutination 
reaction  is  not  usually  obtainable  until  the  end  of  the  first  week.  In  dysentery 
there  will  be  tenesmus,  with  blood  and  mucus  in  the  motions.  In  the  amoebic 
form,  the  Amceba  coli  may  be  found  in  the  stools  (see  Fig.  12,  p.  91).  In  the 
specific  form,  the  blood  serum  agglutinates  Shiga's  bacillus.  Similar  symptoms 
to  those  of  dysentery  are  produced  by  acute  colitis,  especially  of  the  ulcerative 
form.  It  should  also  be  remembered  that  in  young  children  intussusception 
produces  diarrhoea,  with  blood  and  mucus  in  the  motions ;  the  characteristic 
sausage-shaped  tumour  should  therefore  be  looked  for,  and  a  careful  rectal 
examination  made.  The  presence  of  any  faecal  colouring  matter  in  the  discharge 
usually  negatives  intussusception. 

Appendicitis  may  begin  with  acute  diarrhoea,  and  the  possibility  of  this  should 
be  borne  in  mind. 

In  pernicious  ancBmia  and  in  Addison's  disease,  periodic  attacks  of  acute 
diarrhoea  are  apt  to  occur.  The  other  characteristic  signs  and  symptoms  of 
these  affections  will  be  present.    (See  Anaemia  ;  and  Pigmentation  of  the  Skin.) 

Finally,  it  should  be  remembered  that  even  although  diarrhoea  is  due  to  a 
new  growth  in  the  bowel,  it  may  begin  acutely,  and  a  rectal  examination 
should  never  be  omitted. 

2.  Chronic. — In  all  cases  of  chronic  diarrhoea  the  lower  bowel  should  be 
carefully  examined,  preferably  with  the  sigmoidoscope.  This  will  enable  one  to 
exclude  local  conditions  in  the  rectum,  chronic  intussusception,  and  catarrhal,  or 
ulcerative  colitis,  as  causes.  A  test-meal  should  also  be  given,  for  many  cases 
of  chronic  diarrhoea  are  due  to  deficient  secretion  of  gastric  juice,  or  to  its  total 
absence  (achylia)  ;  such  cases  are  spoken  of  as  gastrogenic  diarrhoea.  (See  also 
Indigestion.)  The  stools  should  also  be  examined  both  with  the  naked  eye  and 
the  microscope. 

In  order  to  examine  the  stool  a  portion  the  size  of  a  walnut  should  be  rubbed  up  with 
distilled  water  to  a  fluid  consistency,  and  examined  with  the  naked  eye  against  a  dark 
background. 

Normally  one  sees  a  homogeneous  fluid  made  up  of  very  small  dark-grey  particles. 
In  pathological  conditions  one  may  recognize  mucus,  pus,  blood,  parasites,  the  remains 


DIARRHCEA  197 


of  connective  tissue  in  the  form  of  yellowish-white  shreds,  brown  muscle  fibres,  and  the 
residue  of  potatoes  in  the  form  of  glossy  granules. 

For  microscopical  examination  one  prepares  three  specimens.  The  first  is  examined 
as  it  is  ;  to  the  second  one  adds  a  few  drops  of  30  per  cent  acetic  acid  and  heats  a  little 
to  dissolve  fat  ;    to  the  third  is  added  a  little  iodine  solution. 

A  normal  stool  shows  in  the  first  preparation  a  few  muscle  fibres,  some  yellow  lumps 
of  lime  salts,  and  a  few  empty  potato  cells.  In  the  second  preparation,  a  few  fatty 
crystals  ;  in  the  third  a  very  few  violet-tinted  starch  grains.  In  pathological  conditions 
one  may  find  in  the  first  preparation  many  well-preserved  muscle  fibres,  numerous  fat 
droplets  and  fatty  crystals,  and  abundance  of  potato  cells  ;  in  the  acetic  acid  preparation, 
numerous  masses  of  crystals  of  fatty  acids ;  in  the  iodine  preparation,  an  excess  of  starch. 

In  order  to  test  for  Bile,  mix  some  of  the  stool  with  concentrated  corrosive  sublimate 
solution  and  allow  to  stand  for  twenty-four  hours.  Normally  it  turns  red  from  the 
presence  of  urobilin  ;  greenish  particles  show  the  presence  of  unaltered  bilirubin  ;  absence 
of  green  or  red  colouring  shows  that  bile  is  not  present  at  all. 

Reaction  of  the  Stool. — A  drop  of  the  stool  prepared  as  above  by  rubbing  up  with  water 
is  applied  with  a  glass  rod  to  a  piece  of  moistened  litmus  paper.  The  reaction  can  easily 
be  seen  on  the  other  side  of  the  paper.  A  normal  stool  is  nearly  neutral  ;  marked 
alkalinity  indicates  putrefaction  ;    acidity  shows  carbohydrate  fermentation. 

Test  for  "  Occult  "  Blood. — The  patient  must  have  eaten  no  red  meat  for  two  or  three 
days.  A  portion  of  the  stool  the  size  of  a  hazel-nut  is  rubbed  up  with  2  c.c.  of  distilled 
water  in  a  mortar  and  placed  in  a  test-tube.  Add  half  its  volume  of  glacial  acetic  acid, 
and  shake.  Then  nearly  fill  the  tube  with  ether,  and  reverse  several  times.  To  about 
one  inch  of  the  resulting  yellow,  translucent,  ethereal  solution,  add  :  (a)  a  few  drops  of 
glacial  acetic  acid,  (b)  one  inch  of  freshly  prepared  saturated  solution  of  benzidin  in 
rectified  spirit,  (c)  one  inch  of  liq.  hydrog.  perox.  Shake,  and  pour  a  few  drops  on  to  a 
porcelain  slab.     If  blood  be  present,  a  blue  colour  appears. 

White  stools  containing  excess  of  fat  point  to  disease  in  the  pancreas  (pan- 
creatic diarrhcea)  ;  blood  and  mucus,  to  some  form  of  coUtis  ;  the  presence  of  meat 
fibres  and  connective  tissue  in  excess,  to  gastrogenic  diarrhoea  ;  unaltered  starch 
grains,  to  fermentative  diarrhcea  from  mal-digestion  of  starch  ;  yellow  stools  con- 
taining microscopic  particles  of  bile-stained  mucus,  to  catarrh  of  the  small  bowel. 

If  all  these  causes  can  be  excluded,  one  may  have  to  deal  with  a  case  of  nervous 
diarrhoea,  which  is  characterized  by  a  tendency  for  the  bowels  to  act  immediately 
after  a  meal  {lientery),  and  on  excitement,  or  under  emotional  influences.  A 
good  many  cases  of  so-called  "  morning  diarrhcea  "  are  of  this  type.  The  history, 
the  presence  of  other  evidences  of  nervous  irritability,  and  the  fact  that  the 
general  nutrition  is  well  maintained,  all  yield  confirmatory  evidence. 

In  patients  who  have  lived  in  the  East  the  possibUity  of  sprue  has  to  be  con- 
sidered. The  pale,  frothy,  and  copious  stools  are  characteristic,  as  well  as  the 
presence  of  a  painful  stomatitis  involving  the  tongue  and  lining  of  the  cheeks. 

If  the  indications  point  to  a  chronic  catarrh  of  the  intestine,  phthisis  (see 
Cough)  cirrhosis  of  the  liver  (see  Liver,  Enlargements  of),  and  renal  disease 
(see  Indigestion),  should  always  be  looked  for,  and  the  question  of  possible 
alcoholism  gone  into,  as  all  of  these  conditions  are  apt  to  be  attended  by  a  chronic 
diarrhoea,  which  may  be  the  first  symptom  to  bring  the  patient  to  his  doctor. 

Amyloid  disease  is  a  rare  cause  of  chronic  diarrhoea.  There  may  be  a  history 
of  prolonged  suppuration,  or  of  tertiary  syphilis,  and  signs  of  amyloid  disease 
in  other  organs  (e.g.,  albuminuria,  with  a  low  gravity  urine,  enlargement  of  the 
spleen,  etc.). 

One  should  also  remember  to  enquire  into  the  possibility  of  chronic 
irritant  poisoning,  e.g.,  by  arsenic  or  antimony.  Robert  Hutchison. 

DIAZO-REACTION. — The  diazo-reaction  of  Ehrhch  is  obtained  in  certain 
urines  on  testing  them  with  the  following  solutions  : — 

(i)    Sodium  Nitrite    -     -     o'5  gram.     \     (2)     Sulphanilic  Acid  -     -     o'5  gram. 
Distilled  Water  -     -     100  c.c.         '  Hydrochloric  Acid    -       '5  c.c. 

Distilled  Water    -     -     100  c.c. 

A  strong  solution  of  ammonia  is  also  required,  and  all  should  be  freshly  pre- 
pared.    To  a  drachm  of  sulphanilic  acid  solution  add  a  drop  of  sodium  nitrite 


DIAZO-REACTION 


solution^  mix  with  a  drachm  of  the  urine,  and  add  ammonia  to  excess.  A 
normal  urine  turns  brownish-yellow  ;  when  the  reaction  is  positive  the  mixture 
turns  deep  red,  and,  most  characteristic  of  all,  the  froth  produced  on  shaking 
the  test  tube  is  rosy  red. 

It  is  often  regarded  merely  as  an  obsolete  test  for  typhoid  fever  ;  but  it 
occurs  in  a  great  many  other  conditions — as  will  be  obvious  when  it  is  realized 
that  it  is  merely  an  indication  of  abnormal  protein  metabolism,  leading  to  the 
elimination  of  certain  aromatic  substances  which  react  in  this  way  to  diazo 
compounds.  The  following  are  some  of  the  conditions  under  which  the  diazo- 
reaction  has  proved  positive  : — Many  fevers,  such  as  diphtheria,  erysipelas, 
measles,  pneumonia,  scarlet  fever,  typhoid,  typhus  ;  cachectic  states,  such  as 
advanced  phthisis,  cancer,  cirrhosis,  syphilis,  malaria,  grave  anaemias  ;  and  as 
the  result  of  poisoning  by  certain  drugs,  such  as  chrysarobin,  guaiacol,  carbolic 
acid,  or  opium. 

Clearly  a  reaction  which  is  found  to  occur  under  so  many  different  circum- 
stances can  have  but  a  limited  value.  There  are  some  who  say  that  it  has  no 
value  at  all  ;  others,  however,  find  it  of  clinical  use  in  the  following  respects  : 
(i)  It  is  never  normal  ;  (2)  It  is  more  constantly  present  in  cases  of  typhoid 
than  in  any  other  fever,  so  that,  other  things  being  equal,  the  presence  of  the 
diazo-reaction  may  help  in  diagnosing  typhoid  fever,  though  the  converse  is  not 
true  ;  (3)  In  cases  of  phthisis  a  positive  diazo-reaction  is  a  sign  of  ill-omen, 
whilst  should  the  diazo-reaction  disappear  after  it  has  been  present,  it  is  evidence 
of  material  improvement,  even  though  the  physical  signs  remain  the  same. 

Herbert  French. 

DILATATION  OF  THE  HEART.— (See  Enlargement  of  the  Heart.) 

DIPLOPIA,  or  double  vision,  may  be  either  monocular  or  binocular  ;  that  is 
to  say,  an  object  may  be  seen  double  either  with  one  eye  alone,  or  only  when 
both  eyes  are  open.  To  distinguish  between  the  two  conditions  it  is  only 
necessary  to  close  each  eye  in  turn.  If  with  either  eye  the  object  is  still  seen 
double,  the  diplopia  is  monocular  ;  if,  on  the  other  hand,  the  object  is  seen  singly 
with  each  eye,  and  only  seen  double  when  both  eyes  are  open,  the  double  vision 
is  binocular. 

Monocular  diplopia  may  be  due  to  : — (i)  Dislocation  of  the  lens;  (2)  Incipient 
cataract  ;  (3)  Low  degrees  of  astigmatism  ;  (4)  Double  pupillary  apertures  when 
the  eyes  are  not  in  accurate  focus. 

1.  In  dislocation  of  the  lens  when  its  edge  crosses  the  pupil,  images  of  an  object 
may  be  formed  both  by  the  rays  passing  through  the  periphery  of  the  lens  and 
by  those  passing  beside  it.  Owing  to  the  prismatic  shape  of  the  edge  of  the 
convex  lens,  the  images  will  be  cast  on  different  parts  of  the  retina,  and 
diplopia  will  result. 

Dislocation  of  the  lens  may  be  recognized  by  the  presence  of  the  crescentic 
edge  of  the  lens,  which  appears  dark  in  the  illuminated  pupil,  by  tremulousness 
of  the  iris,  and  by  irregularity  in  the  depth  of  the  anterior  chamber. 

2.  In  incipient  cataract,  especially  the  cortical  variety,  the  lens  may  be  broken 
up  into  sectors  of  varying  refrangibility  by  radial  striae,  both  opaque  and  trans- 
parent. In  this  condition  diplopia,  or  more  commonly  polyopia,  may  result. 
A  candle  or  other  bright  object  appears  double  or  multiple.  The  condition 
can  be  recognized  easily  on  examination  of  the  dilated  pupil  with  the  ophthalmo- 
scope. 

3.  Monocular  diplopia  is  a  fairly  common  symptom  of  low  degrees  of 
astigmatism,  particularly  where  the  curvature  of  the  cornea  is  slightly  irregular. 
Letters  and  test  types  are  accompanied  by  faint  "  ghosts,"  placed  either 
above   or   to    the    side    of    the    real    letters,    and    in    some    cases    overlapping 


DIPLOPIA 


199 


them.  The  cause  of  this  condition  can  be  ascertained  only  by  a  careful 
examination  of  the  refraction,  and  the  diplopia  is  cured  by  the  prescription 
of  suitable  glasses. 

4.  When  the  eyes  are  accurately  focussed,  a  double  pupillary  aperture,  whether 
congenital  or  traumatic,  does  not  produce  diplopia,  all  rays  passing  through 
either  aperture  being  concentrated  on  the  same  spot.  When,  however,  the 
eyes  are  not  focussed  accurately,  two  images  result,  one  being  formed  by  the 
rays  passing  through  each  aperture. 

Binocular  Diplopia  may  be  : — (i)  Physiological;   (2)  Pathological. 

I.  Physiological  diplopia  occurs  unnoticed  in  all  binocular  vision,  owing  to  the 
dissimilarity  of  the  retinal  images  formed  in  the  two  eyes  viewing  the  same 
object  from  a  slightly  different  standpoint.  The  diplopia  is  not  apparent, 
however,  as  the  two  dissimilar  images  are  combined  by  the  higher  visual  centres 
in  the  brain  to  form  a  single  solid  conception  of  the  object  viewed.  The  amount 
of  dissimilarity  in  the  retinal  images  gives  the  impression  of  space  and  distance, 
near  objects  causing  images  more  unlike  than  those  formed  by  things  remotely 


F/'g.  60.  —  Homonymous  double  images. 


Fi,s:.  61. 


-Crossed  double  images. 


placed.  The  dissimilarity  of  the  two  retinal  images  in  normal  binocular 
vision,  giving  the  idea  of  space,  is  termed  in  psychology  "  disparation  "  or 
"  disparateness."  When,  however,  owing  to  some  failure  in  the  centre  which 
controls  the  fusion  of  the  two  ocular  images,  they  are  not  combined,  or  when 
some  disturbance  of  the  accurately  balanced  muscular  mechanism  upsets  the 
automatic  fixation  of  the  two  eyes  upon  the  same  object,  pathological  or  obvious 
diplopia  results. 

2.  Pathological  diplopia. — Before  discussing  the  various  forms  and  causes  of 
this  condition,  it  is  necessary  to  have  a  clear  idea  of  the  process  of  visually 
localizing  objects  in  space — projection,  or  orientation. 

In  looking  at  any  object  the  eye  is  so  turned  that  the  image  falls  upon  the 
central  point  of  the  retina — the  macula  or  yellow  spot.  All  other  objects  form 
images  upon  the  retina  which  are  more  or  less  peripheral,  and  from  experience 
of  such  sensations  and  their  locality  on  the  retina,  objects  are  accurately  placed 
in  space — projection.  An  image  falling  upon  any  particular  portion  of  the 
retina  will  always  be  projected  to  the  same  point  in  space  in  relation  to  the 


200  DIPLOPIA 

position  of  the  eyes.  In  binocular  vision,  however,  it  must  be  remembered  that 
images  of  the  same  object  do  not  fall  upon  corresponding  areas  of  both  the 
retinas.  The  image  of  an  object  to  the  right  of  the  two  eyes  falls  upon  the 
nasal  side  of  the  right,  and  the  temporal  side  of  the  left,  retina.  These  areas, 
which  are  symmetrically  placed  in  the  two  retinse,  are  always  stimulated 
simultaneously  under  normal  circumstances  by  objects  in  the  same  position, 
and  from  these  two  images  is  derived  the  idea  of  the  position  of  the  object  in 
space — orientation. 

Any  disturbance  of  binocular  vision  causes  diplopia.  For  example,  in  Fig.  60 
the  left  eye  fixes  the  object  0,  while  the  right  eye  is  rotated  inwards.  In 
consequence,  the  image  of  the  object  0  falls  upon  an  area  of  the  right  retina,  a, 
internal  to  the  macula  or  fovea,  /.  Under  ordinarj?  circumstances,  with  parallel 
binocular  vision,  the  object  whose  image  fell  upon  the  spot  a  would  be  to  the 
right  of  the  object  O  ;  hence  the  right  eye  under  these  conditions  projects  the 
object  0  to  the  position  O',  causing  a  diplopia  in  which  the  right  of  the  two 
objects  is  seen  by  the  right  eye,  and  the  left  by  the  left  eye.  This  is  termed 
homonymous  diplopia.  Fig.  61  shows  in  a  similar  manner  the  formation  of 
crossed  diplopia. 

It  will  be  seen  from  the  figures  that,  in  lateral  deviations  a  convergent  squint 
causes  homonymous,  and  a  divergent  squint  crossed,  diplopia.  In  ocular 
paralyses  the  diplopia  will  increase  if  the  two  eyes  are  carried  in  the  direction  of 
the  usual  action  of  the  paralyzed  muscle.  As  an  example,  Fig.  60  may  be  chosen 
as  a  diagrammatic  representation  of  a  paralj'sis  of  the  right  external  rectus 
muscle.  The  more  the  ej'es  are  turned  to  the  right  the  greater  will  be  the 
convergence,  owing  to  the  inability  of  the  right  eye  to  turn  to  the  right  to  the 
same  extent  as  the  left  ;  the  greater  therefore  wiU  be  the  diplopia  as  the  image 
of  the  object  0  falls  farther  and  farther  round  on  the  nasal  side  of  the  right 
retina,  the  object  being  projected  farther  and  farther  to  the  right.  It  will  also 
be  seen  from  this  consideration  that  the  farthest  displaced  image  always  belongs 
to  the  paralyzed'  eye. 

The  two  images  are  not  equally  distinct.  That  in  the  unafiected  eye  falls  upon 
the  macula  and  is  most  distinctly  seen  ;  this  is  called  the  real  image.  That 
falling  upon  the  retina  of  the  affected  eye  is  more  peripheral,  and  therefore  not 
so    distinctly    seen,    and   is   termed   the   false   or   apparent   image. 

With  the  above  considerations  in  view,  and  with  a  knowledge  of  the  individual 
actions  of  the  ocular  muscles,  it  is  easy  to  elucidate  cases  of  simple  paralysis  of 
one  or  more  ocular  muscles,  but  for  convenience  of  reference  the  chart  giving 
the  position  of  the  images  in  paralysis  of  the  various  ocular  muscles  is  repro- 
duced on  the  opposite  page. 

Binocular  diplopia  may  be  caused,  as  suggested  above,  by  paralysis  of  ocular 
muscles  (see  Strabismus),  but  it  may  also  arise  from  the  bodily  displacement  of 
one  eye  from  an  orbital  growth,  abscess,  or  kcsmorrhage.  It  may  also  occur  after 
some  operations  for  tenotomy. 

Cases  of  displacement  of  the  eye  can  usually  be  distinguished  from  those  of 
ocular  paralysis  by  the  indeterminate  character  of  the  diplopia,  which  is  accom- 
panied by  more  or  less  fixation  of  the  eyeball,  and  by  proptosis. 

Isolated  paratyses  of  individual  ocular  muscles  or  groups  of  muscles  are  nearh^ 
alwaj's  nuclear  in  origin  ;  basal  growths  rarely  cause  ocular  paralj'ses  of  any 
extent  on  one  side  only,  the  affection  sooner  or  later  becoming  bilateral. 

In  some  rare  cases  of  convergent  or  divergent  squint  with  absence  of  binocular 
vision  and  good  vision  in  each  eye,  there  may  be  the  power  of  alternate  fixation 
with  more  or  less  evident  diplopia.  As  a  rule,  however,  the  individual  has 
the  power  of  suppressing  the  image  of  the  squinting  eye,  obtaining  monocular 
vision. 


DISCHARGE     FROM     THE     NIPPLE 


20I 


I,eft-sided 
Paralysis. 


Behaviour  of  the  Double  Images  in  Paralyses  of  the 
Ocular  Muscles. 

Right-sided 


The  dotted  lines  repycsent  the  appare7it  image.     (After  Fuchs). 

External  Rectus. 
Diplopia  appears  in  looking  toward  the  paralyzed  side. 
The   lateral   separation   of   the   images   increases    as    the 
paralyzed  eye  is  abducted. 


Paralysis. 


Internal  Rectus. 
Diplopia  on  looking  towards  the  sound  side. 
The   lateral   separation    of   the   images   increases   in    ad- 
duction of  the  paralyzed  eye. 


Superior  Rectus.  « 

Diplopia  on  looking  up.  \ 

The  vertical  distance  between  the  images  increases   as  • 

the  paralyzed  eye  is  elevated  and  abducted.  • 

The  obliquity  increases  in  adduction. 
The  lateral  separation  of  the  images   diminishes  when 

the  eyes  are  turned  laterally  in  either  direction. 


Inferior  Rectus. 

Diplopia  on  looking  down. 

The  vertical  distance  between  the  images  increases  as 
the  paralyzed  eye  is  depressed  and  abducted. 

The  obliquity  increases  in  adduction. 

The  lateral  separation  of  the  images  diminishes  when 
the  eyes  are  turned  laterally  in  either  direction. 


Superior  Oblique. 

Diplopia  on  looking  down. 

The  vertical  distance  between  the  images  increases  as 
the  paralyzed  eye  is  depressed  and  adducted. 

The  obliquity  increases  with  the  abduction. 

The  lateral  distance  between  the  images  diminishes  when 
the  eyes  are  turned  laterally  in  either  direction. 


\ 


Inferior  Oblique. 

Diplopia  on  looking  up. 

The  vertical  distance  between  the  images  increases  as 
the  paralyzed  eye  is  elevated  and  adducted. 

The  obliquity  increases  with  the  abduction. 

The  lateral  distance  between  the  images  increases  as  the 
eve  is  elevated  and  abducted. 


0 


DISCHARGE  FROM  THE  EAR.— (See  Otorrhcea. 


Herbert   L.  Eason. 


DISCHARGE  FROM  THE  NIPPLE.— Discharges  from  the  nipple  may  be 
divided  into  three  classes  : — (i)  Normal  discharges.  (2)  Normal  discharges  at 
abnormal  times.      (3)  Abnormal  discharges. 

I.  Normal  Discharges. — It  is  quite  natural  for  a  woman  during  the  period  of 
pregnancy  and  lactation  to  have  a  discharge  of  milk  from  the  breast.  It  is 
usually  of  small  amount,  except  when  the  child  is  put  to  the  breast,  but  occasion- 
ally the  flow  at  other  times  may  be  sufficient  to  be  distressing. 


DISCHARGE     FROM     THE     NIPPLE 


2.  Normal  Discharges  at  Abnormal  Times. — Milk  may  come  from  the  breast  at 
other  times  than  during  pregnancy  and  lactation.  In  infants  it  may  be  found 
as  the  result  of  undue  stimulation  on  the  part  of  the  nurse,  and  it  has  been 
noted  in  the  breasts  of  both  sexes  at  the  time  of  puberty.  No  great  importance 
attaches  to  it. 

3.  Abnormal  Discharges. — Blood  or  Blood-stained  Discharge.  This  is  a  very 
significant  sign  and  should  not  be  neglected,  for  it  almost  always  indicates  the 
presence  of  some  abnormal  condition  in  the  breast  which  requires  careful 
investigation.  The  commonest  is  some  growth  involving  the  larger  ducts  in 
the  neighbourhood  of  the  nipple.  This  may  be  either  innocent — a  duct  papil- 
loma ;  or  malignant — duct  carcinoma,  scirrhous  carcinoma,  or  sarcoma.  It  behoves 
one  therefore  never  to  neglect  such  a  significant  sign. 

In  cases  in  which  a  well-marked  lump  is  easily  felt,  the  diagnosis  can  usually 
be  made  without  difficulty,  and  for  this  the  reader  is  referred  to  the  article 
on  Swelling,  Mammary.  Difficulty  arises  when  there  is  no  obvious  swell- 
ing. In  these  cases  the  breast  must  be  palpated  carefully  with  the  flat  of 
the  hand  and  also  with  the  tips  of  the  fingers,  special  attention  being  given 
to  the  part  immediately  subjacent  to  the  nipple.  If  no  swelling  can  be 
made  out,  and  the  bleeding  remains  a  persistent  sign,  it  may  become  necessary 
to  make  an  incision  into  the  breast  for  diagnostic  purposes,  recognizing 
the  fact  that  a  papilloma  may  be  so  delicate  as  to  escape  detection  with 
the  finger. 

Probably  the  commonest  cause  of  bleeding  is  a  duct  carcinoma  (columnar- 
celled  carcinoma),  and  after  that  duct  papilloma  and  scirrhous  carcinoma,  and 
last  of  all  sa,rcoma. 

A  Purulent  Discharge. — Acute  suppurative  mastitis.  Now  and  again  in  this 
condition  there  may  be  a  discharge  of  pus,  or  pus  mixed  with  milk,  from  the 
nipple.  This  is  rare,  and  the  other  signs  of  abscess  are  so  well  marked  that  there 
is  no  difficulty  in  arriving  at  a  diagnosis. 

Tuberculous  mastitis.  A  discharge  of  tuberculous  pus  is  rare  in  this  disease, 
but  should  it  occur,  this  may  help  to  distinguish  it  from  carcinoma  with  which 
it  is  often  confused. 

A  Discharge  of  Serum. — Chronic  interstitial  mastitis  with  cyst  formation 
accompanied  by  discharge  of  serum,  is  so  rare  as  only  to  call  for  passing 
mention. 

Hydatid  Fluid. — It  has  been  recorded  that  a  hydatid  cyst  has  discharged  itself 
at  the  nipple.  George  E.  Gask. 

DISCHARGE,  NASAL. — A  discharge  from  the  nose  may  be  acute,  subacute, 
or  chronic,  and  it  may  consist  of  clear  fluid  almost  like  water,  of  mucus,  muco-pus, 
pus,  food  regurgitated  through  the  nose,  or  blood.  For  the  differential  diagnosis 
of  the  causes  of  haemorrhage  from  the  nose,  see  Epistaxis. 

Regurgitation  of  Food  through  the  Nose  may  be  due  to  a  congenital  condition, 
especially  cleft-palate  ;  to  acquired  perforation  of  the  palate,  especially  syphilitic  ; 
to  post-diphtheritic  paralysis  ;  or  to  much  rarer  neuro-muscular  lesions,  such 
as  bulbar  paralysis,  pseudobulbar  paralysis,  or  myasthenia  gravis,  all  of  which 
conditions  are  discussed  elsewhere. 

Serous,  Mucous,  and  Muco-purulent  Discharges  differ  from  each  other  chiefly 
in  degree,  for  that  which  may  begin  as  serous  may  later  become  muco-purulent 
and  then  purulent,  as  is  seen  during  the  course  of  a  common  cold.  A  watery 
discharge  is  sometimes  spoken  of  as  corj^za,  though  for  the  latter  to  be  typical 
there  should  at  the  same  time  be  watering  of  the  eyes  ;  it  is  generally  acute  in 
onset,  and  the  diagnosis  of  its  cause  is  not  difficult  as  a  rule.  It  may  be  due 
to  the  following  different  conditions  : — 


DISCHARGE,     NASAL  203 


Common  cold,  early  stage  {Micro-       |       Local    irritants    such    as    snuff, 
coccus  catavrhalis)  1  ammonia    vapour,    sulphur   di- 


Lachrymation 

Hay  fever  {coryza  e  feno) 

Measles 

lodism 

Arsenic 


oxide,  and  other  irritating  gases 
Fog 

Some  cases  of  spasmodic  asthma 
Some  cases  of  trigeminal  neuralgia. 


The  differential  diagnosis  of  these  conditions  needs  little  discussion,  a  careful 
inquiry  into  the  circumstances  of  the  case  generally  pointing  to  its  nature  at 
once.  Measles  probably  presents  the  greatest  difficulty,  for  the  coryza  precedes 
the  macular  eruption,  and  the  patient,  generally  a  child,  may  seem  to  be 
suffering  merely  from  a  severe  cold,  when  in  reality  it  is  in  the  most  infectious 
stage  of  measles.  Examination  of  the  buccal  mucous  membrane  for  Koplik's 
spots  may  sometimes  serve  to  distinguish  this  malady  as  long  as  two  days 
before  the  eruption  appears. 

The  coryza  resulting  from  iodide  of  potassium  or  from  arsenic  may  be  very 
severe,  and  the  patient  generally  complains  of  constantly  catching  cold,  when 
in  reality  the  symptoms  are  due  to  the  drug. 

The  term  influenza  is  sometimes  applied  to  severe  febrile  colds  associated 
with  running  of  the  eyes  and  dripping  at  the  nose,  but  it  is  often  inaccurate  to 
apply  the  term  influenza  here,  for  the  symptoms  are  more  often  due  to  the 
Micrococcus  catarrhalis.  Bacteriological  detection  of  the  Bacillus  influenzce 
in  the  discharge  is  essential  if  influenza  is  to  be  diagnosed  with  accuracy. 

Excessive  secretion  by  the  lachrymal  glands  apart  from  emotion  may,  in  some 
instances,  lead  to  constant  dripping  of  water  from  the  nose  as  the  result  of 
neurosi^. 

One  rare  form  of  watery  discharge  from  the  nose  is  the  escape  of  cerebrospinal 
fluid  ;  this  fluid  is  perfectly  transparent,  like  water,  and  it  may  be  difficult 
to  recognize  its  true  nature  unless  there  is  a  clear  history  of  the  commonest 
cause  for  the  symptom,  namely,  an  injury  to  the  head  leading  to  fracture 
through  the  base  of  the  skull,  involving  one  of  the  anterior  fossae.  The  fluid 
may  drip  steadily,  at  the  rate  of  a  certain  number  of  drops  per  minute,  and 
if  it  is  collected  in  a  test-tube  it  may  be  found  to  reduce  Fehling's  solution, 
though  the  reducing  substance  is  related  to  pyrocatechin  and  not  glucose,  and 
therefore  will  not  give  the  phenyl-glucosazone  reaction. 

A  purulent  discharge  from  the  nose  may  result  from  that  which  has  been  in 
the  first  place  serous,  mucoid,  or  muco-purulent ;  or  it  may  have  been  purulent 
from  the  beginning.  If  it  is  acute  and  bilateral,  it  is  probably  due  to  a  local 
infection  by  some  pyogenic  micro-organism,  and  even  when  it  may  seem  to  be 
due  to  nothing  more  than  a  common  cold,  not  a  few  different  organisms  may  be 
discovered  if  bacteriological  methods  of  diagnosis  are  adopted.  Thus  staphylo- 
cocci, streptococci,  and  pneumococci  (see  Plate  XII)  are  associated  not  at  all 
infrequently  with  the  Micrococcus  catarrhalis.  Influenza  bacilli  may  be  found. 
In  rare  cases,  especially  when  the  purulent  discharge  persists  longer  than  it 
ought  if  it  were  the  result  merely  of  a  cold,  and  especially  in  cases  in  which  the 
discharge  is  so  acrid  as  to  produce  superficial  excoriation  and  extreme  soreness  of 
the  edges  of  the  nostrils  and  the  upper  lip,  diphtheria  bacilli  will  be  found  more 
often  than  might  be  expected.  Nasal  diphtheria,  indeed,  is  not  altogether 
uncommon,  but  it  is  difficult  to  recognize  except  by  bacteriological  examination 
of  the  nasal  discharge.  The  same  applies  to  two  very  much  rarer  purulent 
lesions  of  the  nose,  namely  those  due  to  gonococci  and  to  glanders.  There  may 
be  a  urethral  infection  or  a  vaginal  discharge  to  point  to  the  diagnosis  in  the 
former  case,   the  patient  having  transferred  gonococci  directly  from  the  genital 


204  DISCHARGE,     NASAL 


source  to  the  nose  by  means  of  the  fingers  or  a  towel.  Purulent  rhinitis  due  to 
g'/aw^^ers  is  fortunately  rare,  though  when  it  does  occur  it  may  entirely  escape  recog- 
nition in  its  curable  stage  unless  the  patient's  occupation  as  a  groom  or  horse- 
dealer  suggests  the  source  of  the  infection,  or  unless  bacteriological  methods'  are 
resorted  to  in  all  cases  of  nasal  discharge  that  are  not  perfectly  straightforward. 

Chronic  purulent  nasal  discharges  are  for  the  most  part  due  either  to  lesions 
of  the  mucous  membrane  or  to  the  emptying  into  the  nose  of  purulent  collections 
derived  from  an  accessory  sinus  of  the  nose,  the  antrum  of  Highmore,  frontal, 
ethmoidal,  or  sphenoidal  sinus,  or  from  necrosis  of  the  nasal  bones.  The 
diagnosis  may  be  obvious  enough,  but  very  often  it  is  by  no  means  easy.  It 
is  essential  that  both  nasal  cavities  should  be  inspected  directly  in  a  good  light 
by  means  of  a  speculum  and  mirror  ;  the  various  kinds  of  chronic  rhinitis  may 
be  recognized  in  this  way  ;  in  chronic  atrophic  rhinitis  the  amount  of  discharge 
is  usually  small,  the  cavities  of  the  nose  are  relatively  spacious,  the  smell  offensive 
(ozaena),  and  there  are  generally  crust -like  deposits  upon  the  mucous  membrane. 
Chronic  hypertrophic  rhinitis  may  also  produce  a  very  offensive  smell,  and  a 
considerable  purulent  discharge,  with  difficulty  or  even  inability  to .  breathe 
through  the  nose  owing  to  the  bulging  of  the  inflamed  mucous  membrane. 
There  may  or  may  not  be  polypi  at  the  same  time,  and  perhaps  adenoids  and 
enlarged  tonsils  owing  to  the  necessity  for  breathing  through  the  mouth. 
Membranous  rhinitis  is  not  a  distinctive  variety,  it  being  more  or  less  an  accident 
whether  the  inflaraed  mucous  membrane  produces  a  membranous  exudate  or 
not ;  the  discovery  of  membrane  would  suggest  diphtheria,  but  bacteriological 
examination  alone  can  determine  whether  the  lesion  is  diphtheritic  or  not. 
Syphilis  is  responsible  for  a  large  number  of  the  cases  of  ozsena  and  chronic 
rhinitis,  especially  of  the  atrophic  form,  but  it  is  not  responsible  for  all,  and  the 
diagnosis  as  to  whether  the  lesion  is  syphilitic  or  not  will  rest  upon  concomitant 
signs  elsewhere,  upon  the  history,  and  perhaps  upon  the  result  of  Wassermann's 
reaction.  Necrosis  of  the  nasal  bones,  if  it  occurs  spontaneously,  is  often 
syphilitic,  but  it  may  also  be  the  result  of  injury,  such  for  iastance  as  a  blow 
upon  the  bridge  of  the  nose  at  football  ;  the  deformity  which  results  from  the 
falling  in  of  the  bridge  of  the  nose  is  characteristic. 

-Tuberculous  rhinitis  is  rare.  Rhinoliths,  although  they  may  cause  persistence 
of  a  nasal  discharge,  are  not  in  themselves  a  primary  condition,  but  rather 
the  result  of  preceding  rhinitis.  Endothelioma,  carcinoma,  or  sarcoma  affect- 
ing the  nose  are  not  common  except  as  the  result  of  direct  spread  to  its 
interior  from  the  lip,  jaw,  cheek,  or  forehead.  Sometimes,  however,  consider- 
able nasal  discharge  may  result  from  the  growth  of  a  semi-malignant  tumour 
known  as  recurrent  fibroma  or  fibro-sarcoma  arising  from  the  external  periosteum 
of  the  basi-sphenoid  bone,  thus  affecting  the  back  of  the  nose,  and  detected 
by  a  digital  examination  via  the  back  of  the  mouth. 

A  foreign  body  inserted  into  the  nose  by  a  child  or  by  an  insane  person  may 
produce  considerable  damage,  associated  with  a  purulent  discharge,  which  may 
persist  even  after  the  foreign  body  has  been  detected  by  direct  examination  and 
removed. 

Lupus  of  the  nose  is  hardly  ever  primary,  and  although  it  ma}''  destro}-  the 
margins  and  lead  to  a  purulent  discharge  from  the  nostrils,  the  diagnosis  is 
generally  clear  from  the  apple-jelly  deposits  in  the  adjacent  skin  of  the  cheeks. 

Empyema  of  one  antrum  of  Highmore  may  cause  most  troublesome  purulent 
discharge  from  the  rtose,  but  it  is  not  altogether  difficult  to  diagnose  when  the 
symptoms  are  definite.  The  patient  generally  complains  that  the  pus  invariably 
comes  down  one  nostril  ;  that  it  is  associated  with  an  odour  which  is  offensive 
to  himself  in  a  way  not  common  with  ozsena  generally ;  that  he  can  often 
produce  the  discharge  by  tilting  his  head  sideways  in  the  opposite  direction  to 


DISCHARGE,     NASAL 


205 


that  from  which  the  discharge  comes,  in  such  a  way  as  would  naturally  tilt 
pus  down  through  the  opening  from  the  antrum  of  Highmore  into  the  nose  ; 
and  that  he  experiences  dull  aching  pain  in  one  side  of  the  face,  often  spoken 
of  as  neuralgia,  but  upon  investigation  proving  to  be  associated  with  tenderness 
located  mainly  in  the  corresponding  superior  maxilla.  There  may  be  a  carious 
tooth  or  stump,  particularly  a  canine,  from  which  infection  of  the  antrum  may 
have  taken  place,  though  in  a  small  number  of  cases  a  more  serious  cause  for 
the  empyema  exists,  namely,  carcinoma  or  endothelioma  of  the  antrum,  which 
can  seldom  be  diagnosed  until  either  an  operation  is  undertaken  or  the  growth 


Fig^.  62. — Transilluminations  of   the  antrum.      A  shows  the  normal  appearance.       B  shows  no 
illumination  of  right  side,   owing  to  purulent  contents.     (From  Medical  Annual^   1906.) 


itself  begins  to  cause  a  protuberance  either  into  the  nose  or  through  the  face  ; 
the  nature  of  these  growths  will  be  determined  by  histological  examination. 

Examining  the  patient  in  a  dark  room  by  the  introduction  of  an  electric 
lamp  into  the  mouth  or  posterior  nares,  may  reveal  empyema  of  the  antrum 
by  the  transillumination  of  the  superior  maxilla  of  the  normal  side  and  the 
opacity  of  the  other  in  which  the  antrum  is  full  of  pus  (Fig  62). 

Empyema  of  a  frontal  sinus  has  generally  been  preceded  by  acute  nasal  catarrh, 
which  has  led  subsequently  to  severe  aching  above  one  or  other  eye,  with  tender- 
ness on  percussion  over  the  region  of  the  affected  frontal  sinus,  and  with  so 
much  pain  in  this  region  that  the  patient  may  be  compelled  to  hold  his  head 
before  he  is  able  to  cough  or  blow  his  nose,  because  of  the  increased  pressure 


206  DISCHARGE,     NASAL 


within  this  sinus  due  to  either  of  these  acts.  The  condition  nearly  always  starts 
acutely,  though  if  untreated  it  may  become  chronic  and  come  under  observa- 
tion only  when  the  infection  has  tracked  its  way  through  into  the  subcutaneous 
tissue,  so  as  to  point  above  the  eye  or  in  the  angle  between  the  latter  and  the 
nose. 

Suppuration  in  connection  with  the  ethmoidal  or  sphenoidal  sinuses  can  be  little 
more  than  guessed  at  unless  special  skill  has  been  acquired  in  the  direct 
examination  of  these  air-cells.  If,  however,  there  is  a  purulent  discharge  from 
the  nose  coming  apparently  from  high  up  in  a  patient  who  has  neither  antral 
disease  nor  infection  of  the  frontal  sinus,  and  in  whom  local  conditions  of  the 
mucous  membrane  of  the  nose  itself  can  be  excluded,  infection  of  the  sphenoidal 
or  of  the  ethmoidal  cells  is  to  be  suspected.  Herbert  French. 

DISCHARGE,  URETHRAL. — Any  inflammatory  process  in  the  urethra 
causes  a  discharge.  Although  in  the  greater  number  of  cases  a  urethral  dis- 
charge is  the  direct  result  of  infection  by  the  gonococcus,  it  does  not  necessarily 
follow  that  every  urethritis  is  of  this  nature,  and,  with  the  present  methods 
of  bacteriological  examination,  it  is  found  that  other  organisms  besides  the 
gonococcus  may  produce  a  urethral  discharge  and  the  same  symptoms  as  an 
acute  gonorrhoea.  Further  than  this,  a  discharge  may  occasionally  occur  in 
which  no  micro-organisms  can  be  found,  as  for  instance,  when  the  urethra 
has  been  subjected  to  irritation  by  the  injection  of  strong  solutions,  trauma, 
or  the  presence  of  a  foreign  body,  such  as  a  calculus  or  a  retained  catheter. 
In  these  cases  there  is  a  purulent  discharge  of  greater  or  less  severity  in  which 
bacteria  are  at  first  absent,  and  which  rapidly  clears  up  on  the  removal  of  the 
causative  element,  or  after  the  use  of  a  few  injections  of  a  weak  astringent 
lotion.  It  is  stated  that  a  urethral  discharge  may  be  associated  with  gout  and 
rheumatism  ;  but  although  a  few  cases  of  the  former  have  come  under  my  care, 
I  have  been  unable  to  prove  that  the  small  amount  of  discharge  was  not  the 
remains  of  a  former  uncured  urethral  infection,  or  that  it  was  directly  due  to 
the  same  source  as  the  arthritic  symptoms. 

There  is  no  doubt  that  an  acute  urethritis  may  be  caused  by  other  organisms 
than  the  gonococcus,  and  sometimes  there  is  considerable  trouble  in  completely 
curing  it.  These  cases  may  cause  complications  in  the  genito-urinary  organs 
similar  to  those  due  to  the  gonococcus,  such  as  prostatitis,  epididymitis,  or 
cystitis.  They  may  arise  by  the  infection  of  the  urethra  by  septic  instrumenta- 
tion or  by  connection  with  a  patient  the  subject  of  a  leucorrhceal  discharge, 
so  that  if  any  doubt  exists  as  to  the  nature  of  the  discharge,  a  careful  bacterio- 
logical examination  should  be  made.  It  is  important  that  the  existence  of  a 
septic  urethritis  should  be  remembered,  as  more  than  once  the  reputation  of 
a  wife  has  been  at  stake  until  it  was  proved  that  the  husband's  urethritis  was 
of  a  staphylococcal  and  not  gonorrhoeal  origin. 

Gonorrhoeal  Urethritis  is  by  far  the  most  common  cause,  and  is  due  to 
the  infection  of  the  urethra  by  a  specific  organism,  the  gonococcus  of  Neisser 
(Plate  XII,  Fig.  R).  In  form  it  is  a  diplococcus  with  flattened  surfaces  approxi- 
mating each  other  ;  it  stains  readily  with  basic  aniline  dyes,  but  differs  from 
other  diplococci  in  being  decolorized  by  Gram's  stain.  The  gonococcus  is  seen 
in  a  stained  specimen  to  be  intracellular,  penetrating  not  only  the  leucocytes 
but  also  the  epithelial  cells  found  in  a  smear  preparation,  and,  though  the  cocci 
may  be  found  also  between  the  cells,  their  appearance  in  the  cells  is  strong 
evidence  of  their  specific  nature. 

In  any  case  presenting  a  purulent  discharge  from  the  urethra,  it  is  necessary, 
in  order  that  appropi'iate  treatment  may  be  carried  out,  to  ascertain  the  extent 
of  the  infection,  not  only  in  the  urethra  itself,  but  also  in  the  other  organs  of 


DISCHARGE,      URETHRAL  207 

the  genito-urinary  apparatus.  For  the  purposes  of  cUnical  investigation,  the 
urethra  is  divided  into  anterior  and  posterior  portions,  separated  by  the 
membranous  urethra,  the  anterior  comprising  the  bulbous  and  penile  urethra, 
and  the  posterior  the  prostatic  portion.  A  urethritis  is  also,  according  to  its 
clinical  aspect,  acute  or  chronic,  the  acute  form  being  characterized  by  a  thick, 
creamy,  purulent  discharge,  with  pain,  and  the  chronic  by  a  thin,  greyish,  muco- 
purulent discharge.  Acute  gonorrhoea  affects  not  only  the  superficial  layers 
of  the  urethral  mucous  membrane,  but  also  the  subepithelial  tissues  and  the 
glandular  elements,  causing  a  leucocytic  infiltration.  The  tendency  of  the 
inflammation  is  to  spread  backwards  along  the  canal,  so  that  the  prostatic 
urethra  may  become  infected,  even  in  the  acute  stage,  though  most  frequently 
this  occurs  at  a  later  period  ;  the  prostatic  and  the  ejaculatory  ducts  may 
become  infected,  and  the  inflammation  may  spread  to  the  seminal  vesicles, 
epididymes,  or  testes.  In  all  cases  of  urethral  discharge  it  is  necessary  to 
differentiate  between  an  infection  of  the  anterior  and  the  posterior  urethra. 
In  the  acute  stages  of  the  disease,  the  infection  of  the  anterior  urethra  is  accom- 
panied, as  a  rule,  by  redness  of  the  external  meatus,  scalding  pain  during 
micturition,  and  painful  erections  ;  occasionally  all  pain  is  absent,  especially 
in  patients  previously  infected  with  gonorrhoea.  If  the  anterior  urethra  be 
irrigated  with  sterile  water  or  saline  solution,  the  urine  passed  immediately 
afterwards  will  be  quite  clear  ;  or  without  irrigating,  if  the  urine  be  passed  into 
two  glasses,  the  first  portion  will  be  turbid  from  the  admixture  with  the  urethral 
discharge,  wliilst  the  second  portion  remains  clear. 

When  the  posterior  urethra  becomes  infected  in  the  acute  stages,  the  symptoms 
are  much  more  severe.  Micturition  is  more  painful  and  greatly  increased 
in  frequency,  both  during  the  day  and  night,  the  patient  often  being  obliged 
to  pass  urine  every  half-hour.  Even  after  irrigating  the  anterior  urethra  free 
of  discharge,  the  urine  passed  will  be  turbid  with  pus  that  has  accumulated  in 
the  prostatic  portion  or  passed  backwards  into  the  bladder,  and  the  terminal 
urine  may  be  tinged  with  blood.  In  these  circumstances  it  may  be  necessary 
to  eliminate  actite  prostatitis  or  prostatic  abscess,  either  of  which  may  compli- 
cate an  acute  posterior  urethritis.  In  either  condition,  micturition  may  be 
very  painful,  or  there  may  be  acute  retention  ;  the  temperature  will  be  raised, 
and  in  cases  of  abscess  there  is  often  a  rigor  ;  upon  rectal  examination,  the 
prostate  is  found  much  swollen,  hot  to  the  touch,  and  extremely  tender,  whilst 
with  an  abscess,  a  soft  fluctuating  area  may  be  felt.  An  acute  posterior  gonor- 
rhoea is  practically  always  accompanied  by  infection  of  the  bladder,  and  the 
diagnosis  between  it  and  cystitis  is  practically  impossible. 

Under  suitable  treatment  an  acute  urethritis  may  remain  confined  to  the 
anterior  urethra  and  clear  up,  but  in  less  favourable  cases  a  slight  discharge 
remains.  If  this  continues  for  longer  than  six  weeks  after  the  initial  onset, 
it  is  spoken  of  as  chronic  gonorrhoea  or  gleet.  The  discharge  is  small  in 
amount,  thin  and  watery,  or  may  be  so  slight  as  only  to  be  present  in  the 
morning  after  a  long  period  of  freedom  from  urination,  or  as  filaments  in  the 
urine.  There  is  no  pain  or  increased  frequency  of  micturition,  and  there  is 
no  difference  in  the  subjective  symptoms  between  an  anterior  and  a  posterior 
infection,  although  in  most  cases  of  chronic  gonorrhoea  both  are  present. 

In  any  case  of  chronic  urethral  discharge,  examination  should  be  conducted 
to  ascertain  not  only  the  seat  of  infection,  but  also  the  nature  of  the  lesion 
promoting  the  discharge.  Thus,  the  patient  should  be  directed  to  hold  urine 
for  at  least  three  hours  before  he  presents  himself  for  examination,  when  the 
anterior  urethra  may  be  thoroughly  irrigated  by  a  fairly  forcible  stream  of 
sterile  water,  the  urinary  meatus  being  alternately  occluded  and  opened  during 
the  process,  so  that  the  whole  length  of  the  anterior  urethra  is  distended  by  the 


DISCHARGE,      URETHRAL 


fluid.  The  washing  is  then  examined  for  any  threads,  which,  if  present,  must 
proceed  from  the  anterior  urethra.  The  patient  is  then  directed  to  pass  urine 
into  two  separate  glasses,  and  these  are  again  examined.  If  there  is  any 
Uu'bidity  of  the  urine  due  to  excess  of  phosphates,  this  is  cleared  b}-  the  addition 
of  acetic  acid,  when,  if  any  threads  or  plugs  of  muco-pus  are  present  in  the  first 
specimen,  they  probably  arise  from  the  posterior  urethra,  whereas  an}-  pus  or 
increased  turbidity  of  the  second,  shows  that  cystitis  is  present  in  addition. 
If  there  be  any  threads  in  the  posterior  urethra,  or  if  only  a  small  amount  of 
discharge  is  present,  it  is  ad^i5able  first  to  fill  up  the  bladder  with  sterile  fluid 
by  direct  Janet  irrigation,  after  which  the  prostate  is  massaged  by  a  finger  in  the 
rectum,  and  the  patient  is  again  directed  to  pass  the  fluid  from  the  bladder. 
Plugs  of  muco-pus  vnR  be  found  if  chronic  prostatitis  is  present.  In  any  case 
the  threads  from  either  the  anterior  or  posterior  urethra  should  be  spread  as  a 
film,  stained,  and  examined  under  a  microscope  for  pus  and  micro-organisms. 

If  the  remaining  infection  is  found  to  be  limited  to  the  anterior  urethra,  the 
latter  should  be  examined  under  direct  ^•ision  by  the  endoscope.  A  few  minims 
of  a  3  per  cent  solution  of  cocaine  are  injected  into  the  urethra  and,  with  aseptic 
precautions,  the  largest  sized  endoscope  tube  that  the  meatus  will  admit  com- 
fortablv  is  passed  for  about  an  inch.  The  canal  is  then  illuminated,  and  at  the 
same  time  distended  with  air  by  means  of  the  inflating  bellows  attached  to 
the  instrument ;  the  whole  length  of  the  anterior  urethra  can  then  be  brought 
into  \-iew,  and  each  part  examined  successively  as  the  endoscope  tube  is  passed 
gradually  on  until  the  membranous  portion  of  the  canal  is  reached.  It  will  be 
found  much  better  to  examine  the  urethra  in  this  manner  than  by  first  passing 
the  instrument  to  the  full  extent  and  examining  the  canal  as  it  is  gradually 
withdrawn,  for  any  infection  of  Littre's  glands,  infiltration  of  the  urethral  walls, 
or  granular  areas  are  observed  under  aero-distention  before  the  instrument  has 
passed  over  it.  Where  the  whole  length  has  been  examined  under  distention, 
the  air  is  allowed  to  escape  by  opening  the  window  of  the  instrument,  and  the 
canal  again  examined  from  behind  forward  by  gradually  ■withdra^wdng  the 
tube,  normal  urethral  walls  falling  together  in  a  characteristic  striated 
manner,  which  is  altered  into  a  shght  rigidity  by  infiltration,  whilst  at  the 
same  time  glandular  infection  or  ulceration  is  again  seen.  Similarl}-,  a  definite 
stricture  or  a  small  poh-pus  which  may  keep  up  a  slight  urethral  discharge 
can  be  diagnosed  with  certainty,  and  any  local  treatment  for  the  various  lesions 
appUed. 

By  a  careful  examination  conducted  on  these  lines  we  are  able  to  determine, 
not  only  which  part  of  the  urethra  is  producing  the  discharge,  but  also  the 
nature  of  the  lesion,  so  that  appropriate  treatment  can  be  carried  out.  In  the 
majority'  of  cases  in  which  a  gleet  remains  in  spite  of  treatment  with  various 
kinds  of  injections,  it  wiU  be  found  that  there  is  an  infection  of  the  posterior 
urethra  or  prostatic  ducts,  which  no  urethral  injection  except  a  complete 
irrigation  into  the  bladder  will  reach.  There  is  often  no  abnormality  to  be 
detected  "on  digital  examination  of  the  prostate  in  the  rectum  ;  but  after 
urethral  irrigation,  the  secretion  squeezed  out  from  the  prostate  by  massage 
will  usually  show  pus  corpuscles  in  addition  to  the  refractive  globules  and 
epitheUum  which  are  contained  in  the  normal  prostatic  secretion.  In  other 
cases  of  obstinate  chronic  urethritis,  a  distinct  infiltrative  process  will  be  found 
in  the  anterior  urethra,  a  process  which  results  in  rigidity  of  the  urethral  wall, 
and  in  severe  cases  leads  on  to  stricture.  The  urethral  glands  are  implicated, 
and  their  secretion  gives  rise  to  the  filaments  in  the  urine.  This  infiltration 
is  seen  readily  by  urethroscopy,  but  it  may  be  imperceptible  on  the  passage 
of  a  sound.  The  urethral  meatus  is  the  narrowest  part  of  the  canal,  and  a 
sound  which  will  completely  fill  the  meatus  may  still  pass  readily  through  an 


DISCHARGE,     URETHRAL  209^ 

infiltrated  portion  of  the  urethra,  even  when  its  normal  calibre  is  considerably 
diminished. 

In  spite  of  all  forms  of  treatment,  a  slight  urethral  discharge  occasionally 
remains,  and  the  physician  may  be  asked  if  any  infection  remains,  or  whether  a 
patient  may  be  allowed  to  marry.  A  chronic  urethral  discharge  may  contain 
gonococci  or  may  be  entirely  free  from  any  organisms.  Obviously,  if  any  gono- 
cocci  are  found,  the  discharge  is  still  infectious,  but  there  is  often  difficulty  in 
detecting  the  organism  in  these  chronic  cases,  whilst  in  some  they  may  be  found 
if  any  slight  exacerbation  of  inflammation  occurs.  Other  cases  again,  show 
a  chronic  urethral  discharge  which  resists  all  treatment,  but  which  contains  a 
few  pus  and  epithelial  cells,  though  no  organisms  can  be  found.  That  pus  cells 
are  present  in  this  small  urethral  discharge  is  no  detriment  to  marriage,  provided 
that  no  gonococci  can  be  found,  and  in  practice,  if  no  cocci  are  found  after 
irritation  of  the  urethra  by  irritant  injections,  instrumentation,  or  the  free  use 
of  alcohol,  on  several  successive  examinations,  marriage  may  be  permitted. 

A  urethral  discharge  may  in  rare  cases  be  present  in  other  conditions  than 
that  produced  by  gonorrhcea  or  septic  urethritis,  and  as  difficulty  may  arise  if  one- 
of  these  cases  be  met  with,  it  is  necessary  to  mention  them. 

Herpetic  Urethritis. — The  mucous  lining  of  the  urethra  is  undoubtedly  affected' 
by  herpes  in  the  same  manner  as  other  mucous  membranes,  frequently  as  a 
tertiary  lesion  of  syphilis.  There  is  irritation  of  the  urethra  during  mic- 
turition, and  a  slight  muco-purulent  discharge  from  the  meatus.  The  small 
vesicles  may  be  seen  by  the  endoscope,  and  may  be  associated  with  herpes  of 
the  prepuce. 

Soft  Sores  in  the  Urethra  are  distinctly  uncommon.  They  occur  in  the 
terminal  portion  of  the  urethra,  and  cause  painful  micturition  and  a  profuse, 
thin,  purulent  discharge,  which  contains  no  gonococci.  There  may  be  other 
sores  on  the  glans  penis,  and  an  ulcerated  surface  will  be  seen  readily  on 
endoscopic  examination.  They  occur  within  a  few  days  of  infection,  and,  if 
extensive,  may  produce  narrowing  of  the  urethra  on  healing. 

Syphilis  may  affect  the  urethra  either  as  a  hard  chancre  or  as  a  gumma. 

The  Chancre  occurs  in  the  anterior  end  of  the  urethra,  forming  a  firm  induratecT. 
mass  which  can  be  felt  readily  on  external  palpation.  The  meatus  is  oedematous'. 
and  swollen,  so  that  the  introduction  of  an  endoscopic  tube  is  impossible  ;  there: 
is  a  thin,  purulent,  and  often  blood-stained  discharge  from  the  meatus. 

A  urethral  chancre  must  be  diagnosed  carefully  from  peri-urethral  infiltration, 
due  to  urethritis  ;  the  period  of  incubation  from  the  time  of  infection,  the- 
presence  of  small,  hard  inguinal  glands,  the  occurrence  of  secondary  lesions- 
of  syphilis,  and  Wassermann's  serum  test  will  point  to  the  diagnosis. 

Gummata  of  the  urethra  give  rise  to  a  watery  urethral  discharge  when  they 
break  down  and  cause  ulceration.  They  may  ulcerate  through  the  canal  and! 
form  fistute,  but  may  usually  be  recognized  on  careful  examination. 

Papillomata  of  the  Urethra  may  occur  either  in  the  anterior  or  posterior 
portion,  as  small,  pedunculated  tumours  in  the  canal,  and  frequently  as  a  sequel 
to  a  chronic  gonorrhoea.  They  may  arise,  however,  in  the  urethra  of  a  patient 
who  has  never  had  urethritis.  They  cause  a  thin,  scanty  discharge,  which  does 
not  yield  to  injections  ;    they  are  readily  seen  through  the  endoscope. 

Carcinoma  of  the  urethra  is  very  rare  as  a  primary  disease,  and  in  the  few 
cases  recorded  has  been  in  association  with  stricture.  It  forms  a  tumour  in 
the  urethra  palpable  from  the  exterior,  and  causes  painful  micturition  with  a 
blood-stained  discharge,  and  enlargement  of  the  inguinal  glands.  Suspicion  of 
carcinoma  should  arise  if  a  hard,  irregular  tumour  be  felt  in  the  course  of  the 
urethra,  without  any  gonorrhoeal  infection,  in  an  elderly  patient. 

D  14 


DISCHARGE,     URETHRAL 


Tuberculosis  of  the  Urethra  is  always  secondary  to  disease  elsewhere  in  the 
genito- urinary  tract,  usually  of  the  prostate  or  seminal  vesicles. 

Foreign  Bodies  in  the  Urethra  ma^^  cause  a  purulent  urethral  discharge 
if  they  remain  in  the  canal  for  any  length  of  time.  They  may  be  introduced 
through  the  meatus  by  intent — matches,  pins,  etc.  ;  or  a  piece  may  be 
detached  from  a  damaged  catheter  ;  or  a  small  calculus  may  be  passed  down 
from  the  bladder  and  become  arrested.  In  the  latter  case  the  history  is 
usually  clear — sudden  stoppage  of  the  stream  of  urine  during  micturition, 
with  penile  pain ;  a  calculus  mav  be  felt  from  the  exterior  or  seen  through  the 
endoscope.  r,  h.  Jocelyn  Sic-an. 

DISCHARGE,  VAGINAL. — In  order  to  recognize  the  varieties  of  pathological 
vaginal  discharges,  it  is  first  important  to  realize  what  the  normal  secretions 
found  in  the  vagina  consist  of.  The  secretion  normally  present  must  be  a 
mixture  of  those  from  the  uterine  body,  cervix,  and  vaginal  wall.  That  from 
the  uterine  body  is  watery-  and  small  in  amount,  whilst  that  from  the  cer\dx  is 
thick  and  mucoid,  but  clear  and  transparent,  like  unboiled  white  of  egg.  The 
vaginal  secretion  is  merely  a  transudation  of  plasma  from  the  vessels,  mixed 
with  desquamated  vaginal  epithehum,  and  in  virgins  looks  like  unboiled  starch 
mixed  with  water.  Naturally  it  is  very  small  in  amount.  The  bulk  of  the 
secretion  found  in  the  vagina  comes  from  the  cervix,  because  there  are  far  more 
glands  there  than  in  any  other  part  of  the  genital  tract. 

The  secretion  from  Bartholin's  gland,  which  is  thin  and  mucoid,  may  be 
copious  under  sexual  excitement,  but  under  normal  conditions  is  absent,  and 
so  does  not  contribute  to  the  secretions  in  the  vagina.  The  vaginal  mixed 
secretions  are  acid  in  reaction,  owing,  according  to  Doderlein,  to  the  presence  of 
lactic  acid  produced  by  a  long  bacUlus  which  is  normally  found  in  the  vagina. 
On  the  other  hand,  the  unmixed  uterine  secretions  are  alkaline,  distinctions  which 
liave  been  clearly  pointed  out  by  Gow.  Normally,  the  amount  of  mixed  vaginal 
secretion  should  do  no  more  than  just  moisten  the  vaginal  orifice.  When  the 
amount  is  so  great  as  to  moisten  the  \Tilva  and  consequently  stain  garments, 
the  secretion  is  pathological. 

The  composition  of  an  abnormal  secretion  varies  considerablj"  according  to 
the  source  from  which  most  of  it  comes.  The  commonest  t3^e  is  the  thick  white 
or  yellow  discharge  associated  ^rith  inflammatory  changes  in  the  cervix.  It 
contains  a  large  proportion  of  mucus,  many  leucoc3^tes,  masses  of  shed  epithelium 
from  the  vagina  ("  squames  "),  and  bacteria  of  various  kinds.  This  is  quite 
typical,  and  is  produced  by  endocervicitis  and  cervical  erosions  of  the  various 
kinds.  When,  however,  there  is  a  corporeal  endometritis  present  as  well,  the 
discharge  becomes  thinned,  white,  or  vellow,  on  account  of  the  admixture  of 
much  watery  secretion  from  the  body  of  the  uterus.  The  yelloAv  colour  is  due 
to  the  admixture  of  red  blood  corpuscles,  and  in  some  cases  the  fluid  may 
become  actually  blood  stained. 

Menorrhagia  accompanies  these  discharges,  and  serves  to  distinguish  a  mixed 
corporeal  and  cervical  endometritis  from  a  simple  cervical  catarrh.  Micro- 
scopically the  films  made  from  the  mixed  cases  show  proportionately  less  mucus, 
but  otherwise  the  constituents  are  the  same. 

Vaginitis  rarely  exists  alone,  but  when  it  does  occur,  the  discharge  is  thick  and 
past%-  if  it  is  a  simple  catarrhal  condition  :  past^^  on  account  of  the  large 
admixture  of  desquamated  vaginal  squamous  epithelium.  On  the  other  hand, 
in  granular  catarrhal  vaginitis,  the  discharge  is  much  more  purulent  and  copious. 
owing  to  the  exudation  of  more  fluid  from  the  exposed  blood  capillaries.  This  is 
the  kind  of  discharge  associated  with  traumatism  of  the  vagina,  especially  from 
the  irritation  of  badly-fitting  pessaries,  and  actual  ulceration  as  in  decubitus 


DISCHARGE,     VAGINAL 


ulcers  on  prolapsed  portions.  Practically  no  mucus  is  found  in  such  discharges 
unless  the  cervix  shares  in  the  inflammatory  process. 

There  is  nothing  characteristic  of  gonorrhceal  discharges  to  the  naked  eye  or  on 
simple  microscopical  examination.  The  detection  of  the  gonococcus  alone  can 
decide  the  question.  This  is  often  a  matter  of  great  difficulty,  because  it  is  only 
in  the  few  days  immediately  after  infection  that  the  gonoccocus  can  be  found 
free  in  the  vaginal  discharge.  In  chronic  cases,  the  gonococcus  must  be  looked 
for  in  two  places,  either  the  interior  of  the  cervix  or  in  the  urethra  and  Skene's 
tubes,  which  open  by  the  sides  of  the  meatus  urinarius.  The  best  plan  is  to 
take  some  discharge  from  within  the  cervix,  after  carefully  wiping  away  discharges 
from  the  os  uteri  with  sterile  wool,  using  a  Fergusson's  speculum.  This  discharge 
should  be  spread  on  a  glass  slide  and  put  by  to  dry.  A  second  film  on  another 
slide  should  then  be  made,  by  squeezing  the  urethra  from  behind  forwards  and 
mopping  up  any  secretion  thus  made  to  appear  on  the  meatus.  After  drying 
in  the  air,  the  films  should  be  fixed  by  passing  through  a  flame,  and  then  stained 
by  Gram's  method,  followed  by  neutral  red  as  a  counter-stain.  In  films  prepared 
in  this  way  gonococci  are  stained  red,  whilst  organisms  which  retain  Gram's 
stain  appear  deep  violet  or  black.  The  gonococci  are  usually  found  in  the 
cytoplasm  of  the  polymorphonuclear  leucocytes  (Plate  XII). 

Offensive  smelling  vaginal  discharge  is  associated  with  decomposition,  and  it 
may  be  that  the  discharge  itself  is  decomposing  because  it  cannot  escape  fast 
enough  from  the  passage,  or  that  the  source  of  the  discharge  is  a  decomposing 
substance  like  a  sloughing  fibroid  or  necrotic  carcinoma  of  the  cervix.  In  the 
two  latter  cases  the  discharge  is  copious,  watery,  and  blood-stained,  with  a 
horribly  foetid  smell.  When  the  discharge  itself  is  decomposing,  it  is  usually 
thicker  and  purulent,  and  is  commonly  retained  by  pessaries  or  by  redundant 
folds  of  vaginal  mucous  membrane.  In  old  women,  a  foul  discharge  may  come 
from  the  interior  of  the  uterus,  a  pyometra  ;  in  which  case  pus  can  be  made  to 
flow  from  the  os  uteri  by  squeezing  the  uterus  or  passing  a  sound.  It  is  due  to 
senile  endometritis,  the  result  of  infection,  and  is  often  associated  with  cancer  of 
the  body  of  the  uterus. 

Watery  blood-stained  discharge,  not  offensive,  occurs  in  cancer  of  the  body  of 
the  uterus,  in  early  cancer  of  the  cervix,  with  mucous  polypi,  placental  polypi,  and 
hydatidiform  mole.  The  differential  diagnosis  of  these  conditions  cannot  be 
made  from  the  discharge  alone,  but  must  rest  upon  physical  examination  com- 
bined with  the  use  of  the  microscope  upon  materials  removed  from  the  uterus. 

Vaginal  casts  may  be  composed  of  coagulated  surface  epithelium,  the  result 
of  astringent  injections  or  applications,  and  are  easily  recognized  with  the 
microscope.  Membranous  flakes  may  be  passed  with  discharge  in  cases  of 
membranous  vaginitis.  They  consist  of  vaginal  epithelium  entangled  in 
coagulated  blood  plasma,  and  present  quite  a  different  appearance  to  casts  of 
coagulated  epithelial  layers.  These  membranous  masses  may  be  seen  lining 
the  whole  vagina,  and  are  generally  due  to  special  organisms.  The  Klebs-Loffler 
bacillus  [Plate  XII)  has  been  found  to  be  the  causal  agent  in  such  cases,  and  in  one 
investigated  by  the  writer,  the  Bacillus  coli  communis  was  the  offending  organism. 

T.  G.  Stevens 

DIZZINESS.— (See  Vertigo.) 

DOUBLE    VISION.— ;Sec  Diplopia.) 

DROP-FOOT. — (See  Paraplegia,  and  Paralysis  of  One  Lower  Extremity.) 

DROPSY.— (See  (Edema.) 

DROP-WRIST. — (See  Paralysis  of  the  Upper  Extremity.) 

DULLNESS,  DEFICIENT  HEPATIC.--(See  Liver  Dullness,  Deficient.) 


DWARFISM 


DWARFISM  (Microsomia,  Xanosomia). — For  purposes  of  diagnosis,  dwarfism 
may  be  di\'ided  into  two  classes,  namely,  dwarfism  the  result  of  deformity ,  and 
dwarfism  without  deformity.  Generally  speaking,  well-proportioned  dwarfs  owe 
their  defective  stature  to  a  generalised  delay  or  arrest  of  development,  and  are 
therefore  in  a  state  of  infantilism,  whereas  deformed  dwarfs  are  stunted  in  growth 
only,  though  the  reduction  in  height  may  be  due  rather  to  the  warping  or  collapse 
of  the  bon}-  frame-work  than  to  actual  curtailment  of  height. 

I. — Dwarfism  the  result  of  Deformity. 

As  a  rule  this  kind  of  dwarfism  is  due  mainly  or  soleh'  to  shortness  of  the  lower 
limbs.     In  bv  far  the  larger  number  of  cases  the  fault  lies  in  the  skeleton,  but 

occasionally  it  has  its  source  in 
deficiency  of  the  brain,  and  still 
more  rarely  is  brought  about  by  a 
local  defect  of  development  impli- 
cating the  lower  extremities. 

A .  Skeletal  Dwarfism  is  occasioned 
by  :— 

1.  Rickets 

2.  Achondroplasia 
3-  Osteogenesis  imperfecta 
4.  Anosteoplasia 

3.  Osteomalacia. 

1.  Rickety  Dwarfism  [Fig.  63)  is 
usuall}^  moderate  in  degree  and  is 
due  partly  to  actual  shortening  of 
the  bones  of  the  lower  limbs  and 
partljr  to  bending  (bow-leg  or 
knock-knee).  It  may  also  be  the 
outcome  of  antero-posterior  or  of 
lateral  cur\-ature  of  the  spine.  The 
skull  looks  big  and  is  of  the  square 
or  hot-cross-bun  t^^pe,  with  bulging 
forehead.  The  shape  of  the  nose  is 
not  affected.  There  is  often  a 
pigeon  breast  or  a  transverse  groove 
round  the  lower  part  of  the  chest 
(rickety  girdle,  Harrison's  sulcus) 
and  an  hour-glass  shaped  or,  at 
times,  beaked  (rostrate)  pelvis.  The 
muscles  are  well-developed,  and  the 
body  is  squat  and  thickset. 

2.  In  Achondroplasia  (-Fig.  64)  the 
limbs  are  shorter  than  in  rickets, 
and  the  stature  less.  The  propor- 
tions are  of  the  dachshund  pattern. 

The  shortening  of  the  limbs  is  chiefly  of  the  proximal  segment,  and  the  body, 
though  actually  short,  is  relativeh?  long.  The  legs  are  often  bowed,  and  there 
may  be  bending  of  the  upper  limb  bones.  The  joints  are  usually  prominent. 
The  forehead  is  bulging,  the  bridge  of  the  nose  depressed.  There  is  con- 
.spicuous  lordosis,  and  the  pelvis  is  small  and  contracted.  The  muscles  are 
often  disproportionately  big,  giving  the  achondroplasic  a  sturdy  appearance 
and  a  surprising  degree  of  strength.  The  fingers  are  broad,  the  three  middle 
fingers  being  of  equal  length  and  divergently  curved. 


Fiff.  63. — Extinct  rickets. — Age  13.  The  dwarfism 
is  moderate,  and  i.s  due  to  bending  and  .shortening  of 
the  thigh  and  leg  bones.  There  is  knock-knee,  the 
tibiae  are  sabre-shaped,  the  feet  flat.  The  wrists  md 
ankles  are  large  :   the  muscles  are  not  afifected. 


DWARFISM 


213 


3.  Osteogenesis  Imperfecta  (osteopsathyrosis,  fragilitas  ossium)  {Fig.  65)  is 
characterized  by  brittleness  with  softening.  There  is  not  much  dwarfing, 
except  as  the  result  of  the  yielding  of  the  bones,  and  the  muscles  are  usually 
weak.     The  disease  probably  sometimes  runs  on  into  osteomalaca. 

4.  Anosteoplasia  (Cautley)  or 
cleido-cranial  dysostosis.  With 
general  impairment  of  bone 
growth,  cau.sing  nroderate  dwarf- 
ism, there  is  pronounced  defect 
in  the  formation  of  the  membrane 
bones.  The  skull  is  rounded  and 
broad,  the  face  small,  the  den- 
tition delayed  ;  the  clavicles  are 
rudimentary  or  absent.  The 
disease  is  often  hereditary. 


F/«:  64. — Achondroplasia. — Age  15.  The  trunk  is  al- 
most of  normal  length,  and  the  limbs  very  short,  the 
proximal  being  shorter  than  the  distal  segments.  The 
epiphyses  are  enlarged,  and  the  forearms  and  legs  are 
curved.  The  nose  is  deficient  at  the  bridge.  In  this 
case  there  is  infantilism  as  well  as  dwarfism. 


5.  In  Osteomalacia  the  dwarfism  is  due 
almost  solely  to  the  crumpling  of  the 
decalcified  bones  ;  but  when  the  disease 
occurs  in  childhood  there  is  also  some 
diminution  of  stature  from  arrest  of  bone 
growth.  The  muscles  are  conspicuously 
weak. 


/^ig:  65. — Osteogenesis  imperfecta. — 
Age  32.  Bending  of  the  tibiae,  femora, 
spine,  etc.,  began  at  five  years  and  con- 
tinued for  nearlj'  ten  years  before  it 
ceased.  There  was  no  epiphysial  en- 
largement. 


Diagnosis  of  Skeletal  Dwarfism. — Though 
osteogenesis  imperfecta,  simple  bone  brittle- 
ness, rickets,  and  achondroplasia  can,  as 
a  rule,  be  distinguished    readily  one  from 

another,  cases  occur  in  which  one  of  these  diseases  seems  to  blend  with  another 
or  at  any  rate  to  partake  of  its  characters. 


214  DWARFISM 


In  distinguisMng  rickets  from  achondroplasia  it  must  be  remembered  that  the 
most  characteristic  features  of  rickety  dwarfism  are  the  bending  and  the  post- 
natal origin,  and  of  achondroplasia  the  shortness  of  the  limbs  (micromelia)  and 
the  pre-natal  origin.  The  enlargement  of  the  ends  of  the  bones,  which  is  so 
distinctive  of  rickets,  disappears  as  the  disease  settles  down  and  the  bones  con- 
tinue to  grow,  Avhereas  in  the  hyperplastic  form  of  achondroplasia  it  remains 
throughout  hfe. 

Extreme  softening  must  cause  us  to  suspect  the  existence  of  osteogenesis 
imperfecta  or  of  osteomalacia,  even  if  there  are  rickety  enlargements  as  well, 
especially  if  the  bending  continues  to  increase  after  the  age  of  six  years. 

Dwarfism  may  be  due  solely  to  spinal  curvature.  If  a  kyphosis  it  is  usually  the 
result  of  tuberculous  disease  (caries)  of  the  spine,  but  is  occasionally  a  local 
manifestation  of  rickets,  or  possibly  of  osteomalacia.  When  of  rickety  origin 
there  is  not  onh^  k^-phosis  of  the  dorsal  region,  but  a  compensatorj^  lordosis  of 
the  dorso-lumbar.  If  it  begins  in  middle  or  old  age  it  is  usuallj^  osteo-arthritic, 
but  as  a  rare  event  it  may  be  due  to  osteomalacia  (o.  senilis).  In  the  latter 
event  the  softening  is  usuallj^  confined  to  the  spine  and  pelvis,  and  may  take 
place  with  extraordinary  rapiditjr,  and  be  followed  by  gradual  hardening  and 
fixation  in  the  deformed  position. 

Scoliosis  is  usually  of  mixed  origin,  the  main  factor  being  an  inherent  laxity 
of  tissue  showing  itself  in  weakness  of  the  back  muscles  and  of  the  spinal  liga- 
ments. This  laxity  is  supplemented  by  fault}''  positions  of  standing,  sitting, 
etc.,  or  b\^  the  injudicious  use  of  stays.  But  it  is  probable  that  spinal  curvature 
of  sufficient  severit],^  to  produce  dwarfism  is  invariably  the  result  of  rickets  or, 
in  rare  cases,  of  a  mild  and  local  form  of  osteomalacia. 

B.  Cerebral  Dwarfism. — This  form  of  microsomia  is  most  pronounced  in  micro- 
cephaly, but  hydrocephaly,  porencephaly,  imbecility,  or  any  degenerative  cerebral 
affection  of  earlj'  progressive  development,  is  often  associated  with  puny 
growth.  The  microcephalic  dwarf  is  characterized  not  only  by  the  relative 
smallness  of  his  head  (circumference  never  exceeding  17  ins.),  but  by  his  sloping 
forehead,  projecting  nose,  and  receding  chin,  giving  him  a  ferret-  or  rat-like 
physiognomy.  He  is  usually  quick  of  movement,  and  restless,  and  is  either 
imbecile  or  idiotic,  according  to  the  degree  of  his  microcephaly. 

C.  Dwarfism  from  Pre-natal  Deficiency  of  the  Lower  Limbs. —  This  is  of 
two  kinds  :   phocomelus  and  ectromelus. 

In  phocomelus  the  defect  is  in  one  or  both  of  the  proximal  segments,  leaving 
the  hands  and  feet,  so  that  the  individual  affected  resembles  a  penguin  or  a  seal 
(phoca) . 

In  ectromelus  there  is  absence  of  part  or  whole  of  the  limbs  from  the  feet  up. 

II. — Dwarfism  the  result  of  Defective  General  Development. 
Infantilism. 

Well-proportioned  dwarfs  are  not  invariably  of  backward  development,  for 
we  meet  with  men  of  excellent  development,  who,  if  not  actual  dwarfs,  are  so 
dwarfish  in  stature  that  we  have  to  admit  the  possibility  of  the  existence  of  a 
true  dwarfism  in  which  there  is  no  infantilism.  Ne^"ertheless,  generally  speaking, 
the  dwarf  of  correct  proportions  is  affected  with  infantilism. 

To  Distinguish  Infantilism  from  simple  Dwarfism. — Dwarfism  is  a  defect  of 
growth,  whereas  infantihsm  is  a  defect  of  development.  In  determining  whether 
development  is  implicated,  stature,  ossification,  and  sex  development  are  of  great 
but  not  decisive  importance.  Thus  infantilism  may  co-exist  with  gigantism  ;  and 
the  ossification  in  some  cases  of  symptomatic  infantilism  is  not  only  not  delayed, 
but  may  be  actually  premature.      It  is  also  premature  in  progeria.     Moreover,  a 


DWARFISM 


sexually  mature  child  of  live  or  six  does  not  cease  to  be  a  child  because  its  ossifi- 
cation and  sexual  condition  resemble  those  of  an  adult.  Evidently  therefore 
neither  height,  nor  sex,  nor  ossification  is  a  cardinal  feature  of  infantilism. 
Indeed,  in  some  cases  of  sexual  ateleiosis  the  presence  of  infantilism  is  determined 
by  the  child-like  stature,  proportions,  and  physiognomy  alone,  the  individual 
being  in  all  other  respects  a  well-developed  human  being. 

The  Forms  of  Infantilism. — In- 
fantilism may  be  widespread  among 
whole  races  or  nations  (racial  in- 
fantilism), or  may  select  certain 
individuals  or  families, .  and  occur 
epidemically  or  sporadically  as 
morbid  infantilism  among  people  of 
ordinary  development. 

Morbid  infantilism  is  of  two 
sorts,  namely,  symptomatic,  the 
result  of  causes  ;  and  essential,  or 
cryptogenetic. 

A.  Symptomatic  Infantilism. 

This  is  seldom  or  never  of  ex- 
treme degree,  has  no  uniform  type 
of  physiognomy,  and,  being  an 
acquired  condition,  is  never  trans- 
mitted by  heredity. 

It  is  best  classified  according  to 
the  nature  of  the  cause  by  which 
it  is  produced. 

1.  It  may  be  the  result  of 
intoxication  with  the  poison  of 
syphilis,  wine,  or  tobacco ;  or  of 
rheumatic,  scarlet  or  other  fever, 
or  with  lead.  Herter  claims  that 
the  intoxication  may  arise  from 
over-abundance  of  the  normal  flora 
of  the  intestine  (intestinal  infant- 
ilism), r-  ' 

2.  It  may  be  the  result  of  cor- 
relation, as  when  it  is  associated 
with  kyphosis  or  with  splenomegaly, 
or  with  hypertrophic  cirrhosis  of 
the  liver.  Perhaps  the  best  ex- 
ample of  this  form  of  infantilism 
is  that  which  is  associated  with 
microcephaly.  In  some  microceph- 
alic dwarfs  there  is  not  only  an 
impairment  of  growth,  constituting 
dwarfism,   but  the  development  of 

the  whole  body  is  staj^ed,  apparently  because  it  is  the  custom  for  a  certain 
development  of  the  body  to  go  with  a  certain  size  of  the  brain,  'and  such 
customs  are  liable  to  be  maintained  even  under  abnormal  conditions.  Dwarfs 
with  diminutive  heads  may  be  of  just  proportions  and  of  fairly  good  intelli- 
gence, provided  the  growth  of  the  body  is  so  retarded  that  it  remains  in  keep- 
ing with  the  growth  of  the  brain.  In  thymic  infantilism  there  is  fatness  with 
anaemia,  and  liability  to  syncopal  attacks  which  often  end  in  death. 


/''ij;.  66.  —  .Aii.i!i:;i.  p'.a^tii;  ii I'aii tili-ni.  -  -  Age  i6. 
I  here  is  general  delay  of  de\elopment,  but  nut  to  an 
e.xtreme  degree.  The  phy.siognomy  and  proportions 
are  of  the  adult  pattern,  but  se.\  development  is 
more  immature. 


2l6 


DWARFISM 


3.  In  a  given  case  of  infantilism  it  mav  be  impossible  to  say  how  much  is  due 
to  correlation,  how  much  to  intoxication,  and  how  much  to  mere  lack  of  nutrition. 
This  may  be  said,  e.g.  of  cardiac,  of  arterial,  and  of  pancreatic  infantilism. 

Cardiac  infantilism  exists  when  there  is  some  dominating  incapacity  of  the 
cardiac  valves.  Sometimes  there  seems  to  be  a  deficient  development  of  the 
whole  arterial  system,  constituting  anangioplastic  infantilism  {Fig.  66). 

In  pancreatic  infantilism  there 
are  indications  of  pancreatic  in- 
competence. The  stools  are  fatty, 
copious  or  frequent,  pale  and 
offensive.  Capsules  of  iodoform 
enclosed  in  a  glutoid  envelope 
(Sahli's  capsules)  are  only  soluble 
in  the  pancreatic  secretion,  and 
are  therefore  not  dissolved  in  this 
form  of  infantilism  (Bramwell). 
The  infantilism  is  cured  by  pan- 
creatic extract. 

4.  Thyroid  infantilism  in  its 
most  characteristic  form — cretin- 
ism [Fig.  67) — is  unmistakable. 
But  cases  of  infantilism  occur  in 
which  the  physiognomy,  stunting 
of  growth,  and  backward  sex 
development  suggest  mere  thy- 
roid inadequacy.  Some  reserve 
the  name  of  thyroid  infantilism 
for  these  cases  of  "  myxoedeme 
fruste,"but  the  term  should  only 
be  applied  when  the  intelligence 
is  defective  and  uniform  improve- 
ment sets  in  as  the  result  of 
giving  thyroid  extract.  The  thy- 
roid inadequacy  may  however 
not  be  primary,  but  a  mere  in- 
cident in  some  other  form  of 
infantihsm,  e.g.,  ateleiosis. 

5.  Mongolism  [Fig.  6-8)  is  dis- 
tinguished from  cretinism  or 
myxoedeme  fruste  by  the  pre- 
dominance of  the  imbecility  as 
compared  with  the  slightness  of 
other  cretinoid  symptoms.  In 
realit}'  the  physiognomy  is  only 
cretinoid  because  it  remains  of 
the    infantile     t^'pe.       It    is     not 

eneral  pseudo-oedema  of  cretinism,  and  the 
The  eves  remind  one  of 


/■ig.  67.  —  CretiiiiMn.— Age  20.  The  infantilism  is 
uniform  and  extreme.  The  intelligence,  proportions, 
.attitude,  manner,  correspond  with  those  of  a  child  of" 
18  months.  The  features  are  puffed  and  disfigured 
with  the  characteristic  oedema. 


■disfigured  by  the  thick  lips  and 

tongue,  though  sometimes  protruding,  is  not  large. 

the  obhqueh'-set  eyes  of  the  Chinaman,  but  it  is  sometimes  difficult  to  make 

out  the  resemblance.     The  ligaments  are  lax,  and  mongols  are  liable  to  become 

knock-kneed    and    to    have    "  double-jointed  "    thumbs.     There  is  often  some 

valvular  affection  of  the  heart. 

B.  Essential  or  Cryptogenetic  Infantilism. 

This  is  distinguished  from  sj^mptomatic  infantilism  b}'  its  pronounced  degree, 


DWARFISM 


217 


by  its  seemingly  spontaneous  appearance,   and  occasionally    by  its   heredity. 
There  are  two  forms  :    ateleiosis  and  progeria. 


Fig.  68 Mongolism. — Age  14.     The  general  development  is  delayed.     The  physiognomy  is  un- 
developed, is  without  facial  hair,  and  is  slightly  Mongoloid.    The  boy  is  an  amiable  imbecile. 

I.  Ateleiosis  {Fig.  69)  is  primary,  spontaneous  infantilism.  It  may  begin  at 
any  age  of  progressive  development,  and  its  characters  are  for  the  most  part 
those  normal  to  the  age  of  its  first  appearance.      It  usually  begins  in  infancy  or 


Fig-.  69.— -A-teleiosis. — Age  12.  A  boy  of  twelve  with  asexual  ateleiosis,  standing  behind  a 
normal  boy  of  six.  His  height,  proportions,  contours,  and  physiognoiny  are  conspicuously 
childish.    He  is  inflating  his  chest,  but  in  reality  his  trunk  development  is  of  the  abdominal  type. 


DWARFISM 


early  childhood,  and  the  size,  proportions,  and  physiognomy  of  this  time  of  life 
are  perpetuated.  It  is  prone  to  be  associated  with  cryptorchism,  or  with  some 
corresponding  ill-development  of  the  ovaries,  causing  divergence  into  two 
varieties,  sexual  and  asexual. 

In  asexual  ateleiosis  a\\  the  physical  features  of  infantile  life  are  stereotyped  ; 
but  in  sexual  ateleiosis,  though  the  physiognomy  and  proportions  remain  infantile 
or  childish,  the  onset  of  puberty  (often  greatly  delayed)  brings  with  it  some 
accession  of  growth  and  the  addition  of  the  primary  and  secondary  sex  characters 
of  the  adult. 


Fig.  jc — Progeria — Age  15.  'J'he  stature  .-md  pr..pi)rtions  ate  ijiildish,  liut  the  physiognomy, 
leanness,  and  baldness  are  elderly.  The  scalp  was  in  reality  sparsely  covered  with  grey  hair. 
The  ear  lobule  is  absent,  ihe  nasal  cartilages  are  conspicuous,  and  the  fingers  nodose  owing  to 
the  prominence  of  the  epiphyses. 

2.  Progeria  {Fig.  70)  is  primary,  spontaneous  infantilism  mingled  with  prema- 
ture senility  (senilism) .  Hence,  with  shortness  of  stature  and  other  indications 
of  infantilism,  there  is  baldness,  emaciation,  arterial  sclerosis,  and  general  decrepi- 
tude. Death  from  angina  pectoris  or  other  senile  disease  may  ensue  at  18  or 
even  earlier.  Hastings  Gilford. 

DYSARTHRIA. — (See  Speech,   Abnormalities  of.) 

DYSIDROSIS. — (See  Sweating,   Abnormalities  of.) 


DYSMENORRHCEA  219 


DYSMENORRHCEA — Owes  its  origin  to  a  variety  of  causes,  which  must  be 
carefully  differentiated,  in  order  that  treatment  may  be  successful.  The  follow- 
ing table  presents  the  causes  of  the  three  common  varieties  : — 


I.  Spasmodic. 
Congenital  malformations 
Deficient  uterine  muscle 
Long  conical  cervix 
Stenosed     external     and 

internal  os 
Neurasthenia 


2.  Congestive. 
Endometritis 
Uterine  congestion 
Retroversion  and  flexion 
Uterine  fibroids 
Salpingo-oophoritis 
Pelvic  peritonitis 
Small  cystic  ovary 
Neurasthenia 


3.  Membranous. 


The  distribution  of  the  cases  into  these  three  classes  is  often  quite  easy ;  in  the 
first  place,  because  spasmodic  cases  are  practically  always  primary,  that  is, 
they  commence  with  the  onset  of  menstruation  ;  whilst  congestive  and  mem- 
branous cases  are  secondary,  that  is,  acquired  as  a  result  of  some  definite 
lesion.  Further,  the  nature  of  the  pain  is  often  characteristic  of  the  type  of 
case,  for  in  spasmodic  cases  the  pain  is  intermittent,  griping,  and  "  colicky," 
commencing  at  the  same  time  as  the  blood-flow,  or  only  just  before  it.  In  the 
congestive  cases,  on  the  other  hand,  the  pain  is  continuous  and  aching  in 
character,  and  begins  some  hours  or  days  before  the  flow.  In  typical  cases  also 
this  pain  is  relieved  by  the  flow.  In  the  membranous  cases  the  nature  of  the 
pain  partakes  of  the  characters  of  both  the  former  types,  being  aching  and 
continuous  first ;  then  becoming  colicky  and  spasmodic  when  the  uterus  is 
attempting  to  expel  the  characteristic  membrane  or  cast,  and  being  finally 
relieved  when  this  comes  away.  Many  cases  are  met  with  in  which  the  pain 
partakes  of  the  nature  of  both  the  congestive  and  spasmodic  types.  This 
usually  means  that  a  woman  who  originally  had  spasmodic  dysmenorrhoea, 
acquires  some  lesion  which,  in  its  turn,  gives  rise  also  to  the  congestive  type 
of  pain. 

Having  settled  that  a  case  belongs  to  one  of  the  three  main  types,  it  is  not  very 
difficult  to  work  out  the  actual  causation.  This  is  more  difficult  in  the  spas- 
modic cases  than  in  the  congestive,  because  the  latter  depend  upon  well-defined 
lesions,  and  the  former  do  not. 

1.  Spasmodic    Cases The  causation  of  this  type  of  case  is  often  obscure  ; 

but  a  bimanual  examination,  or  a  recto-abdominal  examination  in  virgins, 
will  usually  reveal  a  condition  of  the  uterus  which  can  only  be  described  as 
a  congenital  malformation.  It  may  be  small,  but  of  the  adult  type  ;  it  often 
has  an  exaggerated  anterior  bend,  the  "  cochleate  "  uterus  of  Pozzi  ;  and,  in 
addition,  the  vaginal  portion  of  the  cervix  is  often  too  long,  with  a  conical  shape, 
and  a  very  small  pin-hole  external  os.  Into  such  uteri  the  sound  may  pass  with 
difficulty,  owing  to  stenosis  and  rigidity  of  the  internal  os.  The  underlying  true 
cause  of  the  pain,  however,  is  commonly  admitted  now  to  be  imperfect  develop- 
ment of  the  uterine  muscle,  in  itself  again  a  congenital  malformation  of  texture 
occurring  in  an  organ  whose  external  form  also  is  malformed.  The  muscle  being 
imperfect,  it  is  also  possible  that  the  endometrium  is  abnormal  in  these  cases, 
unduly  fibrous  perhaps,  and  resistant  :  a  point  which  our  present  knowledge 
does  not  prove  or  disprove.  One  proof,  however,  of  the  truth  of  these  views  is 
the  effect  of  pregnancy  and  labour  on  such  cases.  They  are  nearly  always  cured, 
owing  to  the  great  muscular  development  during  pregnancy,  and  the  extreme 
stretching  of  the  lower  segment  during  labour.  Neurasthenia  also  colours  and 
increases  the  pain  in  these  cases  ;  but,  by  itself,  will  not  start  a  spasmodic  any 
more  than  a  congestive  dysmenorrhoea. 

2.  Congestive  Cases It  is  unnecessary  to  differentiate  the  congestive  cases  as 

tubal,  ovarian,  or  uterine,  because  the  underlying  cause  in  all  is  uterine  conges- 


D  YSMENO'RRHCEA 


tion  accompanying  such  lesions  as  are  shown  in  the  table.  The  differential 
diagnosis  of  these  lesions  is  to  be  made,  by  a  careful  consideration  of  the  history^ 
combined  with  bimanual  examination  of  the  pelvic  organs  and,  if  necessary, 
curettage  of  the  uterus,  which  also  serves  to  cure  the  cases  of  pure  endometritis. 
Cases  due  to  endometritis  are  to  be  recognized  by  the  cardinal  symptoms  of  this 
lesion,  namely,  menorrhagia,  leucorrhoea,  often  blood-stained,  and  chronic  back- 
ache. These  symptoms  accompany  slight  enlargement  of  the  uterus  without  any 
irregularity  in  shape,  such  as  would  occur  if  fibroids  were  present.  Simple 
retroversion  and  flexion  can  be  recognized  on  bimanual  examination  ;  the  fundus 
will  be  felt  posteriorly,  the  cervix  looking  directly  down  the  vagina  in  a  forward 
direction.  Salpingo-oophoritis  in  its  typical  chronic  form  gives  rise  to  irregular, 
very  tender  swellings  on  either  side  and  behind  the  uterus,  sometimes  forming 
definitely  retort-shaped  swellings,  especially  if  pus  is  present  in  the  tubes.  Fixa- 
tion of  these  swellings  and  of  the  uterus  is  a  very  definite  sign  of  the  disease  ; 
whilst  the  history  of  one  or  more  attacks  of  acute  illness,  with  pelvic  pain,  will 
assist  to  make  the  diagnosis  certain.  The  small  cystic  ovary  may  exist  without 
obvious  salpingo-oophoritis,  and  without  widespread  fixation.  The  ovary  is 
found  to  be  permanently  enlarged  and  irregular  in  shape  from  the  projection  of 
■cysts  from  its  surface.  Neurasthenia  is  included  under  this  heading,  because 
any  menstrual  pain  is  made  worse  by  it,  and  only  a  very  slight  lesion  need  be 
present  for  this  nerve  weakness  to  accentuate  any  pain  arising  from  it. 

3.  Membranous  Cases. — The  membrane,  or  cast,  is  of  two  types,  and  is  easily 
recognized  and  distinguished  from  other  uterine  casts,  such  as  those  formed 
by  the  decidua  of  pregnancy.  The  classical  cast  of  membranous  dysmenox- 
Thoea  •  is  hollow,  triangular,  not  more  than  one-eighth  of  an  inch  thick,  and 
possesses  three  openings.  This,  however,  is  not  the  common  form  ;  for  in  most 
cases  the  cast  is  solid,  and  formed  by  the  solid  mucosa  being  rolled  upon  itself. 
These  casts  contain  uterine  glands  in  a  stroma  which  is  crowded  with  leucocytes, 
and  contains  connective-tissue  cells.  The  solid  cast  may  be  nearly  half  an  inch 
thick,  and  looks  microscopically  as  if  it  were  composed  of  endometrium,  into 
which  haemorrhage  and  leucocytic  infiltration  had  occurred.  The  glands  in  it 
are  broken  up,  and  often  lie  on  the  outside.  These  casts  never  contain  any 
compact  masses  of  large  cells  of  the  decidual  type,  but  an  occasional  hyper- 
trophied  connective  tissue  cell  may  be  found.  Decidual  casts,  on  the  other 
hand,  are  the  result  of  pregnancy,  and  consist  of  compact  masses  of  large 
polygonal  cells  without  any  fibrillated  connective  tissue.  They  contain  glands 
with  hypertrophied  epithelial  linings,  and  often  show  large  hsemorrhagic  foci. 
The  occasional  presence  in  them  of  chorionic  villi  absolutely  settles  the 
diagnosis. 

It  must  not  be  forgotten  that  cases  of  dysmenorrhoea  may  be  mistaken  for 
those  of  abdominal  pain  due  to  other  lesions  unconnected  with  menstruation  ; 
and  the  differentiation  of  such  cases  may  be  a  matter  of  considerable  importance. 
It  is  conceivable  that  dysmenorrhoea  may  be  mistaken  for  : — 

Appendicitis  Haemorrhage  from  or  into  a  Graafian 
Colic,  intestinal,  renal,  or  hepatic  follicle 

Perforated  gastric  ulcer  Rupture   of   an   ovarian   cyst   or  pyo- 
Ruptured  tubal  gestation  salpinx 

Torsion  of  the  pedicle  of  an  ovarian  Dyspepsia  with  flatulent  distention, 
cyst 

Obviously,  some  of  these  lesions  are  dangerous  to  life,  and  therefore  it  is 
essential  that  they  are  not  overlooked.  The  danger  of  doing  this  is  increased 
if  any  of  these  lesions  occur  at  or  near  the  expected  time  of  a  menstrual  period, 
and  would  hardly  arise  at  all  if  a  menstrual  period  had   taken  place  recently. 


DYSPAREUNIA 


or  was  not  expected  for  some  days.  It  will  be  noted  that  all  these  lesions  are 
accompanied  by  sudden  abdominal  pain,  which  would  perhaps  lead  to  a  sus- 
picion of  spasmodic  dj-smenorrhoea,  but  hardly  of  congestive,  owing  to  the 
character  of  the  pain.  T.  G.  Stevens 

DYSPAREUNIA,  or  painful  coitus,  may  depend  upon  a  variety  of  local 
lesions  which  require  careful  differentiation  for  their  appropriate  treatment,  or 
it  mav  exist  when  no  local  lesion  can  be  found  at  all.  It  is  closely  associated 
with  vaginismus,  or  painful  spasm  of  the  levator  ani  muscle  on  attempts  at 
coitus,  and  the  same  lesions  which  cause  simple  dyspareunia  may  also  give  rise 
to  vaginismus.  It  is  remarkable  that  in  some  women  a  small  local  lesion  will 
produce  no  pain  upon  attempts  at  coitus  which  in  another  will  cause  pain  accom- 
panied by  violent  spasm  of  the  levator  ani.  In  some  cases  pain  arises  because 
there  is  a  difficulty  of  penetration  of  the  vaginal  orifice,  whilst  in  others  there  is 
no  difficulty,  but  pain  is  caused.  The  lesions  which  commonly  give  rise  to 
dyspareunia  are  the  following  :  congenital  absence  of  the  lower  part  of  the 
vagina,  unruptured  hymen,  inflamed  hymeneal  orifice,  vulvitis.  Bartholinitis, 
leukoplakic  vulvitis,  kraurosis  vulvee,  neuritis  of  the  pudic  nerve,  healed  perineal 
lacerations,  urethral  caruncle,  urethritis,  cystitis,  prolapsed  tender  ovaries  with 
retroverted  uterus,  chronic  metritis,  salpingo-oophoritis  with  adhesions,  anal 
fissure,  thrombosed  and  inflamed  piles. 

It  will  be  noted  from  a  perusal  of  the  above  that  the  lesions  fall  into  natural 
groups,  according  as  the  situation  of  the  lesion  is  at  the  vulva,  the  uterus  and 
ovaries,  the  urinary  passages,  or  the  anus  and  rectum.  Consequently  it  is 
necessary  to  carry  out  a  detailed  examination  of  any  case  of  dyspareunia  in  order 
to  find  out  whether  any  of  these  well-defined  lesions  are  present. 

The  commonest  lesion  is  certainly  inflamed  hymeneal  remains,  very  often 
gonorrhoeal  in  origin  and  accompanied  by  redness  and  swelling  of  the  orifice  of 
the  duct  of  Bartholin's  gland.  The  lesion  is  self-evident  on  inspection,  and  the 
parts  are  acutely  sensitive  to  the  least  touch. 

Leukoplakia  vulvitis  is  an  obvious  lesion  from  the  white,  sodden  appearance  of 
the  labia  minora,  and  causes  pain  on  account  of  the  sensitive  cracks  and  fissures 
which  accompany  it. 

Kraurosis  vulvce  causes  actual  contraction  of  the  vaginal  orifice,  and  conse- 
quently penetration  is  difficult  and  causes  pain. 

The  red  projecting  growth  from  the  meatus  urinarius,  caruncle,  is  self-evident 
and  acutely  tender,  whilst  urethritis  is  diagnosed  by  the  issue  of  pus  on  squeezing 
the  urethra. 

Cystitis  is  diagnosed  by  the  presence  of  pus  and  mucus  in  the  urine,  accom- 
panied by  frequency  of  micturition,  and  it  causes  pain  because  the  bladder  is 
painful  in  such  cases  and  intolerant  of  the  disturbance  caused  by  coitus. 

Pudic  neuritis  is  not  a  well-defined  condition,  but  can  be  recognized  by  tender- 
ness along  the  pudic  nerve  just  inside  the  vaginal  orifice,  where  the  nerve  passes 
along  the  inner  side  of  the  ischial  ramus. 

In  prolapsed  tender  ovaries  and  backward  displacements  there  is  no  pain  on 
penetration  and  no  difficulty,  but  coitus  gives  acute  pain.  The  condition  is 
recognized  by  a  bimanual  examination,  the  same  remarks  applying  to  salpingo- 
oophoritis,  bearing  in  mind  that  there  is  usually  a  history  of  some  acute  attack 
of  pelvic  peritonitis  in  such  cases. 

In  chronic  metritis  the  tubes  and  ovaries  may  be  normal  and  the  uterus  normal 
in  position,  but  in  this  condition  the  uterus  itself  is  tender  to  the  touch,  and 
consequently  coitus  causes  pain. 

Anal  fissure,  thrombosed  and  inflamed  piles,  can  only  be  recognized  by  a  careful 
examination  of  the  anus  and  rectum  bj-  the  finger  and  speculum. 


DYSPAREUNIA 


In  the  cases  which  occur  without  local  lesions,  the  vaginal  entrance  will  be 
found  to  be  h\-per£esthetic  as  a  rule,  and  penetration  is  impossible.  Such  cases 
are  almost  always  accompanied  by  spasmodic  vaginismus.  The  most  careful 
examination  fails  to  demonstrate  a  lesion  in  such  cases,  and  they  are  usuallv 
termed  "  neurotic  "  for  the  want  of  a  better  term.  Such  cases  do  not  necessarily 
mean  absence  of  sexual  desire  ;  on  the  contrary,  many  such  patients  are  desirous 
of  the  consummation  of  marriage.  Enlarging  the  orifice,  or  even  child-bearing, 
does  not  cure  a  true  case  of  this  nature  ;  it  must  be  in  some  way  a  disorder  of 
function  of  the  nerve  centres.  These  cases  must  be  distinguished  from  those  in 
which  the  underl\-ing  factor  is  absence  of  sexual  desire  and  actual  dislike  of  the 
sexual  act.  Unhappy  and  unsuitable  marriages  conduce  to  this  state  of  affairs, 
and  the  patient  is  hable  to  complain  of  pain  when  dislike  is  really  what  is  meant. 
There  is  no  difficulty  in  penetration  in  such  cases.  7-.  q_  Stevens. 

DYSPHAGIA  is  a  someAvhat  loose  term  employed  on  different  occasions  to 
denote  entirely  different  s\"mptoms.  Literally  it  means  difficultv'  in  swallowing, 
but  the  term  itself  does  not  indicate  whether  the  difficulty  is  mechanical,  nervous, 
or  due  to  pain.  There  are  consequently  several  entirely  different  groups  of 
cases,  to  each  of  which  the  term  dysphagia  has  been  applied  at  one  time  or 
another. 

I.  Dysphagia  due  to  Mechanical  Obstruction  to  the  (Esophagus. — The  usual 
history  of  progressive  mechanical  obstruction  to  the  oesophagus  is  as  follows  : 
There  is  Kttle  or  no  pain,  but  the  patient  notices  that  whereas  formerly  he  could 
swallow  an\-thing  with  ease,  he  is  beginning  to  experience  difficult],-  with  the  more 
solid  kinds  of  food,  such  as  meat,  dry  bread,  and  vegetables,  so  that  he  is  obliged 
to  hve  mainly  upon  pulpy  foods :  milk  puddings,  gruel,  and  the  hke.  Later  he 
can  swallow  only  Uquids.  Ultimately  the  patient  finds  that  even  liquids 
are  apt  to  be  regurgitated  soon  after  the}-  have  been  swallowed,  and  there  is 
often  a  sense  of  obstruction  at  some  point  between  the  le\-el  of  the  cricoid 
cartilage  and  the  lower  end  of  the  .gladiolus,  which  latter  corresponds,  as  regards 
sensation,  with  the  cardiac  end  of  the  oesophagus.  When  with  the  above 
histon.-  the  patient  gives  a  definite  account  of  ha\-ing  previously  swallowed 
some  strong  irritant  or  corrosive  substance,  such  as  an  alkah  or  a  mineral  acid, 
accidentally  or  with  suicidal  intent,  the  diagnosis  of  fibrous  stricture  from  corrosive 
injury-,  is  easy.  AMien  similar  obstruction  succeeds  the  swallowing  of  a  foreign 
body,  such  as  a  tooth-plate  {Fig.  71),  a  large  piece  of  bone,  or  a  coin,  the  diag- 
nosis is  also  easy.  Where  the  s},-mptoms  are  not  directly  attributable  to  anj-- 
thing  of  this  nature,  however,  but  come  on  insidiously,  the  diagnosis  generaU}^ 
lies  between  primary  squamous-celled  carcinoma  of  the  oesophagus,  spheroidal  or 
columjiar-celled  carcinoma  of  the  stomach  directly  invading  the  lower  end  of  the 
oesophagus,  and  aortic  aneurysm  stenosing  the  oesophagus  from  outside.  The 
actual  fact  of  obstruction  has  first  to  be  determined,  and  there  is  danger  in 
passing  a  bougie  uiiless  aortic  aneur^-sm  can  be  excluded  ;  this  exclusion  is  by 
no  means  easy,  howeA-er,  for  that  variety-  of  aneurysm  which  is  most  hable  to 
stenose  the  oesophagus  is  one  afiecting  the  descending  thoracic  aorta,  so  that 
it  does  not  give  rise  to  any  tumour,  or  pulsation,  or  bruit,  and  it  is  placed  too 
far  along  the  aorta  to  cause  inequahty  of  the  pulses,  inequahty  oi  the  pupils 
(from  interference  with  the  cer\ical  sympathetic),  paralysis  of  a  vocal  cord 
(from  interference  with  the  left  recurrent  laryngeal  nerve),  tracheal  tugging, 
or  pain  down  either  arm.  The  onlv  other  effects  besides  oesophageal  obstruction 
likely  to  be  due  to  aneurysm  in  this  position  are  :  pain  in  the  dorsal  region  of 
the  spine,  possibly  radiating  along  the  course  of  one  or  more  of  the  mid-dorsal 
intercostal  nerves  towards  the  left,  and  perhaps  obstruction  to  the  lower  part 
of  the  root  of  the  left  lung,  causing  impairment  of  note,  of  air-entry,  or  of  voice 


DYSPHAGIA 


223 


sounds,  with  or  without  some  crackhng  rales  over  the  left  lower  lobe  behind. 
If  a  bougie  is  passed,  it  should  be  a  soft  one,  and  extreme  care  should  be 
taken  ;  but  the  danger  may  be  avoided  in  towns  where  ;ir-ray  installations  exist, 
for  the  obstruction  may  often  be  demonstrated  by  making  the  patient  swallow 
a  capsule  containing  oxychloride  of  bismuth  and  watching  its  course  ;  while  an 
aneurysm  would  cast  a  characteristic  shadow  in  the  posterior  mediastinum. 
The  older  the  patient,  the  more  likely  is  it  to  be  carcinoma  of  the  oesophagus 
and  not  aneurysm.  The  differential  diagnosis  between  primary  growth  of 
the  oesophagus,  and  infiltration  of  the  oesophagus  by  a  growth  starting  at  the 
cardiac  end  of  the  stomach,  is  often  one  of  great  difficulty,  unless  there  have  been 


-Sudden  death  from  acute  dyspncea  and  asphyxia  :    tooth-plate  impacted  in   the  larynx. 
(Fro/u  a  case  of  Dt.    T .   Warner  I.acty's,  of  U'oohvich.) 


definite  gastric  symptoms  before  dysphagia  set  in.  Secondary  nodules  would 
naturally  be  looked  for,  especially  in  the  lymphatic  glands  in  the  lower  part 
of  the  neck.  It  is  unusual  to  find  secondary  deposits  elsewhere,  but  should 
there  be  any,  they  might  possibly  be  in  the  liver.  A  history  of  syphilis  and 
evidence  of  syphilitic  aortic  regurgitation,  especially  in  a  man  between  the 
ages  of  forty  and  fifty  who  had  been  a  hard  manual  worker  and  not  teetotal, 
would  render  aneurysm  probable. 

Dysphagia  lusoria  is  a  very  rare  condition  due  to  compression  of  the  oesophagus 
by  the  right  subclavian  artery  where  it  arises  from  the  aorta  beyond  the 
left   subclavian  and   passes   to   the  right  side  either  in  front  of  or  behind  the 


224  DYSPHAGIA 


oesophagus;  the  diagnosis  in  such  cases  will  be  almost  impossible,  though  it  might 
be  guessed  at  if  there  were  other  congenital  deformities,  such  as  club-foot  or 
transposition  of  the  viscera. 

(Esophageal  Pouches  are  either  congenital  or  acquired ;  when  acquired,  they 
are  said  to  be  of  t^vo  types,  namely,  those  due  to  traction  from  without,  and  those 
due  to  bulging  from  within  ;  but  the  probability  is  that  many  of  those  which  are 
not  congenital  are  caused  by  a  caseous  gland  in  contact  with  the  oesophagus. 
The  contents  of  the  gland  having  escaped  into  the  latter  by  a  process  of  ulceration, 
the  pocket  thus  left  in  communication  with  the  interior  of  the  oesophagus 
subsequently  became  intermittently  filled  with  food,  and  thus  bulged  out  to 
produce  a  larger  diverticulum.  The  symptoms  can  seldom  be  interpreted 
with  certainty  unless  the  case  is  watched  for  some  time.  Generally  the 
patient  can  swallow  with  perfect  ease  on  some  days,  but  with  considerable 
difficulty  on  others ;  aneurysm,  new  growth,  and  traumatic  or  corrosive 
obstruction  to  the  oesophagus  will  be  excluded  partty  by  the  age,  and  partly 
by  the  results  of  ;t;-ray  examination.  The  point  which  suggests  the  diagnosis 
of  a  pouch  is  that  the  patient  who  has  been  able  to  swallow  perfectlj'  well  for 
a  few  days,  and  then  begins  to  have  difficulty  in  getting  the  food  down,  finds 
relief  presently  on  the  regurgitation,  clearly  not  from  the  stomach  but  from 
some  situation  higher  up,  of  a  larger  quantity  of  food  material  than  had  been 
swallowed  immediately  before,  including  perhaps  articles  which  were  taken  one 
or  more  days  previously.  The  reason  for  these  symptoms  is  that  the  pouch 
does  not  obstruct  the  oesophagus  until  it  becomes  very  much  distended  by  the 
gradual  accumulation  in  it  of  portions  of  the  food  swallowed,  relief  coming 
about  when  the  greatly  distended  sac  empties  itself  back  into  the  cesophagus. 

2.  Dysphagia  due  to  Nervous  Causes  without  Obstruction. — The  two  com- 
monest varieties  of  dysphagia  due  to  purely  nervous  causes  are  probably 
post-diphtheritic  and  hysterical.  The  former  is  characterized  by  regurgitation 
of  the  food  through  the  nose,  due  to  paralysis  of  the  soft  palate  ;  inspection 
may  demonstrate  the  flaccid  condition  of  the  latter  ;  there  may  have  been  a 
history  of  sore  throat,  of  other  cases  of  diphtheria  in  the  patient's  neighbour- 
hood, or  Klebs-Loffler  bacilh  may  have  been  found,  or  may  still  be  found, 
in  the  patient's  throat.  When  regurgitation  of  the  food  through  the  nose 
develops  in  a  person  who  is  not  known  to  have  had  diphtheria,  the  s^miptom 
will  usually  arouse  grave  suspicion  that  diphtheria  of  a  mild  type  has  occurred 
but  has  been  overlooked.  There  may  or  may  not  be  other  signs  of  peripheral 
neuritis,  or  there  may  be  paralysis  of  the  ciliary  muscles  of  the  ej^es. 

Hysteria  as  a  cause  for  dysphagia  is  familiar  enough  under  the  heading  of 
globus  hystericus,  the  diagnosis  of  which  is  not  as  a  rule  difficult,  especially 
if  the  patient  be  a  young  woman  who  has  suffered  from  other  functional  nervous 
affections,  such,  for  instance,  as  hysterical  aphonia. 

Less  common  varieties  of  dysphagia  of  nervous  origin  are  : — 

Bulbar  Paralysis,  in  which  the  characteristic  and  progressive  difficultv  in  the 
use  of  the  lips,  tongue,  pharynx,  and  larynx  point  at  once  to  the  diagnosis,  the 
only  difficulty  that  may  arise  being  perhaps  in  distinguishing  true  bulbar 
paralysis,  in  which  the  lesion  is  in  the  motor  nuclei  of  the  medulla  oblongata, 
from  pseudo-bulbar  paralysis,  where  the  lesion  is  due  to  bilateral  cortical  softening  : 
in  the  true  form  there  is  atrophy  of  the  tongue,  in  the  pseudo- varietur- the  tongue 
does  not  atrophy,  and  chiefly  upon  this  point  is  the  differential  diagnosis  made. 

Syphilitic  Degeneration  of  the  medullary  centres  may  produce  symptoms  not 
unlike  those  of  ordinary  bulbar  paralysis,  but  it  is  generally  differentiated  by 
the  fact  that  other  cranial  motor  nerves,  particularly  those  of  the  eyeball,  are 
probably  affected  at  the  same  time,  and  there  may  also  be  evidence  or  a  clear 
history  of  syphilis,  with  or  without  a  positive  Wassermann's  reaction. 


DYSPHAGIA  225 


Lead  Poisoning  and  Alcoholism  may  also  be  responsible  for  degenerative  lesions 
affecting  the  nerves  concerned  in  the  process  of  swallowing. 

General  Paralysis  of  the  Insane  ultimately  results  in  inability  to  swallow, 
though  the  swallowing  reflex  is  amongst  the  very  last  to  disappear,  and  the 
diagnosis  has  long  since  been  established  upon  other  grounds. 

Spasmodic  Dysphagia  due  to  spasm  of  the  muscular  coats  of  the  oe.sophagus 
and  pharynx  is  probably  the  cause  of  globus  hystericus,  but  similar  spasticity 
may  prevent  swallowing  in  much  more  serious  diseases,  and  constitutes  a 
prominent  symptom  in  hydrophobia,  in  which  any  effort  to  swallow  liquids  pro- 
duces the  symptom  in  extreme  degree.  The  history  of  a  dog-bite  as  a  source  of 
contagion  is  the  chief  point  in  arriving  at  the  diagnosis. 

Myasthenia  gravis  is  a  very  characteristic  disease,  in  which  the  muscles  that 
are  affected  are  perfectly  able  to  do  their  work  when  they  first  begin  to  contract, 
but  become  fatigued  with  great  rapidity,  so  that  after  the  first  few  contractions 
those  which  succeed  become  less  and  less  effectual,  until  they  cease,  and  the 
affected  muscles  will  only  be  able  to  work  again  when  they  have  been  given 
a  long  rest.  The  neck  muscles,  and  those  of  the  eye,  larynx,  and  mouth,  become 
involved  early,  and  difficulty  in  swallowing  after  the  first  few  mouthfuls  is 
sometimes  a  characteristic  feature  of  the  case.  The  myasthenic  electrical 
reaction  (see  Reaction  of  Degeneration)  serves  to  distinguish  these  cases 
from  those  due  to  bulbar  paralysis. 

Finally,  there  are  very  rare  cases  in  which,  without  any  known  pathology, 
the  oesophagus  becomes  enormously  hypertrophied  and  dilated,  and  the  patient 
cannot  swallow,  though  a  bougie  passes  perfectly  well.  This  so-called  idiopathic 
dilatation  and  hypertrophy  of  the  oesophagus  is  fortunately  very  rare  ;  it  would 
seem  to  be  due  to  an  erroneous  spasmodic  contraction  of  the  cardiac  orifice, 
which  refuses  to  relax  for  the  ingress  of  food  into  the  stomach.  It  leads  to 
dilatation  of  the  oesophagus  behind  it,  with  much  hypertrophy,  the  latter,  great 
though  it  is,  eventually  failing  to  overcome  the  muscular  constriction  of  the 
oesophageal  sphincter. 

3.  Dysphagia  due  to  Mechanical  Defects  of  the  Mouth  or  Pharynx,  the 
(Esophagus  being  Normal. — This  group  of  cases  includes  patients  suffering  from 
such  conditions  as  widely  cleft  palate,  syphilitic  stenosis  of  the  pharynx,  inability 
to  use  the  tongue,  either  because  it  is  acutely  swollen  from  glossitis,  bee-sting, 
or  angina  Ludovici,  or  because  it  is  fixed  from  carcinomatous  infiltration,  and 
so  forth.  There  is  little  need  to  enter  into  the  differential  diagnosis  of  this 
variety  of  dysphagia,  for  it  can  generally  be  determined  by  direct  examination 
of  the  buccal  cavity.  Mumps,  quinsy,  and  post-pharyngeal  abscess  belong 
to  the  same  group,  the  last-named  causing  more  dyspnoea  than  dysphagia,  and 
being  confined  to  quite  early  childhood. 

4.  Dysphagia  in  which  there  is  no  Mechanical  Obstruction,  but  in  which  the  Act 
of  Swallowing  causes  the  Patient  so  much  Pain  that  he  Hesitates  to  Swallow. — 
The  chief  cau.ses  of  dysphagia  which  come  under  this  heading  are  :  Inflammatory 
affections  of  the  mouth  or  tongue,  including  the  different  varieties  of  stomatitis 
(p.  88)  ;  pemphigus  or  erythema  bullosum  of  the  buccal  cavity,  evidenced  by 
similar  eruption  upon  the  skin  (see  Bullae)  ;  ulcers  of  the  tongue,  whether 
malignant,  gummatous,  tuberculous,  or  due  naerely  to  erosion  by  a  carious  tooth 
or  an  ill-fitting  tooth-plate  ;  sore  throats  of  various  kinds  (see  Sore  Throat)  ; 
pain  in  the  mouth,  larynx,  or  oesophagus  after  swallowing  acute  irritants  or  fluids 
that  are  either  exceedingly  cold  or  burning  hot ;  and  inflammatory  affections  of 
the  larynx  and  its  immediate  neighbourhood.  The  nature  of  the  buccal  lesions 
will  generally  be  indicated  by  inspection.  The  different  varieties  of  sore  throat 
may  be  distinguished  to  some  extent  by  inspection,  though  bacteriological 
confirmation  is  usually  advisable.     The  chief  difficulties  arise  when  the  cause 

D  15 


226  DYSPHAGIA 


of  the  dysphagia  is  an  inflammatory  or  ulcerative  affection  of  the  larynx.  Rarities 
such  as  variolous,  lupoid,  leprous,  typhoidal,  decubital,  and  traumatic  ulcers  of 
the  larynx  will  seldom  be  diagnosed  unless  there  is  obvious  collateral  evidence, 
such  as  the  eruption  of  small-pox  upon  the  skin,  residence  in  leprous  countries, 
prolonged  confinement  to  bed,  and  so  forth,  to  indicate  the  nature  of  the  case. 

The  commoner  varieties  of  laryngeal  trouble  which  produce  dysphagia  are 
acute  laryngitis,  tuberculous  laryngitis  with  or  without  ulcers,  carcinomatous 
ulceration  of  the  larynx,  and  syphilis.  It  is  essential  that  laryngoscopic 
examination  should  be  made,  local  anaesthesia  by  the  use  of  the  cocaine  spray, 
or  by  painting  the  larynx  with  a  solution  of  cocaine,  generally  being  necessary 
first.  If  tubercle  bacilli  can  be  found  in  the  sputum,  or  if  there  are  abnormal 
signs  at  the  apices  of  the  lungs,  the  diagnosis  of  tuberculous  laryngitis  is  pro- 
bable, and  the  pallid  swelling  of  the  arytaeno-epiglottidean  folds,  and,  still  more 
so,  multiple  small  ulcers  of  the  edge  or  posterior  surface  of  the  epiglottis  or  of 
the  free  edges  of  the  true  or  false  vocal  cords,  or  similar  ulcers  in  other  parts 
of  the  larynx,  bilaterally  situated,  would  indicate  the  diagnosis  with  certainty. 
The  chief  difficulty  arises  in  the  more  chronic  cases  in  which,  after  the  larynx 
has  become  involved,  the  lung  condition  has  improved,  and  tubercle  bacilli  may 
not  be  found  in  the  sputum.  Epitheliomatous  ulceration  of  the  larynx  may  be 
very  extensive,  and  yet  for  a  long  time  remain  confined  to  one  side  ;  this 
unilateral  distribution  of  the  infiltration  is  often  important  evidence  in  distin- 
guishing epithelioma  from  syphilis  of  the  larynx,  whilst  the  latter  may  also 
be  distinguished  by  the  repair  which  may  ensue  even  after  extensive  destruction 
of  the  tissues  has  led  to  much  deformity  of  the  parts.  The  influence  of  potassium 
iodide  and  mercury  upon  the  lesions  may  assist  the  diagnosis,  and  Wassermann's 
serum  test  may  be  employed.  Doubt  may  remain,  however,  and  sometimes, 
where  it  is  very  important  to  arrive  at  a  certain  diagnosis  as  soon  as  possible,  a 
small  portion  of  the  affected  tissue  may  be  excised  and  examined  microscopically. 
When  tuberculosis,  syphihs,  and  new  growth  are  excluded,  and  yet  laryngitis  is 
present,  the  probability  is  that  it  is  due  to  some  infecting  organism.  Probably 
the  symptoms  will  have  started  more  or  less  acutely,  even  though  they  persist 
and  become  chronic  ;  laryngeal  inspection  may  show  acute  hypersemia  and 
injection  of  the  parts  with  extensive  oedema  without  ulceration,  and  the  nature 
of  the  micro-organism  concerned — the  diphtheria  bacillus,  streptococcus,  pneumo- 
coccus,  etc. — may  be  determined  bacteriologically  by  preparing  cultures  from 
local  swabbings.  It  is  possible,  of  course,  for  two  or  more  maladies  to  occur 
simultaneously,  and  it  is  particularly  difficult  to  distinguish  syphilitic  laryngitis 
from  tuberculous  in  a  syphilitic  patient  who  has  undoubted  phthisis  ;  similarly, 
it  may  be  difficult  to  distinguish  catarrhal  laryngitis  from  tuberculous  in 
phthisical  patients,  and  so  on  ;  indeed,  in  many  instances  the  diagnosis  may 
be  one  of  opinion  only.  Measles  is  very  apt  to  be  accompanied  by  laryngitis, 
which  may  often  be  merely  catarrhal,  but  which  not  infrequently  is  due  to 
diphtheria  which  developed  synchronously  with  the  measles.  In  order  to 
exclude  diphtheria,  it  is  always  advisable  to  take  swabbings  for  bacteriological 
investigation,  even  where  it  seems  almost  obvious  that  the  laryngeal  catarrh 
is  merely  part  of  the  general  coryza  of  measles.  In  all  these  cases  dysphagia 
will  be  accompanied  by  hoarseness  or  other  alteration  in  the  voice  pointmg  to 
an  affection  of  the  larynx.  Herbert  French. 

DYSPNOEA,  or  marked  difficulty  or  distress   in  breathing,  may  or  may  not 

be  associated  with  orthopnoea :  in  the  milder  cases  a  patient  when  at  rest  has 
no  dyspnoea,  the  difficulty  with  breathing  being  brought  out  only  by  exertion  ; 
nearly  all  conditions  which  may  produce  dyspnoea,  however,  are  capable  in 
later  stages  of  producing  orthopnoea,   so  that  the   causes  of  dyspnoea  and  of 


DYSTOCIA 


227 


orthopnoea  are  similar  in  kind  though  they  differ  in  degree.  There  is  no  need, 
therefore,  to  repeat  what  will  be  found  under  the  heading  of  Orthopncea, 
whilst  the  article  on  Breath,  Shortness  of,  should  also  be  consulted. 

Herbert  French. 

DYSTOCIA A    term    used    by    Hippocrates,    signifying    difficult    birth    or 

labour.  The  difficulties  of  delivery  show  themselves  by  prolongation  or  delay 
in  the  completion  of  the  stages  into  which  labour  is  usually  divided.  Dif&cult 
labour  is  accompanied  by  progressive  symptoms,  objective  and  subjective, 
which  are  to  be  explained  by  physiological  exhaustion,  especially  in  its  effect 
upon  the  central  nervous  system  of  the  patient.  The  results  of  difficult  labour 
are  thus  of  such  importance,  affecting,  as  they  do,  the  life  of  the  mother  and 
child,  that  anticipation  of  it,  and  therefore  early  and  appropriate  treatment,  are 
of  paramount  importance  in  scientific  midwifery. 

The  causes  may  be  best  tabulated  according  as  they  occur  in  the  first  or 
second  stage,  the  first  series  delaying  the  dilatation  of  the  cervix,  the  second 
the  expulsion  of  the  child.  It  is  not  out  of  place  in  this  connection  to  add 
also  the  causes  of  difficulties  in  the  separation  and  expulsion  of  the  placenta, 
for  delivery  cannot  be  said  to  be  complete  until  the  placenta  is  expelled. 


Causes  of  Delay  in  Completion  of  the  Three  Stages 
OF  Labour. 


1st  Stage. 

Weak   uterine   contractions. 

Rigidity  of  cervix.  Relative, 
spasmodic,  cicatricial,  new 
growths. 

Pendulous  belly,  causing 
anteversion. 

Early  rupture  of  mem- 
branes, due  to  malpresen- 
tations,  morbid  adhesions 
to  the  lower  uterine 
segment,  undue  friability. 

Malpresentations  in  general. 

Anything  which  prevents 
the  head  entering  the 
lower  uterine  segment. 

Hydramnios. 

Deficiency  of  liquor  amnii. 

Twins. 


2nd  Stage. 

Weak   uterine   contractions. 

Secondary  uterine  inertia. 

Absence  of  accessory  muscu- 
lar effort. 

Rigidity  of  vagina  and 
perineum. 

Loaded  rectum. 

Distended  bladder — cysto- 
cele. 

Contracted  pelvis. 

Pelvic  tumours  :  Fibro- 
myoma,  ovarian  tumours, 
growths  of  the  pelvic 
bones,  hagmatoma,  vari- 
cose veins,  vaginal 
growths. 

Malpresentations  :  Occipito- 
posterior,  breech,  face, 
brow,  transverse. 

Any  abnormal  enlargement 
of  the  chUd :  Hydro- 
cephalus, meningoceles, 
ascites,  tumours,  double 
monsters,  very  large  child. 

Excessive  ossification  of  the 
head. 

Short  cord  :  absolute,  rela- 
tive. 

Locked  twins. 


yd  Stage. 
Weak   uterine   contractions. 
Morbid  adhesion  of  placenta. 
Uterine  spasm. 
"  Hourglass  "  contraction. 
Adhesion  of  membranes. 


From  the  above  it  will  be  seen  that  the  causes  of  delay  are  very  numerous  and 
important ;  and  the  successful  delivery  of  the  child  under  many  of  these  condi- 
tions depends  very  much  on  their  anticipation,  rather  than  their  recognition 
when  delivery  is  already  dangerously  obstructed.  Consequently,  accurate 
diagnosis  at  the  beginning  of  labour  will  often  save  much  trouble  to  the  practi- 
tioner, and  danger  to  the  mother  and  child.  Indeed,  some  of  the  dangers  of 
obstructed  labour  can  only  be  avoided  satisfactorily  by  careful  examination  of 
the  patient  during  pregnancy,  say  at  the  thirtieth  week.     This  specially  appUes 


228  DYSTOCIA 


to  the  recognition  of  contracted  pelves,  of  the  presence  of  pelvic  tumours,  and 
sometimes  of  malpresentations,  and  constitutes  an  important  reason  why  every 
patient  should  be  urged  to  undergo  an  examination  during  the  later  weeks  of 
pregnancy. 

The  routine  method  of  examination  of  the  pregnant  woman,  whether  in 
labour  or  not,  is  the  same  ;  and  the  deductions  to  be  made  from  it  are  identical. 
The  examination  is  made  as  follows  :  first,  by  abdominal  palpation  ;  secondly, 
by  vaginal  examination. 

Abdominal  Palpation — First  feel  for  the  foetal  head  in  the  pelvis  by  the  "  pelvic 
grip,"  or  Pawlik's  grip.  In  a  primipara  the  head  should  be  well  down  in  the 
pelvis  ;  not  necessarily  so  in  a  multipara.  Failing  to  find  the  head  in  the  pelvis, 
palpate  for  it  at  the  fundus  ;  failing  to  find  it  here,  it  will  be  found  in  one  or  the 
other  lateral  situations.  If  the  head  is  in  the  pelvis,  and  fixed,  there  can  be  no 
pelvic  contraction  of  importance,  and  tumours  of  the  uterus  or  ovaries  below 
the  brim  are  quite  unlikely.  If,  however,  the  head  is  above  the  brim  and  movable 
in  a  primipara,  pelvic  contraction  must  be  suspected,  whilst  a  tumour  preventing 
entrance  into  the  pelvis  is  a  possibility.  Pelvic  contraction  may  be  verified  by 
pelvimetry,  for  which  see  below.  Abnormal  presentations  are  recognized  by 
abdominal  palpation  ;  breech  and  transverse  by  the  actual  position  of  the 
head  ;  occipito-posterior  by  the  presence  of  the  "  small  parts,"  arms  and  legs, 
in  front,  and  the  absence  of  the  back  of  the  foetus  ;  whilst  a  face  cannot  be 
absolutely  diagnosed,  except  in  mento-posterior  cases,  when  the  groove  between 
the  extended  occiput  and  back  will  be  felt  in  front,  whilst  the  head  remains 
above  the  brim.  Hydramnios  may  be  recognized  here  if  there  be  fluctuation, 
and  the  foetal  parts  can  only  be  felt  by  deep  dipping  of  the  hands  through  the 
fluid.  Twins  may  possibly  be  recognized  by  feeling  two  heads,  and  hearing  two 
foetal  hearts  beating  with  different  rhythms. 

Vaginal  Examination, — It  is  important  to  remember  that  very  little  can  be 
made  out  with  one  or  two  fingers.  As  a  rule,  all  that  can  be  noted  is  the  condi- 
tion of  the  canal,  whether  narrow  or  rigid,  with  a  powerfully  acting  levator  ani 
muscle,  and  the  condition  of  the  os  ;  note,  especially,  its  consistence,  and  the 
integrity  of  the  membranes.  It  may  not  even  be  possible  to  recognize  the  pre- 
sentation, if  this  has  not  been  made  out  by  abdominal  palpation.  If  contracted 
pelvis  is  suspected,  the  important  diameter,  namely,  the  diagonal  conjugate, 
should  be  measured  with  the  fingers,  and  the  true  conjugate  estimated  by  sub- 
tracting half  an  inch  from  this  measurement.  The  only  accurate  instrument 
for  taking  this  measurement  is  Skutsch's  pelvimeter  ;  but  its  use  requires 
considerable  experience,  and,  in  general,  the  simpler  method  with  the  fingers  is 
sufficiently  accurate  for  most  purposes.  External  measurements  may  be  made 
to  supplement  the  important  internal  one  ;  but  they  are  not  of  the  same  practical 
importance.  When  a  difficulty  arises  in  labour,  accurate  diagnosis  is  indispens- 
able, and  the  whole  hand  should  be  inserted  into  the  vagina  under  anaesthesia. 
The  presenting  part  may  then  be  grasped,  and  its  absolute  character  determined. 
In  this  way  occipito-posterior  presentations  (the  commonest  cause  of  difficult 
labour)  can  be  diagnosed  with  certainty,  and  rectified.  Hydrocephalus  may 
be  recognized  by  this  manoeuvre  ;  the  hand  may  be  pushed  on  above  the  head 
without  danger  in  most  cases,  and  the  neck  felt  for  coils  of  cord,  the  body  of 
the  child  palpated  for  the  presence  of  tumours  or  enlargement  by  ascites. 
Tumours  obstructing  delivery  are  best  felt  from  the  vagina  ;  they  are  usually 
wedged  between  the  presenting  part  and  the  sacral  promontory,  part  below 
and  part  above  this  prominence.  If  fluctuating  and  soft,  they  are  usually 
ovarian  cysts  ;  if  hard  and  unyielding,  they  may  be  fibromyomata  of  the  uterus  ; 
but  these  also  are  apt  to  soften  during  pregnancy,  and  to  feel  like  fluid  tumours. 
Tumours  of  the  pelvic  bones  are  usually  bony,  or  cartilaginous  ;    growths  of  the 


EARACHE  229 


cervix  may  be  fibroid,  but  more  commonly  are  friable  carcinomata,  bleeding 
freely  on  examination. 

Little  more  than  the  method  of  examination  can  be  indicated  in  a  short  article 
on  the  diagnosis  of  a  case  of  difficult  labour  ;  but  too  much  stress  cannot  be 
laid  on  the  value  of  abdominal  examination  and  palpation  as  the  most  important 
means  of  gaining  information  in  any  labour. 

Delay  in  the  Delivery  of  the  Placenta,  though  not  strictly  a  part  of  difficult 
labour,  presents  difficulties  in  the  completion  of  delivery,  and  must  not  be 
overlooked.  The  placenta  may  be  simply  retained  in  utero  ;  may  be  adherent 
to  the  uterus,  totally  or  partially  ;  or  may  be  retained  in  the  vagina.  In  the 
first  case,  if  there  is  no  haemorrhage,  the  placenta  is  likely  to  lie  in  the  lower 
uterine  segment  and  vagina,  and  is  not  expelled  owing  to  weakness  of  the  acces- 
sory muscles.  If  partially  adherent,  bleeding  is  certain  to  occur,  whilst  total 
adhesion  does  not  permit  of  any  bleeding.  In  any  case  of  this  kind  if,  after  a 
sufficient  time  has  elapsed,  the  placenta  cannot  be  expressed,  the  hand  must 
be  introduced  into  the  uterus  in  order  to  diagnose  the  condition.  It  must  not 
be  forgotten  that  the  placenta  may  be  retained  above  a  spasmodic  stricture  of 
some  part  of  the  uterus,  the  so-called  hourglass  contraction.  Hasmorrhage 
always  accompanies  this  condition  if  the  placenta  is  partly  separated. 

Finally,  the  symptoms  of  exhaustion  consequent  upon  obstructed  labour  may 
be  mentioned.  The  first  are  rise  of  temperature  and  increase  in  frequency  of 
the  pulse-rate.  These  afford  very  important  indications  of  obstructed  labour, 
and  assist  us  to  distinguish  simple  delay  from  weak  uterine  contractions,  in 
which  the  pulse  and  temperature  remain  normal.  The  later  symptoms  of 
obstruction,  if  not  relieved,  are  local  and  general.  Locally,  the  vaginal  secretions 
fail,  the  parts  become  hot,  dry,  and  swollen.  The  uterus  contracts  powerfully, 
and  may  go  into  a  tetanic  condition,  usually  known  as  tonic  contraction,  in 
which  case  the  uterus  is  hard,  never  relaxing,  and  is  tender  to  the  touch.  The 
exact  opposite,  of  course,  occurs  in  uterine  inertia,  when  the  uterus  remains 
flaccid,  along  with  a  normal  pulse  and  temperature.  Later  still,  vomiting  of  a 
reflex  nature  may  occur,  signs  of  septic  infection  may  appear,  and  rupture  of  the 
uterus  may  take  place,  owing  to  the  dangerous  thinning  of  the  lower  segment 
when  tonic  contraction  supervenes.  This  series  of  symptoms  should  never  occur 
in  properly  conducted  midwifery  ;  their  possible  occurrence  should  always  be 
anticipated  by  correct  diagnosis  early  in  labour,  followed  by  immediate  appro- 
priate treatment.  T.  G.  Stevens. 

EARACHE  or  OTALGIA. — Earache  is  the  term  usually  applied  to  the  pain 
experienced  in  acute  inflammation  of  the  middle  ear.  It  is  most  acute  when 
suppuration  ensues.  There  are,  however,  a  number  of  other  conditions, 
many  of  them  of  great  importance,  which  also  give  rise  to  otalgia  or  pain 
in  the  ear. 

In  acute  otitis  media  the  pain  is  usually  dull,  continuous,  and  throbbing,  with 
sharp  exacerbations  in  which  the  pain  shoots  to  the  occiput,  to  the  top  of  the 
head,  or  forwards  to  the  temporal  region.  It  is  usually  worse  at  night — 
indeed  it  may  disappear  in  the  day — and  it  is  increased  by  pressure  over  the 
tragus  and  on  opening  the  mouth.  Not  infrequently  there  is  some  tenderness 
over  the  mastoid  process.  There  is  always  some  impairment  of  hearing.  In 
adults  there  will  probably  be  a  slight  rise  of  temperature,  but  in  children  the 
pain  is  often  very  acute,  and  constitutional  symptoms  may  be  very  marked. 
Thus  there  may  be  convulsions,  vomiting,  and  delirium,  and  the  temperature 
may  rise  to  103°  F.,  or  more.  Such  cases  may  be  mistaken  for  meningitis, 
especially  in  children  too  young  to  talk  ;  but  in  these  little  patients  attention 


230  EARACHE 

may  be  directed  to  the  trouble  by  the  extreme  tenderness  of  the  affected  ear, 
the  least  manipulation  of  which  may  cause  the  child  to  scream.  In  young 
children  the  presence  of  cerebral  symptoms  with  p^nrexia  should  always  lead 
to  a  careful  examination  of  the  ears.  The  presence  of  optic  neuritis  favours  a 
diagnosis  of  extension  of  the  inflammation  to  the  interior  of  the  cranial  cavity, 
but  this  is  not  a  universal  rule,  for  cases  are  recorded  in  which  otitis  media  bv 
itself  has  caused  optic  neuritis.  Attacks  of  earache  in  childhood  are  frequently 
caused  by  adenoids,  and  indeed,  acute  otitis  media  is  practically  always  caused 
by  an  extension  of  inflammation  from  the  nasopharynx  along  the  Eustachian 
tubes.  When  suppuration  occurs,  the  membrane  becomes  perforated,  pus 
escapes,  and  the  pain  usually  ceases.  When  it  persists,  the  perforation  is  pro- 
bably too  small  to  allow  of  satisfactory  drainage  of  the  pus. 

Examination  of  the  tympanic  membrane  by  means  of  a  speculum  will  show 
redness,  loss  of  lustre,  and  probably  bulging  of  the  membrane,  with  blurring  of 
the  handle  of  the  malleus,  thus  enabling  a  diagnosis  to  be  made. 

Chronic  middle-ear  suppuration  is  usually  painless  ;  but  when  caries  or  necrosis 
occur,  pain  is  often  present  and  may  be  very  acute.  This  is,  however,  by  no 
means  invariable,  and  some  cases  of  extensive  caries  are  remarkably  free  from 
pain.  Pain  and  tenderness  over  the  hiastoid  process  are  also  present  in  acute 
mastoid  abscess  and  periostitis. 

Pain  in  the  ear  may  also  be  caused  by  the  following  lesions  of  the  external 
auditory  meatus  : — 

Furuncles  give  rise  to  very  intense  pain,  often  throbbing  in  nature,  followed 
by  a  discharge  of  pus,  after  which  the  pain  diminishes.  Examination  shows 
swelling  of  the  meatus,  which  is  so  tender  that  it  may  be  impossible  for  the 
patient  to  endure  the  presence  of  the  speculum. 

A  foreign  body,  especially  if  an  insect  finds  it  way  into  the  meatus,  may  cause 
intense  pain. 

Cerumen  is  usually  painless,  though  sometimes  a  dull  pain  may  be  present. 

Eczema  of  the  meatus  may  be  the  cause  of  a  burning  or  smarting  pain.  In 
all  these  cases,  examination  with  the  speculum  will  clear  up  the  diagnosis. 

Sometimes  a  careful  examination  of  the  ear  will  fail  to  reveal  any  lesion. 
Under  these  circumstances  the  possibility  of  one  of  the  following  causes  of 
referred  pain  must  be  considered  : — ■ 

A  carious  molar  tooth  is  a  very  common  cause  of  pain  referred  to  the  ear. 

Frequently,  in  epithelioma  of  the  tongue,  pain  in  the  ear  is  a  very  troublesome 
symptom.  The  same  may  also  be  the  case  where  there  is  ulceration  of  the 
pharynx  or  larynx. 

Acute  or  subacute  tonsillitis  often  causes  acute  pain  in  the  ear  without  any 
inflammatory  lesion  of  the  middle  ear.  Less  frequently,  suppuration  in  the 
accessory  sinuses  of  the  nose  has  a  similar  result. 

Otalgia  may  sometimes  be  neuralgic,  and  it  is  then  usually  associated  with 
trigeminal  neuralgia.  It  may  also  occur  in  nervous  anaemic  patients,  and  some- 
times must  be  regarded  as  a  neurosis.  It  must  also  be  remembered  that  the 
glenoid  lobe  of  the  parotid  gland  extends  into  the  non-articular  portion  of  the 
glenoid  fossa,  and  thus  parotitis  may  cause  pain  referred  to  the  ear.  Similarly 
otalgia  may  occur  with  ost&Q-arthritis  or  inflammatory  trouble  in  the  temporo- 
mandibular joint. 

Lastly,  it  must  be  remembered  that  there  is  a  lymphatic  gland  situated  over 
the  mastoid  process  which  drains  lymph  from  the  side  of  the  scalp  ;  when 
inflamed,  this  gland  may  be  the  cause  of  pain  and  tenderness  which  may  lead 
to  a  suspicion  of  suppuration  in  the  mastoid  process.  Philip  Turner. 

ECCHYMOSIS.— (See  Purpura.) 


ENLARGEMENT     OF     THE    HEART  231 


ECTHYMA.— (See  Scabs.) 

ELECTRICAL  REACTIONS. — (See  Reaction  of  Degeneration.) 

EMACIATION. — (See  :Maf<asmus  ;   and  Weight,  Loss  of.) 

EMPHYSEMA,  SURGICAL. — Surgical  or  subcutaneous  emphysema  is  due 
to  distention  of  the  subcutaneous  areolar  tissues  with  air  or  gas.  The  diagnosis 
of  the  condition  and  its  cause  is  not  as  a  rule  difficult  if  the  different  possi- 
bihties  are  borne  in  mind.  Its  commonest  starting-place  is  in  connection 
with  the  thorax,  particularly  when  there  has  been  injury  to  the  lung  tissue 
by  a  broken  rib,  a  stab  with  a  knife,  a  bullet  wound,  the  rupture  of  alveoli  due 
to  excessive  coughing,  as  in  whooping-cough  and  bronchitis,  or  during  great 
strain,  as  in  difficult  labour  ;  or  by  operative  injury  to  the  lung,  as  in  exploratory 
needling  of  the  chest.  The  gas  rapidly  spreads,  and  may  extend  over  the  greater 
part  of  the  trunk  in  a  short  time,  disappearing  again  in  the  course  of  a  few  days. 
Another  cause  for  similar  emphj'sema  is  the  escape  into  the  connective  tissues  of 
air  from  the  trachea,  during  or  after  the  operation  of  tracheotomy . 

The  face  may  sometimes  be  almost  suddenly  involved  unilaterally  by  the 
escape  of  air  into  the  subcutaneous  tissues  from  the  upper  part  of  the  nose, 
after  violent  sneezing  or  energetic  blowing  of  the  nose. 

Rarer  causes  for  the  escape  of  actual  air  into  the  subcutaneous  tissues  are 
ulcerative  or  traumatic  lesions  of  the  cesophagus,  stomach,  duodenum,  ccscum, 
bladder,  or  rectum.  Air  escaping  in  the  areolar  tissues  around  any  of  these 
parts  may  sometimes  extend  and  become  palpable  as  crepitus  under  the  skin. 

All  the  above  conditions  produce  emphysema  from  the  escape  of  air  into  the 
tissues  ;  there  is  another  t}^e,  however,  in  which  the  gases  produced  are  not 
air,  but  the  results  of  infection  by  gas-producing  bacteria.  Fortunately  cases  of 
this  kind  are  now  rare  ;  they  were  less  uncommon  in  the  days  of  hospital 
gangrene  and  putrefaction.  The  Bacillus  coli  communis,  however,  not  infrequently 
Uberates  gas  in  an  abscess  to  which  it  may  give  rise — for  instance  in  the  region 
of  the  vermiform  appendix — and  sometimes  subcutaneous  emphysema  results. 
Another  gas-producing  organism  that  attacks  man,  though  less  often  as  a 
primary  affection  than  intercurrently  during  some  other  malady,  is  the  Bacillus 
a'erogenes  capsulatus  ;  this,  however,  more  often  produces  gas-containing  loculi 
in  the  hver  and  other  internal  organs  than  in  the  tissues  beneath  the  skin. 

Herbert  French. 

ENLARGEMENT   OF    A   BONE.— (See  Swelling  on   a   Bone.) 

ENLARGEMENT  OF  THE  GALL-BLADDER.  — (See  Gall-Bladder  En- 
largement.) 

ENLARGEMENT  OF  THE  HEART. — The  heart  may  become  enlarged  from 
hypertrophy  of  the  walls  of  any  of  its  cavities,  but  especially  of  the  ventricles  ; 
from  dilatation  of  the  cavities  ;    or  from  these  two  conditions  combined. 

The  most  important  physical  signs  of  enlargement  of  the  heart  are  :  (i)  Dis- 
placement of  the  cardiac  impulse  ;  (2)  An  increased  area  of  cardiac  dullness. 
After  puberty  the  normal  cardiac  impulse  is  usually  situated  in  the  fifth  left 
intercostal  space,  about  an  inch  or  three-quarters  of  an  inch  internal  to  the  left 
nipple  hne.  Before  puberty  it  is  normally  in  the  fourth  left  space  in  the  nipple 
line.  When  the  heart  is  enlarged,  the  impulse  is  displaced  outwards  and  also 
downwards.  Particular  care  must  be  taken  to  determine  the  exact  position, 
as  from  this  observation  a  good  idea  of  the  particular  part  of  the  heart  which 
has  enlarged  may  be  obtained.  W'hen  the  left  ventricle  is  much  hypertrophied, 
the  cardiac  impulse  is  displaced  downwards  and  outwards,  but  more  in  a  down- 
ward direction  than  outward,  e.g.,  it  may  be  found  in  the  sixth,   seventh,  or 


232  ENLARGEMENT     OF     THE     HEART 

eighth  left  intercostal  space  in  the  nipple  line  or  outside  it.  When  the  enlarge- 
ment is  due  to  hypertrophy  of  the  right  ventricle,  the  cardiac  impulse  is 
displaced  more  in  an  outw^ard  direction  than  downward,  and  frequently  there 
is  also  a  considerable  amount  of  pulsation  in  the  epigastrium. 

Where  the  cardiac  impulse  is  seen  to  be  thus  displaced,  before  cardiac  enlarge- 
ment is  diagnosed  the  possibility  of  mechanical  displacement  of  the  heart  by 
fluid  or  air  in  the  right  pleural  cavity  pushing  it  to  the  left,  or  a  retracted  left 
lung  pulling  it  over  to  the  left,  must  be  excluded  by  a  careful  phj^sical  examination 
of  the  front  and  the  back  of  the  chest.  In  the  case  of  pleuritic  effusion  the 
dullness  on  the  right  side  of  the  chest,  and  the  absent  or  deficient  vesicular  murmur 
over  that  lung,  Avould  point  to  fluid  ;  and  in  the  case  of  retraction  of  the  left  lung 
the  left  side  of  the  chest  would  be  smaller,  there  would  be  deficient  movement, 
dullness  and  deficient  voice  sound  and  vesicular  murmur,  or  possibly  bronchial 
breathing,  consonating  rales,  and  pectoriloquy  over  the  left  lower  lobe. 

The  character  of  the  impulse  must  be  carefully  noted,  for,  when  forcible  and 
heaving,  it  denotes  hypertrophy ;   when  feeble  and  diffused,  dilatation. 

The  cardiac  impulse  is  invisible  and  impalpable  in  some  cases  of  enlargement  of 
the  heart,  on  account  of  emphysema  of  the  lungs,  a  condition  which  causes  these 
organs  to  become  enlarged  and  to  cover  the  anterior  surface  of  the  heart,  so  that 
the  cardiac  impulse  is  obliterated.  In  these  circumstances  the  diagnosis  of  enlarge- 
ment must  rest  on  the  discovery  of  an  increased  area  of  cardiac  dullness  on  deep 
percussion,  and  on  the  fact  that  the  cardiac  sounds  are  best  heard  in  a  position 
lower  and  further  outwards  than  the  normal  situation  of  the  cardiac  impulse. 

Careful  mapping  out  of  the  area  of  cardiac  dullness  may  afford  valuable 
information  as  to  the  part  of  the  heart  involved  in  the  enlargement.  If  the 
area  of  deep  dullness  is  increased  downwards  and  outwards,  an  increase  in  the 
size  of  the  left  ventricle  is  indicated  ;  if  upwards  and  to  the  right,  hypertrophy 
of  the  right  ventricle  ;    if  in  all  directions,  enlargement  of  both  ventricles. 

As  a  result  of  the  elasticity  of  the  bones  of  the  thorax  in  children,  enlargement 
of  the  heart  in  them  may  produce  a  definite  and  obvious  local  bulging  of  the 
chest  wall  in  the  cardiac  area. 

Having  determined  the  position  and  character  of  the  impulse,  mapped  out 
carefully  the  area  of  cardiac  dullness,  and  thus  arrived  at  the  conclusion  that 
the  heart  is  increased  in  size,  the  next  step  is  to  determine  not  only  what  par- 
ticular part  is  enlarged,  but  also  the  actual  cause  of  the  enlargement. 

ENLARGEMENT  OF  THE  LEFT  VENTRICLE. 

The  left  ventricle  may  become  enlarged  in  : — 

1.  Aortic  Disease  : — 

Stenosis  and  regurgitation 

Regurgitation 

Stenosis 

Aneurysm  of  the  first  part  of  the  aorta  involving  the  aortic  ring. 

2.  Mitral  Regurgitation  : — 

Disease  of  the  mitral  valve 

Dilatation  of  the  left  ventricle  involving  the  mitral  ring. 

3.  Arteriosclerosis  and  Granular  Kidney. 

4.  Alcoholism. 

5.  Long-continued  Over-exertion: — 

Athletes 

\\^orkers   at  laborious   occupations,    e.g.,   stokers,    firemen,    furnacemen, 
blacksmiths. 

6.  Exophthalmic  Goitre. 

7.  Congenital  Heart  Disease. 


ENLARGEMENT     OF     THE    HEART  233 


I.   Aortic  Disease. 

Aortic  disease  may  cause  very  great  enlargement  of  the  heart — cor  bovinum 
or  bovine  heart.  In  the  Guy's  Hospital  Museum  there  is  a  heart  of  this  kind 
which  weighs  53  ounces,  the  normal  weight  being  about  10  ounces. 

Stenosis  and  regurgitation  is  the  commonest  form  of  aortic  disease,  then 
regurgitation,  and  pure  stenosis  is  the  rarest. 

Aortic  Stenosis  and  Regurgitation. — In  addition  to  the  cardiac  impulse  being 
displaced  downwards  and  outwards,  and  the  cardiac  dullness  being  much  increased 
towards  the  left,  there  are  many  signs  and  symptoms  which  are  characteristic 
of  this  valvular  lesion. 

Patients  are  usually  anasmic,  and  the  carotid,  brachial,  and  other  superficial 
arteries  are  seen  to  be  pulsating  forcibly. 

A  feeling  of  faintness  on  rising  from  the  supine  to  the  erect  posture,  dizziness, 
headache,  a  sensation  of  throbbing  in  the  extremities,  palpitation,  dyspnoea,  and 
precordial  pain  on  exertion  are  all  early  manifestations  of  this  disease.  As 
compensation  fails,  the  dyspnoea  and  palpitation  increase,  oedema  of  the  legs 
supervenes,  pain  becomes  worse,  and  is  felt  not  only  over  the  region  of  the  heart, 
but  tends  to  radiate  into  the  left  shoulder  and  arm,  and  it  may  be  followed  by 
true  attacks  of  angina  pectoris. 

The  curious  splashing  or  "  water-hammer  "  pulse  is  pathognomonic  ;  it  is 
best  appreciated  if  the  radial  pulse  is  felt  when  the  arm  is  raised,  the  pulse-wave 
striking  the  finger  with  a  sudden  sharp  jerk,  and  then  as  suddenly  collapsing. 
When  compensation  fails,  the  pulse-rate  may  become  rapid  and  the  beats  irregular 
and  intermittent,  as  in  mitral  disease,  but  earlier  in  the  disease  the  rate  and 
rhythm  are  normal. 

Capillary  pulsation,  which  may  be  detected  in  the  lips,  finger-nails,  and  skin, 
is  a  very  characteristic  sign.  It  can  be  demonstrated  best  by  drawing  the  edge 
of  one  of  the  nails  two  or  three  times  across  the  skin  of  the  forehead  or  abdomen 
so  as  to  produce  a  line  of  hyperaemia,  which,  if  carefully  watched,  will  be  seen  to 
blush  and  pale  alternately,  each  blush  being  synchronous  with  the  pulse. 

The  cardiac  impulse  is  in  the  fifth,  sixth,  seventh,  or  even  eighth  space  in  or 
outside  the  left  nipple  line,  and  may  be  situated  as  far  out  as  the  anterior  axillary 
line.  The  further  the  impulse  is  down,  the  larger  the  left  ventricle,  and  the 
further  it  is  out,  the  more  the  dilatation  of  this  cavity.  When  the  impulse  is 
forcible,  heaving,  and  limited,  it  indicates  that  hypertrophy  predominates  ;  when, 
on  the  other  hand,  the  impulse  is  diffused  and  feeble,  dilatation  preponderates. 
Young   people  may  present  well-marked  bulging  in  the  precordial  area. 

A  systolic  thrill  may  be  felt  over  the  base  of  the  heart,  especially  over  the 
second  right  intercostal  space  close  to  the  right  border  of  the  sternum.  More 
rarely  a  diastolic  thrill  may  be  felt  also  or  independently. 

The  area  of  cardiac  dullness  is  increased  in  a  downward  and  outward  direction. 

On  auscultation,  a  systolic  and  early  diastolic  murmur  are  heard  over  the 
base  of  the  heart.  The  former  usually  replaces  the  first  sound,  is  loudest  in 
the  second  right  intercostal  space  close  to  the  sternum,  and  is  transmitted  up- 
wards towards  the  clavicle  and  into  the  carotids.  It  varies  in  character,  being 
in  some  cases  soft  and  faint,  and  in  others  harsh,  rough,  and  loud.  The  dia- 
stolic might  be  described  as  post-systolic,  for  it  replaces  the  second  sound  ;  it 
is  generally  soft  and  blowing  in  quality,  though  in  rare  instances  it  is  harsh  or 
even  musical.  It  may  be  heard  over  the  upper  part  of  the  sternum  and  on 
both  sides  of  it.  When  the  aortic  incompetence  is  due  to  fibrosis  resulting  from 
endocarditis  following  acute  rheumatism  or  chorea,  it  is  usually  best  heard  to  the 
left  of  the  sternum,  loudest  in  the  third  left  intercostal  space  close  to  the  sternum. 
When  the  incompetence  is  due  to  sj'philitic  atheroma  or  to  aneurysra  of  the  first 


234 


ENLARGEMENT     OF     THE     HEART 


part  of  the  aorta,  the  bruit  is  generally  loudest  and  best  heard  in  the  second 
space  to  the  right  of  the  sternum.  The  early  diastolic  bruit  which  denotes 
aortic  regurgitation  may  also  be  heard  at  the  cardiac  impulse,  and  in  some  cases 
may  even  be  traced  out^vards  into  the  left  axilla. 

It  cannot  be  mistaken  for  a  mitral  stenotic  bruit,  because  there  is  no  interval 
between  the  second  sound  and  it.  If  there  is  complete  compensation,  the  first 
sound  may  be  loud  and  clear  at  the  apex,  but  if  dilatation  of  the  left  ventricle 
has  occurred,  there  may  be  a  loud  blowing  systohc  murmur  replacing  the  first 
sound  and  traceable  outwards  into  the  left  axilla.  Another  bruit,  which  is 
rumbling  in  character  and  pre-systolic  in  time,  may  be  heard  at  the  cardiac 
impulse  when  the  ventricle  is  dilated,  the  so-called  Flint's  bruit.  This  is  similar 
to  the  bruit  of  mitral  stenosis,  but  is  neither  so  loud  nor  so  rumbling.  It  usually 
runs  up  to,  and  is  continuous  with,  the  systolic  murmur,  but  there  is  no  loud 


Fig;.  72. — Obstruction  to  the  superior  vena  cava  by  intrathoracic  aneurysm.  The  patient, 
who  was  under  the  care  of  Dr.  Moorhead,  of  Blind  ley  Heath,  was  of  normal  appearance  until, 
almost  suddenly,  his  face  and  neck  increased  enormously  in  size  and  became  violaceous  without 
beinsr  definitely  oedematous.  There  had  been  a  brass}-  cough  for  some  time  previously.  He 
survived  the  acute  obstruction  to  his  superior  vena  cava  a  few  months.  The  photograph, 
taken  when  he  was  lying  very  ill  in  bed,  shows  the  bloated  appearance  it  produced. 


slapping  first  sound  as  in  mitral  stenosis.  This  pre-systohc  bruit  is  probabl}^ 
due  to  the  dilatation  of  the  left  ventricle  producing  a  condition  of  relative  stenosis, 
i.e.,  the  circumference  of  the  cavity  of  the  ventricle  is  increased,  but  the  mitral 
orifice  is  not  enlarged  or  only  shghtl}'  so  (see  p.  109).  The  method  of  distin- 
guishing betAveen  a  true  and  a  relative  stenosis  is  discussed  below. 

Aortic  Regurgitation. — The  symptoms  are  practically  the  same  as  in  aortic 
stenosis  and  regurgitation,  but  there  is  no  systolic  thrill  and  no  well-marked 
systolic  bruit  in  the  aortic  area. 

The  pulse  is  of  the  typical  water-hammer  type.  The  presence  of  a  soft 
systolic  bruit  in  the  second  right  intercostal  space  close  to  the  sternum  does  not 
indicate  aortic  stenosis  unless  there  be  at  the  same  time  a  thrill  there. 

Aortic  Stenosis. — This  is  the  rarest  form  of  aortic  disease.  In  addition 
to  the  absence  of  a  diastolic  bruit  at  the  base,  there  is  a  pulse  very  different 
from  that  of  the  water-hammer  type.     If  there  is  full  compensation  the  pulse  is 


ENLARGEMENT     OF     THE     HEART 


235 


slow,  frequently  below  60,  and  it  may  be  only  40  or  less,  to  the  minute.  It 
is  usually  regular,  long  sustained,  and  of  good  tension.  A  sphygmographic 
tracing  shows  a  slow  rise,  a  broad  summit,  and  a  gradual  decline. 

It  is  important  to  remember  that  the  mere  presence  of  a  systolic  murmur  in 
the  aortic  area,  even  if  its  point  of  maximum  intensity  be  in  this  region,  is  not 
sufficient  evidence  on  which  to  base  a  diagnosis  of  aortic  stenosis.  A  little 
roughening  of  a  segment  of  the  aortic  valves,  slight  sclerosis  of  a  valve,  atheroma 
or  dilatation  of  the  first  part  of  the  aorta,  and  even  anaemia,  may  give  rise  to  a 
well-marked  systolic  bruit  in  this  region.  Before  diagnosing  aortic  stenosis  of 
clinical  degree,  one  should  have  a  big  heart,  a  harsh  systolic  bruit  in  the  aortic 
area,  and  a  well-marked  systolic  thrill  corresponding  with  this  bruit. 

Aneurysm  of  the  First  Part  of  the  Aorta  is  another  important  cause  of 
hypertrophy  of  the  left  ventricle  if  the  dilatation  of  the  aorta  involves  the  aortic 


Fig.   Ti- — Obstruction   to   the   superior   vena    cava    \>y  an    aonic    aneurysm  ;    collatera 
circulation  through  the  distended  superficial  veins  of  ihe  neck  and  thora.\. 


ring,  increases  its  circumference,  and  thus  renders  the  aortic  valves  incompetent, 
though  the  cusps  may  be  individually  healthy. 

In  addition  to  the  characteristic  pulse  and  the  usual  signs  and  symptoms  of 
aortic  regurgitation,  there  may  be  several  indications  which  point  to  an  aneurysm 
of  the  first  part  of  the  aorta  as  the  cause  of  the  aortic  incompetence  : — 

There  may  be  a  distinct  bulging  of  the  thoracic  wall  involving  the  first  and 
second  interchondral  spaces  close  to  the  right  border  of  the  sternum. 

There  may  be  well-marked  pulsation  in  the  second  right  interchondral  space 
and  also  in  the  adjacent  spaces,  according  to  the  size  of  the  aneurysm,  close  to 
the  sternum  ;  when  not  obvious  to  the  hand  this  may  sometimes  be  detected 
by  the  ear  laid  flat  on  the  chest. 

In  addition  to  an  increase  of  the  cardiac  dullness  downwards  and  to  the  left. 


236 


EXLARGEMEXT     OF     THE     HEART 


there  -will  be  a  decided  area  of  dullness  in  the  second  right  space  close  to  the 
sternum. 

There  may  also  be  some  signs  of  intrathoracic  pressure  : — 
The  right  carotid  pulse  may  be  weaker  than  the  left. 

The  face  and  neck  may  be  deeply  cyanosed  if  the  aneurysm  has  extended  out- 
wards and  has  stenosed  the  superior  vena  cava,  though  this  is  a  rare  occurrence 

in  this  disease  {Fig.  72).  There 
may  be  a  loud  systolo-diastohc 
bruit  audible  in  the  second  right 
space  over  the  superior  vena 
cava,  with  maximum  intensity 
an  inch  or  more  to  the  right 
of  the  sternum.  The  superficial 
veins  over  the  upper  part  of 
the  right  side  of  the  chest  in 
front  may  be  varicose  {Fig.  73), 
and  the  direction  of  the  blood- 
current  in  them  may  be  from 
above  downwards,  instead  of 
from  below  upwards. 

The  right  bronchus  may  be 
stenosed  if  the  aneurysm  pro- 
jects posteriori}-,  and  this  leads 
to  impairment  of  percussion 
note  and  deficiency  in  the  vesi- 
cular murmur  over  the  upper 
lobe  of  the  right  lung.  The 
-v-rays  might  be  used  to  deter- 
mine the  diagnosis  {Fig.  74), 
though  the  aortic  diastolic 
bruit  should  serve  to  distin- 
guish aneurysm  from  new 
growth. 


J^i'g:  74  — Skiagram  of  a  large  saccular  :.•.■■.-•/-  -  i  A)  of 
the  ascending  part  of  the  arch  of  the  aorta  :  (B  transverse 
arch  displaced  to  the  left  :  (C  C)  clavicles  :  (D)  dia- 
phragm :  (El  apex  of  left  ventricle. — By  Dr.  Alfred  C. 
Jordan. 


Causes    of    Aortic   Disease. 
A  diagnosis  of  aortic  disease  is  incomplete  until  the  actual  cause  of  the  lesion 
ha5  been  determined.     It  may  be  due  to  : — 
I.  Lesions  of  the  Valves  : — 


Acute  endocarditis 
Fibrosis  after  former  endocar- 
ditis 
Infective  endocarditis 


Sclerosis  due  to  : — Strain  (persistent), 

S}-philis,  Alcohol 
Rupture  of  a  segment 
Congenital  malformation. 


2.  Dilatation  of  the  Aortic  Ring  from  Aneurysm  of  the  first  portion  of  the  Aorta. 

Lesions  of  the  Valves. 

Acute  Endocarditis  occurs  most  frequentl}-  as  a  comphcation  of  acute  rheu- 
matism, chorea,  or  scarlet  fever.  The  indications  of  acute  inflammation  of  the 
aortic  valves  wiU  be  a  systohc  murmur  in  the  aortic  area,  and  less  commonly  an 
early  diastolic  (post-systolic)  murmur,  which  first  becomes  audible  in  the  third 
left  space  close  to  the  left  border  of  the  sternum.  If  the  bruits  are  already 
present  when  the  patient  is  first  seen,  it  may  be  difficult  to  decide  whether  they 
are  due  to  existing  acute  inflammation  or  to  fibrosis  after  former  inflammation. 
They  may  be  noticed  to  arise  whilst  the  patient  is  under  treatment  in  bed  for 
acuti^  rheumatism,  and  then  their  acute  nature  wiU  be  obvious.     In  cases  in 


ENLARGEMENT     OF     THE    HEART  237 

which  the  bruits  are  due  to  acute  aortic  endocarditis  and  not  to  permanent 
fibrosis,  the  pulse  will  have  little  of  the  water-hammer  type,  the  heart  will  not 
be  much  hypertrophied,  though  it  maybe  dilated  from  acute  rheumatic  toxaemia, 
and  the  bruits  will  be  found,  as  the  days  go  by,  either  to  diminish  or  increase 
in  intensity,  according  as  the  inflammation  of  the  valves  resolves  or  passes  on 
into  permanent  fibrosis. 

Fibrosis  from  Previous  Endocarditis. — When  aortic  disease  is  due  to  fibrosis 
from  previous  endocarditis,  there  will  generally  be  a  history  of  attacks  of  acute 
rheumatism,  chorea,  scarlet  fever,  or  tonsillitis.  The  diastolic  bruit  which 
indicates  the  presence  of  aortic  regurgitation  is  heard  best  along  the  left  border 
of  the  sternum,  the  point  of  maximum  intensity  being  in  the  third  left  intercostal 
space  close  to  the  left  border  of  the  sternum.  There  will  generally  be  evidence 
of  organic  mitral  disease  at  the  same  time,  and  if  mitral  stenosis  be  associated 
with  aortic  disease,  whether  there  is  a  history  of  acute  rheumatism  or  not,  the 
valvular  lesions  may  be  considered  without  doubt  to  be  due  to  the  effects  of 
former  endocarditis.  The  patients  are  generally  children  or  young  adults,  though 
a  few  survive  into  middle  life. 

Infective  Endocarditis. — In  this  form  of  endocarditis,  in  addition  to  the  signs 
and  sj'mptoms  of  aortic  disease,  there  may  be  irregular  pyrexia,  occasionally 
rigors  and  sweating,  subcutaneous  petechiae  and  ecchymoses,  haematuria  and 
albuminuria  from  embolism  of  the  kidneys,  pain  and  tenderness  in,  and  enlarge- 
ment of,  the  spleen,  retinal  haemorrhages  and  signs  of  embolism  in  other  arteries, 
such  as  those  of  the  brain  causing  coma,  which  may  be  followed  by  hemiplegia, 
or  of  the  limbs,  causing  painful  local  swellings  and  loss  of  pulsation  in  the  vessel 
below  the  embolus. 

In  some  cases  a  bacteriological  examination  of  the  blood  shows  the  presence 
of  such  micro-organisms  as  the  Streptococcus  pyogenes,  Staphylococcus  pyogenes 
aureus.  Micrococcus  rheimiaticus,  Pneumococcus,  or  others. 

Sclerosis  not  due  to  former  Endocarditis  : — 

Strain. — Persistent  strain,  which  is  continually  increasing  the  tension  of  the 
segments  of  the  aortic  valves  during  the  ventricular  diastole,  is  an  important 
factor  in  the  production  of  aortic  disease.  Occupations  entaiUng  long  and  con- 
tinued ma.nual  labour,  and  excessive  indulgence  in  athletics  are  the  commonest 
causes  of  such  a  continuous  strain  on  the  valve  segments,  and  lead  to  a  gradual 
and  progressive  sclerosis  and  curling  of  the  edges,  which  narrow  the  width  of 
cusp  and  thus  lead  to  incompetence.  The  tendency  is  not  nearly  so  great, 
however,  in  those  who  have  not  had  syphilis  as  in  those  who  have  ;  so  that 
sclerosis  from  strain  alone  must  not  be  diagnosed  unless  there  be  neither  a  history 
nor  evidence  of  rheumatism,  chorea,  syphilis,  or  alcoholism. 

Syphilis. — A  history  of  syphilis,  and  any  manifestations  of  this  disease  in  the 
form  of  pigmented  scars  on  the  legs,  body,  and  face,  ulceration  of  the  tongue, 
patches  of  leukoplakia,  ulceration,  scarring,  or  perforation  of  the  palate,  necrosis 
of  the  nasal  bones,  etc.,  would  point  to  this  disease  as  the  cause,  and  this  con- 
clusion would  be  strengthened  if  there  were  no  previous  history  of  rheumatism, 
scarlet  fever,  or  chorea.  In  aortic  disease  from  this  cause  the  diastolic  murmur 
is  usually  best  heard  along  the  right  border  of  the  sternum  in  the  third  or  fourth 
right  intercostal  space.  The  patients  are  nearly  all  males  who  have  worked 
hard,  and  their  first  symptoms  are  often  brought  on  by  some  undue  muscular 
effort  which  strains  the  enlarged  heart,  or  even  bursts  an  atheromatous  patch  in 
the  diseased  valve.  Uncommon  before  forty,  the  lesion  is  met  with  often  enough 
between  forty  and  fifty  ;  in  many  cases  the  heart  has  been  passed  as  normal 
at  forty,  whilst  at  forty-five  the  aortic  regurgitation  is  extreme.  These  patients 
often  suffer  from  very  severe  attacks  of  angina  pectoris,  to  which  they  are  much 
more  liable  than  are  rheumatic  aortic  cases. 


238  ENLARGEMENT     OF     THE    HEART 

Alcohol. — The  constant  use  of  alcohol  raises  arterial  tension  and  may  be 
followed  by  sclerosis.  The  general  appearance  of  the  patient,  the  tremor  of 
the  tongue  and  hands,  and  the  history  of  loss  of  appetite  for  breakfast,  morning 
vomiting,  and  cramps  in  the  calves  of  the  legs  at  night,  would  suggest  alcohol  as 
the  cause  in  the  absence  of  any  evidence  of  rheumatism  or  syphilis,  but  alcoholism 
without  syphilis  leads  to  definite  aortic  disease  less  often  than  it  does  to  a 
generallv  hypertrophied  heart  which  sooner  or  later  exhibits  fibroid  or  fatty 
degeneration. 

Rupture  of  a  Segment  of  the  Aortic  Valve. — This  is  a  rare  occurrence,  and 
usually  is  brought  about  by  some  severe  and  sudden  muscular  exertion.  The 
following  is  a  good  illustrative  case  of  aortic  regurgitation  caused  b}-  rupture 
of  a  valve  segment.  A  sailor,  who  had  been  examined  just  previously  by  the 
medical  officer  and  found  to  be  sound,  was  one  day  pulling  on  a  rope,  when 
suddenly  the  strain  on  it  was  unexpectedly  and  much  increased.  He  made  a 
tremendous  effort  to  prevent  the  rope  slipping  through  his  hands,  and  in  doing 
so  fainted,  and  was  picked  up  in  an  unconscious  condition  ;  on  coming  round 
he  was  very  dyspnoeic,  and  complained  of  pain  in  the  precordial  region.  When 
the  doctor  examined  him  again  he  found  a  well-marked  musical  early  diastolic 
murmur  in  the  third  and  fourth  left  intercostal  spaces  close  to  the  sternum,  and 
came  to  the  conclusion  that  as  his  heart  sounds  were  normal  before  the  accident, 
he  must  have  ruptured  one  of  the  segments  of  his  aortic  valve  and  thus  caused 
the  incompetence.  There  is  always  the  possibiUty,  however,  of  such  a  valve 
having  previously  been  the  site  of  syphilitic  atheroma,  without  bruit,  until  the 
extra  strain  caused  a  weak  spot  in  the  valve  to  give  way  suddenly. 

Congejtital  Malformations  of  the  Aortic  Valves  are  extremely  rare,  and  they  are 
to  be  diagnosed  with  great  caution. 

Dilatation  of  the  Aortic  Ring  from  Aneurysm  of  the  first  portion  of  the  Aorta  is 
nearly  always  due  to  syphihtic  atheroma  of  the  aortic  walls,  and  in  such  a  case 
it  will  be  probable  that  there  is  syphilitic  disease  of  the  aortic  valves  themselves 
also.  The  dilatation  of  the  aorta  ("fusiform  aneurysm")  will  be  indicated  by 
definite  impairment  of  note  in  the  second  right  intercostal  space  near  the  ster- 
num ;  and  the  A--rays  will  confirm  it.  It  will  be  next  to  impossible  to  assess  with 
any  degree  of  accuracy  how  much  of  the  aortic  regurgitation  is  due  to  the  dila- 
tation of  the  ring  and  how  much  is  due  to  the  concomitant  valve  changes. 

2.  Mitral    Regurgitation. 

As  a  result  of  mitral  regurgitation  the  left  auricle  becomes  dilated  and  hyper- 
trophied, the  left  ventricle  dilated  and  hypertrophied,  and  later  from  backward 
pressure  the  right  ventricle  and  auricle  may  be  affected  similarh^  The  chief 
symptoms  are  dyspnoea  on  exertion,  palpitation,  congestion  of  the  face  and  hps, 
cough,  possiblv  haemoptysis,  oedema  of  the  feet  and  legs,  and  distention  of  the 
abdomen  from  ascites  and  enlargement  of  the  hver.  In  the  earh'  stages  the  pulse 
may  be  regular,  full,  and  of  low  tension.  When  compensation  begins  to  fail,  the 
pulse  becomes  rapid,  irregular,  and  intermittent. 

The  cardiac  impulse  is  displaced  downwards  and  outwards.  It  may  be  in 
the  fifth  intercostal  space  in  the  left  nipple  fine,  or  outside  it,  or  in  the  sixth 
space  outside  the  nipple  line.  It  is  usually  diffused,  and  there  maybe  epigastric 
pulsation. 

There  may  be  marked  bulging  of  the  precordial  area  in  children. 

A  systolic  thrill  is  rare,  but  it  may  be  felt  at  the  cardiac  impulse. 

The  cardiac  dullness  is  increased  outwards  and  downwards,  but  also  upwards 
and  to  the  right  when  the  right  side  is  involved. 

At  the  impulse  there  is  a  systolic  murmur,  usually  of  a  blowing  character, 
which  may  either  follow  or  replace  the  first  sound.      It  is  best  heard  at  the 


ENLARGEMENT     OF     THE    HEART  239 


cardiac  impulse,  but  it  can  generally  be  traced  outwards  into  the  left  axilla, 
can  sometimes  be  heard  behind  at  the  inferior  angle  of  the  left  scapula,  and 
can  also  be  traced  inwards  towards  the  left  border  of  the  sternum. 

The  pulmonary  second  sound  is  accentuated  or  reduplicated  in  the  second 
interspace  close  to  the  left  border  of  the  sternum. 

When  compensation  fails,  in  addition  to  the  above  there  may  be  : — 

A  systolic  murmur,  softer  than  and  different  in  character  from  that  at  the 
impulse,  over  the  lower  part  of  the  sternum  and  the  fourth  and  fifth  left  inter- 
spaces, due  to  tricuspid  regurgitation  ;  oedema  of  the  feet,  legs,  and  lower  part 
of  the  body  ;  abdominal  distention  from  ascites  ;  enlargement  and  pulsation  of 
the  hver ;    signs  of  hydro  thorax  ;    albuminuria. 

A  diagnosis  of  mitral  regurgitation  is  incomplete  and  insufficient  by  itself, 
for  it  is  a  lesion  which  may  be  due  to  any  of  a  large  number  of  different  con- 
ditions.     It  is  necessary  to  determine,  if  possible,  the  actual  cause  of  the  defect. 

Causes   of  Mitral  Regurgitation. 
I.  Lesions  of  the  Mitral   Valve: — 


Acute  endocarditis 
Fibrosis   the    result   of   former 
endocarditis 


Infective  endocarditis. 


2.  Dilatation,  or   Hypertrophy   and    Dilatation,    of   the  Left    Ventricle,   without 
organic  changes  in  the  Mitral  Valve  itself  : — 

Secondary  to  aortic  disease 

Secondary  to  increased  systemic  blood-pressure  : — 

Chronic  Bright's  disease 

Arteriosclerosis. 

3.  Diseases  of  the  JMyocavdium  and  Pericardium  : — 


Mj^ocarditis 

Fatty  degeneration 

Fibroid  degeneration 


Pericarditis 

Adherent  pericardium. 


4.  Acute  Dilatation  of  the  Heart  from  : — 

Over-exertion  ■     Acute  nephritis. 

Acute  febrile  diseases  ' 

Lesions  of  the  Mitral  Valve  : — 

Acute  Endocarditis. — Simple  acute  endocarditis  is  not  a  disease  per  se,  but 
occurs  as  a  comphcation  of  some  other  disorder,  especially  acute  rheumatism, 
chorea,  and  scarlet  fever.  It  sometimes  complicates  tonsillitis,  which  is  in 
many  instances  a  manifestation  of  rheumatism  occurring  without  any  changes 
in  the  joints  ;  and  it  should  also  be  remembered  that  in  children  acute  endo- 
carditis may  be  the  chief,  and  in  fact  the  only,  indication  of  an  attack  of 
rheumatism. 

There  are  no  characteristic  symptonrs  which  point  to  acute  endocarditis.  If 
in  the  course  of  acute  rheumatism  the  patient  complains  of  a  little  palpitation, 
precordial  pain,  and  distress,  and  it  is  found  that  the  heart  action  has  increased 
in  rapidity  without  any  increase  in  the  joint  affection,  endocarditis  should  be 
suspected.  The  temperature  chart  seldom  indicates  the  complication.  At 
first  the  position  of  the  cardiac  impulse  and  the  heart-sounds  remain  normal, 
but  if  watched  from  day  to  day,  endocarditis  having  developed,  the  impulse 
will  be  found  to  have  moved  outwards,  the  first  sound  becomes  prolonged  and 
roughened,  then  doubled,  and  in  a  few  days  it  is  either  followed  or  replaced  by 
a  localized  soft  blowing  systolic  murmur. 

Fibrosis    the    result    of    Previous    Endocarditis. — If  acute   endocarditis  of  the 


240  ENLARGEMENT     OF     THE     HEART 

mitral  valves  does  not  resolve,  the  valve-flaps  become  sclerosed.  The  valve 
gets  thickened  from  fibrotic  changes,  and  in  the  later  stages  it  may  become  quite 
firm  and  brittle  from  a  deposit  of  lime  salts.  The  chordse  tendinese  also  may  be 
shortened  and  thickened.  The  circumference*  of  the  orifice  may  be  considerably 
increased  in  some  cases,  and  although  the  valve  is  thickened,  it  is  narrowed  if 
measured  from  its  free  edge  to  its  line  of  attachment  to  the  auriculo-ventricular 
ring.  In  the  majority  of  cases,  however,  the  circumference  of  the  orifice  is 
narrowed,  so  that  the  valve  is  not  only  incompetent  but  also  stenosed.  A 
diagnosis  of  fibrosis  after  endocarditis  as  the  cause  of  mitral  incompetence  may 
be  made  if  there  is  a  previous  history  of  acute  rheumatism  or  chorea,  and 
independently  of  such  a  history  if  there  is  evidence  of  stenosis  as  well  as  regurgi- 
tation. If  actual  mitral  stenosis  can  be  diagnosed  with  certainty,  it  must  be 
due  to  fibrosis  from  endocarditis,  though  there  may  of  course  be  recent  endo- 
carditis as  well. 

Infective  Endocarditis  of  the  mitral  valve  :  if  there  is  a  mitral  bruit,  any  sudden 
or  radical  change  in  its  character  may  suggest  infective  endocarditis,  especially 
if  any  of  the  symptoms  and  signs  mentioned  on  page  237  are  present  at  the 
same  time. 

Hypertrophy  and  Dilatation  of  the  Left  Ventricle. 

Secondary  to  Aortic  Disease. — Aortic  disease  leads  to  hypertrophy  of  the  left 
ventricle,  which  is  followed  after  a  time  by  dilatation  of  that  cavity  and  mitral 
regurgitation.  Marked  pulsation  of  the  superficial  arteries,  a  splashing  pulse, 
capillary  pulsation,  and  the  systolic  and  early  diastoUc  murmur  at  the  base  of 
the  heart,  the  former  best  heard  in  the  second  right  space  close  to  the  sternum, 
and  the  latter  in  the  third  left  space  close  to  the  left  border  of  the  sternum,  would 
indicate  the  presence  of  aortic  disease.  If  the  patient  has  suffered  from  either 
rheumatism  or  chorea,  the  mitral  regurgitation  might  be  due  to  primary  endo- 
carditis of  the  mitral  valve,  but  if  the  aortic  disease  is  the  result  of  syphihs, 
hard  work,  or  aneurysm  of  the  first  part  of  the  aorta,  then  it  may  be  assumed 
that  the  mitral  regurgitation  is  the  result  of  secondary  dilatation  of  the  left 
ventricle,  and  not  of  primary  disease  of  the  mitral  valve. 

Secondary  to  Increased  Systemic  Blood-pressure  due  to  Chronic  Bright' s  Disease. — 
Associated  with  the  increased  blood-pressure  of  chronic  Bright's  disease,  the  left 
ventricle  hypertrophies  first  of  all,  and  then  after  a  time,  when  compensation  fails, 
dilates  ;  mitral  regurgitation  follows,  and  may  be  succeeded  by  all  the  signs  of 
backward  pressure,  such  as  oedema  of  the  feet  and  legs,  ascites,  enlargement  of 
the  liver,  hydrothorax,  heemoptysis  from  congestion  or  infarction  of  the  lungs, 
and  so  forth.  A  patient  presenting  such  a  group  of  symptoms  may  at  a  first 
glance  be  considered  to  be  a  case  of  primary  disease  of  the  heart,  but  a  careful 
investigation  will  often  enable  one  to  determine  that  the  primary  changes  have 
occurred  in  the  kidneys.  The  radial  artery  may  be  thickened  and  tortuous,  the 
tension  of  the  pulse  higher  than  in  mitral  regurgitation  from  primary  heart 
disease  ;  and  ophthalmoscopic  examination  may  in  many  instances  reveal  the 
presence  of  albuminuric  retinitis  and -retinal  haemorrhages  ;  the  urine  is  variable, 
for  whereas  it  may  formerly  have  been  abundant,  of  low  specific  gravity  (1008 
to  1012),  with  only  a  trace  of  albumin,  heart  failure  may  lead  to  its  being 
diminished  in  amount,  of  specific  gravity  1020  or  more,  and  albumin  may  be 
abundant ;  microscopical  examination,  however,  will  generally  reveal  renal 
tube-casts. 

Secondary  to  Increased  Systemic  Blood-pressure  due  to  Primary  Arteriosclerosis. 
— In  this  disease  there  may  be  signs  of  enlargement  of  the  heart,  mitral  regurgi- 
tation, backward  pressure,  and  a  thickening  of  the  arteries,  but  in  contrast 
to  chronic  Bright's  disease  the  urine  will  be  of  higher  specific  gravity,  and 
there  will  be  no  albuminuric  retinitis.      It  often  becomes  merely  a  matter  of 


ENLARGEMENT     OF     THE    HEART  241 

opinion,  however,  whether  a  given  patient  is  suffering  from  arteriosclerosis 
or  from  granular  kidney;  post-mortem  examination  may  reveal  both,  or 
arteriosclerosis  may  predominate  when  granular  kidney  had  been  diagnosed, 
and  vice  versa. 

Diseases  of  the  Myocardium  and  Pericardium. 

Myocarditis — Inflammation  of  the  myocardium  is  most  frequently  associated 
with  either  pericarditis  or  endocarditis,  but  occasionally  it  may  occur  in 
acute  rheumatism  as  a  primary  condition.  In  one  form  of  the  disease 
there  is  an  infiltration  of  leucocytes  between  the  muscular  fibres — interstitial 
myocarditis ;  in  another  form  the  actual  muscle  fibres  are  involved — parenchy- 
matous myocarditis ;  and  there  is  a  third  variety  which  occurs  in  pyaemia, 
especially  from  bone  disease,  characterized  by  the  formation  of  abscesses  in 
the  myocardium.  The  weakened  condition  of  the  heart  muscle  leads  to 
dilatation  of  the  ventricles,  and  thus  to  enlargement  of  the  heart.  When 
accompanied  by  pericarditis  or  endocarditis,  the  signs  of  myocarditis  are  over- 
shadowed by  the  symptoms  associated  with  these  other  conditions.  The 
diagnosis  of  myocarditis  is  therefore  a  difficult  matter.  If  in  a  case  of  acute 
rheumatism  there  is  no  evidence  of  either  pericarditis  or  endocarditis,  but  there 
are  signs  of  cardiac  failure,  a  feeble  irregular  pulse,  a  good  deal  of  precordial 
pain  and  distress,  dyspnoea  and  palpitation,  a  tendency  to  sudden  collapse,  and 
signs  of  dilatation  of  the  left  ventricle,  with  a  feeble  cardiac  impulse  and  a  weak 
first  sound,  myocarditis  may  be  suspected. 

Fatty  Heart. — The  heart  may  be  covered  with  fat  (fatty  superposition)  ;  fat 
may  infiltrate  between  the  muscular  fibres  (fatty  infiltration)  ;  the  muscle  fibres 
may  be  degenerated,  losing  their  striation,  and  containing  fat  granules  (fatty 
degeneration)  ;  or  all  these  conditions  may  be  associated.  Fatty  degeneration 
may  occur  in  patches  or  be  general.  When  general,  the  heart  becomes  enlarged 
from  dilatation  as  the  muscle  becomes  flabby,  has  less  contractile  force,  and  is 
more  yielding.  It  is  a  condition  which  may  be  associated  with  general  obesity, 
severe  anemia,  wasting  diseases  such  as  cancer,  phthisis,  phosphorus  poisoning, 
and  alcoholism.  It  may  be  a  sequela  of  severe  attacks  of  tvphoid  and  other 
specific  fevers.  The  symptoms  and  signs  of  the  condition  are  due  to  the 
diminished  contractile  power  of  the  ventricles  which  leads  to  dilatation.  The 
pulse  may  be  small,  feeble,  and  slow — 30  to  40  beats  per  minute — or  it  may 
be  frequent  and  irregular.  The  cardiac  impulse  is  very  feeble  or  imperceptible. 
There  may  be  an  increased  area  of  cardiac  dullness  from  dilatation,  and  the  first 
sound  may  be  very  faint.  The  patient  is  usually  feeble  and  anaemic,  and  suffers 
from  faintness  or  severe  syncopal  attacks  which  come  on  suddenly  and  are 
characterized  by  coma,  convulsive  twitching,  and  stertorous  breathing.  (Edema 
of  the  legs  and  venous  congestion  of  the  lips  and  face,  which  are  common  in 
valvular  disease,  are  usually  absent.  There  is  dyspnoea  on  exertion,  a  feeling  of 
coldness  and  depression,  and  a  general  impairment  of  the  nutrition  of  the 
muscles,  which  are  soft,  flabby,  and  diminished  in  power.  In  some  cases  attacks 
of  cardiac  "  asthma  "  in  the  early  morning  are  complained  of,  and  in  the  later 
stages  of  the  disease  there  may  be  Cheyne-Stokes'  breathing. 

The  chief  diagnostic  signs  are  the  feeble  cardiac  impulse,  the  feeble  pulse, 
and  the  weak  first  sound,  associated  with  dyspnoea  and  attacks  of  syncope, 
and  the  absepce  of  evidence  of  other  causes  for  the  heart  svmptoms. 

Fibroid  Heart. — Fibroid  degeneration  of  the  myocardium  is  usually  associated 
with  some  obstructive  lesion  of  the  coronary  arteries  caused  by  syphilis.  The 
apex  of  the  left  ventricle  is  the  part  most  frequently  affected.  It  leads  to  a 
thinning  and  weakening  of  the  ventricular  wall,  and  may  be  followed  by 
aneurysm  of  the  heart  and  then  b}^  rupture.  The  enlargement  of  the  heart  is 
chiefly  due  to  dilatation  of  the  left  ventricle.  It  is  one  of  the  causes  of  sudden 
D  .  16 


242  ENLARGEMENT     OF     THE     HEART 

death.  The  most  important  symptoms  are :  dyspnoea  on  slight  exertion,  palpi- 
tation, and  precordial  pain. 

The  physical  signs  are  those  of  dilatation  of  the  left  ventricle.  The  pulse  is 
feeble  and  irregular,  and  maj'  be  slow.  There  may  be  severe  attacks  of  angina 
pectoris.  The  diagnosis  is  more  or  less  a  matter  of  guesswork.  Such  signs  and 
s}Tnptoms  in  a  patient  who  has  had  sj^hiUs  but  neither  acute  rheumatism  nor 
chorea,  and  who  has  neither  aortic  disease  nor  signs  of  granular  kidney  or  arterio- 
sclerosis, might  be  considered  indications  of  this  form  of  cardiac  degeneration. 

Pericarditis — In  pericarditis  the  cardiac  impulse  is  usually  displaced,  and 
the  area  of  cardiac  dullness  increased.  These  physical  signs  may  be  due  to 
enlargement  of  the  heart,  or  to  effusion  of  serous  fluid  into  the  pericardial  sac, 
but  whatever  the  text-books  say  to  the  contrary,  it  is  practically  impossible  to 
differentiate  between  these  two  conditions.  Enlargement  of  the  heart  due  to 
dilatation  is  generally  the  result  of  the  myocardium  being  affected  as  well  as  the 
pericardium,  and  the  cardiac  impulse  is  diffused  and  displaced  out^vards.  If  there 
is  an  effusion  of  serous  fluid  into  the  pericardial  sac,  it  is  said  that  the  impulse 
is  displaced  upwards  as  well  as  outwards,  so  that  it  may  be  found  on  a  level 
with,  or  above  and  external  to,  the  left  nipple,  but  this  is  a  very  unrehablesign. 
The  dullness  is  increased  laterally  and  upwards,  and  when  carefully  mapped  out 
it  is  said  to  have  a  triangular  shape,  with  the  base  on  the  diaphragm  and  a  some- 
what rounded  apex  pointing  towards  the  left  clavicle,  and  reaching  to  the  second 
left  intercostal  space  or  higher.  Percussion,  however,  is  quite  unable  to  distin- 
guish between  a  pericardial  effusion  and  a  much  enlarged  heart  without  effusion. 
The  intercostal  spaces  are  filled  out,  and  may  be  almost  obhterated,  so  that 
the  ribs  feel  much  less  prominent  on  this  part  of  the  chest.  On  auscultation,  in 
addition  to  a  systohc  murmur  at  the  impulse  due  to  mitral  incompetence  from 
the  accompanjdng  dilatation  of  the  left  ventricle,  a  triple  "  cantering  "  sound 
and  perhaps  a  definite  rub  may  be  heard  in  some  part  of  the  precordial  region, 
especially  near  the  sternum,  independently  of  respiration,  and  generally  increased 
in  intensity  by  firm  pressure  of  the  stethoscope.  The  rub  is  audible  whether 
effusion  is  present  or  not. 

Adherent  Pericardium. — Adhesions  between  the  visceral  and  parietal  layers 
of  the  pericardium  are  frequently  found  post  mortem  when  thej^  had  never  been 
suspected  during  life.  Sometimes,  however,  thej^  are  associated  with  chronic 
mediastinitis,  or  what  should  more  correctly  be  termed  mediastinal  fibrosis,  the 
outer  surface  of  the  pericardial  sac  becoming  adherent  to  the  thoracic  wall  and 
to  adjacent  structures.  This  condition  usually  leads  to  very  considerable 
hvpertroph}'  and  dilatation  of  the  heart.  There  may  be  marked  bulging  of  the 
precordial  area  to  the  left  of  the  sternum.  The  cardiac  impulse  ma}-  be  seen 
not  only  in  the  sixth  space  outside  the  left  nipple  line,  but  also  in  the  fifth, 
fourth,  and  third  left  spaces,  and  the  pulsation  may  extend  in  these  spaces  from 
the  left  border  of  the  sternum  to  the  left  nipple  hne,  or  even  outside  that  line. 

The  impulse  has  a  curious  wavy  character,  and  it  may  be  noticed  that 
coincident  with  the  impulse  in  the  sixth  space  there  may  be  a  systohc  retraction 
of  the  spaces  above,  or  of  the  lower  ribs  below  and  outside  the  cardiac  area, 
best  seen  when  the  patient  hes  over  to  the  other  side  with  his  left  arm  raised 
above  his  head.  If  the  heart  is  adherent  to  the  diaphragm,  there  may  be  a 
S3^stolic  retraction  of  the  eleventh  and  twelfth  ribs  on  the  left  side  behind. 
Nearly  all  the  cases  of  adherent  pericardium  of  this  type  exhibit  marked  dilata- 
tion of  the  superficial  veins  in  the  precordial  area.  Diastohc  collapse  of  the 
cervical  veins  is  said  to  occur  also.  On  rolling  the  patient  from  side  to  side 
it  is  found  in  many  cases  that  the  cardiac  impulse  remains  nearly  in  the  same 
position,  not  altering  so  much  as  it  does  in  health  under  similar  circumstances. 
The  hand  placed  over  the  heart  may  feel  a  diastohc  shock  or  rebound,  which  is 


ENLARGEMENT    OF     THE     HEART  243 

regarded  bj'  some  as  one  of  the  most  characteristic  signs  of  the  condition.  On 
auscultation  there  is  a  s^'stoHc  murmur  at  the  apex,  which  is  indicative  of 
mitral  regurgitation,  and  frequently  there  is  also  a  pre-systolic  murmur  which 
is  due  to  a  relative  stenosis  of  the  mitral  orifice. 

There  is  also  a  therapeutic  sign  which  may  help  in  doubtful  cases.  Mitral 
regurgitation  in  young  people,  if  due  simply  to  fibrosis  of  the  valve  after  endo- 
carditis, will  usually  improve  under  treatment  by  rest  in  bed  and  the  administra- 
tion of  appropriate  doses  of  digitahs.  Where  the  mitral  regurgitation,  however,  is 
associated  with  adherent  pericardium,  similar  treatment  has  httle  effect,  and 
very  slight,  if  any,  improvement  follows.  Another  way  of  expressing  the  same 
fact  is  that  if,  in  a  young  person  who  is  presumably  rheumatic,  the  size  of  the 
heart  and  the  symptoms  are  not  easily  accountable  for  by  the  extent  of  valvular 
disease  suggested  by  the  bruits,  the  patient  probably  has  adherent  pericardium 
with  mediastinal  fibrosis.    The  diagnosis,  therefore,  is  guessed  at  rather  than  made. 

Acute  Dilatation  of  the  Heart. 

From  Over-exertion. — Acute  dilatation  may  occur  as  a  result  of  over-exertion. 
For  example,  if  a  man  who  has  been  run  down  from  excessive  mental  work,  and 
in  consequence  is  in  poor  condition  or  bad  training  from  lack  of  efficient  exercise, 
takes  a  holiday,  and  attempts  the  ascent  of  a  high  mountain  or  engages  in  some 
violent  form  of  exercise,  his  heart  is  very  liable  to  give  way  under  the  strain. 
The  chief  indication  of  such  an  occurrence  will  be  a  feeling  of  pain,  distress,  and 
discomfort  in  the  region  of  the  heart,  dyspnoea,  and  palpitation.  The  pulse  will 
be  rapid,  weak,  and  irregular.  The  cardiac  impulse  will  be  displaced  outwards, 
will  be  diffuse,  weak  and  undulating  in  character,  and  although  a  maximum 
point  of  the  impulse  may  be  visible,  it  cannot  be  detected  clearly  by  palpation. 
There  will  be  marked  epigastric  pulsation,  the  cardiac  dullness  will  be  increased 
outwards,  and  the  first  sound  will  be  feeble,  reduphcated,  or  replaced  by  a  soft 
blowing  systolic  murmur. 

From  Acute  Specific  Fevers. — Similar  signs  and  sjmiptoms  occurring  in  the 
course  of  diphtheria,  typhoid  fever,  typhus,  scarlet  fever,  erysipelas,  and  other 
fevers,  would  point  to  dilatation  of  the  heart  in  consequence  of  the  toxaemia 
producing  loss  of  tone  in  the  cardiac  muscle  from  parenchymatous  degeneration. 

3.   Arteriosclerosis    and   Granular    Kidney   (see    p.   18). 

4.   Alcoholism. 

Patients  who  have  been  addicted  to  alcohohsm  are  liable  to  develop  enlarge- 
ment of  the  heart.  It  is  a  cause  of  which  the  importance  is  frequently 
overlooked.  The  usual  signs  of  hypertrophy  and  dilatation  may  be  present, 
with  mitral  and  tricuspid  incompetence  and  signs  of  backward  pressure.  The 
enlargement  may  be  considerable.  At  a  post-mortem  examination  it  is  by  no 
means  unusual  to  find  the  heart  weighing  as  much  as  from  20  to  30  ounces.  The 
valves  are  healthy,  the  aorta  is  normal,  and  evidence  of  arteriosclerosis  and 
granular  kidney  is  absent.  Alcoholism  may  therefore  be  suspected  as  the  cause 
of  enlargement  of  the  heart  where  there  is  no  evidence  of  primary  valvular 
disease,  adherent  pericardium,  arteriosclerosis,  or  chronic  Bright's  disease. 
Other  signs  and  symptoms  of  alcohohsm  may  also  be  present,  e.g.,  loss  of 
appetite,  morning  sickness,  hsematemesis,  jaundice,  rectal  bleeding  from  haemor- 
rhoids, furred  and  tremulous  tongue,  and  so  on. 

5.   Long-continued    Over-exertion 

produces  hypertrophy  of  the  ventricles,  and  for  a  considerable  period  may 
give  rise  to  no  sj^mptoms  of  disease,  but  after  a  time,  when  compensation  fails 
owing  to  the  hypertrophy   being    insufficient   to    continue  the  excessive  work. 


244  ENLARGEMENT     OF     THE     HEART 

dilatation  is  produced,  and  mitral  incompetence  and  signs  of  backward  pressure 
become  prominent.  The  subjects  of  this  form  of  enlargement  of  the  heart  are 
usually  either  middle-aged  men  who  are  robust  and  healthy  in  appearance,  but 
have  had  to  follow  for  many  years  a  laborious  occupation  entaihng  severe 
manual  labour,  or  else  young  men  of  good  physique  who  have  indulged  in  exces- 
sive athletic  exercises,  such  as  rowing,  football,  boxing,  and  running,  often  with 
insufficient  preliminary  training.  At  first,  palpitation,  dyspnoea,  and  irregular 
cardiac  action  are  noticed.  Later  the  ventricles  dilate  and  the  mitral  valves 
become  incompetent,  and  all  the  signs  of  backward  pressure  may  follow. 
Enlargement  of  the  heart  from  tfiis  cause  is  much  more  Uable  to  occur  where 
the  patient  is  accustomed  to  take  a  considerable  amount  of  alcohol.  As  a  cause 
of  enlargement  of  the  heart  it  should  not  be  diagnosed  until  primary  valvular 
disease,  granular  kidney,  and  primary  arteriosclerosis  can  be  excluded. 

6.  Exophthalmic  Goitre. 
In  this  disease,  moderate  enlargement  of  the  heart,  as  shown  by  the  displace- 
ment outwards  of  the  cardiac  impulse  and  the  increased  area  of  cardiac  dullness, 
is  common,  and  is  probably  the  result  of  the  long-continued  increased  rapidity 
of  cardiac  action.  It  is  rarely,  however,  the  most  prominent  sign  of  the  disease. 
It  is  distinguished  from  other  forms  of  enlargement  by  the  presence  of  tachy- 
cardia— the  pulse-rate  in  a  well-marked  case  varying  between  120  and  160  or 
being  even  higher  than  this — the  marked  pulsation  of  the  carotids  and  other 
superficial  arteries,  the  exophthalmos,  the  enlargement  and  pulsation  of  the 
thyroid  gland,  the  fine  tremor  of  the  extremities,  the  loss  of  weight,  the 
excitability,  and  the  pigmentation  of  the  skin  of  the  eyehds.  There  is  very 
often  a  loud  blowing  systolic  bruit  in  the  pulmonarj^  area,  less  often  one  at 
the  impulse,  but  frequently  one  over  the  thyroid  gland.  Certain  signs  associated 
with  the  names  of  von  Graefe,  Stellwag,  and  Moebius,  are  not  of  the  least 
value  in  making  the  diagnosis. 

7.  Congenital  Heart  Disease. 
When  there  is  a  patent  interventricular  septum  there  may  be  considerable 
enlargement  of  the  heart  from  hypertrophy  and  dilatation  of  both  ventricles. 
It  is  frequently  associated  with  some  narrowing  of  the  pulmonary  orifice.  In 
addition  to  the  symptoms  which  are  common  to  most  forms  of  congenital 
heart  disease,  viz.,  cyanosis,  clubbing  of  the  fingers  and  toes,  dyspnoea,  and 
polycythaemia,  the  cardiac  impulse  will  be  displaced  downwards  and  outwards, 
there  will  be  epigastric  pulsation,  perhaps  a  prolonged  systolic  thrill,  best  felt  over 
the  third  left  intercostal  space  close  to  the  sternum,  an  increased  area  of  cardiac 
dullness  in  all  directions,  and  a  loud  systolic  murmur  at  the  base  of  the  heart, 
the  maximum  point  of  intensity  being  the  third  or  fourth  left  intercostal  space, 
close  to  the  left  border  of  the  sternum.  It  is  often  very  difficult  to  say  whether 
the  lesion  is  pulmonary  stenosis  or  patent  interventricular  septum.  A  well- 
marked  thrill  is  more  constantly  associated  with  the  former  than  with  the  latter, 
but  the  maximum  point  of  intensity  of  the  murmur  produced  by  pulmonary 
stenosis  is  in  the  second  left  space,  close  to  the  left  border  of  the  sternum, 
whereas  in  patent  interventricular  septum  the  murmur  is  loudest  lower  down. 

ENLARGEMENT     OF     THE     RIGHT     VENTRICLE. 

When  the  enlargement  of  the  heart  is  due  to  hypertrophy  or  dilatation  of  the 
right  ventricle,  the  cardiac  impulse  is  displaced  outwards  more  than  downwards, 
there  is  frequently  well-marked  epigastric  pulsation,  and  the  dullness  is  increased 
upwards  and  to  the  right  rather  than  to  the  left.  The  causes  of  enlargement  of 
the  right  ventricle  are  as  follows  : — 


ENLARGEMENT     OF     THE    HEART  245 

1 .  Diseases  of  the  Left  Side  of  the  Heart : — 

Mitral  stenosis 

All   the    conditions    which  cause    enlargement  of    the    left    ventricle. 

2.  Diseases  of  the  Lungs  : — 

Fibroid  lung 

Chronic  bronchitis  and  emphysema. 

3.  Diseases  of  the  Right  Side  of  the  Heart : — 

Congenital  pulmonary  stenosis 

Pulmonary  incompetence : 

Due  to  dilatation  of  the  pulmonary  artery 

Due  to  infective  endocarditis  of  the  pulnionary  valve. 

I.  Diseases  of  the  Left  Side  of  the  Heart. 

Mitral  Stenosis. — This  is  by  far  the  commonest  and  most  important  cause  of 
enlargement  of  the  right  ventricle.  The  obstruction  to  the  flow  of  blood  from 
the  left  auricle  into  the  left  ventricle  leads  to  hypertrophy  and  dilatation  of  the 
left  auricle,  passive  congestion  of  the  lungs,  red  and  brown  induration  of  these 
organs,  thickening,  dilatation  and  atheroma  of  the  branches  of  the  pulmonary 
arteries  in  the  lungs  as  a  result  of  the  increased  tension  in  these  vessels.  All 
these  changes  increase  the  amount  of  work  to  be  performed  by  the  right  side  of 
the  heart,  and  are  responsible  for  the  hypertrophy  of  the  right  ventricle,  by  which 
means  compensation  may  be  maintained  for  some  time.  When  the  right  ventricle 
dilates,  compensation  fails. 

In  the  early  stages  the  pulse  shows  little  variation  from  the  normal,  and  there 
may  be  no  obvious  synaptoms  pointing  to  the  existence  of  mitral  stenosis.  In 
more  advanced  conditions  of  the  disease  the  pulse  becomes  rapid,  small,  irregular, 
and  intermittent.  The  cardiac  impulse  is  displaced  outwards,  and  pulsation 
occurs  in  the  epigastrium  and  in  the  third,  fourth,  and  fifth  intercostal  spaces 
close  to  the  sternum.  On  placing  the  palm  of  the  hand  over  the  region  of  the 
cardiac  impulse  and  the  adjacent  fourth  and  fifth  intercostal  spaces,  a  character- 
istic thrill  may  be  felt.  It  usually  has  a  curious  rough  grating  quality.  It  is 
diastolic  in  rhythm,  and  may  be  felt  to  terminate  suddenly  in  a  sharp  shock 
which  is  synchronous  with  the  apex  beat.  The  dullness  is  increased  upwards 
from  the  third  left  rib  to  the  second,  or  even  higher ;  it  extends  well  to  the 
right  of  the  sternum,  but  it  does  not  reach  far  to  the  left,  though  in  a  few  cases 
it  extends  to  the  left  nipple  line,  even  when  mitral  stenosis  is  the  only  lesion 
present.  The  more  the  dullness  extends  to  the  left,  however,  the  less  likely  is 
the  diagnosis  of  mitral  stenosis  alone  to  be  correct. 

At  or  just  inside  the  cardiac  impulse,  a  loud,  rough,  rumbling,  vibrating 
bruit  may  be  heard,  which  runs  up  to,  and  is  continuous  with,  a  loud,  accentuated, 
slapping  first  sound,  which  may  or  may  not  be  followed  by  a  systolic  murmur. 
This  characteristic  bruit  may  occupy  the  whole  of  the  diastole,  and  may  com- 
mence with  a  doubling  of  the  second  sound.  It  increases  in  intensity  until  it 
finally  ends  in  the  loud  first  sound.  It  may,  however,  be  shorter,  and  commence 
in  the  middle  or  latter  part  of  diastole.  It  is  usually  termed  a  late  diastolic  or 
presystolic  bruit,  as  it  runs  up  to  and  is  continuous  with  the  first  sound.  The 
other  abnormal  signs  to  which  mitral  stenosis  may  give  rise  are  described  on 
p.  107  and  loS. 

All  the  Conditions  which  cause  Enlargement  of  the  Left  Ventricle. — When- 
ever compensation  begins  to  tail  in  cases  of  mitral  regurgitation  from  any 
cause,  aortic  disease,  enlargement  of  the  left  ventricle  from  chronic  Bright's 
disease,    arteriosclerosis,    alcoholism,    or    other    causes    discussed    above,    and 


246  ENLARGEMENT     OF     THE    HEART 

there  is  backward  pressure  through  the  lungs,  hypertrophy  of  the  right  ventricle 
serves  to  maintain  compensation  for  a  time.  The  increase  in  the  size  of  the 
right  ventricle  would  be  indicated  by  the  advent  of  epigastric  pulsation  and  a 
further  increase  of  the  dullness  to  the  right  of  the  sternum,  but  the  diagnosis  of 
its  cause  would  rest  upon  data  already  discussed  under  the  heading  of  mitral 
regurgitation  (see  p.  239). 

2.  Diseases   of  the   Lung. 

Fibroid  Lung  gives  rise  to  symptoms  and  physical  signs  so  characteristic 
that  there  is  rarely  any  difficulty  in  making  a  diagnosis.  The  hypertrophy  of 
the  right  ventricle  is  of  secondary  importance,  and  does  not  become  manifest 
until  late  in  the  disease.  On  account  of  the  retraction  of  the  lung,  the  heart  is 
drawn  over  towards  the  affected  side,  and,  in  consequence  of  the  displaced  cardiac 
impulse  and  the  increased  area  of  pulsation,  it  may  appear  to  be  much  larger 
than  it  really  is.  When  the  right  lung  is  affected,  there  may  be  well-marked 
epigastric  pulsation,  and  the  cardiac  impulse  may  be  to  the  right  of  the  sternum 
in  the  fifth  intercostal  space,  the  maximum  point  being  in  some  cases  as  far  out 
as  the  right  nipple  line.  When  the  left  lung  is  affected,  the  heart  may  be  pulled 
over  towards  the  left,  so  that  the  cardiac  impulse  is  situated  in  the  anterior,  or 
even  in  the  mid-axillary  line.  In  consequence  of  the  shrinking  of  the  lung,  more 
of  the  anterior  surface  of  the  heart  will  lie  in  contact  with  the  thoracic  wall, 
and  there  may  be  therefore  an  increased  area  of  visible  pulsation  in  the  second, 
third,  or  fourth  intercostal  space.  In  addition  to  the  displacement  of  the  cardiac 
impulse,  there  is  a  diminution  in  the  size  and  a  decrease  in  the  movement  of  the 
affected  side  of  the  chest,  the  shoulder  is  drawn  down,  the  spine  curved  with 
the  concavity  towards  the  affected  side ;  there  is  increased  tactile  vocal  fremitus, 
impairment  of  note  on  percussion,  and  possibly  a  cracked- pot  sound  ;  and,  should 
there  be  dilated  bronchial  tubes,  there  are  cavernous  or  amphoric  breathing, 
bronchophony,  pectoriloquy,  and  loud  crackling  rales.  With  the  exception 
of  compensatory  emphysema,  there  may  be  no  sign  of  disease  in  the  other  lung, 
a  point  which  helps  to  distinguish  this  condition  from  phthisis. 

The  chief  symptoms  are  chronic  cough,  dyspnoea,  abundant  expectoration  on 
rising  in  the  morning,  the  sputum  often  being  foetid  on  account  of  the  bronchi- 
ectasis which  is  so  frequently  associated  with  fibroid  lung.  The  patient  may  be 
well  nourished  and  show  no  signs  of  loss  of  flesh.  Haemoptysis  occv;rs  occasion- 
ally, but  no  tubercle  bacilli  will  be  found  in  the  sputum.  There  is  often 
extreme  clubbing  of  the  fingers. 

Chronic  Bronchitis  and  Emphysema  may  so  increase  the  volume  of  the  lungs 
that  they  completely  cover  the  anterior  surface  of  the  heart  ;  consequently  the 
cardiac  impulse  may  be  invisible,  the  superficial  cardiac  dullness  diminished  or 
absent,  and  the  heart  sounds  faint  or  even  inaudible.  In  these  circumstances 
it  is  not  an  easy  matter  to  diagnose  with  certainty  the  presence  of  enlargement 
of  the  heart.  Should  there  be  dilatation  of  the  right  ventricle  as  well  as  hyper- 
trophy, and  also  tricuspid  regurgitation,  a  systolic  murmur  may  be  heard  over 
the  lower  part  of  the  sternum  and  in  the  fourth  and  fifth  left  intercostal  spaces 
close  to  the  sternum,  and  oedema  of  the  legs,  ascites,  enlargement  of  the  liver,  and 
albuminuria  may  also  be  present.  If,  in  addition,  there  are  signs  of  pulmonary 
emphysema,  viz.,  the  cubical  chest,  wide  epigastric  angle,  increased  tactile  vocal 
fremitus,  hyper-resonant  percussion  note,  diminished  area  of  hepatic  and  cardiac 
dullness,  increased  voice  sounds,  diminished  vesicular  murmur  with  prolongation 
of  the  expiratory  sound,  with  or  without  non-consonating  rales  and  rhonchi, 
and  if  there  are  no  indications  of  fibrosis  of  the  heart  valves  from  former  endo- 
carditis, chronic  Bright's  disease,  or  primary  arteriosclerosis,  enlargement  of  the 
heart  with  failure  of  compensation  as  a  result  of  chronic  bronchitis  and  emphy- 
sema may  be  diagnosed. 


ENURESIS  247 


3.  Diseases   of   the   Right  Side  of   the   Heart. 

Pulmonary  Stenosis. — This  is  the  commonest  form  of  congenital  heart  disease. 
In  addition  to  cyanosis,  clubbing  of  the  fingers  and  toes,  polycythaemia,  dyspnoea, 
and  signs  of  hypertrophy  of  the  right  ventricle,  there  is  usually  a  well-marked 
systolic  thrill  over  the  second  left  intercostal  space  close  to  the  sternum,  and  a 
loud,  rough  systolic  murmur  in  the  same  position.  The  murmur  is  not  trans- 
mitted to  the  carotids  in  the  neck  as  is  that  of  aortic  stenosis. 

Pulmonary  Incompetence. — This  lesion  may  be  associated  with  congenital 
pulmonary  stenosis,  or  may  be  due  to  infective  endocarditis  (especially  gono- 
coccal), but  by  far  the  commonest  cause  is  functional  incompetence  from 
dilatation  of  the  pulmonary  artery  and  orifice  secondary  to  the  high  tension 
produced  in  the  pulmonary  circulation  by  mitral  stenosis.  It  may  be  difficult 
to  distinguish  from  aortic  regurgitation  :  the  early  diastolic  bruit  of  pulmonary 
incompetence  is  most  audible,  however,  in  the  third  and  fourth  left  intercostal 
spaces  midway  between  the  left  nipple  line  and  the  left  border  of  the  sternum, 
whereas  in  aortic  disease  the  diastolic  bruit  is  usually  heard  best  in  the  third 
left  space  close  to  the  left  border  of  the  sternum.  The  visible  pulsation  of 
the  superficial  arteries,  and  the  collapsing  pulse,  which  are  so  characteristic 
of  aortic  incompetence,  are  not  present  in  cases  of  pulmonary  incompetence. 

Herbert  French. 

ENLARGEMENT   OF  THE    KIDNEY.— (See  Kidney,  Enlargement  of.) 

ENLARGEMENT  OF  THE  LIVER.— (See  Liver,  Enlargement  of.) 

ENLARGEMENT  OF  THE  LYMPHATIC  GLANDS.— (See  Lymphatic  Gland 
Enlargement.  ) 

ENLARGEMENT    OF  THE  SPLEEN. — (See  Spleen,  Enlargement  of.) 

ENLARGEMENT  OF  THE  THYROID  GLAND.— (See  Thyroid  Gland,  En- 
largement of.) 

ENOPHTHALMOS  (or  Retraction  of  the  Eyeball). — This  may  occur  :  (i)  In 
wasting  diseases  ;  (2)  In  paralysis  of  the  cervical  sympathetic  ;  (3)  In  various 
congenital  afl:ections. 

1.  The  enophthalmos  in  wasting  diseases  is  due  to  the  absorption  of  the 
orbital  fat,  and  the  diagnosis  as  regards  the  eye  presents  no  difficulty. 

2.  Enophthalmos  due  to  paralysis  of  the  cervical  sympathetic  is  always 
associated  with  the  other  well-defined  symptoms  of  this  condition,  namely, 
diminution  in  the  size  of  the  palpebral  aperture,  consti^iction  of  the  pupil,  and 
absence  of  sweating  and  blushing  on  the  paralyzed  side.  The  pupil  is  constricted 
owing  to  the  paralysis  of  the  dilator  fibres,  the  pupil  therefore  not  dilating  in  a 
feeble  light. 

3.  In  certain  congenital  cases,  there  is  well-marked  retraction  associated  with 
defective  or  irregular  movements  of  the  affected  eyeball.  The  ocular  muscles 
are,  as  a  rule,  inserted  much  farther  back  in  the  sclerotic  than  is  normally  the 
case.  The  condition  appears  to  be  due  to  the  absence  or  defective  insertion  of 
the  extrinsic  muscles  of  the  eye,  and  may  be  recogniied  by  its  existence  since 
birth.  Herbert  L.  Eason. 

ENURESIS  is  the  term  used  to  denote  micturition  that  is  carried  out  involun- 
tarily by  the  reflex  stimulation  of  the  detrusor  muscle  of  the  bladder.  It 
occurs  almost  exclusively  in  children,  and  although  most  frequently  confined 
to  the  night,  it  may  occur  in  the  day.  It  must  be  distinguished  carefully  from 
incontinence  of  urine  ;  the  patient  has  usually  full  control  of  micturition  during 


248  ENURESIS 

the  day,  although  sometimes  the  desire  to  urinate  must  be  satisfied  quickly  or 
a  little  dribbhng  ma}'-  take  place.  In  this  disease,  the  child  completely  empties 
the  bladder,  often  without  waking,  once  or  several  times  during  the  night. 
The  bladder  need  not  be  quite  filled  for  micturition  to  occur,  for  it  takes  place 
in  the  early  hours  of  the  night. 

Enuresis  is  often  accompanied,  and  may  be  caused,  by  slight  affections,  such 
as  phimosis,  balanitis,  small  urinary  meatus,  vulvitis,  constipation,  or  intestinal 
worms,  the  correction  of  which  remedies  the  trouble,  but  in  other  cases  there 
seems  nothing  to  promote  the  excitabihty  of  the  detrusor  muscle.  It  is  cured 
not  infrequently  by  an  operation  for  the  removal  of  enlarged  tonsils  and 
adenoid  growths,  or  after  the  administration  of  small  doses  of  thyroid  extract. 
It  has  been  stated  that  the  condition  is  due  to  faulty  development  or  deficient 
innervation  of  the  sphincter  muscle,  or  to  spasm  of  the  detrusor ;  but  it  is 
difficult  to  reconcile  these  affections  in  practice.  If  the  sphincter  muscle  were 
paralyzed  or  deficient,  there  would  be  true  incontinence  of  urine  present, 
whereas  this  is  not  so,  and  the  children  are  often  of  good  development  and 
health.  It  is  probable  that  the  infantile  condition  in  which  the  detrusor 
muscle  holds  the  mastery  over  the  sphincter  persists,  and  it  is  a  relative 
disparity  between  the  innervation  of  the  two  sets  of  muscles,  so  that  the  con- 
traction of  the  detrusor,  which  normally  is  held  in  check  by  the  sphincter,  is 
able  to  overcome  the  comparatively  weak  action  of  the  latter.  When  enuresis 
persists  throughout  childhood,  it  may  disappear  at  puberty,  when  the  prostate 
gland  enlarges  and  strengthens  the  action  of  the  sphincteric  apparatus. 

It  is  important  to  exclude  both  pyelitis  and  oxaluria  before  a  diagnosis  of 
simple  enuresis  is  made.  In  either  case  nocturnal  micturition  may  be  the  chief 
symptom  ;  microscopical  examination  of  the  centrifugalized  deposit  will  at 
once  detect  the  pus  cells  or  the  excess  of  calcium  oxalate  crystals  respectively. 

R.  H.  Jocely'n  Swan. 

EOSINOPHILIA  denotes  a  relative  increase  in  the  coarsely  granular  eosino- 
phile  cells  of  the  blood  {Plate  II,  Fig.  L)  ;  it  is  determined  by  preparing  blood 
films  and  making  a  differential  leucocyte  count.  Normally,  the  coarsely  granular 
eosinophile  cells  vary  from  o  to  2  per  cent  ;  the  point  at  which  eosinophilia 
begins  is  quite  arbitrary  ;  but  one  may  say  that  although  it  is  unusual,  under 
perfectly  healthy  conditions,  to  find  more  than  2  per  cent  of  these  cells  in  the 
differential  count,  they  should  reach  5  per  cent  or  more  before  the  term 
eosinophilia  is  applied  to  the  condition.  It  is  probable  that  some  normal  people 
have  upwards  of  5  per  cent  of  these  cells,  but  beyond  this  point  they  are  nearly 
always  pathological. 

One  may  divide  the  causes  of  eosinophilia  under  main  headings  as  follows  : — - 

I. — Conditions  in  which  Eosinophilia  is  slight,  inconstant,  and  of  little  diagnostic 
significance  : — 


Post-febrile  states,  after  : — • 
Scarlet  fever 
Pneumonia 
Acute  articular  rheumatism 

Affections  of  the  bone-marrow  : — ■ 
Splenomedullary  leukaemia 
Sarcoma  of  bone 
Rickets 


Measles 

Varicella 

Malaria 


Osteomyelitis 
Osteomalacia 


Addison's  disease 

After  certain  remedies,  particularly  camphor 

In  ovarian  maladies  Gonorrhoea 


EOSINOPHILIA  249 

During  the  positive  stage  of  tuberculin  reaction. 

Some   cases   of   malignant   disease,   especially  when   there   are   metastases — 
carcinoma  ;    lymphosarcoma. 

2.  Conditions  in  which  Eosinophilia  may  be  marked. 

[a).   Spasmodic  Asthma. 

(b).   Certain  Skin  Diseases,  more  particularly  : — ■ 
The  bullous  dermatoses  : — 


Pemphigus 
Erythema  bullosum 
Dermatitis    herpetiformis   (Diih- 
ring's  disease) 


Hydroa 

Herpes  iris,  or  erythema  iris 

Herpes  gestationis. 


It  is  much  rarer  in  other  cases  of  skin  disease,  but  is  noted  occasionally  in 
psoriasis,  eczema,  and  exceptionally  in  some  other  affections  of  the  skin, 
(c).    Certain  Parasitic  Affections,  particularly  : — 


Ankylostomum  duodenale 
Bilharzia  hsematobia 
Bothriocephalus  latus 
Taenia  solium 
It  is  much  less  constant,  and  indeed  generally  absent,  in  cases  of  : 


Taenia  mediocanellata 
Filaria  sanguinis  hominis 
Trichina  spiralis. 


Pediculus  pubis 
Pediculus  corporis 
Acarus  scabiei. 


Ascaris  lumbricoides 
Trichocephalus  dispar 
Oxyuris  vermicularis 
Pediculus  capitis 

The  list  above  almost  speaks  for  itself,  and  little  discussion  is  needed.  None 
of  the  conditions  named  is  necessarily  associated  with  eosinophilia,  but  the 
coarsely  granular  eosinophile  cells  often  reach  a  figure  between  5  and  15  per  cent 
in  the  differential  count  in  many  of  the  diseases  that  come  under  headings  (a),  {b), 
and  (c),  whilst  sometimes  during  paroxysmal  asthma  they  may  reach  25,  50,  or 
even  more  per  cent,  and  they  are  often  over  20  per  cent  in  the  severer  forms  of 
parasitic  disease.  The  eosinophilia  of  leukaemia  has  often  had  stress  laid 
upon  it  in  text-books,  but  as  a  matter  of  fact,  although  the  coarsely  granular 
eosinophile  cells  per  cubic  millimetre  of  blood  may  be  considerably  above  the 
normal  along  with  all  the  other  corpuscles,  yet  when  reduced  to  percentages  in 
the  differential  leucocyte  count,  the  eosinophile  corpuscles  seldom  number  more 
than  2  or  3  per  cent  of  all  the  white  cells  present. 

The  value  of  eosinophilia  in  discriminating  between  artificial  bleb-formation 
and  a  true  bullous  dermatosis  is  mentioned  in  the  article  upon  Bull.^  (?-W-)- 

The  difficulty  sometimes  present  in  deciding  whether  in  a  given  case  the 
lesion  is  primary  emphysema  and  bronchitis,  or  primary  asthma  succeeded  by 
emphysema  and  bronchitis,  is  discussed  under  Polyuria  ;  and  the  value  of  eosino- 
philia in  discriminating  between  truly  asthmatic  cases  and  those  which 
simulate  asthma  but  are  really  cardiac,  renal,  or  bronchitic,  is  there  referred  to. 
It  should  be  noted  that  the  eosinophilia  is  not  confined  to  the  blood,  being 
present  also  in  the  cells  in  the  sputum  ;  it  occurs  during  the  paroxysms  of 
asthma,  and  rapidly  disappears  in  the  intervals. 

When  a  patient  is  suffering  from  an  obscure  form  of  anaemia,  and  when  the 
blood  at  the  same  time  exhibits  considerable  eosinophilia,  the  latter  may  some- 
times be  the  first  suggestion  that  there  is  a  serious  parasitic  infection  in  the  case, 
and  careful  examination  of  the  faeces  or  urine  for  the  parasites  themselves  or 
for  their  ova,  with  the  administration  of  anthelmintic  drugs,  may  then  be  resorted 
to  for  confirmation  of  the  diagnosis  (see  Parasites,  Intestinal).  Persons 
who  have  been  resident  in  the  tropics  are  more  liable  to  unsuspected  infection 
of  this  kind  than  are  others.  Herbert  French. 


250  EPIPHORA 

EPIPHORA,  or  overflow  of  the  tears,  may  be  due  to  (i)  Increased  secretion  ; 
(2)  The  puncta  lachrymalia  not  being  in  close  apposition  to  the  globe  ;  (3)  Obstruc- 
tion of  the  lachrymal  canaliculi  or  duct. 

1.  The  most  famihar  cause  of  epiphora  due  to  increased  secretion  of  tears 
is  the  act  of  weeping,  in  which  the  flow  is  due  to  psychical  stimuh.  Epiphora 
may  also  occur  in  the  lachrymation  caused  by  conjunctivitis,  corneal  ulcers, 
and  other  inflammatory  affections  of  the  eye. 

2.  Tears  only  find  their  way  down  the  canaUculi  by  capillary  attraction, 
the  puncta  lachrymalia  being  applied  closely  to  the  surface  of  the  globe.  In 
facial  paralysis,  owing  to  the  failure  of  the  orbicularis  palpebrarum  muscle,  the 
lids  are  no  longer  braced  up  against  the  eye,  and  the  lower  lid  droops  away  from 
the  globe.  The  tears  coUect  in  the  sulcus  thus  formed,  and  run  over  on  to  the 
cheek.  The  condition  is  easily  diagnosed  by  the  inability  to  close  the  eye 
entirely,  either  by  passive  or  active  movements.  In  cases  of  chronic  marginal 
blepharitis ,  hypertrophy  of  the  hd-edge  and  the  conjunctiva  result  in  a  shght 
eversion  or  ectropion.  The  punctum  lachrymale  of  the  lower  lid  is  no  longer 
in  apposition  with  the  eye,  and  epiphora  foUows,  causing  continual  moisture  of 
the  edge  of  the  lids  and  aggravation  of  the  original  condition. 

Cicatricial  ectropion  from  burns,  injury,  scleroderma,  or  lupus  of  the  cheek  may 
also  result  in  epiphora  ;  and  so  may  severe  proptosis  (see  Exophthalmos),  result- 
ing from  tumours  or  inflammation  at  the  back  of  the  orbit,  or  from  Graves'  disease. 

3.  The  lachrymal  ducts  may  be  congenitally  obstructed.  The  obstruction  is 
usually  unilateral,  and  is  due  to  a  plug  or  septum  of  uncanalized  epithelium 
situated  in  the  lower  part  of  the  duct.  The  epiphora  is  as  a  rule  not  evident  till 
the  seventh  or  eighth  day,  at  which  period  the  infant  first  begins  to  shed  tears, 
and  owing  to  the  suppuration  of  the  tears  collected  in  the  lachrymal  sac,  the 
malady  may  be  mistaken  for  a  chronic  conjunctivitis.  The  unilateral  nature 
of  the  affection,  and  the  presence  of  tears  or  pus  in  the  sac,  are  the  diagnostic 
signs,  and  the  obstruction  may  generally  be  cured  by  a  single  probing  of  the  duct 
through  the  dilated  but  uncut  canaliculus.  Congenital  absence  of  one  or  both 
canaliculi  has  been  recorded.  Stenosis  of  the  lachrj^mal  duct  may  also  occur  as 
the  result  of  catarrhal  congestion  of  the  mucous  membrane,  or  from  some  organic 
obstruction,  due  to  cicatrization  following  abscess  in  the  lachrymal  sac  or  necrosis 
of  the  bones  forming  the  walls  of  the  duct.  The  diagnosis  can  only  be  made 
by  syringing  through  the  canaliculi ;  in  catarrhal  obstruction,  fluid  can  usually 
be  forced  into  the  nose,  but  in  organic  stricture  it  is  returned  through  the  other 
canaliculus.  In  such  cases  the  stenosis  can  be  reHeved  by  the  passage  of  a 
probe,  after  slitting  the  lower  or  upper  canaliculus. 

Excision  of  the  lachrymal  sac  for  chronic  suppuration  is  always  followed  by 
epiphora,  but  this  condition  may  often  be  preferable  to  the  discomfort  caused  by 
recurrent  lachrymal  abscess  and  the  risk  of  corneal  ulcer  with  hypopyon. 

Injury  to  the  duct  or  canaliculus  may  also  cause  permanent  epiphora. 

Herbert   L.  Eason. 

EPISTAXIS — rhinorrhagia,  or  bleeding  from  the  nose,  is  a  common  occur- 
rence that  may  be  due  to  local  or  general  causes,  or  to  a  combination  of  both. 
In  a  certain  number  of  cases  it  occurs  spontaneously,  and  no  cause  can  be 
indicated. 

Local  Causes. 

Injury. — Falls,  blows,  fractures  of  the  base  of  the  skull,  foreign  bodies  in  the 
nose,  operations  on  the  nose,  violent  coughing,  sneezing  or  nose-blowing,  nose- 
picking. 

Ulceration. — Traumatic,  tuberculous,  syphilitic,  malignant,  leprous. 

New  growth. — Adenoid  growths,  polypi,  fibroma,  angioma,  malignant  disease, 
in  the  nose  or  nasopharynx. 


EPISTAXIS  251 

Varicosity  of  the  veins  of  the  nasal  mucosa  :    multiple  hereditary  telangiectases. 

Acute  infective  inflammation.  —  Severe  catarrh,  diphtheria,  scarlet  fever, 
influenza. 

General  Causes. 

High  arterial  blood-pressure,  such  as  obtains  in  granular  kidney  and  chronic 
renal  disease,  arteriosclerosis,  gout,  cirrhosis  of  the  liver,  heart-disease. 

High  venous  blood-pressure. — Seen  in  bronchitis  and  emphysema,  with  dilatation 
of  the  right  heart ;  in  cerebral  congestion,  when  blood  passes  from  the  superior 
longitudinal  sinus  by  an  emissary  vein  going  through  the  foramen  csecum  to  the 
nasal  mucosa  ;    in  "  determination  of  blood  to  the  head." 

Altered  conditions  of  the  blood. — Hasmophilia,  pernicious  anaemia,  purpura, 
scurvy,  leukaemia,  chlorosis,  jaundice,  and  the  onset  of  acute  specific  fevers, 
particularly  enteric,  scarlet  fever,  and  measles. 

Alterations  in  atmospheric  pressure. — Mountaineering,  diving,  caisson  disease. 

Epistaxis  of  Obscure  Origin,  often  attributed  to  congestion,  and  occurring  : — In 
childhood  ;  at  puberty,  especially  in  girls  ;  as  the  alleged  vicarious  menstruation  ; 
or  as  the  result  of  sexual  irritation  in  either  sex ;   in  women  at  the  menopause. 

The  phenomena  of  epistaxis  are  familiar.  In  some  cases  the  blood  issues  from 
both  nostrils  ;  in  the  majority,  and  particularly  when  the  cause  of  the  bleeding 
is  local,  from  one  only.  But  it  must  be  remembered  that  nose-bleeding  may 
occur  without  the  appearance  of  any  blood  at  the  anterior  nares.  If  the  patient 
is  lying  down,'  the  effused  blood  will  run  down  the  sides  or  floor  of  the  nose, 
passing  through  the  posterior  nares  and  entering  the  nasopharynx.  When 
this  occurs,  the  patient  may  cough  and  spit  it  up,  when  haemoptysis  will  be 
observed.  If,  on  the  other  hand,  he  swallows  the  blood,  he  may  vomit  it  later, 
when  hasmatemesis  will  take  place.  In  the  rare  instances  in  which  either  of 
these  events  occurs  from  epistaxis,  careful  enquiry  should  suffice  to  make  the 
diagnosis  clear  ;  but  it  should  not  be  forgotten  that  either  haematemesis  or 
haemoptysis  may  indicate  nothing  more  serious  than  an  attack  of  nose- 
bleeding. 

In  every  case  of  epistaxis,  the  history  of  the  attack  should  be  gone  into  care- 
fully. Particular  enquiry  should  be  made  as  to  the  occurrence  of  any  sort  of 
trauma  that  might  account  for  it,  and  also  as  to  the  occurrence  of  previous  attacks 
of  nose-bleeding.  More  important  still  is  a  careful  examination  of  the  local 
condition  of  the  nose,  with  use  of  a  nasal  speculum  to  dilate  the  nares,  and  of 
a  mirror  and  lamp  to  secure  a  good  illumination.  In  many  cases,  the  bleeding 
point  can  be  seen  in  this  way,  whether  the  heemorrhage  be  arterial  or  venous  ; 
the  so-called  "  seat  of  election  "  of  epistaxis  being  a  small  and  perhaps  ulcerated 
spot  on  the  cartilage  of  the  septum  not  far  from  its  junction  with  the  ethmoid 
and  vomer.  In  other  instances  no  such  bleeding  point  can  be  seen,  the  blood 
being  the  result  of  general  oozing  from  the  mucous  membrane.  Examination 
of  the  urine  for  albumin  should  not  be  overlooked,  and  the  arterial  blood-pressure 
may  be  measured  instrumentally. 

Recurrent  Epistaxis  at  irregular  intervals  is  likely  to  be  due  to  some  local 
cause.  For  example,  there  may  be  a  small  ulcer  on  the  septum  nasi,  due 
perhaps  to  injury  in  the  first  instance,  that  scabs  over  from  time  to  time 
but  never  heals  satisfactorily  ;  a  comparatively  trifling  injury,  such  as  that 
occasioned  by  blowing  the  nose,  may  suffice  to  detach  the  scab,  when  epistaxis 
may  follow.  Malignant  disease  of  or  about  the  nose,  and  also  adenoid  vegetations, 
often  give  rise  to  repeated  nose-bleeding.  Epistaxis  has  been  a  prominent 
symptom  in  the  rare  hereditary  disease  in  which  numerous  friable  telangiectases 
appear  about  the  surfaces  of  the  body  and  on  mucous  membranes. 

Considerable  aid  in  diagnosing  the  probable  cause  of  an  epistaxis  is  afforded 
by  the  age  of  the  patient.     In  infancy,  the  cause  is  likely  to  be  local  ;  falls  are 


EPISTAXIS 


not  infrequent,  foreign  bodies  are  often  introduced  into  the  nose,  the  habit  of 
nose-picking  may  be  formed,  or  syphihtic  disease  of  the  nasal  bones  may  become 
estabhshed.  In  childhood,  falls  and  blows  on  the  nose  are  common,  the  tempta- 
tion to  insert  foreign  bodies  up  the  nose  still  asserts  itself,  adenoid  growths  in 
the  nasopharynx  are  common  ;  and  general  causes  such  as  heart-disease,  diseases 
of  the  blood,  or  obscure  conditions  of  local  congestion,  may  exist  and  account 
for  the  onset  of  epistaxis.  About  the  age  of  puberty  nose-bleeding  may  occur 
in  either  sex,  and  particularly  in  girls,  not  only  in  consequence  of  the  causes 
enumerated  already,  but  also  spontaneously.  In  the  healthy,  or  apparently 
healthy,  young  adult,  almost  any  of  the  list  of  local  and  general  causes  may 
account  for  nose-bleeding  ;  diagnosis  here  must  rest  upon  the  results  of  the 
examination  into  the  local  conditions  of  the  nose,  and  the  general  state  of  the 
organs  of  the  body.  In  the  old,  on  the  other  hand,  and  in  middle-aged  patients 
of  plethoric  habit,  high  blood-pfessure  with  or  without  general  arterial 
disease  becomes  the  most  important  factor  in  determining  the  occurrence  of 
epistaxis.  Nose-bleeding  in  such  persons  may  sometimes  be  regarded  as  a 
natural  remed}^  for  the  plethora  from  which  they  suffer,  and,  indeed,  not 
infrequently  does  relieve  them  from  such  symptoms  as  a  sense  of  fullness  and 
congestion  of  the  head,  tinnitus  aurium,  or  the  appearance  of  flashes  of  light 
or  muscK  vohtantes  before  the  eyes.  In  other  instances,  it  may  serve  as  a 
warning,  drawing  attention  to  the  abnormally  high  blood-pressure  and  to  the 
chronic  interstitial  nephritis  or  arteriosclerosis  that  underlies  it.  Examination 
of  the  urine  in  these  cases  will  often  show  that  the  specific  gravity  is  low,  and 
that  a  trace  of  albumin  is  present  ;  the  heart  will  be  enlarged,  the  first  sound 
at  the  impulse  thudding,  prolonged,  or  even  replaced  by  a  soft  blowing  murmur, 
whilst  the  aortic  second  sound  will  be  very  much  accentuated. 

A.  J.  J  ex-Blake. 

ERUPTIONS,    BULLOUS,    VESICULAR,  Etc.— (See  Bull^,  Vesicles,  Etc.) 
ERYTHffiMIA. — (See  Polycythemia.) 

ERYTHEMA  is  a  local  congestion  of  the  skin,  manifesting  itself  by  a 
superficial  redness  which  disappears  on  pressure.  Though  anatomically  the 
rashes  of  the  infectious  fevers  are  erythematous,  they  have  no  independent 
existence  as  pathological  processes,  but  are  the  result  of  the  irritation  caused  by 
specific  poisons  in  the  blood-stream.  They  will  not  therefore  be  considered  in 
this  place.  Nor  shall  I  deal  with  the  eruptions  caused  by  drugs  or  by  enemata, 
for,  though  often  erythematous  in  appearance,  they  are  due  either  to  a  toxic 
action  of  the  chemical  substances  on  the  nerve  centres,  or  to  direct  irritation  of 
the  peripheral  ends  of  the  nerves  supplying  the  integument. 

Erythema  simplex — characterized  by  patches  of  redness  on  any  part  of  the 
cutaneous  surface,  scarlet  at  first,  afterwards  pinkish,  which  gradually  fade  away, 
often  with  slight  desquamation — is  distinguished  from  urticaria  by  the  absence 
of  the  wheals,  and  the  comparatively  persistent  nature  of  the  eruption,  and  from 
erysipelas  by  the  fact  that  the  reddened  area  is  not  raised  and  is  not  bounded  by 
a  sharply  defined  edge.  The  local  symptoms,  too,  are  milder,  and  usually 
there  is  no  systemic  disturbance.  If  the  hj^eraemia  is  transitory,  the  red  patches 
coming  out  suddenly  and  disappearing  in  a  day  or  two,  the  condition  is  styled 
erythema  fugax. 

In  erythema  solare  the  history  of  exposure  to  the  sun  will  supply  the  diagnosis, 
and  the  same  may  be  said  of  the  erjrthema  and  dermatitis  set  up  by  exposure  to 
the  AT-rays. 

Erythema  intertrigo,  occurring  in  parts  where  two  opposed  surfaces  of  skin 
chafe  each  other,  is  a  simple  erythema  modified  b}'  the  secretion  of  the  sweat- 


EXOPHTHALMOS  253 

glands.  It  is  readily  distinguished  from  eczema  by  the  absence  of  weeping. 
When  it  occurs  in  children  it  may  possibly  be  confused  with  the  erythema  of 
congenital  syphilis.  In  intertrigo,  however,  hypersemia  is  usually  limited  to  the 
napkin  region,  while  in  hereditary  syphilis  it  extends  down  the  legs,  often  to  the 
heels  and  soles  of  the  feet.  In  the  latter  disease,  too,  concomitant  syphilitic 
signs  will  be  found. 

Erythema  scarlatiniforme  begins  with  shivering  and  systemic  disturbance, 
quickly  followed,  if  not  actually  accompanied,  by  the  appearance  on  the  trunk 
and  elsewhere  of  vivid  red  efflorescences,  which  often  run  together  until  the 
whole  body  is  involved.  The  resemblance  to  scarlet  fever  is  marked,  even 
to  a  more  or  less  "  strawberry"  appearance  of  the  tongue,  usually  with  some 
reddening  of  the  fauces  and  soreness  of  the  throat.  But  desquamation  begins 
quite  early  in  the  course  of  erythema  scarlatiniforme — often  on  the  second  day, 
and  at  the  latest  on  the  third  or  fourth  day — while  the  eruption  is  still  in  the 
florid  stage.  Other  points  of  difference  are  that  in  erythema  scarlatiniforme 
the  eruption  may  persist  for  several  weeks,  if  not  indefinitely,  while  in  scarlet 
fever  it  does  not  last  longer  than  ten  days,  and  that  in  the  former  condition  the 
con.stitutional  symptoms  are  less  pronounced.  If  the  patient  has  had  previous 
attacks  of  erythema  scarlatiniforme,  the  fact  may  be  allowed  some  weight  in  the 
diagnosis ;  but  the  resemblance  between  the  two  affections  is  so  close  that  in  all 
cases  isolation  should  be  enjoined  until  the  diagno.sis  is  clear.  From  measles, 
erythema  scarlatiniforme  differs  in  that  the  eruption  rarely  begins  on,  and  often 
spares,  the  face,  as  well  as  in  the  absence  of  the  characteristic  symptoms  of  that 
affection.  From  German  measles  it  is  distinguished,  inter  alia,  by  the  absence  of 
glandular  swelling.  The  scaliness  in  erythema  scarlatiniforme  is  less  generally 
diffused  than  in  pityriasis  rubra,  and  there  is  repetition  of  the  desquamative 
process  as  relapses  occur. 

The  diagnosis  of  erythema  pernio  can  hardly  ever  be  in  doubt.  That  of  other 
forms  of  erythema  is  dealt  with  elsewhere — of  erythema  multiforme  (of  which 
erythema  perstans  may  be  regarded  as  a  variety)  under  Vesicles,  of  erythema 
keratodes  and  erythema  nodosum  under  Nodules,  of  erythema  paratrimma  under 
Finger,  Sore,  and  of  infantile  erythemas  under  Napkin-region  Eruptions. 

Malcolm  Morris. 

ERYTHROPSIA. — (See  Vision,  Defects  of.) 

EXOPHTHALMOS    (or  Proptosis)— May   be    bilateral   or    unilateral. 

Bilateral  Exophthalmos. — The  commonest  cause  of  this  condition  is  Graves' 
disease,  in  which  the  exophthalmos  is  associated  with  other  general  symptoms, 
such  as  tachycardia,  swelling  of  the  thyroid  gland,  fine  tremors,  and  general 
nervousness.  The  eyes  are  pushed  forward  to  a  varying  extent  (see  Facies, 
Fig.  85,  p.  261),  in  some  cases  the  protrusion  being  so  great  that  they  cannot  any 
longer  be  entirely  covered  by  the  lids.  The  protrusion  causes  the  upper  lid  to 
be  unusually  raised,  and  the  eyes  look  wide  open,  giving  the  patient  an  expression 
of  alarm  or  astonishment  (Stellwag's  sign,  due  to  spasm  of  the  levator  palpebrae 
superioris).  When  the  eyes  are  lowered,  the  upper  lids  do  not  descend  to  the 
same  extent  as  the  cornea,  but  leave  a  broad  portion  of  the  sclerotic  visible 
above  the  cornea  (von  Graefe's  sign).  Winking  takes  place  less  frequently,  and 
convergence  of  the  eyes  is  sometimes  rendered  difficult  (the  sign  of  Mobius). 

Bilateral  exophthalmos  may  also  be  caused  by  thrombosis  of  the  cavernous 
sinuses.  This  condition  is  usually  secondary  to  some  furuncle  or  carbuncle  of 
the  skin  of  the  face  in  the  region  of  the  eye,  to  orbital  cellulitis,  or  suppuration 
in  the  accessory  sinuses  of  the  nose.  It  usually  starts  on  one  side,  and  invariably 
spreads  to  both  in  the  later  stages  of  the  attack.  The  eyes  are  protruded  and 
fixed,  the  eyelids  are  red  and  engorged,  and  the  frontal  and  ophthalmic  veins  are 


254 


EXOPHTHALMOS 


dilated  and  full.  Movements  of  the  eyes  are  very  limited,  and  there  is  much 
swelling  and  induration  of  the  orbital  tissues.  In  association  with  the  orbital 
infiltration  there  is  often  some  swelling  in  the  region  of  the  mastoid  process, 
owing  to  the  exit  in  this  region  of  an  emissary  vein  in  connecton  with  the  sinuses 
that  communicate  with  the  two  cavernous  sinuses.  This  condition  is  nearly 
always  fatal,  as  it  is  followed  by  a  suppurative  meningitis. 
Unilateral  Exophthalmos  may  be  due  to  : — 


Orbital  cellulitis 

Thrombosis  of   the  cavernous 

sinus 
Orbital  periostitis 
Meningocele  and  encephalocele 
Gumma 


New  Growth 
Exostosis 
Tubercle 

Arterio-venous  aneiirysm 
Distention  of  the  accessory  sinuses 
of  the  nose. 


The  diagnosis  of  orbital  cellulitis  and  thrombosis  of  the  cavernous  sinus  presents 
little  difficulty,  owing  to  the  symptoms  of  acute  inflammation  that  are  present, 

orbital  cellulitis  being  distin- 
guished from  cavernous  sinus 
thrombosis  by  the  fact  that  it  is 
usually  unilateral  and  there  is  no 
oedema  in  the  mastoid  region. 

Orbital  periostitis,  especially  in 
more  chronic  cases,  may  give  rise 
to  varying  degrees  of  proptosis, 
and  in  the  absence  of  any  obvious 
thickening  of  the  orbital  margins 
the  diagnosis  may  be  obscure. 
In  any  periosteal  inflammation  of 
long  standing,  a  skiagram  will 
usually  show  a  very  definite  in- 
crease of  density  in  the  affected 
bone. 

Meningoceles  and  encephaloceles 
may  in  some  cases  be  difficult  to 
diagnose  from  dermoid  cysts. 
The  latter  are  usually  placed 
anteriorly  in  the  orbit,  and  do 
not  therefore  cause  any  proptosis, 
though  they  may  displace  the 
eyeball.  A  meningocele  usually 
presents  itself  through  a  gap 
between  the  ethmoid  and  the  frontal  bones  (Fig.  75),  and  is  attached  to  the 
bone.  An  opening  may  sometimes  be  found  through  which  the  meningocele 
communicates  with  the  cranial  cavity.  Meningoceles  sometimes  pulsate  in 
association  with  the  arterial  and  respiratory  oscillations.  They  may  also  be 
diminished  in  size  by  pressure  of  the  fingers,  as  the  fluid  can  be  squeezed  into 
the  cranial  cavity.  In  many  cases  an  exploratory  puncture  is  the  only  means 
of  making  a  certain  diagnosis. 

A  gumma  of  the  orbit  can  only  be  diagnosed  from  the  patient's  general 
history,  evidence  of  specific  disease  elsewhere,  a  rapid  improvement  in  the 
condition  after  the  administration  of  iodide  of  potassium,  and  perhaps  a 
positive  Wassermann's  serum  reaction. 

A  growth  of  the  orbit  has  usually  no  distinctive  feature,  and  can  only  be 
diagnosed  by  means  of  an  exploratory  operation  and  the  removal  of  a  portion 


Fig.  75. — Meningocele  projecting  into  the  face  from 
the  anterior  part  of  the  base  of  the  skull.  (From  a. 
draioing  in   tlie  Gordon  Musetan,  Guys  Hospital.) 


EYE,     ACUTE     INFLAMMATION     OF  255 

for  microscopical  examination  ;  but  it  is  to  be  remembered  that  tumours  of  the 
optic  nerve  can  usually  be  diagnosed  with  accuracy  by  the  fact  that  they  always 
produce  some  compression  of  the  eyeball  in  the  antero-posterior  diameter.  Cases 
of  proptosis^  therefore,  in  which  there  is  increasing  hypermetropia  on  the  affected 
side,  may  be  ascribed  to  a  primary  tumour  of  the  optic  nerve. 

Ivory  exostoses  or  osteomata  usually  arise  from  the  frontal  bone  and  are 
attached  by  a  broad  base,  so  that  their  removal  presents  very  great  difficulty  ; 
the  diagnosis  depends  on  their  slow  growth  and  excessiv^e  hardness  ;  a  skiagram 
shows  their  presence  with  great  certainty. 

Some  cases  of  tubeyculous  disease  of  the  orbit  may  closely  simulate  orbital 
cellulitis  or  distention  of  the  accessory  sinuses  of  the  nose,  and  the  diagnosis 
can  only  be  made  with  certainty  after  excision  of  a  portion  of  the  infiltrated 
tissue  and  a  microscopical  examination  of  the  fragment. 

An  arterial  aneurysm  is  nearly  always  associated  with  a  pulsating  exoph- 
thalmos, in  which  there  is  protrusion  of  the  eye-ball  and  dilatation  of  the  blood- 
vessels of  the  retina,  hds,  and  conjunctiva.  There  is  distinct  pulsation  of  the 
eyeball,  and  a  loud  blowing  murmur  on  examination  with  the  stethoscope. 
Compression  of  the  carotid  on  the  same  side  diminishes  the  pulsation  and  the 
sound.  The  usual  cause  of  arterial  aneurysm  is  the  rupture  of  the  carotid  into 
the  cavernous  sinus  as  the  result  of  an  injury.  Rare  cases  are  also  seen  of  inter- 
mittent exophthalmos,  which  appears  only  at  intervals  or  when  the  head  is 
depressed.  These  are  usually  due  to  varicose  veins  in  the  orbit  not  in  com- 
munication with  an  artery. 

The  protrusion  of  the  eyeball  in  dilatation  of  the  accessory  sinuses  of  the  nose 
is,  as  a  rule,  less  an  exophthalmos  than  a  displacement  of  the  eyeball  downwards 
and  outwards.  In  dilatation  of  the  frontal  sinus  there  may  be  some  thickening 
and  fullness  of  the  supra-orbital  ridge  associated  with  pain  and  tenderness  over 
the  eyebrow.  In  dilatation  of  the  ethmoidal  cells  there  is  usually  a  definite 
swelling  to  be  felt  at  the  inner  side  of  the  orbit,  which  is  compressible  though  not 
distinctly  fluid.  Dilatation  of  the  sphenoidal  sinus  is  frequently  accompanied 
by  neuritis  or  atrophy  of  the  optic  nerve.  In  all  cases  of  proptosis  due  to  sinus 
trouble  of  any  duration,  there  is  evidence  in  the  nose  of  inflammation  of  these 
cavities,  the  usual  symptom  being  the  existence  of  polypi  or  of  definite  swelhngs 
in  the  region  of  the  infundibulum.  Herbert  L.  Eason. 

EXPECTORATION. — (See  Sput.\  ;   and  Hemoptysis.) 

EXTENSOR  PLANTAR   REFLEX. — (See  Babinski's   Sign.) 

EYE,  ACUTE  INFLAMMATION  OF. — The  three  most  important  causes  of 
acute  inflammation  of  the  eye  are  conjunctivitis,  iritis,  and  glaucoma. 

Pain,  photophobia,  and  lachrymation  are  common  to  all  three,  so  that  they 
are  liable  to  be  mistaken  for  one  another. 

Acute  Conjunctivitis  occurs  as  a  result  of  the  infection  of  an  eye  with  bacteria 
of  the  most  various  descriptions.  In  the  milder  cases  it  is  only  the  conjunctiva 
of  the  lids  or  the  lower  lid  that  is  affected  ;  the  surface  is  more  or  less  vividly 
reddened  by  a  reticulate  injection,  smooth,  waterv'-looking,  and  the  patient 
often  complains  that  the  lids  are  gummed  together  by  secretion  when  he  wakes. 
In  the  severer  infections  the  conjunctiva  of  the  eyeball  is  also  involved,'  it  is 
more  highly  and  more  uniformly  coloured,  the  secretion  of  tears  and  the  deposit 
of  mucous  flakes  are  considerably  increased,  and  small  haemorrhages  into  the 
loose  subconjunctival  tissue  may  be  seen  ;  there  is  more  pain  about  the  eye, 
and  a  persistent  feehng  as  if  sand  or  some  foreign  body  were  in  it.  In 
the  worst  cases,  such  as  those  of  gonococcal  ophthalmia  in  new-bom  children, 
the    cornea   becomes   ulcerated,   when   the    pain    and   photophobia   are    greatly 


256  EYE,     ACUTE    INFLAMMATION     OF 

increased,  and  the  outlook  becomes  much  more  serious — for  the  crescentic 
marginal  ulcer  that  now  forms  on  the  cornea  may  lead  to  the  setting  up  of  iritis. 
•  In  other  instances  of  conjunctivitis  the  infiamed  membrane  is  seen  to  be  studded 
with  small  raised  bodies  the  size  of  a  pin's  head — follicular  conjunctivitis.  In 
trachoma,  or  granular  conjunctivitis,  small  greyish  or  pink  granules  appear 
in  the  conjunctival  fornices.  Bilateral  conjunctivitis  often  occurs  in  epidemics 
("  pink  eye  "),  sometimes  in  connection  with  influenza  or  German  measles. 
It  must  be  remembered  that  acute  conjunctivitis  is  often  secondary  to  the 
intrusion  of  some  foreign  body  into  one  or  other  of  the  conjunctival  sacs,  to  a 
corneal  ulcer,  to  keratitis,  to  infiammatory  processes  (such  as  a  stye)  in  other 
parts  of  the  ocular  apparatus,  and  that  all  these  may  be  in  more  urgent  need  of 
detection  and  treatment  than  the  conjunctivitis  itself.  It  must  be  distinguished 
from  such  non-inflammatory  or  chronic  conjunctival  conditions  as  oedema, 
sub-conjunctival  hcemorrhage,  Pinguecula,  as  well  as  from  inflammations  of 
the  sclerotic,  iris,  and  ciliary  body.  The  conjunctival  oedema  of  Bright's  disease 
(Bright's  "  bright  eye  ")  or  severe  heart  disease,  in  which  the  bulbar  conjunctiva 
becomes  prominent,  shiny,  and  obviously  oedematous  on  close  inspection, 
should  hardly  be  mistaken  for  inflamraation,  even  when  the  vessels  are  dilated 
by  passive  hypersemia,  as  they  often  are.  Subconjunctival  hcBmorrhage  or 
ecchymosis  follows  the  rupture  of  a  small  vessel  in  the  bulbar  conjunctiva  and 
the  escape  of  blood  into  its  lax  tissue,  with  the  result  that  a  vivid  or  dark-red 
patch  forms  over  a  part  or  the  whole  of  the  white  of  one  or  both  eyes.  It  occurs 
as  the  result  of  vascular  over-stress,  and  is  common  in  old  people  with  sclerotic 
arteries.  In  the  young  it  may  be  seen  after  the  severe  straining  of  whooping- 
cough,  vomiting,  lifting  heavy  weights,  an  epileptic  fit ;  while  in  cases  of  head- 
injury  it  is  symptomatic  of  htemorrhage  into  the  orbit  from  fracture  of  the 
base  of  the  skull.  Such  an  ecchymosis  is  distinguished  from  conjunctivitis 
by  its  uniformly  red  colour,  the  absence  of  a  network  of  dilated  vessels  in  it, 
and  by  its  sharp  limitation  from  adjoining  normal  parts  of  the  conjunctiva. 
Pinguecula  is  the  name  given  to  a  chronic  yellowish  thickening  of  the  scleral 
conjunctiva  where  it  is  most  exposed  at  the  inner  and  outer  margins  of  the  cornea. 
It  results  from  prolonged  exposure  to  weather,  wind,  and  dust,  occurs  in  the 
second  half  of  life,  and  even  when  its  vessels  are  injected  it  should  hardly  be 
mistaken  for  conjunctivitis.  Inflammation  of  the  sclerotic,  called  scleritis  if 
deep,  episcleritis  if  more  superficial,  though  not  common,  is  found  in  rheumatic, 
gouty,  or  syphilitic  adults.  It  takes  the  form  of  small  dusky-red  or  violet 
inflamed  spots  in  the  sclerotic,  placed  near  the  corneal  margin,  and  covered  by 
the  more  or  less  injected  conjunctiva.  Periodic  and  transient  attacks  of 
episcleritis  have  been  described  by  Hutchinson  ("  hot  eye  ").  The  deep  and 
dusky  injection  of  scleritis  should  suffice  to  distinguish  it  from  conjunctivitis. 

The  general  diagnosis  of  Iritis,  of  inflammation  of  the  ciliary  body  or  Cyclitis, 
and  of  the  common  combination  of  the  two,  or  Iridocyclitis,  from  conjunctivitis, 
is  indicated  in  the  table  opposite.  Apart  from  trauma  and  from  the  spread  of 
infection  through  the  cornea,  these  conditions  are  due  to  syphilis  in  over  half  the 
cases,  to  rheumatic  infection  in  many  of  the  remainder,  to  diabetes,  tuberculosis, 
or  gonorrhoea  in  others.  The  pain  felt  is  often  extremely  severe.  It  is  neuralgic 
in  character,  and  not  confined,  as  it  is  in  conjunctivitis,  to  the  inflamed  eye 
It  radiates  into  the  brow  (supra-orbital  neuralgia),  the  side  of  the  nose,  the 
malar  region  ;  and  in  the  syphilitic  cases  is  often  worst  at  night.  Inflammation 
of  the  ciliary  body  as  well  as  of  the  iris  is  to  be  diagnosed  if  deposits  of  pigmented 
lymph  are  seen  in  the  anterior  chamber  or  in  the  vitreous,  if  the  inflammation 
is  so  severe  as  to  bring  about  oedema  of  the  upper  eyelid,  if  the  ciliary  region 
is  tender,  and  if  the  tension  of  the  eyeball  is  raised — as  it  often  is  in  cyclitis. 
It  is  of  the  utmost  importance  to  the  patient  that  an  iritis  or  iridocyclitis  should 


EYE,     ACUTE     INFLAMMATION     OF 


257 


not  be  diagnosed  as  a  conjunctivitis,  or  glaucoma  as  either  ;  for  complete  loss  of 
sight  may  result  from  the  application  of  the  treatment  suitable  to  iritis  in  a 
case  of  glaucoma,  and  vice  versa. 

Inflammatory  Glaucoma  is  an  acute  disease  of  the  later  years  of  life,  coming 
on  in  bouts  often  precipitated  by  indiscretions  in  diet  or  regimen,  and  affecting 
both  eyes.  At  first  the  chief  complaint  is  of  attacks  of  obscuration  of  vision, 
and  the  appearance  of  halos  or  rainbows  round  bright  lights — the  same  com- 
plaint may  be  made  in  chronic  conjunctivitis.  During  a  mild  attack  of  glaucoma 
there  is  a  feeling  of  tension  in  the  eye,  and  often  a  dull  frontal  headache,  in 
addition  to  the  loss  of  vision.  In  severe  attacks  the  pain  is  very  violent,  radiating 
from  the  eyes  to  the  head,  the  ears,  the  teeth  ;  oedema  of  the  lids  and  of  the 
congested  conjunctiva  is  also  common.  Examination  of  the  eyes  will  show  the 
signs  tabulated  above  ;  ophthalmoscopically,  glaucomatous  cupping  of  the 
optic  disc  will  be  seen  so  long  as  the  media  remain  transparent  [Plate  VIII, 
Fig.  V).  Subacute  or  simple  glaucoma  may  occur  in  young  persons  or  in 
adults  ;  but  for  its  slower  course  and  the  absence  of  severe  attacks  it  resembles 
inflammatory  glaucoma.  The  importance  of  discriminating  between  iritis  and 
glaucoma  cannot  be  over-emphasized  ;  for  the  exhibition  of  atropine  or  some 
similar  mydriatic  is  the  sine  qua  non  of  the  treatment  of  iritis,  whilst  in  glaucoma 
it  is  contraindicated. 

The  points  which  serve  to  differentiate  these  three  conditions  from  one  another 
have  been  summarized  in  tabular  form  by  Dr.  Eason  as  follows  : — 


CoNJUiNXTlVITIS 

Iritis 

Glauco.ma. 

Conjunctiva 

Conjunctival  vessels 
bright     red      and 
injected ;  movable 
over  subjacent 
sclerotic :       injec- 
tion most  marked 
away  from  corneo- 
sclerotic    margin ; 
colour     fades     on 
pressure 

Ciliary     vessels     in- 
jected,     deep     or 
bluish-red ;    most 
marked  at  corneo- 
sclerotic    margin : 
colour     does    not 
fade  on  pressure 

Both  conjunctival 
and  ciliary  vessels 
injected 

Cornea 

Clear,  sensitive 

Clear,  sensitive 

Steamy,  hazy,  in- 
sensitive 

Anterior  chamber 

Clear,  normal  depth 

Aqueous   turbid, 
anterior   chamber 
slightly  shallow 

Very  shallow 

Iris 

Normal  colour 

Injected,       swollen, 
adherent  to  lens, 
and         muddy 
coloured 

Injected 

Pupil 

Black,  active 

May  be    filled   with 
lymph,    small, 
fixed 

Dilated,  fixed, 
greenish 

Tension 

Normal 

Normal 

Raised 

A.  J.  J  ex-Blake. 


258 


FACIES,     ABNORMALITIES     OF 


FACIAL   PARALYSIS.— (See  Paralysis,  Facial.) 

FACIES,  ABNORMALITIES  OF. — The  study  of  the  face  in  health  and  disease 
cannot  fail  to  prove  profitable  and  interesting  to  all  medical  men.  While  it 
cannot  replace  careful  systematic  examination  of  the  body  as  a  whole,  it  may, 
in  many  cases,  direct  the  experienced  observer's  attention  to  the  most  likely 
and  fruitful  field  in  which  to  find  data  for  his  diagnosis.  Nothing  but  observation 
and  experience  can  teach  the  student  to  detect  all  the  features  of  a  face.  Photo- 
graphs and  drawings  can  only  illustrate  for  him  the  coarse  and  obvious  defects 
which  are  present  when  the  face  is  at  rest  or  when  some  particular  movement  is 
being  sustained.  The  more  subtle  abnormalities  of  expression,  the  play  of  the 
emotions,  and  the  response  of  the  features  to  intelligence,  are  often  too  fleeting 
and  too  mobile  to  allow  of  reproduction  on  paper,  and  sometimes  so  intangible 
as  to  defy  any  effort  to  describe  them.  Even  if  the  pen  of  a  skilled  artist  could 
succeed  in  portraying  the  passive  vacant  aspect  of  a  chronic  alcoholic,  it  must 
necessarily  fail  to  depict  the  traitorous  tremor  which  hovers  about  the  corners 


I^ig:  76. —  Myxcedenia  :  the  character- 
istic facies,  illustrating  the  broadening  of 
the  features  and  the  malar  flush,  (Com- 
pare Fig-.  77.) 


J^ig:  77. — The  same  patient  as  J^yg:  76, 

previous  to  the  development  of  myxcedenia. 

(From   photographs    kindly  lent  by  Dr. 

Hale  White.) 


of  his  mouth  when  he  opens  it  to  proclaim  his  temperance.  The  shifty  eyes  of 
the  drug-taker,  the  fatuous  placidity  of  the  patient  with  advanced  insular 
sclerosis,  the  anxious  look  born  of  abdominal  disease,  the  explosive  suddenness 
with  which  the  victim  of  double  hemiplegia  bursts  into  laughter  or  tears,  are 
only  a  few  of  the  many  familiar  and  striking  lessons  of  the  face  which  must  be 
seen  in  real  life  if  they  are  to  be  learned  and  utilized. 

On  the  other  hand,  there  are  facies  the  description  and  illustration  of  which 
may  serve  to  impress  their  more  important  features  on  the  minds  of  those  to 
whom  they  are  not  familiar.  To  these  more  classical  pictures  attention  must 
now  be  drawn. 

Cretinoid  Facies. — Compared  with  the  general  stunted  growth  of  the  rest  of 
the  body,  the  head  is  relatively  large.  The  face  is  broad  and  remarkable  for 
thick  eyelids,  broad  flat  nose,  thick  lips,  and  large  coarse  ears.  The  mouth  is 
usually  open  and  expressionless,  the  tongue  may  be  more  or  less  constantly 
protruded,  and   the  chin  is  poorly   developed    (see    Dwarfism).     The    hair   is 


FACIES,     ABNORMALITIES     OF 


259 


scanty  and  brittle,  the  skin  coarse,  dry,  and  often  almost  yellow  in  colour. 
Confirmation  of  the  diagnosis  may  be  sought  for  in  the  dwarfed  size  of 
the  child,  the  pendulous  "  frog  belly,"  and  the  thick  .pads  of  subcutaneous 
tissue  especially  frequent  above  the  clavicles.  The  lack  of  mental  develop- 
ment, the  slow  pulse,  and  subnormal  temperature  complete  the  clinical 
picture. 

Myxcedematous  Fades. — -The  dulled  intelligence  of  the  patient  is  betrayed 
by  the  apathetic  physiognomy  {Fig.  76).  Fig.  77  shows  the  same  patient 
previous  to  the  attack.  The  skin  of  the  myxcedematous  face  is  coarse,  dry, 
and  sallow,  with  occasional  cyanotic  areas  over  the  cheeks.  The  puffiness  of 
the  eyelids  may  suggest  nephritis,  but  the  subcutaneous  tissue  is  everywhere 
of  firm  consistence,  and  podgy  rather  than  oedematous.  The  nose  is  broadened, 
the  ears  are  thickened,  and  the  lips  so  much  swollen  that  more  than  the  usual 
amount  of  mucous  membrane  is  exposed.  The  hair  is  scanty,  receding  from 
the  forehead,  and  the  eyebrows  become  poorly  marked  for  the  same  reason. 
Similar  conditions  of  hair  and  skin,  together  with  brittle,  striated  nails,  are  found 


fig:  78. — Congenital  syphilis,  showing 
prominent  forehead  and  depressed  nasal 
bridge. 

Pholi}  by  Dr.  Rendie  Short. 


Fig.  79.  —  Facies  of  congenital 
sj-philis,  showing  notched  teeth  and 
sore  angles  of  the  mouth. 

Photo  by  Dr.  S.  A.  K.  Wilson. 


elsewhere.  Masses  of  fatty  tissue,  like  those  described  in  cretins,  may  be  found 
scattered  about  the  neck  and  trunk. 

The  slow  speech,  the  expressionless  face,  and  the  general  attitude  of  the 
patient  may  suggest  paralysis  agitans,  but  the  diagnosis  may  be  made  readily 
by  paying  attention  to  the  features  just  mentioned,  and  by  observing  the 
slow  pulse  and  subnormal  temperature  in  myxoedema,  and  the  effects  of 
thjrroid  treatment. 

Congenital  Syphilitic  Facies. — The  victims  of  congenital  syphilis,  after  ten  or 
twelve  years  of  age,  may  present  a  facies  which  is  highly  characteristic.  An 
overhanging  forehead,  perhaps  frontal  bosses,  a  depressed  nasal  bridge  {Fig.  78), 
striated  scars  radiating  from  the  corners  and  other  parts  of  the  lips  (Fig.  79), 
with  a  sallow,  earthy  complexion,  are  the  most  prominent  features  of  the 
luetic  facies.  Closer  observation  of  the  eyes  and  teeth  may  detect  the 
opacities  of  old  keratitis  and  the  changes  in  the  upper  incisors  which  are 
claimed  by  Hutchinson  to  be  pathognomonic  [Fig.  80).  These  teeth  are  peg- 
shaped,  irregular,   and  so    deficient   in    enamel  over  the  anterior  and  median 


26o 


FACIES,     ABNORMALITIES     OF 


parts  of  their  cutting  edge  that  the  resulting  crescentic  notch  gives  them  a 
striking   appearance.      When    such    a    facies   is    noted,   the   diagnosis    may    be 

chnched  b}'  the  discovery  of  one  or  more 
,,;  of    the    following    symptoms    and    signs : 

deafness,  mental  deficiency,  physical  in- 
fantihsm,  tibial  deformities,  and  chronic 
arthritis,  especially  of  the  knee  joints. 

Myopathic  Facies.  —  Many  cases  of 
mj^opathy  show  no  characteristic  facies  ; 
others  are  remarkable  chiefly  for  the 
loose  pout  of  their  hps  at  rest  {Fig.  8i), 
and  the  "transverse"  character  of  their 
smile  {rire  en  travers.  Fig.  82).  Both 
features  are  due  to  deficient  facial 
musculature,  and  particularly  to  weak- 
ness of  the  orbicularis  oris.  The  paresis 
of  the  orbiculares  palpebrarum  is  only 
striking  when  an  attempt  is  made  to  close  the  eye,  although  it  may  sometimes 
lead  to  a  prominent  and  perhaps  staring  appearance  of  the  eyeballs.  In  other 
instances  there  is  a  droop  of  the  upper  ej^elids  rather  than  anjr  tendency  to 
exophthalmos.      The  inabilit}-  on  the  part  of  the  patient  to  whistle  or  to  blow 


,mmmm  ^ 


Fi^.%a. — Hutchinson  ian  notched  teeth. 
(From  Introduction  to  Surg^ery,  Prof. 
Rutherfjrd  Morison.) 


/•y^.  81. —  Myopathic  facies  :  the 
loose  pout  due  to  weakness  of  the 
orbicularis  oris. 

Photo  by  Dr.  S.  A.  K.   Wilson. 


Fig.    82. —  Mj'opathic    facies  :     the 
transverse  smile. 

Photo  by  Dr.  S.  A.  K.   Wilson. 


out  his  cheek  quickly  demonstrates  the  weakness  of  the  orbicularis  oris,  it  it 
is  not  made  obvious  by  the  large  amount  of  labial  mucous  membrane  exposed 
while  the  mouth  is  at  rest. 

Myasthenic  Facies. — In  patients  suffering  from  m^^asthenia  gravis  there  are 
t\vo  types  of  facies  which  can  hardly  be  reproduced  by  other  diseases.  The 
fiist  illustrates  the  exhaustion  of  the  patient  {Fig.  83)  ;  she  can  hardly  keep 
her  eyes  open,  and  her  chin  tends  to  drop  exhausted  on  her  chest.  The  second 
depends  for  its  effect  on  the  characteristic  myasthenic  smile,  a  smile  which  is 
sometimes  more  appropriately  named  a  sneer  {Fig.  84).  This  unfortunate  and 
misleading  facial  expression  is  the  result  of  deficient  action  on  the  part  of  the 
zygomatic  and  risorius  muscles,  and  exemplifies  the  curious  way  in  which  some 


FACIES,     ABNORMALITIES     OF 


261 


muscles  are  affected  and  others  escape,  in  this  disease,  even  when  they  derive 
their  innervation  from  the  same  source.  The  accompanying  photograph  shows 
how  a  shght  assymmetry  in  the  muscular  affections  may  be  responsible  for  very 
different  expressions  on  the  two  sides  of  the  face. 


Rcproiitcced  fi-oin  Blocks  kindly  lent  hv  Messrs.   Ma.-niillnn  <5---  Co. 


Hg.  83. —  Myasthenic  facies  ;  the 
appearance  of  fatigue  prod  need  by  the 
droopingof  the  eyelids  and  dropping  of 
the  jaw  is  very  apparent. 


^^^ 


Fig.  84. —  iNIyasthenic  facies:  this 
photograph  was  taken  to  ilkistrate  a 
"  nasal "  smile  on  the  left  side  of  the 
face,  and  a  natural  smile  on  the  right. 
These  are  best  seen  by  covering  up  one 
half  of  the  face  at  a  time. 


The  Facies  of  Exophthalmic  Goitre. — The  facial  appearance  in  Graves'  diseas'e 
depends  chiefly  upon  the  "  stare  "  {Fig.  85).  Surprise  or  fear  is  suggested 
by  the  prominence  of  the  eyeballs  and  the 
retraction  of  the  eyelids.  The  degree  of 
exophthalmos  varies  greatly,  and  it  is  not 
present  in  all  cases  ;  sometimes  it  occurs 
on  one  side  and  not  on  the  other.  Close 
observation  shows  that  the  sclera  is  visible 
between  the  edge  of  the  iris  and  the  eye- 
lids, and  that  the  usual  harmony  of  move- 
ment between  the  eyeball  and  the  eyelid 
is  lacking.  Normal  winking  is  frequently 
much  diminished  or  entirely  in  abeyance. 
The  surface  of  the  conjunctiva  may  be 
abnormally  bright  and  glistening,  and  the 
secretion  of  tears  may  be  excessive.  In 
contrast  with  the  white  of  the  eyeballs, 
there  is  often  considerable  dark  pigmenta- 
tion of  the  eyelids,  which  may  also  be  the 
site  of  some  oedema.  The  size  of  the  pupils 
varies,  undue  dilatation  occurring  only  in 
exceptional  cases.  A  moist  skin  and  a 
readiness  to  flush  may  often  be   remarked  in  the  face. 

The  Facies  of  Paralysis  Agitans. — In  this  disease,  a  cardinal  symptom  is 
muscular  rigidity,  which  affects  the  skeletal  muscles  generally  as  well  as  those 
of  the  face.      The  ocular  muscles,  however,  escape.      It  is  due  to  this  fact  that 


Fi^.  85. — Exophthalmic    goitre. 
Photo  hv  Dr.  S.  A.  K.  Wilsoh 


262 


FACIES,    ABNORMALITIES     OF 


showing  the  fixed  ii^rliig  expreis; :;r. 


while  the  face  as  a  whole  is  expressioiiless,  "  starch}-  "  or  "  masked  "  [Fig.  86), 
the  eves  appear  to  move  -vrith  natural  or  even  abnormal  rapidity' ;  for 
instance,   thev   -prill    turn   in    the    direction   to   which  the   patient   desires    to 

look,  before  the  head  has  assumed  a  cor- 
responding position.  Frequenth-  the  face 
has  a  staring  expression,  the  e^-eUds  being 
constantly  retracted  bj-  the  tonic  spasm 
of  the  orbiculares  palpebranrm.  An  absence 
of  normal  winking  has  been  noted  and 
ascribed  to  the  same  cause.  In  contrast 
with  the  slow  development  of  facial  ex- 
pression under  the  iniiuence  of  emotion, 
there  is  sometimes  marked  want  of  control 
over  the  fully-developed  emotional  move- 
ment, and  the  patient  complains  that  the 
exuberance  of  his  laughter  or  tears  is 
entirely  out  of  proportion  to  his  feeUngs  of 
merriment  or  sorrow. 

Tabetic  Fades. — In  a  considerable  per- 
centage of  cases  of  locomotor  ataxy  the 
appearance  of  the  face  is  sufficiently  striking, 
to  a  close  obser^-er,  to  afford  a  clue  to 
diagnosis.  The  small  size  or  the  inequahtj'' 
of  the  pupils  may  first  attract  attention.  The  shght  drooping  of  the  upper 
eyehds,  combined  with  some  wrinkling  of  the  forehead  (Fig.  87),  due  to  a 
compensating  effort  on  the  part  of  the  frontahs  muscle,  gives  a  sad  expression 
to  the  face.  This  drooping  of  the  evehd, 
vrhich  may  be  termed  pseudo-ptosis  or 
hypotonic  ptosis,  is  not  due  to  anv  paresis 
of  the  levator  palpebrse  superioris,  as  mav 
be  shown  b}-  the  raising  of  the  hd  when 
the  patient  is  looking  up.  It  really  depends 
on  the  fact  that  this  muscle,  like  most  of 
the  muscles  of  the  body,  is  in  a  condition 
of  hypotonia.  This  allows  the  action  of 
gra%"iir\-  to  assert  its  influence,  "svith  the 
result  that  the  hd  hangs  like  a  half -raised 
curtain  in  front  of  the  eyeball.  In  other 
respects  the  face  may  be  normal,  but  the 
majorit}.-  of  tabetics  have  a  sallow  complexion 
and  ver\-  httle  subcutaneous  fat,  two  facts 
which  contribute  to  their  generallv  un- 
healthy aspect.  The  writer  beheves  that 
many  \actims  of  this  disease  exhibit  a 
deficiency-  of  the  emotional  reflex  move- 
ments of  the  facial  muscles.  During  con- 
versation, the  play  of  their  features  in 
response  to  the  subject  of  their  talk  is 
not  so   noticeable   as   that  of   health}-  indi^-iduals. 

Fades  of  Acromegaly. — In  the  course  of  acromegaly,  changes  in  appearance 
frequentl}^  take  place  to  such  a  degree  that  the  patient  becomes  unrecogniz- 
able by  those  of  his  friends  who  have  onl}-  knoA^m  him  before  the  onset  of 
his  disease.  These  changes  are  the  result  of  abnormal  gro%^-th  on  the  part  of 
the  bony  and  subcutaneous  tissues  in  many  parts  of  the  body,  and  especially 


Fig,  87. — Tabetic  fades.    The  photo- 
graph shows  the  partial  bilateral  ptosis 
and  the  %4-rinkling  of  the  forehead,  which 
contribute  to  the  expression  of  sadness. 
P/u>io  by  Dr.  S.  A.  K.  Wilson. 


FACIES,     ABNORMALITIES     OF 


263 


Acromegaly. 


part  of  the  face  tends  to  make  the  head  lean 
to   rest   upon  the  sternum.      In  some    cases 
the   lower  jaw  is  not  affected,  and  the  face 
may    be     described    as     abnormally    square 
{type   carree). 

Fades  of  Mongolian  Idiocy. — This  facies  is 
so  characteristic  that  the  diagnosis  may 
often  be  made  at  sight  (Fig.  89  ;  see  also 
Dwarfism).  The  head  is  brachycephalic  ; 
the  palpebral  fissures  slant  obliquely  inwards 
and  downwards  towards  a  broad  flat  nose, 
rendered  even  broader  by  the  presence  of 
epicanthus ;  the  eyelids  show  signs  of  chronic 
blepharitis  ;  the  ears  are  large  and  pitcher- 
shaped  ;  the  lips  are  fissured  and  often 
left  open  to  allow  a  coarse  tongue  to 
protrude  (Figs.  90,  91)  ;  the  forehead  is 
downy,  and  the  hair  of  the  scalp  scanty, 
wiry,  and  frequently  mouse-coloured  ;  the 
complexion     is     florid      and  mottled.        The 


in  the  skull  and  ex- 
tremities. The  char- 
acteristic facies  is 
brought  about  by 
osseous  hj'perplasia  of 
the  frontal  ridges,  the 
mastoid,  zj^gomatic, 
malar,  and  nasal  pro- 
cesses, while  the  lower 
jaw  is  usually  enlarged 
in  all  directions.  The 
prominent,  arched 
brows,  with  retreating 
and  wrinkled  fore- 
head, the  massive 
nose,  the  long,  thick 
upper  lip,  and  the 
heavy  chin  {Fig.  88) 
form  the  most  con- 
spicuous features.  The 
lower  set  of  teeth  may 
project  some  distance 
in  front  of  the  upper, 
and  they  are  unduly 
wide  apart.  The 
tongue  may  be  so 
enlarged  as  to  keep 
the  mouth  open  and 
to  display  many  fis- 
sures and  indentations 
as  the  result  of  its 
pressure  against  the 
teeth.  The  increased 
weight  of  the  lower 
forward  and  perhaps  ultimately 


J^i^.  Sg. — Achondroplasia. 
P/ioia  by  Dr.  S.  A.  K.  Wilson 


264 


FACIES,     ABNORMALITIES     OF 


almond-shaped    eyes,  the    presence    of   epicanthus,  the  florid  complexion,  and 
the   absence   of   fatty   masses    serve    to    distinguish  ■  the   Mongolian   from  the 


J^i£:  90.  —  A  Mongolian  Idiot  in 
infancy.  The  photograph  shows  the 
oblique  palpebral  fissures  and  the  large 
protruding  tongue. 


J^!,g'.  91. — A  JNIongolian  Idiot,  show- 
ing a  large  flabby  tongue,  which  is 
deeply  fissured. 

Photos  by  Dr.  S.  A.  K.   Wilsoti. 


cretinoid  idiot ;    in  case  of  doubt  the  benefit  or  otherwise  of  thyroid  treatment, 
may  clinch  the  diagnosis.  e.  Farquhar  Buzzard. 

F^CES,  BLOOD  IN. — (See  Blood  per  Anum,  and  Helena.) 

F^CES,  FAT  IN.— (See  Fatty   Stools.) 

F^CES,  MUCUS  IN. — (See  Mucus  in  the  Stools.) 

F.ffiCES  PASSED  PER  URETHRAM.— Fajces  or  fa;cal  fluid  are  only  passed 
per  urethram  when  the  bladder  is  in  fistulous  communication  with  some  part  of 
the  bowel,  or  with  some  fseculent  abscess  cavity  infected  with  the  Bacillus  coli 
communis.  Pneum\turia  (q.v.)  is  liable  to  occur  at  the  same  time.  The  chief 
causes  are  as  follows  : — 

Cancer  of  the  bladder  opening  into  the  rectum  or  into  some  loop  of  bowel 
which  has  become  adherent  to  the  bladder. 

Cancer  of  the  rectum  ,    opening  into  the  bladder  either  directly,   or 

Cancer  of  the  sigmoid  colon    '      .   through    the    medium    of    an    intervening 

Cancer  of  the  caecum  )        abscess.  . 

Cancer  of  the  uterus  opening  both  into  the  bladder  and  into  the  rectum. 

Proctitis  and  periproctitis  leading  to  the  formation  of  an  abscess  which  opens 
into  the  bladder. 

Prostatitis  and  prostatic  abscess  opening  into  the  rectum. 

Retrovesical  fistula  following  injury  and  local  sloughing,  particularly  after 
childbirth. 

Caseous  tuberculous  disease  in  the  pelvis  opening  both  into  the  bladder  and 
the  rectum. 

Appendicular  abscess  opening  into  the  bladder,  with  or  without  an  opening 
into  the  caecum  also. 

The  passage  of  faeces  in  the  urine  may  be  simulated  by  some  cases  of  very 
foetid  cystitis,  when  the  bladder  has  been  infected  by  the  Bacillus  coli  comm,unis. 


FATTY     STOOLS  265 


If  the  symptom  is  due  to  cancer,  it  matters  little  which  viscus  is  the  primary 
site  by  the  time  the  growth  has  involved  both  bladder  and  bowel.  The  diagnosis 
resolves  itself,  therefore,  into  one  between  malignant  conditions  on  the  one  hand 
and  non-malignant  on  the  other.  If  malignant  disease  is  not  obvious,  it  will 
nearly  always. be  advisable  to  resort  to  surgical  measures  in  the  hope  of  curing 
the  primary  condition — rectal,  appendicular,  prostatic,  or  otherwise.  The 
commonest  causes  other  than  malignant,  are  local  sloughing  of  the  parts  after 
labour,  and  fseculent  appendicular  abscess  opening  into  the  bladder.  In  any 
case  the  diagnosis  will  be  suggested  by  the  history  and  confirmed  by  local 
examination  or  exploration.  Herbert  French. 

FiECES,  PUS  IN.— (See  Pus  in  the  Stools.) 

FiECES,  SAND  IN. — (See  Sand,   Intestinal.) 

FiECES,  WORMS  IN.— (See  Parasites.) 

FAINTING   ATTACKS.— (See  Coma.) 

FAT  IN  URINE.— (See  Chyluria.) 

FATTY  STOOLS. — All  stools  contain  a  little  fat  ;  many  contain  more  than 
.they  should,  the  fact  being  discoverable  on  analysis,  although  it  may  not  be 
obvious  to  the  unaided  eye  :  the  relative  proportions  of  saponified  and  of 
unsaponilied  fats  may  have  an  important  bearing  on  the  diagnosis  of  pan- 
creatic lesions  [see  Cammidge's  Pancreatic  Reaction).  Fatty  stools  in  which 
the  fat  is  obvious  to  the  naked  eye  are  rare  ;  when  they  do  occur  they 
indicate  one  of  three  things  :  either  that  enormous  amounts  of  fat  are  being 
ingested — more  than  can  be  absorbed  by  the  normal  mucosae  ;  or  that  the 
secretions  are  defective,  so  that  even  ordinary  amounts  of  fat  remain  unab- 
sorbed  ;  or  that  the  food  is  being  hurried  through  the  alimentary  canal  so 
fast  that  much  fat  remains  undigested. 

It  is  easy  to  exclude  the  first  of  these  three  possibilities  by  regulating  the 
diet  ;  the  other  two  factors  generally  occur  together,  and  the  chief  diseases  in 
which  fatty  stools  may  be  a  prominent  feature  are  : — 

1.  Those  associated  with  severe  diarrhoea,  especially  where  the  patient  may 

be  having  an  abundance  of  milk,  as  in  : — Typhoid  fever  ;    Infantile  diar- 
rhoea ;   Sprue. 

2.  Those  associated  with  jaundice,  especially  where  the  cause  of  the  latter 

also  prevents  the  pancreatic  secretions  from  entering  the  duodenum, 
such  as  : — Chronic  pancreatitis  ;  Carcinoma  of  the  duodenum,  including 
the  ampulla  of  Vater. 
The  diagnosis  of  Group  i  need  not  be  discussed  further  here,  for  it  will  be 
indicated  by  other  symptoms  than  the  fatty  stools.  The  different  maladies 
belonging  to  Group  2,  on  the  other  hand,  may  be  directly  indicated  by  the  fatty 
condition  of  the  stools.  If,  for  instance,  there  is  doubt  as  to  whether  the  patient 
is  suffering  from  gall-stones  obstructing  the  common  bile-duct,  or  from  chronic 
pancreatitis,  the  occurrence  of  pale  abundant  stools  upon  the  surface  of  which 
an  iridescent  scum  of  fat  is  obvious,  will  be  in  favour  of  the  latter,  for  fat  can  be 
digested  to  a  far  greater  extent  without  bile  but  with  pancreatic  juice  than  it 
can  be  without  the  latter.  The  symptom  affords  no  means  of  distinguishing 
inflammation  from  new  growth,  however  ;  the  distinction  between  these  will 
depend  mainly  upon  the  duration  of  the  symptoms — growth  of  the  pancreas 
kills  within  a  few  months  of  producing  fatty  stools,  whilst  chronic  pancreatitis 
may  continue  for  years,  or  even  get  quite  well.  Other  points  to  be  on  the 
watch  for  would  be  the  presence  of  a  tumour,  of  a  dilated  gall-bladder,  or  of 


266  FATTY     STOOLS 


secondary  deposits.  The  age  of  the  patient  is  seldom,  much  help,  for  neither 
disease  is  common  before  adult  life.  The  distinction  bet%veen  carcinoma  of  the 
head  of  the  pancreas  and  carcinoma  of  the  ampulla  of  Vater  and  duodenum 
may  be  next  to  impossible  without  laparotomy  or  post-mortem  examination  ; 
although  carcinoma  of  the  head  of  the  pancreas,  rare  though  it  is,  is  much 
commoner  than  new  growth  starting  in  the  duodenum  near  the  bihar\-  papilla. 

Herbert  French. 
FEVER. — (See  Pyrexia,  and  Hyperpyrexia.) 

FINGER^  SORE. — Digital  lesions  may  be  erj-thematous,  papular,  vesicular, 
bullous,  pustular,  squamous,  or  ulcerative,  representing  a  long  hst  of  cutaneous 
affections.  The  erythematoits  affections  which  maj-  attack  the  fingers  are 
er}-thema,  lupus  er\-thematosus,  eczema,  urticaria,  chilblains  and  frostbite ; 
the  papular,  hchen  planus  and  hchen  annularis,  pit^-riasis  rubra  pilaris,  angio- 
keratoma, eczema,  and  papular  s^-phihdes  ;  the  vesicular,  scabies,  cheiropom- 
phoK^x  (dysidrosis),  eczema,  dermatitis  herpetiformis,  chilblains,  the  irritation 
set  up  by  the  habitual  handling  of  sugar,  or  (in  washersvomen)  by  immersion  in 
water  containing  soda,  or  by  contact  with  such  vegetable  irritants  as  rhus, 
mustard,  thapsia,  the  common  orange,  eucah-ptus  leaves,  arnica,  etc.  ;  the 
bullous,  pemphigus,  epidermolysis  bullosa,  dermatitis  herpetiformis,  scabies, 
leprosy,  and  S}'phi1is  (chiefly  in  infants)  ;  the  pustular,  scabies,  boils,  impetigo 
contagiosa,  eczema,  and  pustular  s^.'phihde  ;  the  squamous,  psoriasis,  eczema, 
ichthyosis,  hchen  planus,  S}-phihs,  acanthosis  nigricans,  and  verruca  necrogenica  ; 
the  ulceroMve,  bedsore,  chilblains  and  frostbite,  ;ir-ray  ulcer,  dissection  wounds, 
lupus  ■\Talgaris,  leprosy,  chancre  and  s}"pliihtic  ulcer,  epithehoma,  Ra^"naud's 
disease,  diabetic  gangrene,  trophic  ulcer,  and  scleroderma. 

The  dia,gnosi5  of  these  various  afi:ections  will  be  found  under  the  names  of 
the  primar\-  lesions — ^papules,  vesicles,  etc. — and  here  it  is  onh-  necessary  to 
particularize  bedsore,  diabetic  gangrene,  verruca  necrogenica  and  dissection 
wounds,  and  chancre.  Bedsore  on  the  fingers  is  caused  by  friction  bet^veen 
the  knuckles  and  the  bedclothes  as  the  patient  raises  himself  to  the  sitting  position. 
It  begins  as  er\^hema,  and  its  significance  can  hardly  be  mistaken,  though  its 
presence  in  such  a  situation  may  take  the  nurse  by  surprise.  Diabetic  gangrene 
most  frequently  attacks  the  toes  or  other  part  of  the  foot  ;  but  occasionally'  it 
has  been  observed  in  the  penis,  and  I  have  seen  cases  in  which  the  fingers 
have  been  aft'ected.  Post-mortem  wart,  or  post-mortem  pustule,  the  condition 
sometimes  met  with,  chieflj'  on  the  knuckles  and  in  the  interdigital  folds,  in 
those  who  have  to  handle  dead  bodies,  whether  of  human  beings  or  of  the  lower 
animals,  is  a  form  of  tuberculosis,  caused  by  infection  with  hving  bacilli  from 
the  dead  tissue.  It  is  sometimes  met  with  also  in  coUiers,  in  whom  the  site  of 
inoculation  is  probably  an  abrasion  recei\"ed  in  the  handling  of  coal.  The 
pustule,  beginning  as  a  flat  papule,  dries  up  and  forms  a  scab,  which,  when  it 
faUs  oft',  leaves  a  surface  that  is  made  irregular  by  overgrowth  of  papillae.  These 
grow  and  become  harder,  until  they  form  a  warti.-  mass.  The  avocation  of 
the  patient  will  suggest  the  true  nature  of  the  lesion.  Of  dissection  wounds, 
consisting  of  pustules  or  small  abscesses  on  the  site  of  a  puncture  or  scratch, 
or  of  lymphangitis  and  ceUuhtis,  which  may  be  followed  by  pyaemia,  the  history 
will  supply  the  diagnosis.  In  chancre  of  the  finger,  usually  met  with  in  mid- 
wives,  nurses,  and  medical  men,  but  occasionall}-  in  others  also,  a  favourite 
situation  of  the  sore  is  at  the  lateral  nail-groove,  and  in  many  cases  the  lesion 
first  attracts  notice  as  a  persistent  fissure.  If  the  sore  undergoes  induration, 
and  there  is  enlargement  of  glands,  the  diagnosis  can  no  longer  be  doubtful. 

Malcolm   Morris. 

FITS,— (See  Cox\x-lsions.) 


FLATULENCE  267 


FLATULENCE. — It  is  important  to  distinguish  between  (i)  Gastric  flatulence, 
in  which  wind  is  eructated  ;  and  (2)  Intestinal  flatulence,  in  which  it  is  passed 
per  anuni. 

1 .  Gastric  Flatulence. — Before  concluding  that  excess  of  gas  is  being  produced 
in  the  stomach,  it  is  necessary  to  exclude  the  possibility  of  air-sucking  or  aiy- 
swallowing  {aerophagia,  eructatio  nervosa).  This  condition  is  by  no  means  un- 
common, but  it  is  apt  to  be  wrongly  diagnosed.  It  is  met  with  often  in  women 
about  the  menopause  ;  it  is  also  by  no  means  infrequent  in  young  and  other- 
wise healthy  men,  although  the  patient  is  prone  to  be  "  neurotic,"  or  to  exhibit 
signs  of  neurasthenia  or  psychasthenia.  Eructatio  nervosa  is  recognized  by 
the  violence  of  the  belching  and  the  excessive  amount  of  wind  expelled.  It 
comes  on  in  attacks  both  by  day  and  by  night,  sometimes  waking  the  patient. 
If  a  patient  can  belch  "  to  order,"  one  may  conclude  with  almost  perfect 
certainty  that  he  is  suffering  from  this  form  of  neurosis  ;  and  by  watching  him 
during  the  attack,  one  can  recognize  that  he  is  gulping  down  air. 

True  gastric  flatulence  is  present  to  a  greater  or 
less  degree  in  many — one  might  almost  say  in  all — 
forms  of  gastric  disorder.  For  purposes  of  diagnosis 
one  must  distinguish  between  the  cases  in  which 
gas  is  produced  as  the  result  of  fermentation  in 
stagnating  gastric  contents,  and  those  in  which  no 
such  fermentation  is  taking  place.  In  the  former 
group  the  stomach  will  be  dilated,  vomiting  will 
almost  certainly  be  present,  and  examination  of 
the  gastric  contents  will  show  delay  in  their  trans- 
mission, and  the  presence,  probably,  of  sarcinae 
{Fig.  92)  and  yeasts.  One  may  then  diagnose 
pyloric    obstruction,    either    simple   or    mahgnant.  /r,;^.  g.^sarcina  Ve'ntriculi. 

In  these  cases  the  eructations  are  sometimes  offen-  (Medium  power  of  the 

sive,  revealing  the  existence  of  putrefaction  in  the  microscrope.) 

stomach  contents. 

Non-fermentative  flatulence  occurs  in  almost  all  forms  of  functional  disorder 
of  the  stomach  ;  but  is  specially  prone  to  occur  in  gastric  atony.  In  that  case 
there  will  be  a  well-marked  splash  over  the  gastric  area,  even  some  hours  after 
a  meal,  but  without  any  evidence  of  actual  dilatation  of  the  organ,  although 
there  may  be  some  gastroptosis.      (See  also  Indigestion.) 

In  other  forms  of  gastric  disorder  flatulence  is  only  a  minor  symptom,  and  of 
little  diagnostic  value. 

Flatulence  is  also  not  an  uncommon  symptom  in  emphysema  of  the  lungs,  and 
in  cases  of  cardiac  disease,  especially  when  due  to  degeneration  of  the  heart 
muscle.  In  elderly  persons  these  conditions  should  always  be  looked  for.  In 
angina,  also,  flatulence  may  be  a  prominent  symptom,  but  in  that  case  the 
attacks  tend  to  come  on  after  exertion,  and  are  accompanied  by  the  charac- 
teristic pain  of  angina. 

2.  Intestinal  Flatulence  may  be  either  acute  (see  Meteorism),  or  chronic 
(intestinal  flatulence  proper).  In  the  latter  case,  it  is  often  attended  by 
colicky  pain,  which  is  relieved  by  the  passage  of  wind.  It  is  important  to  note 
that  flatulence  is  not  a  feature  of  ordinary  constipation.  When  markedly 
present,  it  is  suggestive  either  of  chronic  obstruction  or  of  intestinal  fermentation. 

If  obstruction  be  present,  coils  of  intestine  undergoing  peristaltic  contraction 
are  often  to  be  seen,  and  there  is  marked  constipation,  sometimes  alternating 
with  diarrhoea.  A  diagnosis  of  the  exact  cause  of  the  obstruction  may  necessitate 
the  use  of  the  sigmoidoscope,  or  even  of  an  exploratory  operation.  In  cases  of 
intestinal  fermentation,  either  constipation  or  diarrhoea  may  be  present.     Micro- 


26S  FLATULEXCE 


scopic  examination  of  the  stools  is  often  of  help  in  elucidating  the  nature  of 
the  fermentative  process,  undigested  muscle  fibres  (proteid  fermentation  or 
putrefaction)  or  an  excess  of  starch  cells  (carbohydrate  fermentation)  being 
seen.      (See  also  Diarrhoea.)  Robert  Hutchison. 

FLUSHING. — The  difference  between  flushing  and  blushing  is  that  the 
former  only  occasionally,  the  latter  invariably,  arises  from  emotion,  and  that 
the  emotions  which  find  expression  in  blushing  are  always,  as  Darwin  points 
out,  the  result  of  excessive  self-attention — sh^mess,  shame,  and  modestj-.  A 
flush  mav  begin  instantaneously  in  all  the  parts  in  which  it  is  felt,  or,  arising 
in  a  lower  region,  it  mav  ascend  to  the  head,  or,  beginning  in  the  head,  it  may 
descend  to  some  part  of  the  body,  or  it  may  pass  both  upwards  and  down- 
wards (Harry  Campbell) .  The  sensation  varies  in  severity-,  and  may  be  actually 
painful.  The  nerve-storm  generally  ends  in  a  cold  stage,  though  this  may 
precede  the  hot  stage.  The  cutaneous  s^-mptoms  may  be  accompanied  or 
followed  by  nausea,  vomiting,  fainting,  a  sense  of  suffocation,  numbness,  tremors, 
tinnitus,  giddiness,  palpitation,  paresis.  The  physical  states  and  conditions 
from  which  flushing  arises  include  menstruation  and  menstrual  irregularities, 
the  climacteric,  pregnancy,  lactation,  chlorosis,  indigestion,  feeble  circulation, 
general  debility.-;  it  may  also  be  an  expression  of  emotion,  may  be  caused  by 
alcohoHc  indulgence,  or  may  merge  into  an  epileptic  aura.  If  it  becomes 
chronic,  the  skin  of  the  face,  especially  of  the  flush  area — the  middle  third 
of  the  face — ^is  permanently"  reddened,  and  the  case  becomes  one  of  rosacea. 
Sooner  or  later  the  superficial  vessels  undergo  dilatation.  Hj^ersecretion  and 
retention  of  sebaceous  matter  follow,  and  inflammation  may  be  set  up.  The 
inflammatory.-  process,  becoming  chronic,  may  give  rise,  especiallj-  if  the  patient 
is  much  exposed  to  the  weather,  to  h]i"pertrophic  thickening  of  the  skin  of  the 
nose,  with  lobulation  (rhinoph}-ma) . 

The  condition  or  habit  which  is  the  cause  of  rosacea  will  be  deduced  from  the 
histor\-,  especially  as  regards,  tea,  alcohol,  and  dyspepsia,  and  from  examination 
of  the  patient.  Rosacea  is  distinguished  from  aoie  vidgaris  hy  the  absence  of 
comedones,  the  redness  of  the  affected  surface,  the  limitation  of  the  eruption  to 
the  face,  the  telangiectasis,  the  h}"pertrophy,  and  by  its  being  an  affection  of 
middle  life  rather  than  of  pubert}'.  It  differs  from  lupus  erythematosus  in  the 
absence  of  scaliness  and  of  atrophic  scarring,  in  the  border — which  is  not  raised 
and  shows  no  signs  of  active  spreading — and  by  its  fluctuations.  Seborrhceic 
eczema  may  be  met  with  in  the  flush  area,  but  it  is  usually  associated  with  sebor- 
rhoea  capitis,  there  is  no  telangiectasis,  and  the  affected  surface  is  oily  or  scaly. 
From  tertiary  syphilides,  rosacea  is  distinguished  by  its  slow  course,  its  sjtnmetry, 
the  dilatation  of  blood-vessels,  and  the  absence  of  any  tendency  to  ulceration 
and  scarring,  or  to  atrophy.  In  s^-philis,  further,  there  will  be  the  stigmata  or 
the  historj-  of  earher  lesions.  Malcolm  Morris. 

FOOT-DROP. — 'See  Paraplegia  ;  and  Paralysis  of  One  Lower  Extremity.) 

FORGETFULNESS.— (See  Amxesia.) 

FORMICATION.—  See  Pruritus.) 

FRACTURE,  SPONTANEOUS.  —  Spontaneous  fracture  signifies  fracture  of 
a  bone  from  causes  which  ordinarily  would  have  been  inadequate.  Tremendous 
muscular  efforts  sometimes  lead  to  the  breaking  of  bones  without  any  external 
\-iolence,  but  this  variet}-  would  not  be  included  under  the  heading  of  spontaneous 
fracture  if  the  degree  of  muscular  effort  seemed  adequate.  A  man  has  been 
known,  for  instance,  to  di\-e  into  shallow  water,  and  in  order  to  bring  himself  to 


FRACTURE,     SPONTANEOUS  269 

the  surface  quickly  and  prevent  his  head  from  striking  the  bottom,  he  has 
used  his  neck  muscles  so  strenuously  in  bending  his  head  back  as  actually  to 
fracture  his  vertebrae.  This  fracture  is  not  spontaneous,  but  due  to  excessive 
muscular  exertion. 

There  are  three  main  groups  of  causes  for  true  spontaneous  fracture,  namely, 
excessive  brittleness,  or  innate  lack  of  strength  of  the  bones — fragilitas  ossium  ; 
general  paralysis  of  the  insane  ;  and  unsuspected  lesions  of  the  bones, 
particularly  myeloid  sarcoma,  chloroma,  tuberculous  caries,  or  secondary 
deposits  of  carcinoma  or  sarcoma. 

Fragilitas  ossium. — -When  the  first  fracture  occurs  in  such  a  patient,  there  may 
be  doubt  as  to  the  diagnosis  ;  but  when  repeated  breaking  of  different  bones 
occurs,  in  each  case  from  apparently  trivial  causes,  the  diagnosis  becomes  clear. 
The  undue  fragility  may  show  itself  in  early  life,  but  more  often  not  until  the 
patient  has  reached  adult  stature  and  weight. 

Two  maladies  which  differ  from  fragilitas  ossium,  and  yet  which  may  cause 
undue  bending,  or  partial  or  green-stick  fracture  of  bones,  are  rickets  in  children, 
in  which  disease,  for  a  time  at  least,  there  is  excess  of  preparation  for  bone 
formation,  but  difficulty  in  completing  the  ossifying  process,  so  that  the  bones, 
being  unduly  soft,  not  only  bend,  but  also  give  way  as  a  green  stick  would, 
causing  the  partial  or  green-stick  fracture  ;  and  mollities  ossium,  a  rather  rare 
affection  in  this  country,  though  reported  to  be  less  uncommon  in  certain  parts 
of  the  Continent,  notably  in  the  Rhine  valley,  coming  on  especially  after 
pregnancy,  and  associated  with  concentric  thinning  of  the  bones  from  the 
marrow  outwards,  so  that  they  eventually  consist  of  a  mere  shell,  which  bends 
with  undue  ease,  and  may  sometimes  break  spontaneously.  The  relationship 
to  pregnancy  may  suggest  the  diagnosis,  and  there  is  no  other  disease  which 
produces  the  same  degree  of  pathological  softening  and  fragility  of  the  bones  in 
adults  ;  active  rickets  is  practically  confined  to  young  children,  only  a  few  cases 
having  been  recorded  during  adolescence  and  none  in  adult  hfe. 

Spontaneous  fractures  in  general  paralysis  of  the  insane  occur,  like  the  aural 
hsematomata  of  this  disease,  at  a  late  stage  when  the  patient  is  bedridden.  They 
may  arouse  suspicion  that  the  attendants  have  been  unduly  rough  in  their 
handling  of  the  patient ;  but  so  atrophic  do  the  tissues,  and  particularly  the 
bones,  become,  that  the  latter  may  fracture  from  slight  and  otherwise  inadequate 
causes.  The  diagnosis  will  have  been  made  months  or  more  previously,  by 
reason,  first,  of  the  mental  changes  of  the  patient,  particularly  ideas  of  grandeur  ; 
and  secondly,  by  the  occurrence  of  convulsive  seizures  after  there  have  been 
changes  in  the  patient's  mental  condition  for  a  longer  or  shorter  time.  The 
case  is  generally  that  of  a  man  who  has  suffered  previously  from  syphilis,  for 
which  treatment  was  not  very  prolonged,  and  whose  business  has  entailed  much 
mental  hard  work,  and  possibly  worry,  in  a  city.  Confirmatory  evidence  may  be 
obtained,  if  need  be,  by  finding  relatively  large  numbers  of  small  lymphocytes 
in  the  cerebrospinal  fluid  removed  by  lumbar  puncture,  and  Wassermann's 
serum  reaction  for  syphilis  may  be  positive. 

Before  concluding  that  spontaneous  fracture  of  a  bone  is  due  either  to  neuro- 
trophic causes,  or  to  fragilitas  ossium,  it  is  important  to  exclude  the  possibility 
of  primary  or  secondary  new  growth  in  the  affected  bone,  or  tuberculous  caries. 
It  may  be  that  the  patient  is  already  suffering  from  a  bony  swelling,  such  as 
myeloid  sarcoma,  before  the  fracture  takes  place,  or  it  may  be  known  that  there 
is,  or  has  been,  a  primary  growth  elsewhere ;  for  instance,  in  the  pelvis,  breast, 
or  stomach,  in  which  case  the  spontaneous  fracture  of  a  bone  would  suggest 
that  a  second  metastasis  has  occurred  at  the  site  of  fracture,  eroding  the 
bone  until  it  finally  broke  from  a  trivial  cause.  The  chief  difficulties  arise,  first, 
when  there  are  no  symptoms  of  the  primary  growth  itself,  for  instance,  in  the 


270  FRACTURE,     SPONTANEOUS 

case  of  a  diffuse  carcinoma  of  the  stomach  of  the  indiarubber-bottle  type  ;  and 
secondly,  when  the  patient  is  really  suffering  from  tuberculous  caries  whose 
existence  has  been  entirely  unsuspected.  As  an  instance,  one  might  mention 
the  case  of  a  woman  fifty  years  of  age,  who,  seeming  to  be  in  perfectly  robust 
health,  was  standing  in  her  kitchen,  when  her  son  unexpectedly  entered, 
causing  her  to  start  suddenly,  giving  her  body  a  twist  at  the  same  time.  This 
movement  was  immediately  followed  by  paralysis  of  both  legs,  and  it  seemed 
as  though  the  sudden  muscular  exertion  had  led  either  to  a  haemorrhage  or 
to  a  fracture-dislocation  of  the  spine  ;  the  cause  for  the  fracture  was  in  itself 
inadequate,  however,  and  it  would  not  have  produced  the  symptoms  had  there 
not  been  spinal  caries  which  had  been  slowly  eroding  the  bones  for  some  time 
previously,  until  they  now  gave  way  as  the  result  of  what  would  otherwise  have 
been  a  trivial  movement.  The  diagnosis  in  cases  of  the  kind  depends  chiefly 
upon  remembering  the  possibilities,  and  not  omitting  a  most  careful  exami- 
nation of  every  part  of  the  body.  When  the  .3;-rays  are  available,  they  may 
sometimes  be  of  considerable  value  in  detecting  a  neoplasm  or  a  tuberculous 
focus  in  the  affected  bone.  Herbert  French. 

FREQUENCY  OF  MICTURITION.— (See  Micturition,   Abnormalities  of.) 

FULLNESS,  SENSE  OF.— A  sense  of  fullness  may  be  felt  in  the  abdomen  in 
any  condition  which  leads  to  abdominal  distention.  Such  distention  may  be 
due  to  the  presence  of  Flatulence  {q.v.),  of  Ascites  (q.v.),  or  of  a  tumour,  or 
enlargement  of  any  of  the  abdominal  viscera.  It  is,  therefore,  by  itself,  of  little 
diagnostic  value.  Robert  Hutchison 

FUNGOUS  AFFECTIONS  OF  THE  SKIN.  —  We  here  include  (I)  Favus, 
(II)  Ringworm,  (III)  Eczema  marginatum,  (IV)  Tinea  imbricata,  (V)  Tinea 
versicolor ,   and   (VI)  Erythrasma. 

I. — Favus. 

In  man  this  affection  is  due,  in  about  99  per  cent  of  cases,  to  inocula- 
tion with  the  A  chorion  Schonleinii.  Four  other  achorions,  of  animal  origin, 
have  been  identified,  and  it  has  been  proved  that  the  affection  can  be  com- 
municated from  animals  to  man,  but  the  instances  are  so  rare  as  to  be  negligible. 
Between  the  achorions  on  the  one  hand  and  the  microsporons  and  trichophytons 
on  the  other  (see  Ringworm,  p.  272),  there  are  close  morphological  resemblances, 
but  the  clinical  differences  are  well  marked. 

Favus,  while  showing  a  distinct  preference  for  the  scalp,  may  attack  any 
part  of  the  skin  {Fig.  93),  and  even  a  mucous  membrane.  The  characteristic 
lesion — a  tiny  sulphur-yellow  disc  with  a  cup-like  depression  in  the  centre,  resemb- 
ling both  in  colour  and  in  shape  a  honeycomb  (hence  favus),  and  in  hairy  parts 
pierced  by  a  hair — can  hardly  be  mistaken.  An  even  more  unmistakeable 
diagnostic  point  is  furnished  by  its  peculiar  mousy  smell.  The  lesion  begins 
as  a  collection  of  whitish  material,  somewhat  resembling  a  pustule,  which  grows 
and  presently  becomes  dry  and  friable.  The  cup-like  disc  can  then  be  detached 
from  the  epidermis,  leaving  a  pimply,  smooth,  greasy  surface.  As  they  grow, 
the  discs  often  run  together.  In  a  later  stage  roughish  crusts  are  formed, 
separated  by  pale,  bluish-pink  scars.  The  crusts,  when  broken  up,  are  seen 
under  the  microscope  to  consist  of  spores,  varying  much  both  in  size  and  shape, 
and  of  short  threads  of  mycelium,  which  may  penetrate  into  the  mucous  layer 
of  the  epidermis,  and  may  even  reach  the  derma  ;  this  never  occurs  in  tricho- 
phytosis. Hairs  affected  with  favus  are  discoloured  and  lustreless  ;  but  instead  of 
breaking  off  as  in  ringworm,  they  may  fall  out.     Under  the  microscope  one  may 


FUNGOUS     AFFECTIONS     OF     THE     SKIN  271 

see  in  favus-hairs  segments  of  fungus  12-15  jj.  in  length,  dichotomised  at 
an  acute  angle.  If  the  nails  are  affected,  the  ungual  cells  will  be  found  to  be 
separated  by  irregular  threads  of   mycelium,  or  by  spores. 

In  the  less  characteristic  cases,  the  lesions  must  be  closely  examined  under 
a  good  lens  for  remains  of  the  yellow  discs  of  favus  or  the  broken  hairs  of 
ringworm.     If,  owing  to  applications  to  the  skin,  the  crusts  are  lacking,  treat- 


■^'£-  93. — Favus  :  showing  the  very  wide  distribution  over  the  body,  as  well  as  the  scalp. 
(From  Diseases  o/ the  Skin,  Sir  Malcolm  Morris.) 

ment  should  be  stopped  for  a  few  days,  when  the  whitish  points  and  the  discs 
will  usually  have  reappeared.  In  prolonged  cases,  the  crusts  may  be  replaced 
by  an  irregular,  lumpy,  dirty-yellowish  accumulation,  but  the  odour  of  favus 
will  still  remain.  At  this  stage  the  disease  may  resemble  psoriasis  of  the  scalp  ; 
but  there  is  a  much  greater  loss  of  hair,  the  scales  are  less  pearly,  and  even  when 
no  discs  or  sulphur-yellow  scabs  can  be  seen  about  the  edges,  the  lustreless  hair 


FUXGOUS     AFFECTIOXS     OF     THE     SKIX 


and  the  atrophic  scarring  left  by  the  scahs  are  sufficiently  distinctive  of  favus. 
The  scarring  ma}-  suggest  lupus  erythematosus  of  the  scalp,  but  in  that  affection 
the  crusting  and  the  mouse-hke  odour  are  absent,  while  generally-  there  are 
characteristic  lesions  on  the  face.  From  both  eczema  and  seborrhcea  favus  is 
differentiated  by  the  fact  that  its  lesions  are  never  diffuse,  but  always  have  a" 
definite  margin.     In  alopecia  areata  there  is  no  scaling,  crusting,  or  cicatrix. 

II. — Ringworm. 

All  the  forms  of  ringworm,  whether  of  the  scalp,  the  beard,  the  hairless  skin, 
the  mucous  membrane,  or  the  nails,  are  due  to  fungi  belonging  to  two  different 
famihes,  the  microspora  and  the  trichoph^^ta,  each  of  them  comprising  a  number 
of  different  species.  In  the  one  case  the  affection  is  st\-led  microsporosis,  or 
tinea  with  small  spores  ;  in  the  other,  tricJwphytosis,  or  tinea  with  large  spores. 
Eleven  species  of  ringworm  microsporons  have  been  identified  ;  of  the  tricho- 
phi.'ta,  upwards  of  thirty.  In  a  diagnostic  sense,  however,  only  four  species 
of  the  microspora,  and  the  same  number  of  species  of  the  trichophj^la,  are  of 
importance.  The  four  microsporons  are  M.  Andouini,  M.  felineimi,  M.  cajiis 
and  M.  tardum  ;  the  four  trichophytons,  T.  crateriforme,  T.  acuminatum,  T. 
sulphureum  and  T.  violaceum.  In  both  famihes  some  of  the  species  are  of 
animal  origin,  and  it  is  these  which  account  for  nearlv  all  the  inflammatory 
forms  of  ringworm,  including  kerion. 

Of  the  microsporons,  the  ty^e  species  is  M.  Audoiiini ,  which  is  the  cause  of 
some  go  per  cent  of  the  juvenile  ringAvorm  of  London.  It  is  also  the  cause  of 
much  of  the  juvenile  ringworm  of  Paris,  though  of  much  less  than  was  the  case 
a  few  years  ago.  M.  felineiim-  and  M.  cams,  closely  allied  species,  are  responsible 
for  an  appreciable  percentage  of  human  ringworms — the  one  in  England,  the 
other  in  France.  M.  tardum,  the  fourth  species  mentioned  as  of  clinical  sig- 
nificance, is  occasional!}'  met  ^^-ith  in  France.  Of  the  four  clinicall}-  important 
species  of  trichoph^.'tons,  the  one  most  frequenth"  encountered  is  T.  crateriforme. 
Xext  comes  T.  acuminatum,  then  T.  sulphureum,  which,  however,  is  not  known 
in  France  ;    and  lastly  T.  violaceum. 

The  di\-ision  of  the  ringAvorms  into  a  small-spored  and  a  large-spored  group 
may  easily  lead  to  confusion  in  diagnosis.  For  among  both  microsporons  and 
trichophytons  the  spores  var\'  considerably'  in  size,  according  to  the  species. 
Those  of  the  microsporons  may  be  as  large  as  4  fi,  while  those  of  the  trichoph^'tons 
may  be  as  small  as  3  ^  ;  the  limits  of  the  one  are  2  to  4  ^,  and  of  the  other,  3  to 
8  fi.  Clinically,  therefore,  microsporosis  and  trichoph}-tosis  are  to  be  differen- 
tiated from  each  other  not  alone  by  the  size  of  the  spores,  but  also  by  their 
shape  and  arrangement  and  modes  of  growth. 

First,  as  to  shape  :  In  microsporosis  the  spores  are,  speaking  generally,  round 
or  ovoid  ;  in  trichophytosis,  they  tend  to  be  square  with  rounded  angles,  or 
oblong  with  sharper  angles.  StiU  more  important,  for  diagnosis,  is  the  arrange- 
ment of  the  spores.  In  microsporosis  they  are  dotted  about  irregularly,  and 
the  mycehum  intenvoven  ■\%-ith  them  is  curved  and  branching,  and  irregularly 
jointed.  In  trichophytosis  they  are  arranged  in  regular  chains,  and  the 
mycehum  is  short  and  regularh-  jointed.  In  microsporosis  the  fungus  forms 
a  greyish  sheath  around  the  hair — ^whether  of  the  scalp  or  of  the  bod}- — ^^vhich 
it  eats  away,  fra}-ing  the  edges,  penetrating  to  the  interior  of  the  shaft,  and 
growing  downwards  towards  the  root.  Presently  the  hair  breaks  off,  at  some 
distance  from  the  follicular  orifice,  and  the  parasitic  sheath  is  disintegrated 
and  may  be  seen  as  a  patch  of  ash-coloured  scales  on  the  epidermis.  In 
trichophytosis,  the  parasite  attacks  the  root  of  the  hair  first,  and  grows  upward. 
The  hairs  are  broken  off  short,  and  no  sheath  is  to  be  seen  outside  the  foUicular 
orifice.     By  way  of  quahfication,  it  should  be  added  that  a  group  of  small- 


FUNGOUS     AFFECTIONS     OF     THE     SKIN  273 

spored  trichophytons  form  a  sheath  outside  the  hair  hke  that  of  microsporosis, 
but  the  spores  observe  the  chain-formation  which  is  characteristic  of  tricho- 
phytosis, and  this  is  never  present  in  microsporosis.  These  small-spored 
trichophytons  are  all  pyogenic,  and  are  the  cause  of  many  cases  of  kerion. 

Trichophytons  may  be  either  endothrix  or  endo-ectothrix.  If  the  parasite 
penetrates  the  hair  between  the  cuticle  cells  and  develops  entirely  within  the 
hair-structure,  it  belongs  to  the  endothrix  class.  If  it  not  only  develops  within 
the  hair,  but  continues  to  proliferate  in  the  follicle  outside,  it  must  be  allocated 
to  the  endo-ectothrix,  or  as  Sabouraud  rather  inaptly  styled  it,  the  ectothrix 
class.  The  great  majority  of  the  cases  of  scalp  trichophytosis,  both  in  London 
and  in  Paris,  are  due  to  endothrix  infections.  But  the  endo-ectotriches  are 
responsible  for  most  of  the  ringworms  of  the  hairless  skin,  for  nearly  all  the 
adult  ringworms,  and  for  the  majority  of  specially  inflammatory  cases. 

Sabouraud  divides  the  endotriches  into  (i)  true  endotriches,  and  (2)  neo- 
endotriches,  the  distinguishing  feature  between  them  being  that  in  the  latter 
the  early  [neo)  stage  of  the  attack,  the  stage  in  which  the  outside  of  the  hair  is 
assailed,  is  prolonged.  If  the  parasite  is  a  true  endothrix,  it  is  easy  to  miss  the 
invasion  stage,  so  short  is  it  ;  if  it  is  a  neo-endothrix,  the  invasion-stage  is  so 
protracted  that  it  is  possible  to  mistake  the  case  for  one  of  trichophytosis  due 
to  an  endo-ectothrix.  The  endo-ectotriches  are  sub-divided  into  those  with  large 
spores  (megaspores),  and  those  with  small  spores  (microides).  It  is  the  latter 
which,  as  mentioned  above,  may  be  mistaken  for  microsporons,  unless  the  chain- 
formation  be  looked  for. 

In  the  case  both  of  the  microspora  and  of  the  trichophyta,  cultures  may  have 
to  be  grown  to  distinguish  between  the  different  species.  There  are  four  species 
of  microspora  which  are  of  human  origin,  and  these  give  either  a  small  [petite) 
or  medium  [moyenne)  culture  ;  to  this  group  belong  M.  Audouini  and  M.  tardum. 
The  seven  species  of  animal  origin  yield  a  large,  enduring  (vivace)  culture  ;  in 
this  group  occur  the  two  remaining  species  of  clinical  importance,  M.  cams  and 
M.  felineum.  In  the  first  group  pleomorphism  is  never  met  with  ;  in  the  second, 
on  a  suitable  medium,  a  white  downy  pleomorphism,  quite  different  from  the 
mother  culture,  is  exhibited. 

Of  trichophyton  cultures,  there  are  four  main  types  :  (i)  the  crateriform  or 
acuminate  ;  (2)  those  with  large  white  growths,  either  powdery  or  velvety  ;  (3) 
the  faviform  ;  (4)  a  single  species,  Epidermophyton  inguinale,  which  is  the  cause 
of  eczema  marginatum.  In  the  first  group,  to  which  belong  all  the  four  clinically 
important  species,  the  culture  resembles  the  crater  of  a  volcano,  and  is  white, 
cream-coloured,  or  primrose-coloured,  or  it  is  like  a  mountain  peak  ("  acuminate") 
and  is  grey  or  yellowish  in  colour.  The  parasites  of  this  cultural  group  are  all 
endotriches.  In  the  second  group  the  cultures  are  very  large  and  white,  some 
of  them  powdery,  others  velvety.  The  species  which  yield  cultures  of  this  type 
are  all  endo-ectotriches,  and  are  of  animal  origin.  The  three  species  which  give 
cultures  like  those  of  the  parasites  of  favus,  although  the  clinical  course  of  the 
lesions  and  the  appearance  of  the  fungus  in  the  hair  leave  no  doubt  that  they 
are  trichophytons,  are  also  of  animal  origin.  The  Epidermophyton  inguinale 
yields  a  yellow-orange  culture,  dry  and  powdery,  but  often  white  and  velvety 
as  the  result  of  pleomorphism. 

Ringworm  of  the  Scalp  [Tinea  tonsurans). — Both  the  small-spored  and  the 
large-spored  ringworm  of  the  scalp  begin  alike  as  a  small  red  papule,  which 
develops  near  the  orifice  of  a  hair-follicle.  But  the  size,  and  yet  more  the 
shape  and  arrangement  of  the  spores,  and  the  way  in  which  the  hair  is 
attacked,  help  to  distinguish  between  them.  These  points  have  been  touched 
upon  already,  but  it  may  be  added  that  in  trichophytosis  there  is  a  much 
smaller  number  of  stumps  to  be  seen  with  the  naked  eye,  and  that  on  the  surface 
D  18 


274  FUNGOUS     AFFECTIONS     OF     THE     SKIN 


of  the  scaly  patches,  among  the  remainmg  healthy  hairs,  one  may  detect  those 
dark  points  to  which  the  affection  owes  its  name  of  "  blatk-dot  ringworm." 
These  dots  are  pigmented,  coiled-up  hair-stumps.  If  the  whole  scalp  is  thus 
affected,  the  case  becomes  one  of  "  disseminated  ringAvorm."  In  tricho- 
phytosis, again,  the  scales  are  scantier,  or  may  even  be  absent,  and  the  outline 
of  the  lesions  is  not  so  rounded  or  so  well-defined.  As  a  rule  it  is  not  difficult 
to  distinguish  tinea  tonsurans,  whatever  its  form,  from  other  scalp  affections, 
the  clinical  picture — the  broken  hairs,  the  black  dots,  the  slight  scaliness, 
the  prominent  follicles,  the  baldness,  in  varying  degrees,  of  the  involved 
area — being  sufficiently  distinctive.  In  favus  there  is  the  same  dull  and 
brittle  condition  of  the  hair,  but  the  patches  are  not  generally  circular,  while 
in  ringworm  the  cup-shaped  crusts  are  absent,  nor  is  the  skin  atrophic.  The 
broken  hairs  serve  to  distinguish  tinea  tonsurans  from  pityriasis  of  the  scalp 
and  from  psoriasis  of  the  hairy  skin,  since  in  both  these  affections  the  hairs 
fall  out  unbroken.  In  psoriasis,  too,  there  is  a  greater  degree  of  scaliness,  and 
generally  it  is  not  the  scalp  only  that  is  affected.  Nor,  in  psoriasis,  is  loss  of  hair 
usual,  though  it  sometimes  occurs.  In  the  anomalous  form  of  ringworm  known 
as  tinea  decalvans,  or  as  bald  ringworm,  in  which  the  hair  falls  out  in  places, 
leaving  smooth  bare  patches,  confusion  with  alopecia  areata  may  be  avoided 
without  much  difficulty.  The  billiard-ball  smoothness  of  the  patches  in  the 
latter  condition  is  not  present  in  ringworm.  Another  differential  feature  is  the 
shape  of  the  short  hairs  found  at  the  edge  of  the  patches  :  in  tinea  tonsurans 
they  are  bent,  whereas  in  alopecia  areata  they  may  be  compared  to  a  note  of 
exclamation  (!)  In  the  latter  condition,  too,  the  hairs  that  remain  are  free  from 
fungus.  In  the  infrequent  cases  of  inflammatory  ringworm,  a  condition  some- 
what resembling  impetigo  or  eczema  may  be  set  up  ;  but  the  broken  stumps  and 
the  limited  area  of  the  affection,  together  with  the  history  of  the  case,  should 
prevent  confusion  with  those  affections.  In  these  forms  of  ringworm  again, 
the  lesions  are  sharply  defined,  and  the  pustules  are  invariably  situated  round 
the  hairs.  Seborrhcea  can  be  ruled  out  by  remembering  the  greasiness  of  the 
scales,  the  diffusion  of  the  condition  over  the  whole  scalp,  and  the  absence  of 
patches  of  baldness. 

Ringworm  of  the  Beard  {Tinea  sycosis). — From  ordinary  sycosis  this  affection 
is  distinguishable  by  its  more  rapid  spread,  and  the  greater  lumpiness  of  the 
affected  surface.  In  sycosis  vulgaris,  too,  the  pustules  are  usually  pierced  by 
a  hair,  and  are  quite  small,  and  unless  there  is  much  more  suppuration  than  is 
usual,  the  hairs  do  not  fall  out.  Tinea  sycosis  differs  from  eczematous  folliculitis 
in  the  absence  of  the  serous  discharge  that  marks  the  latter  affection.  In  the 
eczematous  condition,  again,  there  is  but  slight  if  any  loosening  of  the  hairs, 
so  that  if  they  are  extracted  they  bring  with  them  their  root-sheaths.  The 
affection  is  not  confined  to  the  hairy  parts,  as  in  tinea  sycosis,  nor  do  the  patches 
assume  the  ring-like  form.  The  ring-formation  is  absent  also  in  seborrhcea, 
nor  is  the  hair  involved  as  in  beard-ringworm.  In  the  circinafe  tubercular 
syphiloderm,  the  border  of  the  lesion  is  darker  in  colour  and  more  infiltrated, 
and  there  is  either  atrophy  or  pigmentation,  or  both.  Occasionally  the  severer 
ca.ses  of  ringworm  of  the  beard  take  the  form  of  a  single  tumour-like  formation 
which  may  be  mistaken  for  a  carbuncle.  But  the  inflammation  is  almost  always 
less  active  than  in  carbuncle,  and  the  swelling  and  pain  are  correspondingly 
less.  In  any  clinically  doubtful  case,  an  examination  of  the  hairs  imder  a 
microscope  will  show  whether  or  not  the  case  is  one  of  beard  ringworm  bj^ 
revealing  the  presence  or  the  absence  of  the  trichophytic  fungus. 

Ringworm  of  the  Body  Skin  {Tinea  circinata). — The  small,  red,  slightly 
raised  spot  which  is  the  first  visible  lesion  of  ringworm  of  the  body,  gradually 
spreads  at  the  edge  and  becomes  scalv.     Fading  away  at  the  centre,  the  redness 


FUNGOUS     AFFECTIONS     OF     THE     SKIN  275 

leaves  a  slightly  discoloured  branny  area,  which  forms  the  inside  of  a  red  ring. 
The  circle  slowly  enlarges,  without  any  widening  of  the  edge.  Usually,  though 
not  always,  there  are  several  rings,  sometimes,  though  seldom,  arranged  con- 
centrically, and  those  adjoining  each  other  may  run  together.  Frequently, 
as  the  edge  advances,  there  is  no  involution  in  the  centre,  the  lesions  then 
appearing  not  as  rings  but  as  patches.  As  a  rule,  inflammation  is  present  in 
varying  degrees,  and  the  neighbouring  lymphatic  glands  may  be  slightly  enlarged. 

These  symptoms,  with  the  tingling  and  itching,  form  an  ensemble  which  can 
hardly  be  mistaken  for  any  other  affection.  In  eczema  seborrhceicum  the  scales 
are  greasy,  and  often  there  are  projections  into  the  glandular  openings.  In 
psoriasis  the  skin  is  affected  in  ring-like  areas,  but  all  the  other  characters  are 
different.  From  the  circinate  tubercular  syphiloderm,  ringworm  of  the  body 
may  be  distinguished  in  the  same  way  as  ringworm  of  the  beard  (see  above). 
As  a  rule  microscopic  examination  will  disclose  the  ringworm  fungus, — usually 
a  trichophvte — without  difficulty  ;  but  occasionally  the  parasitic  elements  are 
deep-seated,  and  must  be  sought  in  a  section  of  the  affected  tissue. 

Ringworm  of  the  Nails  {Onychomycosis) . — Usually,  though  not  invariably, 
ringworm  of  the  nails  appears  in  association  with  trichophytosis  of  the  beard  or 
of  the  body  skin.  The  first  visible  lesion  shows  as  greyish  stains  under  the 
borders  of  the  nail  and  at  the  root.  Inflammation  of  the  matrix  follows  and  the 
structure  of  the  nail  degenerates,  becoming  thickened,  spongy,  and  more  or 
less  brittle,  with  a  dulled  surface.  When  exfoliation  occurs,  a  mass  of  dis- 
integrated nail  substance  is  seen,  in  which  the  fungus  may  be  found. 

Similar  symptoms  to  those  described  may  arise  in  connection  with  gout  and 
rheumatism  and  other  constitutional  disorders — those  for  instance  in  which 
there  is  impaired  nutrition — as  well  as  in  such  inflammatory  affections  as  eczema 
and  psoriasis.  From  all  such  cases,  the  presence  of  the  parasitic  elements  will 
suffice  to  differentiate  onychomycosis.  In  the  onychomycosis  of  favus,  the 
stains  under  the  borders  of  the  nail  are  yellower,  and  the  mycelial  elements 
shorter  and  less  regular. 

III. — Eczema    Marginatum. 

In  this  form  of  ringworm  of  the  body,  more  frequent  in  tropical  climates  than 
in  Europe,  the  parts  chiefly  attacked  are  the  lower  portion  of  the  abdomen, 
the  groins,  the  buttocks,  the  fold  of  the  nates,  and  the  axilla — parts,  that  is, 
where  the  skin  surfaces  are  in  contact.  The  hair  is  never  involved.  The 
characteristic  feature  of  the  lesions  is  their  broad,  bluff  margin  ;  it  is  scaly,  and 
as  a  rule  papular.  Thej^  are  often  eczematoid,  but  they  can  be  distinguished 
from  eczema  and  from  eczema  seborrhceicum  by  their  gradual  spread  and  broad, 
elevated  margin  and  by  the  ring-like  formation  of  the  early  stage.  If  any  doubt 
remains,  the  microscope  will  clear  it  up  by  revealing  the  parasite,  the  Epidermo- 
phyton    inguinale. 

From  eczema  marginatum,  dhobie's  itch  is  very  imperfectly  differentiated. 
It  is  in  fact  a  popular  name  for  all  epiphytic  skin  diseases  of  warm  chmates, 
but  usually  it  connotes  diseases  of  this  group  of  which  the  sites  are  the  inguinal 
regions  and  the  axillae.  Castellani  distinguishes  two  fungi  as  the  cause  of 
dhobie's  itch,  besides  Epidermophyton  inguinale,  namely  E.  Perneti  and  E. 
rubrum ;  and  Manson  holds  that,  in  many  cases,  the  parasites  concerned  are 
Microsporon  minutissimum  and  M.  furfur.  For  practical  purposes,  dhobie's 
itch  may  be  regarded  as  another  name  for  eczema  marginatum. 

IV. — Tinea  Imbricata. 

This  form  of  tinea,  known  also  as  Tokelau  ringworm,  was  formerly  peculiar 
to  certain  oceanic  tropical  climates  in  the  East,  but  now  has  a  wider  area  of 


2  76  FUNGOUS     AFFECTIONS     OF     THE     SKIN 

distribution.  The  fungus  has  not  5?et  been  classified  definitely.  Sabouraud 
holds  it  to  be  a  trichophyton  allied  to  species  of  animal  origin  met  with  in  Europe  ; 
by  other  authorities  it  is  regarded  as  a  lepidophyton.  It  has  not  so  far  been 
cultivated.  The  affection  to  which  it  gives  rise  is  characterized  by  a  concentric 
arrangement  of  closely-set  rings  of  scaly  epidermis.  The  conditions  from  which 
it  has  to  be  distinguished  are  thiea  circinata  and  ichthyosis.  From  the  former 
it  is  differentiated  by  the  greater  abundance  of  the  fungus  elements,  the  tendency 
of  the  process  to  spread  centripetally,  the  absence  of  marked  inflammation 
or  congestion  of  the  rings,  their  concentric  disposition,  and  the  greater  size 
of  the  scales.  From  the  latter,  by  the  presence  of  the  fungus,  the  concentric 
arrangement  of  the  scales,  and  the  fact  that  the  attached  border  of  each  scale 
is  towards  the  periphery,  the  free  border  being  towards  the  centre  of  the  circle, 
or  group  of  circles,  to  which  the  scale  belongs. 

Y. — Tinea   Versicolor. 

This  affection,  often  styled  pityriasis  versicolor,  is  caused  by  the  Microsporon 
furfur,  the  mycology  of  which  is  httle  understood.  The  disease  is  contagious, 
but  only  in  a  low  degree.  The  lesions,  confined  to  the  horny  laj^er  of  .  the 
epidermis,  take  the  form  of  roundish,  scaly  patches,  with  a  definite  margin,  and 
of  a  colour  varying  from  fawn  to  liver — in  coloured  races,  grey  or  white  ;  in 
persons  "who  have  hved  in  Avarm  climates,  it  may  be  black.  The  hair  is  not 
assailed,  nor  are  the  hands  and  feet.  As  a  rule  the  lesions  are  limited  to  the 
trunk,  but  occasionally  they  extend  to  the  upper  parts  of  the  limbs  :  they  have 
been  mistaken  for  secondary  syphilides,  but  the  colour  and  distribution,  and  the 
large  patches  in  which  they  are  found,  should  serve  to  obviate  the  confusion. 
In  exceptional  cases  the  face  may  be  invaded,  and  the  affection  might  then  be 
confounded  with  chloasma.  From  pityriasis  rosea  and  from  eczema  seborrhceicum 
it  may  be  distinguished  by  the  absence  of  inflammatory  reaction,  except  in 
persons  who  perspire  freelj'  ;  in  pitj^riasis  rosea,  too,  the  upper  parts  of  the  limbs 
are  affected  equalh^  with  the  trunk.  The  lesions  of  tinea  versicolor  offer  some 
resemblances  to  the  pigmentary  patches  sometimes  met  with  in  leprosy  ; 
but  from  these,  as  from  the  other  cutaneous  manifestations  mentioned,  they 
may  be  differentiated  almost  certainly  by  the  ease  with  which  the  scales  can 
be  detached  b}^  a  stroke  of  the  finger-nail,  and  quite  certainly  by  the  fungus 
elements  which  may  be  detected  in  the  scales  after  these  have  been  treated  with 
potash.  The  spores  are  rounded  and,  like  the  mycelium,  have  a  double  contour 
with  a  diameter  of  3  to  5  ^  ;  they  are  generally  grouped  together  in  masses, 
suggesting  a  resemblance  to  bunches  of  currants. 

VI . Er  YTHRASMA . 

There  are  several  points  of  resemblance  between  erythrasma,  due  to  the 
Microsporon  minutissinium,  and  tinea  versicolor.  In  both,  it  is  only  the  horny 
stratum  of  the  epidermis  that  is  affected,  nor  is  the  hair  ever  attacked.  In 
both,  too,  there  is  but  a  low  degree  of  contagiousness.  The  lesions  offer 
some  likeness  to  those  of  tinea  versicolor,  but  they  are  reddish-brown  in  colour, 
and  their  usual  site  is  the  genito-crural  region  or  the  axillae,  or  both,  though 
occasional!}-,  in  fat  subjects,  there  may  be  extension  to  the  abdominal  and 
submammary  folds  and  those  of  the  large  joints.  In  rare  cases,  erythrasma 
resembles  one  type  of  eczema  marginatum,  but  is  distinguished  from  that  affec- 
tion by  its  low  degree  of  contagiousness  and  its  slow  evolution,  and  by  the 
absence  of  inflammation,  which  also  distinguishes  it  from  eczema  seborrhceicum 
and  from  pityriasis  rosea.  Any  doubt  between  erj'thrasma  and  any  other 
affection,  including  tinea  versicolor,  may  usually  be  cleared  up  by  examination 


GAIT,     ABNORMALITIES     OF  277 

of  a  preparation  under  a  microscope  of  sufficiently  high  power.  The  spores  of 
M.  minutissimum,  like  the  threads  of  mycelium,  are  extremely  minute,  having 
a  diameter  of  about  06  |/.  The  mycelial  threads,  of  the  same  diameter,  are  so 
abundant  and  so  twined  together  as  to  form,  here  and  there,  a  network  over 
the  epidermic  cells.  Malcolm  Morris. 

GAIT,  ABNORMALITIES  OF.— As  a  genuine  aid  to  diagnosis  the  gait  cannot 
be  of  much  real  assistance.  There  are,  however,  several  diseases  and  affections 
which  produce  manifest,  and  in  some  cases  peculiar,  alterations  in  gait.  In 
some  respects,  indeed,  the  gait  is  a  diagnostic  point  in  identity,  though  this 
probably  also  depends  on  the  total  back  or  front  view  of  the  individual,  rather 
than  on  real  peculiarities  of  gait  as  such. 

In  analyzing  gait  for  diagnostic  purposes,  we  find  that  it  consists  of  co-ordinate 
and  painless  movements  of  the  muscles  of  the  lower  limbs  and  pelvis — often, 
indeed,  sinking  into  purely  reflex,  or  at  least  subconscious,  movements — and 
these  are  associated,  in  easy  and  ordinary  walking,  with  rhythmical  movements 
of  arms,  body,  and  head  too,  in  many  cases.  The  directions,  therefore,  in  which 
it  can  be  disordered  are:  (i)  Inco-ordination  ;  (2)  Local  loss  of  power  ;  (3)  Pam 
calling  attention  to  the  movements. 

1.  Inco-ordination. — The  test  for  the  presence  of  this  is  the  complaint  of  the 
patient  that  he  feels  unsteady  in  walking,  especially  on  turning  or  walking  on 
uneven  ground,  or  on  walking  or  standing  with  the  eyes  shut  ;  and  if  co-ordina- 
tion only  be  at  fault,  it  will  then  be  found  that  on  testing  the  legs  for  simple 
movements,  such  as  flexion  and  extension,  the  power  of  the  muscles  is  unimpaired. 
Having  discovered  inco-ordination,  the  next  question  is,  to  what  may  this  be 
due  ?  Tabes  dorsalis,  ataxic  paraplegia  (combined  lateral  and  posterior  sclerosis) , 
disseminated  sclerosis,  and  hereditary  ataxy  (Friedreich's  disease),  are  far  and 
away  the  commonest  causes  of  this,  in  the  order  of  mention  ;  their  differential 
diagnosis  depends  on  many  other  symptoms  and  signs,  and  it  is  discussed 
elsewhere.  Cerebellar  disease  causes  rather  a  reeling  in  the  gait  than  a  simple 
inco-ordination  in  the  individual  movements  ;  and  here  again,  other  symptoms 
will  be  to  the  front.  Localized  paralyses  of  eye  muscles  may  also  cause  inco- 
ordination ;  this  will  probably  cause  complaints  of  double  vision,  and  may  be 
diagnosed  by  the  fact  that  the  patient  walks  better  with  one  eye  shut  than 
with  both  open — in  cases  of  some  duration  it  is  quite  likely  that  this  simple 
test  will  not  discover  which  is  the  affected  eye. 

2.  Local  Loss  of  Power. — The  most  peculiar  illustration  of  this  defect  is  the 
waddling  gait  of  pseudo-hypertrophic  paralysis,  calculated  to  get  the  weight  of 
the  body  as  speedily  as  possible  on  the  foot  as  a  basis.  The  diagnosis  depends  on 
the  peculiar  way  in  which  the  patient  climbs  up  himself  (see  Paraplegia). 
Another  condition  in  which  the  loss  of  power  is  due,  not  to  the  muscles  them- 
selves, but  to  the  position  of  their  attachments,  is  seen  in  congenital  dislocation 
of  the  hips  ;  the  gait  here,  too,  is  somewhat  waddling,  the  lower  part  of  the 
back  exhibits  extreme  lordosis,  and  the  belly  is  thrown  forward  through 
attempts  to  balance  on  the  pelvis,  or  rather  to  balance  the  pelvis  on  the  loose 
supports  at  the  hips. 

Other  forms  of  local  loss  of  power  betray  themselves  by  a  limp  or  by  a  dragging 
of  the  foot  or  leg,  and  (or)  peculiar  positions  of  the  feet.  Infantile  paralysis, 
and  old  hemi-  or  mono-  or  para-plegias  are  the  common  causes  of  this,  if  it  be 
unassociated  with  pain,  and  enquiry  must  be  made  as  to  mode  of  onset  and 
duration,  in  completing  diagnosis. 

3.  Pain  on  Walking. — This  is  at  once  obvious,  because  complained  of  by  the 
patient  ;  acute  inflammatory  troubles  of  muscles,  joints,  or  tissues  will  be 
obvious  on  examination,  and  chronic  joint  troubles,  osteo-arthritis,  etc.,  may  be 


278  GAIT,     ABNORMALITIES     OF 

easily  discovered,  chronic  gonorrhoea  or  pj'orrhoea  alveolaris  not  being  for- 
gotten as  possible  causes  of  these.  The  only  thing  that  may  escape  observation 
is  hip-joint  disease,  when  pain  in  the  knee  may  be  the  complaint. 

The  only  other  caution  we  can  administer  here,  is  to  warn  practitioners  against 
any  hasty  conclusions  as  to  the  nature  of  a  disease  from  the  gait  ;  the  high 
stepping  gait  of  tabes,  the  shuffling  gait  of  lateral  sclerosis,  the  festinating  gait 
of  paralysis  agitans,  are  all  easy  enough  of  recognition  when  a  diagnosis  is  made, 
but  are  too  frequently  absent  or  atypical  to  allow  much  diagnostic  superstructure 
to  be  built  on  them  alone.  Pred  J.  Smith. 

GALL-BLADDER  ENLARGEMENT. 

Physical  Signs. — The  onlj^  physical  method  of  examination  which  is  of  any 
material  assistance  in  determining  the  existence  of  an  enlargement  of  the  gall- 
bladder, is  palpation  ;  inspection,  percussion,  and  auscultation  are  seldom  if 
ever  helpful.  On  careful  palpation,  however,  one  may  feel  an  oval,  smooth 
swelling,  which  maj^  be  no  larger  than  a  hen's  egg,  or  as  big  as  a  swan's,  moving 
downwards  close  behind  the  anterior  abdominal  wall  when  the  patient  inspires, 
descending  either  from  beneath  the  right  costal  margin  near  the  tip  of  the  ninth 
rib,  or  approaching  the  under  surface  of  an  enlarged  and  palpable  liver  in  the 
right  nipple  line.  This  smooth  oval  tumour  generallj-  extends  inwards  as  well 
as  downwards  as  it  grows  bigger,  so  that  it  may  ultimately  cross  the  middle 
line  below  the  level  of  the  umbilicus.  It  may  be  large  enough  to  be  palpable 
bimanuall)-  in  a  thin  patient  ;  but  it  seldom  fills  out  the  loin  in  the  way  that 
a  renal  tumour  would.  It  may  or  may  not  be  tender,  according  as  the  cause 
of  the  enlargement  is  associated  with  inflammation  or  not  ;  it  feels  firm  and 
tense,  rather  than  hard  ;  on  careful  percussion  it  may  be  found  to  give  a  very 
impaired  note,  but  it  is  seldom  quite  dull  unless  it  is  verj^  big. 

Diagnosis  from  other  Swellings. — It  has  to  be  distinguished  particularly  from 
four  groups  of  conditions  which  may  simulate  it  : — (i)  From  carcinoma  arising 
in  the  bile-ducts  or  gall-bladder,  and  replacing  the  latter  with  new  growth  ; 
(2)  From  tumours  in  or  attached  to  the  liver  in  the  neighbourhood  of  the  gall- 
bladder ;  Riedel's  lobe  ;  secondary  new  growth  ;  or  more  rarely  gumma,  abscess, 
or  hydatid  cyst ;  (3)  From  movable  kidney  or  hydronephrosis  ;  (4)  From  tumours 
in  organs  in  the  neighbourhood,  such  as  carcinoma  of  the  pylorus,  carcinoma 
of  the  duodenum,  carcinoma  or  sarcoma  of  the  right  suprarenal  capsule. 

Carcinoma  of  the  Gall-bladder. — It  may  be  very  difficult  sometimes  to  decide 
whether  a  given  mass  is  merely  an  enlarged  gall-bladder,  or  a  growth  replacing 
the  latter  ;  in  either  case  there  may  be  a  history  of  gall-stones,  Avith  bihary 
colic,  pj^rexia,  and  even  jaundice,  extending  over  years,  ;  for  primary  new 
growth  of  the  gall-bladder  is  nearly  always  secondary  to,  and  associated 
with,  gall-stones.  The  rapidity  of  the  enlargement,  in  the  absence  of  any 
definite  cause,  may  suggest  growth,  particularly  in  a  person  of  the  cancer  age  ; 
careful  palpation  may  show  that  the  mass  is  not  smooth  as  most  gall-bladder 
enlargements  themselves  are,  but  more  or  less  nodulated  or  covered  with 
bosses  or  irregularities,  which  in  themselves  suggest  new  growth  ;  in  some  cases 
there  ma}'  be  secondary  deposits  in  the  liver,  and  sometimes  the  enlargement 
of  the  left  supraclavicular  gland  points  to  malignant  disease  Avith  metastasis. 
XotAvithstanding  these  points,  hoAvcA-er,  the  differential  diagnosis  may  be  so 
difficult  that  laparotomy'  aa'III  be  resorted  to  in  order  to  decide  it,  with  a  view 
also  to  remoA'ing  the  gall-stones. 

The  Tumours  attached  to  or  in  the  Liver  that  are  most  hkely  to  be  mistaken 
for  enlargement  of  the  gall-bladder,  or  vice  versa,  are  Riedel's  lobe,  secondary 
carcinoma  or  sarcoma  of  the  liver,  and  much  more  rarely  gumma,  abscess,  or 
hydatid  cyst.     A  Riedel's  lobe  is  a  tongue-shaped,  floating  or  accessory  lobe. 


GALL-BLADDER     ENLARGEMENT  279 

sometimes  lound  attached  by  a  narrow  bridge  of  hepatic  or  even  fibrous  tissue 
to  the  anterior  part  of  the  lower  border  of  the  right  lobe.  It  gives  rise  to  no 
symptoms  whatever,  but  it  may  be  quite  impossible  to  distinguish  it  by  physical 
examination  from  an  enlarged  gall-bladder  or  from  a  movable  kidney.  Owing 
to  the  absence  of  s^-mptoms,  there  is  seldom  need  for  laparotomy  ;  but  sometimes 
the  Riedel's  lobe  arouses  such  alarm  lest  it  is  some  more  serious  condition, 
that  laparotomy  may  be  resorted  to  and  the  diagnosis  verified  in  that  way.  It 
is  commoner  in  wonien  than  in  men,  possibly  as  the  result  of  the  use  of  stays. 

Secondary  new  growth  in  the  liver,  whether  carcinoma  or  sarcoma,  nearly  always 
causes  ver}'  considerable,  and  sometimes  enormous,  enlargement  and  great  hard- 
nessof  the  organ,  not  infrequently  associated  with  Jaundice  (^.w.).  Ascites  (q-v.), 
or  both.  The  diagnosis  depends,  first,  upon  the  discovery  of  a  primary  growth, 
which  in  the  case  of  carcinoma  is  likely  to  be  in  the  stomach,  duodenum,  pancreas, 
colon,  or  rectum  ;  or  in  the  case  of  sarcoma,  the  eye — some  of  the  very  greatest 
enlargements  of  the  liver  being  due  to  secondary  deposits  of  melanotic  sarcoma, 
secondary  to  a  primary  ocular  growth  ;  and  secondly,  on  the  discovery  in  the 
liver  of  several  separate  nodules,  some  of  which  may  be  felt  to  be  umbilicated, 
that  is  to  say,  depressed  in  their  central  part  and  raised  around  the  edges. 

Gumma  of  the  liver  is  not  very  frequent  nowadays,  and  when  it  occurs  is 
very  apt  to  be  mistaken  for  new  growth  unless  there  is  a  very  obvious  history 
of  syphilis,  or  the  effects  of  tertiary  lesions  are  visible  elsewhere,  especially 
gummatous  lesions  of  the  skin  or  tongue.  The  diagnosis  may  be  confirmed  by 
obtaining  a  positive  Wassermann's  serum  reaction,  or  by  the  beneficial  effects 
of  giving  potassium  iodide  and  mercury,  though  these  drugs  do  not  always  cause 
a  gumma  of  the  liver  to  disappear  rapidly.  In  cases  that  have  come  to 
laparotomy,  the  diagnosis  between  gumma  and  new  growth  is  by  no  means 
easy,  even  when  the  liver  is  inspected. 

Abscess  of  the  liver,  if  it  is  to  simulate  an  enlargement  of  the  gall-bladder, 
is  likely  to  be  a  single  large  one,  which,  if  it  has  not  arisen  in  some  pre-existent 
mass,  such  as  a  gumma,  new  growth,  or  hydatid  cyst,  is  likely  to  have  been 
acquired  in  a  tropical  countrj^,  where  the  patient  may  have  suffered  from  amoebic 
dysentery,  even  if  the  attack  was  onh-  mild  in  degree.  The  diagnosis  may 
not  be  evident  until  laparotomy  is  resorted  to,  or  until  the  mass  is  punctured 
with  an  exploring  needle,  when  the  chocolate-and-milk  appearance  of  the  pus 
obtained  may  be  characteristic.  It  is  often  sterile,  although  scrapings  of  the 
abscess  wall  would  show  the  Amoeba  coli  {Fig.  12,  p.  91).  The  existence  of  an 
abscess  would  be  suggested  by  the  occurrence  of  considerable  leucocytosis, 
together  w-ith  a  relative  increase  in  the  large  polymorphonuclear  cells. 

Hydatid  cyst  of  the  liver  is  seldom  situated  in  such  a  position  as  to  cause 
difficulty  of  diagnosis  from  gall-bladder  enlargement,  the  cyst  being  more  often 
embedded  in  the  liver  substance,  or  projecting  from  its  upper  surface.  The 
diagnosis  might  be  arrived  at  if  the  patient  were  known  to  have  had  hydatid 
cysts  elsewhere  ;  but  in  most  cases  it  is  only  when  laparotomy  has  been  performed 
that  the  correct  diagnosis  can  be  made.  It  might  have  been  suggested  by  the 
occurrence  of  eosinophilia,  and  also  by  a  specific  hydatid  serum  reaction,  though 
neither  of  these  is  likel}^  to  be  found  unless  the  hydatid  cyst  has  produced  toxic 
symptoms,  because  latent  hj'datid  cysts  cause  no  sjmiptoms. 

The  Distinction  between  an  Enlarged  Gall-bladder  and  a  Movable  Kidney  or 
Hydronephrosis  might  seem  to  otter  no  difficulty  ;  but  clinically  the  distinction  is 
not  always  so  ea.s\  as  might  be  expected.  There  is  often  no  jaundice  to  suggest 
gall-bladder  trouble,  nor  need  there  be  any  obvious  urinary  changes  to  suggest 
kidney,  so  that  the  diagnosis  has  to  be  made  chiefly  by  palpation.  One  would 
lay  stress  upon  the  fact  that  the  gall-bladder  is  more  easily  felt  anteriorly  than 
posteriorly,  whilst  the  reverse  is  the  case  with  the  kidney  ;    that  the  kidney  is 


28o  GALL-BLADDER     ENLARGEMENT 

the  more  freely  movable  of  the  two,  as  a  rule  ;  that  it  is  seldom  possible  to 
demarcate  the  upper  pole  of  an  enlarged  gall-bladder  in  the  way  that  a  mo\able 
kidnev  can  sometimes  be  made  out ;  that  with  a  kidney  tumour  the  loin  is  dull, 
whilst  with  gall-bladder  enlargement  it  is  resonant ;  and  that,  on  rather  firm 
bimanual  palpation,  the  pecuhar  sickening  sensation  that  the  patient  may  com- 
plain of  is  more  characteristic  of  kidney  than  it  is  of  gall-bladder. 

Tumours  of  other  Organs  simulating  Enlargement  of  the  Gall-bladder  have  to 
be  distingmshed  partly  by  the  fact  that  new  growths  of  the  pylorus,  duodenum, 
or  suprarenal  capsule,  big  enough  to  simulate  an  enlargement  of  the  gall- 
bladder, wiU  seldom  have  the  smooth  oval  outhne  that  the  latter  nearh*  always 
possesses.  There  mav,  moreover,  be  distinct  S}Tnptoms  attributable  to  the 
primarv  growth,  such  as  dilatation  of  the  stomach,  cofTee-ground  vomit,  and 
so  on,  or  there  mav  be  extensive  secondan,-  deposits  in  the  fiver,  in  the  left  supra- 
clavicular gland,  or  elsewhere,  to  indicate  the  diagnosis.  It  is  not  easy,  how- 
ever, to  exclude  enlargement  of  the  gall-bladder  ^vithout  resorting  to  laparotomy 
in  some  of  these  cases. 

The  Cause  of  Enlargement  of  the  Gall-bladder. — Having  decided  that  a  given 
tumour  is  an  enlargement  of  the  gall-bladder,  it  is  necessar\-  to  determine  which 
of  the  foUowing  causes  it  is  due  to  : — 
^  Empvema  of  the  gall-bladder 

Chronic  pancreatitis 

Carcinoma  of  the  head  of  the  pancreas 

T^-phoid  fever 

Cholecystitis  from  :— (i)-  Gall-stones  ;     (ii.)   New  gro^vth 

Obstcucjion_pf--theTomjnoir  bile-duct -bp-galPs?one 

05iEruction  of  the  cystic  duct  by  gall-stone 

Simple  mucocele. 
It  is  particularlv  noteworthy  that  gall-stones  lead  to  enlargement  of  the  gall- 
bladder far  less  often  than  might  ha\-e  been  expected  ;  if  the  inflammation  they 
lead  to,  and  which  leads  to  them,  does  not  go  on  to  empyema  of  the  gall- 
bladder, the  latter  usuaUy  becomes  thick-walled,  contracted,  and  embedded  in 
dense  adhesions,  the  latter  preventing  it  from  dilating,  even  when  the  cystic  or 
common  bile-ducts  become  obstructed  by  a  stone.  It  is  the  exception  to 
find  a  ver\-  big  gaU-bladder  with  gaU-stones.  Indeed,  in  a  middle-aged  patient 
in  whom  there  has  not  been  any  very  definite  attack  of  bihary  cofic,  the 
occurrence  of  progressive  and  considerable  enlargement  of  the  gall-bladder, 
associated  with  a  deepening  jaundice  and  no  ascites,  should  always  arouse 
serious  suspicion  of  there  being  a  lesion  of  the  head  of  the  pancreas  which  has 
extended  along  the  pancreatic  duct  so  as  to  occlude  the  common  bile-duct 
gradually,  the  commonest  cause  of  these  S3-mptoms  being  either  chronic  pan- 
creatitis or,  more  serious  still,  carcinoma  of  the  head  of  the  pancreas.  The 
greater  the  epigastric  pain  in  such  a  case,  especially  if  it  is  paroxysmal,  and  such 
as  to  suggest  gaU-stones,  the  more  hkely  is  the  lesion  to  be  chronic  pancreatitis 
rather  than  new  growth,  and  the  suspicion  may  be  confirmed  by  Cammidge's 
Paxcreatic  Reaction  [q.v.).  There  are,  of  course,  cases  in  which  gall-stones 
are  the  cause  of  the  enlargement ;  but  when  this  is  so,  there  is  nearly  always 
tenderness  over  the  gaU-bladder,  and  pain  when  it  is  firmly  palpated,  associated 
with  a  rise  of  temperature,  possibly  with  rigors,  especiaUj-  if  the  inflammation 
has  spread  to  the  bile-ducts  (infective  or  suppurative  cholangitis).  Leucocytosis, 
with  a  relative  increase  in  the  polymorphonuclear  cells,  would  indicate  that 
in  addition  to  gall-stones  there  is  suppurative  inflammation — that  is  to  say, 
empyema  of  the  gall-bladder — requiring  surgical  treatment. 

Another  important  cause  for  empyema  of  the  gall-bladder  is  typhoid  fever. 
The  diagnosis  is  not  difficult  as  a  rule,  for  there  will  be  no  question  of  new  growth 


PLATE     III. 

SYMMETRICAL      GANGRENE      OF      THE       FINGERS      IN       RAYNAUD'S      DISEASE 


Rc/>?  oduccd  by  J>a/nission  of  tJic  House  Co7}nnittec  of  St.  George's  Hospital 
fioin  a  %vater-colour  drawing;  hy  Dr.  E.  A.   IVHson. 

INDEX    or-     DIAG.MISIS 


GANGRENE 


281 


or  of  gall-stones  in  most  of  the  cases,  and  the  patient  will  have  been  suffering 
from  a  prolonged  asthenic  fever,  which  will  have  been  diagnosed  already  by 
Widal's  test.  Infection  of  the  gall-bladder  by  typhqid  bacilli  is  relatively 
common,  and  seeing  that  gall-stones  are  seldom  if  ever  primary,  but  rather  the 
result  of  preceding  microbial  inflammation  in  the  gall-bladder,  it  is  not  surprising 
that  gall-stones  are  more  common  in  patients  who  have  previously  had  typhoid 
fever  than  in  other  persons.  Apart  from  gall-stone  formation,  however,  slighter 
degrees  of  inflammation  of  the  gall-bladder  by  Bacillus  typhosus  are  common, 
and  it  is  thought  that  the  continued  infectivity  of  the  excreta  in  typhoid-carriers 
is  due  to  the  constant  discharge  of  infected  bile  from  the  gall-bladder,  persisting 
sometimes  for  thirty  years  or  more.  The  gall-bladder  is  not  enlarged  in  these 
cases ;  but  in  a  certain  number  of  typhoid  patients,  rapid  enlargement  of  the 
gall-bladder  occurs  owing  to  the  bacil- 
lary  infection,  and  there  are  instances 
in  which  the  distention  has  become  so 
great  that  the  gall-bladder  has  ruptured 
spontaneously  and  produced  general 
peritonitis.  Sometimes  the  inflamma- 
tory products  discharge  themselves 
naturally  by  the  bile-passages  ;  but  it 
is  often  necessary  to  open  and  drain 
the  gall-bladder,  the  diagnosis  of  the 
nature  of  the  empyema  being  settled 
by  bacteriological  examination  of  its 
contents.  It  is  noteworthy  that, 
whereas  in  uncomplicated  cases  of 
typhoid  fever  Widal's  reaction  rapidly 
becomes  negative  during  convalescence, 
when  there  are  persistent  bacillary 
complications,  the  serum  test  may 
remain     positive,    or     at    least    partly 

positive,  over  much  longer  periods.  When  an  empyema  of  the  gall-bladder 
due  to  typhoid  fever  remains  latent  for  weeks  or  longer,  the  nature  of  the 
case  may  be  suggested  by  the  previous  history,  and  by  the  persistence  of  the 
positive  serum  reaction. 

Simple  mucocele  of  the  gall-bladder  is  probably  the  result  of  former  catarrh 
of  the  cystic  duct,  or  often  of  a  gall-stone  which  has  disappeared  ;  nevertheless, 
in  many  cases  it  may  be  impossible  to  determine  the  precise  cause  ;  the  gall- 
bladder may  become  very  greatly  distended  with  perfectly  colourless  mucoid 
fluid,  free  from  bile  pigment,  though  sometimes  containing  crystals  of  cholesterin 
{Fig.  94).  The  fluid  is  sterile.  The  cystic  duct  is  generally  obstructed  as 
the  result  of  former  inflammation.  There  are  usually  no  symptoms  unless 
the  patient  may  by  chance  have  discovered  the  tumour  for  herself.  Such  a 
mucocele  may  be  mistaken  for  a  movable  kidney,  and  the  diagnosis  of  the  nature 
of  the  mass  is  sometimes  obscure  until  operation  is  resorted  to.        Herbert  French. 

GANGRENE. — When  any  necrotic  tissue  is,  or  becomes,  infected  with  putre- 
factive micro-organisms,  the  resulting  condition  is  known  as  gangrene.  According 
to  the  appearances  it  presents,  gangrene  is  further  described  as  either  dry, 
moist,  or  spreading.      (See  also  Gangrene  of  the  Lung.) 

Causes   of  Gangrene. 
Local  Traumatic  Causes  : — 

Severe  bruising  or  crushing  of  the  tissues,  with  or  without  fractures  of  the 
bones. 


^i]g'.  94. — Cholesterin  crystals. 


282  GANGRENE 


The  application  of  extreme  heat  or  cold — burns,  hot-water  bottles,  frost- 
bite, freezing,  ice-bags,  etc. 
The  action  of  strong  chemicals — acids,  alkalies,  phenol,  etc. 
The  action  of  powerful  electric  currents,  or  of  lightning. 

Lowered  Vitality  of  the  Tissues,  either  (a)  Local,  or  (fo)  General. 

Local  :    seen  in  the  immediate  neighbourhood  of  the  infected  area  in  such 
acute  infections  as — 


Septic  wounds  I        Syphilis 


Erysipelas 

Anthrax 

Gonorrhoea 


Diphtheria 
Scarlet  fever. 


General  :    occurring  after  some  slight  injury  as  a  complication  or  sequela  of- 
Enteric  fever  i        Cholera 


Small-pox 

Chicken-pox 

Measles 

Diabetes 

Infantile  marasmus 

Disturbances  of  the  Innervation  of  the  Tissues,  such  as  occur  in 


Plague 

Yellow  fever 

Malaria 

Poisoning  by  snake- venom. 


Hemiplegia 
Myelitis 

Meningo-myelitis 

Lesions  of  the  spinal  cord  and  Cauda 
equina. 


Raynaud's  disease 
Erythromelalgia 
Peripheral  neuritis 
Syringomyelia 
Tabes  dorsalis 
Leprosy 

Stoppage  of  the  Circulation,  due  to — 

Embolism 

Thrombosis 

Endarteritis  ;    senile  gangrene 

Occlusion  of  vessels,  complete  or  partial,  by — 

Ligature,  tight  bandages,  splints 

Pressure  of  new  growths 

Pressure  of  aneurysms  or  effused  blood 
The  arterial  spasm  of  ergotism,  the  so-called  "  epidemic  gangrene." 

Speaking  generally,  more  than  one  of  the  causes  enumerated  above  will 
be  at  work  in  the  production  of  gangrene  in  any  particular  instance.  Thus, 
in  the  gangrene  following  severe  injury  to  one  of  the  extremities,  stoppage  of 
the  circulation  through  the  affected  part  is  usually  observed  in  addition  to  the 
direct  injury  caused  by  the  mechanical  crushing  of  its  tissues.  Again,  in  cancrum 
oris  or  noma — the  name  given  to  the  spreading  gangrene  of  the  soft  tissues  of  the 
mouth  and  cheek  occurring  in  debilitated  children  after  measles  or  scarlet  fever — 
great  feebleness  of  the  circulation  contributes  to  its  production,  in  addition  to 
the  lowered  vitality  of  the  necrotic  tissues  {Fig.  ii,  p.  88).  A  diabetic  patient 
with  gangrene  may  owe  it  partly  to  the  impoverished  or  altered  quality  of  his 
blood,  partly  to  the  arteriosclerosis  that  is  often  associated  with  diabetes,  and 
partly  to  peripheral  neuritis  occurring  as  a  further  complication  of  his  disease. 

In  dry  gangrene,  or  mummification,  the  affected  part  of  the  body,  usually  the 
distal  end  of  a  limb,  becomes  livid  and  cold,  and  gradually  blackens  as  the  blood- 
pigment  diffuses  out  of  the  blood-corpuscles  and  enters  the  tissues,  and  withers 
as  the  fluid  in  it  evaporates.  It  is  a  slow  process  ;  putrefaction  is  little  in 
evidence,  and  there  is  no  markedly  offensive  odour  about  the  part,  for  it  is  too 
dry  to  afford  a  satisfactory  culture-medium  for  the  bacteria  of  putrefaction  that 


GANGRENE 


283 


no  doubt  swarm  on  its  surface  and  in  its  tissues.  Between  this  dry  gangrenous 
tissue  and  the  adjoining  healthy  part  of  the  Hmb,  is  an  inflammatory  zone  :  the 
line  of  demarcation  (Plate  IV).  Dry  gangrene  is  common  in  cases  of  embolism 
or  other  complete  obstruction  of  the  arteries,  in  senile  gangrene,  and  in 
Raynaud's  disease  (Plate  III)  ;  the  affected  part  is  ultimately  converted  into  a 
shrunken,  black,  and  mouldy-smelling  mass. 

Moist  gangrene,  sphacelus,  or  sloughing,  may  often  be  seen  after  severe  crushing 
of  a  leg  or  an  arm,  when  the  distal  portion  of  the  limb  dies  and  rapidly  putrefies. 
At  first  hot,  red,  and  painful,  the  crushed  extremity  presently  becomes  mottled, 
purplish,  and  cold,  as  thrombosis  occurs  in  its  vessels,  and  the  circulation  through 
it  stops.  Signs  of  putrefaction  soon  appear  in  the  dead  tissue,  the  skin  rising 
into  discoloured  blebs,  which,  on  rupture,  give  issue  to  a  highly  offensive  sanious 
fluid.  A  dusky  red  line  of  demarcation  separates  the  gangrenous  from  the 
adjoining  healthy  part.  "  Sloughing  "  is  the  name  commonly  given  to  the  putre- 
factive separation  of  smaller  parts  of  the  soft  tissues  from  the  body  ;  sloughs  are 
the  localized  gangrenous  patches  that  result  frcm  most  of  the  injuries  described 
under  the  first  heading. 

Spreading  gangrene  is  the  form  of  gangrene  due  to  infections  by  special  virulent 
bacteria,  which  cause  the  death  and  partial  dissolution  of  the  tissues  in  which 
they  grow  and  spread.  Fatty  acids  and  sulphides  are  among  the  chemical  com- 
pounds formed  by  these  micro-organisms,  and  it  is  to  them  that  the  offensive 
odour  of  the  debris  of  tissues  is  due. 

The  Diagnosis. 

Traumatic  Local  Causes  and  Lowered  Vitality  of  the  Tissues. — Gangrene  being 
no  more  than  an  infective  necrosis  of  some  part  of  the  body,  and  producing 
changes  obvious  to  the  eye  and  nose,  the  fact  of  its  occurrence  can  rarely  be 
difficult  to  determine.     Consideration  of  the  lists  above  will  show  that  in  every 


Pig.  95. — Raynaud's  disease:  stage  of  local  asphyxia. 


case  the  gangrene  is  a  direct  consequence  of  some  local  infection  or  injury,  and 
occurs  in  its  immediate  neighbourhood.  The  history  of  exposure  to  one  or 
another  of  the  forms  of  severe  injury  or  infection,  or  of  exposure  to  some  injury 
or  infection  that  would  be  unimportant  if  it  occurred  in  a  healthy  person,  but 
may  lead  to  gangrene  in  severely  debilitated  patients,  ought  to  be  elicited 
readily. 


J  84 


GANGRENE 


Disturbances  of  the  Innervation  of  the  Tissues. — Gangrene  due  to  disturb- 
ances in  the  innervation  of  the  tissues  is  commonly  described  as  a  trophoneurosis 
or  trophic  change.     It  may  be  either  chronic  or  acute  in  its  onset. 

Gangrene  of  a  Chronic  Type. — In  Raynaud' s  disease  gangrene  may  affect  the 
tips  of  the  fingers  or  the  toes,  less  often  the  edges  of  the  ears  and  the  end  of  the 
nose  or  tongue.  It  is  often  symmetrical  in  its  distribution,  and  is  preceded  by 
the  other  two  well-known  stages  of  the  disease,  namely,  local  syncope,  in  which 
the  affected  extremities  become  cold,  numb,  and  white ;  and  local  asphyxia 
(Fig.  95),  in  which  they  turn  from  white  to  blue-grey  or  purple.  Rarely, 
Rajmaud's  disease  is  characterized  only  by  recurring  attacks  of  necrosis  in  the 
extremities  [Fig.  96).  It  is  a  chronic  affection,  and  gangrene  only  occurs  in 
marked  cases  and  in  their  later   stages,  although  it  maj^  be    seen  at  any  age. 


Fi^.  95. — The  eflFect  of  Raynaud's  disease  after  it  has  produced  recurrent  necrosis  ot  the  fingers. 


As  a  dry  gangrene  attacking  the  superficial  and  terminal  parts  of  some  of  the 
digits,  it  may  bear  some  resemblance  to  senile  gangrene  [Plate  IV)  ;  this,  however, 
generallv  attacks  only  one  limb,  usually  a  lower  limb  ;  it  is  more  extensive  and 
more  progressive  than  the  gangrene  of  Raynaud's  disease  ;  and  it  is  associated 
with  weU-marked  disease  of  the  arterial  walls. 

Gangrene  ma}^  be  a  part  of  the  manifestations  of  erythromelalgia,  a  rare  and 
chronic  disease  of  adults  who  do  hard  work  while  exposed  to  considerable  changes 
of  temperature.  It  is  characterized  by  pain,  heat,  and  flushing  of  one  or  more 
of  the  extremities,  all  aggravated  when  the  limb  is  allowed  to  hang  downwards. 
The  colour  varies  from  rosy  red  to  purple,  and  the  affected  parts  are  hot :  hence 
the  condition  should  not  be  confused  with  Raynaud's  disease.  The  gangrene 
of  erj-thromelalgia  is  confined  to  the  extremities  and  may  be  S5rmmetrical  ;  as 
a  rule  it  is  more  narrowly  localized  and  less  superficial  than  the  gangrene  met 
with  in  Raynaud's  disease. 


PL  A  TE     I V. 


GANGRENE      OF      THE       FOOT 


a 


Note  the  line  of  demarcation  at   {n). 


F7-07II  "  Introduction  to  Surgery" 

by  kind  permission  of  Prof.   Rutherford  Motison. 


INDEX     OF     DIAGNOSIS 


GANGRENE  285 


Gangrene  is  a  rare  complication  of  peripheral  neuritis  clue  to  alcoholic,  arsenical, 
or  other  forms  of  poisoning.  It  occurs  exceptionally,  and  only  in  patients 
exhibiting  the  vasomotor  type  of  neuritis.  These  instances  closely  resemble 
cases  of  Raynaud's  disease,  with  which,  indeed,  some  hold  them  to  be  identical. 
The  gangrene  is  symmetrical  ;  the  patient  will  very  probably  exhibit  some  of 
the  other  signs  and  symptoms  of  peripheral  neuritis — disturbances  of  sensation, 
tremor,  paresis,  wasting,  trophic  changes — and  a  history  of  alcoholic  excess 
should  be  sought  from  the  patient  or  the  patient's  friends. 

Gangrene  of  the  skin  and  superficial  tissues  of  the  hands  or  feet,  and  even 
of  the  terminal  phalanges  of  the  digits,  may  be  met  with  in  syringomyelia  ; 
this  disease,  if  associated  with  painless  whitlows  on  the  fingers,  is  known 
as  Morvan's  disease.  This  gangrene  is  to  some  extent  traumatic  in  origin,  and 
may  be  symmetrical  ;  but  the  diagnosis  should  not  be  difficult,  for  in  most  cases 
three  prominent  symptoms  are  seen  in  syringomyelia  :  {a)  Loss  of  the  sensations 
of  pain  and  of  temperature,  tactile  sense  being  preserved  over  the  anaesthetic 
area  ;  this  is  the  "  dissociated  anaesthesia  "  of  Charcot,  [b)  Trophic  changes 
about  the  extremities,  often  originating  in  some  neglected  or  unnoticed  injury  ; 
hypertrophy  or  atrophy  of  the  skin  or  nails  ;  trophic  changes  in  the  joints,  the 
so-called  "  Charcot's  joints  "  ;  brittleness  of  the  long  bones,  with  a  tendency  to 
the  occurrence  of  spontaneous  fractures,  (c)  Progressive  muscular  atrophy, 
invading  the  hands  first,  later  the  forearms,  arms,  and  shoulders  ;  atrophy  of  the 
spinal  muscles  may  ensue,  giving  rise  to  spinal  curvature.  Thus  the  gangrene 
of  syringomyelia  is  characterized  by  its  painlessness,  and  by  its  combination 
with  other  well-marked  special  symptoms  ;  in  addition,  it  may  be  mentioned 
that  the  hands  themselves  often  present  certain  deformities,  the  "Claw-hand  " 
{q.v.)  resulting  when  the  muscular  atrophy  of  the  hands  is  marked,  the  "  succulent 
hand  "  being  exhibited  when  there  are  much  hyperplasia  and  redundancy  of  the 
soft  parts  of  the  hand  and  fingers. 

Gangrene  of  the  toes  may  occur  in  tabes  dorsalis,  usually  in  connection  with  a 
perforating  ulcer  about  the  ball  of  the  toe.  The  process  is  slow  and  painless, 
not  symmetrical  ;  and  is  associated  with  the  other  main  signs  of  tabes,  especially 
loss  of  the  knee-jerks,  Argyll  Robertson  pupils,  ataxia,  and  finally  diminution, 
or  loss,  of  control  over  the  sphincters. 

Gangrene  of  a  similar  sort,  and  similarly  started  by  some  ulceration  or  a 
neglected  injury,  is  common  in  leprosy  of  the  "  smooth,"  "  nerve,"  or  "  an- 
aesthetic "  type.  It  occurs  only  in  the  later  stages  of  this  disease,  and  from 
its  rarity  calls  for  no  further  consideration  here. 

Gangrene  of  an  acute  type,  and  attributable  to  trophic  changes,  occurs  in 
the  form  of  decubitus  acutus,  or  acute  bedsore  in  certain  acute  disorders  or  infec- 
tions of  the  central  nervous  system  or  spinal  cord.  These  are  all  characterized 
by  the  fact  that  the  primary  lesion  of  the  nervous  system  produces  both  paralysis 
and  anaesthesia,  and  is  also,  in  all  probability,  irritative.  Within  a  few  days 
or  even  hours  of  the  primary  lesion,  secondary  changes  are  seen  in  the  skin  and 
soft  tissues  where  they  are  most  exposed  to  pressure.  These  parts  are  those 
about  the  buttock,  sacrum,  coccyx,  iliac  crest,  great  trochanter,  tibia,  or  heel, 
according  to  the  position  in  which  the  paralyzed  patient  lies  in  bed.  When  the 
pressure  is  unduly  great  or  unduly  protracted,  the  skin  turns  red  or  purple,  and 
unless  most  carefully  protected  may  presently  undergo  extensive  and  spreading 
necrosis  and  gangrene.  Hot-water  bottles  that  would  expose  an  ordinary 
patient  to  no  discomfort  or  danger  whatever,  may  set  up  analogous  necrosis 
and  gangrene  if  allowed  to  remain  too  long  or  too  closely  in  contact  with  the 
skin  of  a  paralytic  patient  liable  to  the  formation  of  bedsores.  The  chief  nervous 
lesions  in  which  the  acute  bedsore  is  seen  are  the  following  :  hemiplegia,  whether 
due  to  cerebral  embolism,  cerebral  haemorrhage,  or  cerebral  thrombosis  ;    acute 


GANGRENE 


infections  of  the  spinal  membranes  or  spinal  cord,  or  both,  such  as  meningitis, 
myelitis,  or  meningo-myelitis,  whatever  the  origin  of  the  infection  may  be  ; 
transverse'  lesions  of  the  spinal  cord  or  cauda  equina,  such  as  are  caused  by 
fractures  or  fracture-dislocations  of  the  spinal  column,  or  by  penetrating  wounds 
involving  the  spinal  cord.  These  bedsores  occur  only  in  the  anaesthetic  areas, 
and  hence  tend  to  escape  the  notice  of  the  patient,  who  may  also  be  unconscious 
or  delirious.  But  it  is  of  the  greatest  importance  that  a  sharp  look-out  should 
be  kept  upon  the  skin  covering  all  bony  prominences  particularly  exposed  to 
pressure  in  these  patients,  in  order  that  the  occurrence  of  a  bedsore  may  be 
detected  at  once,  and  suitable  treatment  applied  without  delay  to  check  its 
spread.  Once  well  established,  the  acute  bedsore  tends  to  spread  in  area  and 
in  depth,  in  spite  of  the  most  careful  treatment,  and  to  bring  about  the  death  of 
the  patient  by  septic  absorption,  pyaemia,  or  the  exhaustion  consequent  to 
prolonged  suppuration. 

Stoppage  of  the  Circulation. — Among  the  most  important  and  extensive  causes 
of  gangrene  are  those  in  which  the  exciting  factor  is  some  more  or  less  com- 
plete vascular  obstruction,  with  consequent  stoppage  of  the  circulation,  and  the 
death  of  those  tissues  whose  blood-supply  is  cut  off.  In  this  connection,  occlusion 
of  the  arteries  is  more  important  than  that  of  the  veins,  the  channels  for  venous 
return  being  more  extensive  and  better  supplied  with  anastomotic  by-passes 
than  those  for  arterial  supply  ;  nevertheless,  in  exceptional  cases,  moist  gangrene 
of  some  distal  part  follows  blocking  of  the  veins  by  thrombosis  or  by  pressure 
from  without,  while  the  arteries  are  still  patent.  The  importance  and  amount 
of  the  pathological  changes  following  vascular  obstruction  depend  to  a  large 
degree  on  the  extent  to  which  collateral  or  anastomotic  channels  exist  and  are 
able  to  carry  on  the  circulation  through  the  affected  area.  If  they  are  ill- 
developed,  and  the  artery  which  has  been  blocked  by  embolism  or  thrombosis 
is  an  "  end-artery  "  in  the  sense  in  which  Cohnheim  used  the  term,  the  conse- 
quences of  the  stoppage  are  likely  to  be  far  more  serious  and  extensive  than  if 
there  are  adjacent  vessels  able  to  make  good  some  supply  of  blood  for  the 
nourishment  of  the  affected  tissues.  Embolism  of  an  artery  is  likely  to  occur 
in  patients  who  have  valvular  disease  of  the  heart,  with  vegetations  on  the 
mitral  or  aortic  valves  that  may  be  swept  off  into  the  blood-stream  ;  or 
else  the  embolus  may  be  derived  from  a  blood-clot  formed  in  a  diverticulum 
of  one  of  the  chambers  of  the  left  heart,  or  in  an  aneurysm,  or  upon  the 
surface  of  a  rough  atheromatous  aorta.  Thrombosis,  whether  arterial  or 
venous,  may  be  suspected  in  patients  in  whom  no  source  for  an  embolus 
can  be  detected,  but  who  exhibit  widespread  arterial  degeneration,  phlebo- 
sclerosis,  or  local  disease  that  may  spread  to  some  vessel  and  set  up  clotting 
in  its  contents. 

The  occurrence  of  arterial  embolism,  in  the  leg  for  example,  is  marked  by  a 
sudden  and  very  severe  pain  in  the  limb  at  about  the  level  of  the  blockage. 
The  distal  portion  of  the  limb  becomes  numb,  cold,  insensitive  ;  pulsation  can 
no  longer  be  felt  in  the  arteries  distal  to  the  obstruction.  The  gangrene  that 
follows  is  usually  of  the  dry  type.  Very  similar  symptoms  may  mark  the 
occlusion  of  an  artery  in  the  leg  by  thrombosis,  but  the  onset  is  usually  much 
more  gradual,  and  the  pain  may  be  terribly  protracted  and  severe,  death  of  the 
nerves  of  sensation  coming  on  but  slowly. 

Senile  gangrene  occurs  in  patients  who  are  advanced  in  years  and  exhibit 
extensive  arterial  sclerosis  ;  in  many  instances  they  also  give  a  history  of  gout, 
or  suffer  from  diabetes  mellitus.  It  is  in  reality  a  form  of  thrombotic  or  occlusive 
gangrene,  and  due  either  to  the  clotting  of  blood  on  the  diseased  and  roughened 
arterial  intima,  or  else  to  the  increasing  obstruction  of  the  arterial  lumina  by  a 
proliferative  endarteritis.    Senile  gangrene  is  often  of  insidious  onset  and  confined 


GANGRENE     OF     THE     LUNG  287 

to  one  lower  limb,  just  as  embolic  gangrene  may  be  ;  but  it  has  a  tendency 
to  spread  upwards  slowly  and  indefinitely,  a  tendency  that  finds  a  natural 
explanation  in  the  very  extensive  character  of  the  arterial  degeneration  that 
goes  with  it.  It  is  not  often  symmetrical  ;  if  more  than  one  limb  is  affected, 
the  lesions  are  successive  in  their  development. 

Little  need  be  said  about  the  gangrene  that  follows  complete  or  partial  occlusion 
of  the  vessels  by  the  other  causes  enumerated  above.  The  gangrene  will  be 
secondary  to  some  primary  lesion  that  will  seldom  fail  to  be  obvious.  The 
ligature  of  an  artery  in  the  course  of  a  surgical  operation — of  the  femoral  artery, 
for  example,  in  the  treatment  of  popliteal  aneurysm — has  been  known  to  cause 
gangrene  of  the  leg  in  patients  whose  collateral  circulation  unfortunately  proved 
to  be  inadequate.  The  application  of  tight  bandages  round  a  limb,  possibly  to 
check  haemorrhage,  may  cause  a  similar  gangrene  if  they  are  left  on  too  long. 
The  pressure  of  new  growths  on  an  artery  may  be  such  as  to  cause  its  occlusion 
in  exceptional  instances,  whereas  it  readily  compresses  or  invades  veins  and 
renders  them  impervious  ;  in  either  case  gangrene  of  some  distal  part  may 
result.  The  new  growth  may  be  primary,  or  may  be  a  secondary  deposit  growing 
perhaps  in  a  lymphatic  gland.  Thus,  a  carcinoma  in  the  mammary  gland,  or  an 
endothelioma  of  the  lung  or  pleura,  may  give  rise  to  secondary  deposits  about 
the  axillary  and  subclavian  vein  and  artery  ;  and  these  may  be  so  extensive  as 
to  obstruct  the  circulation  through  the  arm,  and  set  up  moist  gangrene  in  the 
fingers.  Similar  gangrene  of  the  fingers  may  result  from  the  vascular  obstruction 
caused  by  a  large  intrathoracic  aneurysrn,  or  by  blood  that  has  escaped  and  clotted 
round  the  vessels  of  the  arm. 

The  epidemic  gangrene  of  ergotism  is  only  of  historic  interest  in  Great  Britain 
at  the  present  time,  although  it  is  said  to  occur  still  in  Russia.  It  is  seen  only 
in  persons  who  consume  quantities  of  mouldy  rye  ;  the  gangrene  does  not  appear 
to  occur  in  human  beings  as  the  result  of  excessive  doses,  of  the  pharmaceutical 
preparations  of  ergot.  It  is  stated,  however,  that  minor  degrees  of  ergotism 
may  simulate  Raynaud's  disease  or  erythromelalgia.  Gangrene  due  to  ergot  is 
dry,  chronic  in  progress,  extremely  painful,  and  usually  asymmetrical  ;  it  results 
in  much  disfigurement  from  loss  of  tissue,  and  has  had  a  high  mortality  in 
many  of  its  epidemics.  A.  J.  J  ex-Blake. 

GANGRENE  OF  THE  LUNG.— This  occurs  whenever  a  portion  of  the  lung 
undergoes  necrosis,  and  then,  owing  to  invasion  by  one  or  more  of  many  kinds 
of  bacteria,  putrefies.  It  usually  occurs  in  senile,  intemperate,  or  debilitated 
patients.  Most  often  it  affects  a  circumscribed  area  of  lung-tissue  only,  but  it 
may  be  a  diffuse  process  involving  a  whole  lung.  It  occurs  as  a  rare  complication 
of  pneumonia  or  broncho-pneumonia  ;  and  as  a  comparatively  common  compli- 
cation of  aspiration-pneumonia,  when  it  is  due  to  direct  infection  of  the  lung  by 
the  bacteria  contained  in  food,  mucous  secretions,  or  foreign  bodies  generally 
(peas,  beans,  fish-bones,  extracted  teeth,  etc.)  that  have  made  their  way  past 
the  larynx  and  into  the  trachea  or  bronchi.  .Gangrene  may  also  result  from  an 
extension  of  the  infection  in  such  chronic  suppurative  affections  of  the  lungs 
as  chronic  pulmonary  tuberculosis,  bronchiectasis,  or  fcetid  bronchitis.  In  other 
instances  the  infecting  agent  reaches  the  lungs  by  the  blood-stream  ;  thus 
gangrene  may  follow  pulmonary  embolism  if  the  emboli  contain  septic  or 
putrefactive  bacteria,  secondary,  for  instance,  to  lateral  sinus  thrombosis,  the 
result  of  middle-ear  disease.  Finally,  pulmonary  gangrene  may  result  from 
penetrating  wounds  of  the  lung,  or  from  the  spread  of  infection  from  the  pleura, 
peritoneum,  or  pericardium,  to  the  tissue  of  the  lungs. 

Gangrene  of  the  lung  is  characterized  by  great  prostration,  irregular  fever, 
cough,  and  in  most  cases  the  expectoration  of  copious  fluid  and  frothy  sputum 


288  GANGRENE     OF     THE     LUNG 

of  disgusting  odour.  The  sputum  settles  into  three  laj^ers  on  standing,  and  the 
lowermost  of  these  will  be  found  to  contain  fragments  of  elastic  tissue.  Severe 
haemoptysis  from  gangrenous  erosion  of  a  blood-vessel  may  be  noted  in  chronic 
cases.  In  a  minority  of  instances  the  sputum  lacks  the  indescribable  but 
characteristic  fcetor,  and  this  is  often  est  so  in  the  pulmonary  gangrene  of 
diabetic  patients  and  of  children.  The  physical  signs  of  gangrene  of  the  lungs 
are  in  no  wa}^  distinctive  ;  more  or  less  extensive  consolidation  or  infiltration 
of  the  affected  part  Avill  be  indicated  early  in  the  disease,  and  later,  when  the 
gangrenous  tissue  has  softened  and  been  expectorated,  the  signs  of  a  cavity 
ma}'  appear.  Occurring  as  a  terminal  event,  shortly  before  the  death  of  an 
exhausted  and  debilitated  patient,  pulmonary  gangrene  may  not  be  suspected, 
and  so  msLy  escape  detection. 

As  a  rule,  however,  the  diagnosis  presents  no  great  difficulty,  being  suggested 
by  the  supervention  of  copious  and  highly  offensive  expectoration  in  a  patient 
known  to  be  suffering  from  one  or  another  of  the  diseases  already  mentioned. 
The  gangrene  may,  however,  be  simultaneous  with  the  development  of  an 
aspiration-pneumonia,  and  this  condition  may  therefore  be  more  fully  con- 
sidered. As  already  mentioned,  aspiration-pneumonia  is  often  set  up  by  the 
entry  of  a  foreign  body  into  the  trachea  or  into  a  bronchus';  it  may  follow 
stenosis  of  a  bronchus  from  any  cause  such  as  syphilis,  the  pressure  of  an 
aneurj'sm  or  of  a  new  growth ;  it  may  result  from  the  establishment  of  a 
fistula  leading  from  the  oesophagus  to  the  trachea  or  a  bronchus,  as  may 
happen  as  a  terminal  event  in  malignant  disease  of  the  air-passages  or 
oesophagus  ;  it  is  seen  in  patients  with  spreading  infections  of  the  mouth, 
pharynx,  or  larynx  ;  it  occurs  in  the  insane,  or  in  persons  with  extensive 
laryngeal  or  bulbar  paralj^sis  who  are  constantly  exposed  to  the  danger  of 
swallowing  food  directly  into  their  air-passages  ;  and  it  is  observed  occasion- 
ally after  operations,  particularly  those  on  the  mouth,  pharynx,  larynx,  or 
trachea,  when  infective  matter  has  made  its  way  into  the  bronchi  while  the 
patient  was  under  the  influence  of  a  general  anaesthetic.  In  patients  with 
pycsmia,  gangrene  of  the  lung  due  to  the  establishment  of  multiple  embolic 
pulmonary  abscesses  would  be  suggested  if  the  patient  should  develop  the 
signs  of  pulmonary  consolidation,  cough,  and  offensive  expectoration.  Similar 
symptoms  occurring  after  wounds  or  contusions  of  the  lungs  would  make  the 
same  diagnosis  highly  probable. 

Greater  difficulty  is  experienced,  however,  in  deciding  the  question  whether 
or  no  gangrene  of  the  lung  has  occurred  in  a  patient  suffering  from  bronchiectasis, 
foetid  bronchitis,  chronic  pulmonary  tuberculosis  with  cavity  formation,  or  putrid 
empyema  discharging  through  the  lung,  in  whom  the  expectoration  of  highly 
offensive  sputum  was  already  present.  To  some  extent  the  question  is  then 
mainh'  of  academic  interest.  Elastic  fibres  and  shreds  of  pulmonary  tissue  may 
be,  and  often  are,  present  in  the  sputa  of  all  these  conditions  ;  but  they  are 
commonest,  and  present  in  greatest  amount,  in  pulmonary  gangrene.  Again, 
the  onset  of  pulmonary  gangrene  is  often  acute,  and  is  accompanied  by  much 
prostration,  no  doubt  due  to  septic  absorption  ;  these  facts,  coupled  with  evidence 
of  the  appropriate  changes  in  the  physical  signs  of  the  patient's  lungs,  should  be 
of  assistance  in  arriving  at  the  diagnosis. 

Pulmonarjr  gangrene,  as  already  stated,  may  occur  so  soon  before  death  as 
to  be  unsuspected.  In  a  few  instances  the  sputum  is  not  foetid.  In  other  cases, 
particularly  when  it  occurs  in  children,  the  gangrene  may  lead  to  no  expectoration 
at  all.  Under  these  circumstances  the  diagnosis  is  impossible,  and  the  gangrene 
of  the  lung  may  be  described  as  latent.  A.  J.  J  ex-Blake. 

GIDDINESS.— (See  Vertigo.) 


GLYCOSURIA  289 


GIRDLE  PAIN,  or  "  girdle  sensation,"  which  is  often  a  better  description 
of  the  phenomenon,  is  a  sense  of  constriction,  sometimes  of  painful  constriction, 
as  though  a  tight  band  encircled  the  trunk.  The  band  may  be  narrow  or  broad, 
and  may  be  referred  to  any  level  of  the  thorax  or  abdomen.  Although  a  common 
symptom  of  tabes,  it  is  not  pathognomonic  of  that  disease,  and  may  occur  with 
any  morbid  condition  involving  symmetrically  the  posterior  spinal  roots,  such 
as  syphilitic  spinal  meningitis. 

Another  form  of  girdle  sensation,  having  a  different  pathological  basis,  is 
often  described  by  patients  suffering  from  spastic  paraplegia  due  to  focal  disease 
within  or  outside  the  dorsal  region  of  the  spinal  cord.  In  such  a  case  the  tight 
feeling  is  found  to  correspond  with  the  highest  level  of  spasticity,  sometimes 
to  the  highest  level  of  sensory  loss.  Thus  a  girdle  sensation  may  be  a  symptom 
of  disseminated  sclerosis,  of  myelitis,  or  of  compression  paraplegia.  In  the  last 
it  may  help  the  physician  to  localize  the  level  of  the  disease,  but  it  is  rarely  so 
reliable  for  this  purpose  as  the  information  which  can  be  obtained  from  a  careful 
investigation  of  the  distribution  of  motor  and  sensory  paralysis,  and  of  the 
superficial  reflexes  (see  Paraplegia).  e.  Farquhar  Buzzard. 

GLANDS,  LYMPHATIC,  ENLARGEMENT  OF.—  (See  Lymphatic  Gland 
Enlargement.) 

GLYCOSURIA.  —  The  diagnosis  of  glycosuria  falls  naturally  into  two 
divisions  : — (I)  The  recognition  of  glucose  in  the  urine;  and  (II)  The  inference 
as  to  the  disorder  with  which  it  is  associated. 

I. — -The  Recognition    of  Glucose  in  the  Urine. 

The  following  are  the  more  important  chemical  tests  for  the  presence  of 
dextrose  in  the  urine  : — 

1.  Trommer's  Test. — This  and  the  two  succeeding  tests,  which  are  modifica- 
tions of  it,  depend  on  the  power  possessed  by  glucose  of  reducing  alkaline  solu- 
tions of  salts  of  copper  with  formation  of  red  oxide  of  copper.  To  perform 
Trommer's  test,  a  small  amount  of  solution  of  potassium  hydrate  is  poured  into 
a  test-tube  (say  -^-in.  depth),  and  to  it  are  added,  first  a  few  drops  of  solution  of 
copper  sulphate,  which  will  produce  a  precipitate  of  copper  hydrate,  and  secondly 
a  small  quantity  of  the  suspected  urine.  On  boiling  the  mixture,  if  glucose  be 
present  a  red  precipitate  or  suspension  of  cuprous  oxide  appears  ;  while  if  glucose 
is  absent,  black  cupric  oxide  is  formed  instead. 

2.  Fehling's  Test. — This  is  Trommer's  test  modified  by  the  addition  of 
sodio-potassic  tartrate,  which  holds  the  black  oxide  of  copper  in  solution.  Two 
solutions  are  prepared  as  follows  :  (i)  Dissolve  36'64  grams  of  copper  sulphate 
crystals  in  distilled  water  and  make  up  to  500  c.c.  ;  (ii)  Dissolve  125  grams 
potassic  hydrate  and  173  grams  sodio-potassic  tartrate  (Rochelle  salt)  in  distilled 
water  and  make  up  to  500  c.c.  These  two  fluids  should  be  kept  in  separate 
stoppered  bottles.  For  use,  take  equal  quantities  of  each  (say  \-m.  deep  in  a 
test-tube),  mix  and  boil.  Add  to  the  hot  fluid  a  few  drops  of  boiling  urine. 
If  glucose  is  present  a  red  suspension  of  cuprous  oxide  is  formed  ;  if  it  is  absent, 
the  fluid  retains  its  blue  colour. 

3.  Pavy's  Test. — This  is  practically  the  same  as  Fehling's,  with  the  exception 
that  a  certain  amount  of  ammonia  is  added,  to  retain  the  red  oxide  of  copper  in 
solution.  The  solution  is  made  thus  :  Copper  sulphate,  4- 16  grams  ;  sodio-potassic 
tartrate,  20-4  grams  ;  strong  solution  of  ammonia,  300  c.c.  ;  and  distilled  water 
to  I  litre.  On  boiling  this  with  urine  containing  glucose  it  is  decolorized.  The 
blue  colour  returns  on  contact  with  the  air.  This  test  is  seldom  used  except  for 
quantitative  purposes  (see  below). 


290  GLYCOSURIA 


Sources  of  Error  in  the  Above  Tests. — Error  may  be  caused  by  the  presence  in 
the  urine  of  other  bodies  besides  glucose  which  have  the  power  of  reducing 
copper  salts.  The  most  important  of  these  are  Lactose  and  Pentose.  Both  of 
these  sugars  form  "  osazone  "  crv-stals  with  phenyl- hydrazine,  but  they  do  not 
ferment  with  yeast.  Pentoses  give  a  chern,--red  colour  when  heated  with  hydro- 
chloric acid  and  a  little  phloroglucin.  Thej-  also  react  with  the  following  solutions 
(Bial's  Test)  :  Orcin,  i  gram  ;  lO  per  cent  solution  of  ferric  chloride,  25  drops; 
and  strong  hydrochloric  acid,  500  c.c.  On  heatings  c.c.  of  the  urine  with  loc.c. 
of  this  solution  a  greenish-blue  colour  is  produced,  and  finally  a  precipitate  of 
this  colour  is  formed. 

Other  substances  which  may  cause  error  in  testing  with  Fehling's  solution  are 
Glycuronic  Acid,  Uric  and  Hippuric  Acids,  Xanthin,  Creatinin,  and  Alkapton. 
They  do  not,  however,  as  a  rule,  produce  more  than  a  dull  greenish-yellow 
precipitate,  instead  of  the  golden  colour  given  with  glucose.  They  are  none  of 
them  fermented  hy  5'east.  Glycuronic  acid  gives  the  reactions  described  as 
characteristic  of  pentose.  Alkaptonuria  is  suggested  by  the  dark  colour  of  the 
urine  (see  Urine,  Abxormal  Coloration  of).  The  reduction  sometimes  seen 
on  testing  the  urine  of  patients  who  have  been  taking  certain  drugs,  such  as 
morphine,  chloroform,  chloral,  salol,  camphor,  phenazone,  benzoic  acid,  or 
carbolic  acid,  is  probably  due  to  glycuronic  acid. 

If  the  urine  to  be  tested  for  glucose  by  means  of  the  copper-reduction  method 
contains  anj-  large  amount  of  albumin,  this  should  be  removed  first  by  boihng 
and  filtration.  If  the  urine  be  ammoniacal,  FehHng's  test  ma^-  be  unwittingly 
converted  into  Pavy's,  and  decolorization  be  produced  instead  of  a  red  precipi- 
tate. Strongly  alkahne  urine  should  therefore  be  rendered  slightly  acid  with 
acetic  acid. 

4.  Bottger's  Test. — Put  a  small  quantity  of  urine  (freed  if  necessary  from 
albumin)  into  a  test-tube,  and  add  an  equal  quantity  of  liquor  potassae  and  a 
couple  of  grains  of  bismuth  subnitrate  (as  much  as  will  lie  on  the  point  of  a  small 
penknife).      On  boiling,  a  black  precipitate  is  formed. 

5.  Nylander's  Test. — Make  up  the  following  solution  :  Bismuth  subnitrate, 
2  grams  ;  sodio-potassic  tartrate,  4  grams  ;  caustic  soda  solution  (sp.gr.  i"i2), 
to  100  c.c.  On  boiling  5  c.c.  urine  containing  glucose  with  5  or  10  drops  of  this 
solution  a  black  precipitate  is  formed.  Glycuronic  acid,  pentose,  and  lactose 
also  reduce  bismuth. 

6.  Moore's  Test. — Put  a  small  quantity  of  urine  into  a  test-tube,  add  an 
equal  amount  of  liquor  potassce,  and  boil.  If  sugar  is  present,  a  dark-brown 
colour  is  produced  and  gradually  deepens  to  an  almost  black  tint.  This  test  is 
not  of  much  value,  as  it  requires  the  presence  of  a  considerable  percentage  of 
sugar,  and  a  dark  colour  may  be  produced  by  other  substances,  such  as  indican 
and  alkapton. 

7.  Picric  Acid  Test. — Pour  about  5  c.c.  of  urine  into  a  test-tube  ;  add  2  c.c. 
of  saturated  solution  of  picric  acid  in  water  and  a  few  drops  of  liquor  potassae, 
and  boil.  A  dark-brown  colour  is  produced  if  glucose  be  present.  This  test  also 
is  of  Uttle  value,  as  a  dark  colour  is  produced  also  by  lactose,  and  even  by 
creatinin  ;  while  impure  picric  acid  alone  may  darken  on  boiling. 

S.  Plienyl-hydrazine  Test.— Fill  a  test-tube  about  a  quarter  full  of  urine,  and 
add  as  much  phenyl-hydrazine  as  will  lie  on  the  point  of  the  large  blade  of  a 
penknife,  and  a  rather  larger  amount  of  sodic  acetate.  Boil  some  water  in  a 
beaker,  and  place  the  test-tube  in  this  for  half  an  hour.  Then  remove  it,  and 
allow  it  to  cool.  If  glucose  be  present,  cr\-stals  of  phenyl-glucosazone  will  form 
in  the  shape  of  sheaves  of  bright  yellow  needles  as  seen  under  a  low  power  of  the 
microscope.  Other  sugars,  such  as  lactose  and  pentose,  as  well  as  glycuronic 
acid,   form  cr>-stals  with  this  test.     These   differ  somewhat  in  shape,  phenyl- 


GLYCOSURIA  291 


lactosazone  for  example  being  shorter,  and  rather  in  the  form  of  bundles  than  of 
sheaves.  The  melting-points  of  the  different  compounds  also  differ.  Glycuronic 
acid  usually  gives  rise  to  an  amorphous  precipitate,  or  scales,  not  to  crystals. 
The  urine  to  be  tested  should  be  free  from  albumin. 

9.  Safranin  Test. — Place  in  a  test-tube  about  a  -J-inch  of  urine  (free  from 
albumin)  ;  add  equal  quantities  of  liquor  potassse  and  of  solution  of  safranin 
(i-iooo).  A  dark-red  fluid  is  produced,  which  turns  yellow  or  brownish  on 
boiling  if  glucose  be  present.  This  test  is  seldom  used,  but  appears  to  be  a 
sure  indication  of  the  presence  of  glucose  (Bedford). 

10.  Fermentation  Test. — Boil  some  urine  (200  c.c.)  in  a  beaker,  and  allow  it 
to  cool.  Then  stir  into  it  a  piece  of  yeast  about  the  size  of  a  small  cherry,  till  it 
is  thoroughly  mixed.  Alkaline  urine  should  first  be  rendered  acid  with  a  few 
drops  of  acetic  acid.  Fill  the  graduated  limb  of  a  ureometer  with  the  fluid, 
and  let  it  stand  for  twenty-four  hours  in  a  warm  place.  If  glucose  is  present, 
carbon  dioxide  gas  will  be  formed  and  will  accumulate  at  the  top  of  the  tube. 
If  carefully  performed,  this  test  is  a  certain  indication  of  the  presence  of  glucose. 
A  small  amount  of  fermentation  may  be  produced  by  bacterial  action  on  other 
sugars,  but  by  boiling  the  urine  this  error  is  eliminated.  Laevulose  may  also 
ferment  with  yeast,  but  its  presence  in  urine  is  so  exceptional  that  it  may  practi- 
cally be  disregarded.  A  rough  indication  of  the  amount  of  sugar  present  may 
be  gained  by  taking  the  specific  gravity  of  the  urine  after  fermentation,  and 
comparing  it  with  that  of  a  specimen  kept  under  similar  conditions  but  without 
yeast.  It  is  said  that  a  fall  of  one  point  in  the  specific  gravity  takes  place  for 
every  grain  of  sugar  per  ounce  of  urine  ;  but  this  mode  of  quantitation  is  very 
inaccurate. 

Quantitative  Measurement  of  the  glucose  present  may  be  made  by  either 
Fehling's  or  Pavy's  fluid. 

If  Fehlitig's  Fluid  is  used,  10  c.c.  of  the  mixed  fluid  (i.  and  ii. )  are  placed 
in  a  porcelain  dish  along  with  about  40  c.c.  of  distilled  water,  and  heated  to 
boiling  over  a  flame.  A  burette  is  filled  up  to  a  known  mark  with  the  urine, 
diluted  to  i  in  10  (10  c.c.  in  90  c.c.  of  distilled  water),  and  this  is  allowed  to  run 
slowly,  a  few  drops  at  a  time,  into  the  boiling  fluid,  which  is  stirred  meanwhile 
with  a  glass  rod.  A  precipitate  of  red  oxide  of  copper  forms,  and  the  blue 
colour  is  gradually  discharged.  When  this  has  completely  disappeared,  the 
quantity  of  diluted  urine  is  read  off  ;  and  the  amount  of  sugar  in  this  is  known 
to  be  0'05  gram.  Suppose  that,  for  example,  8  c.c.  of  urine  diluted  to  i  in  10  have 
been  used  ;  then  8  c.c.  of  undiluted  urine  will  contain  10  x  0'05  gram  glucose, 
or  o'5  gram.  Knowing  this,  the  percentage  of  sugar  is  easily  calculated  to  be 
0"5  X  100-=- 8,  or  6-25  per  cent. 

The  method  of  using  Pavy's  Solution  is  similar,  with  the  exception  that  it  must 
be  boiled  in  a  closed  flask,  and  the  nozzle  of  the  burette  connected  to  this  by  a 
piece  of  tubing  which  passes  through  the  cork  of  the  flask.  The  complete 
reduction  of  the  copper  is  known  by  the  decolorization  of  the  fluid.  Ten  c.c. 
of  Pavy's  solution  are  equivalent  to  0-005  gram  sugar  (it  is  thus  only  one-tenth 
the  strength  of  Fehling's). 

The  Polarimeter  may  also  be  used  for  quantitative  estimation  of  glucose  ;  but 
as  the  instrument  is  not  likely  to  be  available  in  ordinary  medical  practice,  it 
will  not  be  described  here. 

II. — Diagnostic   Importance   of   Glucose   in   the   Urine. 

In  the  great  majority  of  instances,  if  glycosuria  persists  for  any  length  of 
time — e.g.,  if  sugar  is  found  in  the  urine  at  frequent  examinations  during  six 
weeks  or  two  months — the  patient  is  suffering  from  some  form  of  diabetes 
mellitus.     Two  main  varieties  may  be  distinguished  : — 


292  GLYCOSURIA 


1.  True  or  Acute  Diabetes. — This  occurs  usually  in  youngish  subjects  ;  the 
urine  is  largely  increased  in  amount,  and  the  condition  is  accompanied  by 
muscular  weakness,  wasting,  marked  thirst,  and  increased  appetite.  The  face 
may  be  flushed,  and  the  tongue  often  looks  large  and  deep-red  in  colour.  The 
amount  of  sugar  in  the  urine  is  but  slightly  influenced  by  diet.  As  the  disease 
advances,  acetone,  diacetic  acid,  and  oxybutyric  acid  make  their  appearance  in 
the  urine.  (See  Acetonuria.)  The  knee-jerks  are  lost.  Death  finally  occurs, 
usually  within  two  or  three  years  of  the  occurrence  of  the  first  symptoms,  in  a 
condition  of  coma.  It  may  be  hastened  by  the  supervention  of  acute  pneumonia, 
or  of  a  rapidly  progressive  tuberculosis  of  the  lungs. 

2.  Chronic  Glycosuria. — This  occurs  in  elderly  subjects,  who  are  often  obese, 
and  may  show  gouty  tendencies.  The  urine  is  not  markedly  increased  in  amount , 
and  does  not  contain  acetone  bodies.  The  amount  of  sugar  present  is  consider- 
ably reduced  by  strict  dieting.  There  is  no  wasting,  and  little  alteration  of 
thirst  or  appetite. 

Forms  of  intermediate  severity  are  met  with,  the  rapidity  of  the  progress  of 
the  disease  diminishing  somewhat  as  age  advances. 

There  are  a  few  conditions  associated  with  temporary  glycosuria  which 
have  to  be  distinguished  from  true  diabetes.  The  following  are  the  most 
important  : — 

1.  Cerebral  Injuries,  Haemorrhage,  and  Tumours  may  be  associated  with 
glycosuria.  In  the  case  of  cerebral  tumours  the  glycosuria  may  persist  till 
death,  and  is  by  some  writers  described  as  diabetes  due  to  this  affection.  It  will 
usually,  however,  be  associated  with  the  cardinal  signs  of  cerebral  tumour — 
headache,  vomiting,  and  optic  neuritis.  None  of  these  are  common  in  diabetes, 
though  optic  neuritis  may  occur.  If  a  patient  is  seen  for  the  first  time  during 
the  coma  which  is  caused  by  a  cerebral  haemorrhage  or  injury,  the  presence  of 
glycosuria  may  lead  to  a  mistake  in  diagnosis.  It  must  be  borne  in  mind  that 
in  diabetic  coma  there  are  usually  acetone  bodies  present  in  the  urine  ;  also 
that  cerebral  haemorrhage  is  most  often  seen  in  elderly  subjects,  diabetic  coma 
in  younger  persons,  and  that  the  amount  of  sugar  found  in  cases  of  cerebral 
disease  is  not  as  a  rule  large. 

2.  In  Alcoholic  Subjects  considerable  quantities  of  sugar  may  occur  in  the 
urine  and  persist  for  some  weeks,  and  may  yet  disappear  entirely  on  careful 
dieting  and  complete  abstinence  from  alcoholic  liquors.  This  condition  may  be 
due  to  disturbance  of  the  pancreatic  or  hepatic  functions  by  the  poison,  and  may 
really  be  an  early  stage  of  true  diabetes,  which  is  amenable  to  treatment.  It  is 
well,  therefore,  not  to  make  a  diagnosis  of  incurable  diabetes  in  an  alcoholic 
subject  until  the  effects  of  careful  regime  have  been  noted. 

3.  Pancreatic  Disease,  acute  and  chronic,  may  be  accompanied  by  glycosuria. 
Pancreatic  haemorrhage  and  acute  pancreatitis  are  signalized  by  severe  pain  in 
the  upper  part  of  the  abdomen,  constipation,  vomiting,  and  collapse — in  short, 
by  symptoms  suggestive  of  acute  intestinal  obstruction.  In  only  a  minority  of 
these  cases  does  sugar  appear  in  the  urine  ;  when  it  does,  it  is  an  important  aid 
in  diagnosis  of  the  affection  present.  In  chronic  pancreatitis — as  also  in  some 
cases  of  gall-stones,  in  which  this  condition  is  probably  present — glycosuria  is 
encountered  ;  indeed,  the  condition  may  go  on  to  true  and  fatal  diabetes.  Wast- 
ing, pigmentation  of  the  skin,  repeated  rigors,  and  the  passage  of  undigested 
meat-fibres  and  of  an  increased  quantity  of  fat  (especially  neutral  or  unsplit  fats) 
in  the  faeces,  accompany  this  form  oif  pancreatic  disease.  Jaundice  is  often 
a  marked  symptom. 

4.  Other  conditions  in  which  small  quantities  of  sugar  may  be  found  in  the 
urine  are  Graves'  Disease,  Starvation,  and  so-called  Alimentary  Glycosuria,  in 
which  glucose  is  excreted  after  meals  containing  large  quantities  of  this  substance 


HMMA  TEMESIS  29  3 


or,  more  rarely,  of  starchy  food.     These  conditions  should  not  lead  to  difficulties 
of  diagnosis. 

It  is  well  to  bear  in  mind  that  the  onset  of  true  diabetes  may  be  signalized  by 
the  transitory  appearance  of  glucose  in  the  urine.  This  symptom  may  disappear 
once  or  twice,  with  or  without  special  treatment,  but  may  finally  return  and 
persist.  This  occurrence  may  be  observed  sometimes  in  connection  with  preg- 
nancy, sugar  being  found  in  the  urine,  or  increased  thirst  and  appetite  noted 
along  with  polyuria,  the  patient  subsequently  regaining  her  health  ;  then,  at  a 
subsequent  pregnancy,  the  symptoms  may  recur  and  persist. 

W.  Cecil  Bosanquet. 

GOITRE. — (See  Thyroid  Gland   Enlargement.) 

GRINDING  OF  THE  TEETH  DURING  SLEEP  is  a  symptom  which  troubles 
the  patient  little,  but  may  considerably  disturb  those  who  sleep  with  him. 
In  itself  it  is,  however,  a  symptom  of  little  importance.  It  is  popularly  held 
that  grinding  of  the  teeth  at  night,  especially  in  children,  is  an  indication 
of  the  presence  of  intestinal  worms,  particularly  of  the  Oxyuris  vermicularis  ; 
it  would  be  well,  therefore,  to  have  the  faeces  examined  in  all  cases  of  the  kind, 
both  for  parasites  and  for  their  ova.  The  popular  belief  of  the  association 
of  intestinal  parasites  with  the  teeth-grinding  habit  is  seldom  verified  clinically, 
however,  and  the  habit  may  be  very  bad  and  persistent  in  children,  or  even 
adults,  who  are  in  perfect  health.  Very  often  it  is  rather  a  rattUng  of  the  upper 
teeth  against  the  lower,  owing  to  lateral  movements  made  by  the  lower  jaw 
as  the  patient,  when  half  roused,  turns  over  in  bed  ;  actual  gritting  of  the 
teeth  during  sleep  is  far  less  common.  It  is  possible  that  in  its  beginning 
there  was  a  gumboil  or  other  local  irritation  which  led  to  jaw-movements 
that  persisted  as  habitual  grinding  of  the  teeth  long  after  the  primary  cause 
was  gone.  Herbert  French. 

GUMS,  BLEEDING (See  Bleeding  Gums.) 

GUMS,  RETRACTION  OF.— (See  Retraction  of  Gums.) 

GUMS,  SPONGY.— (See  Bleeding  Gums.) 

HiEMATEMESIS.  —  This  term  indicates  vomiting  of  blood.  It  has  to  be 
differentiated  from  haemoptysis,  but  the  distinction  is  not  difficult  if  the 
following  points  are  remembered  : — • 

In  haematemesis  the  blood  is  vomited,  and  in  consequence  may  be  mixed  with 
particles  of  partly-digested  food  ;  it  is  usually  dark  in  colour,  but  if  the  haemor- 
rhage is  considerable,  the  blood  may  be  bright  red  and  liquid,  or  slightly  altered 
in  colour,  and  in  clots  ;  if  the  haemorrhage  has  been  gradual  and  the  blood  has 
remained  for  some  time  in  the  stomach,  it  becomes  of  a  dark  brownish  colour, 
and  has  been  likened  in  appearance  to  coffee  grounds,  the  cause  of  this  alteration 
being  the  action  of  the  gastric  juice,  which  converts  the  oxj^hsmoglobin  into 
hasmatin  ;  it  may  be  acid  in  reaction.  In  haemoptysis  the  blood  is  coughed  up  ; 
the  first  indication  may  be  a  tickling  or  gurgling  sensation  in  the  throat  and  a 
saltish  taste  in  the  mouth  ;  the  amount  of  blood  may  vary  from  a  few  streaks 
to  a  pint  or  more  ;  it  is  bright  red  in  colour,  and  often  frothy  from  admixture 
with  air  ;  it  is  usually  liquid  when  expectorated,  but  it  may  coagulate  in  the 
vessel  which  receives  it  ;  it  is  alkaline  in  reaction  ;  it  may  be  mixed  with 
sputum  which  may  consist  chiefly  of  mucus  or  muco-pus  ;  if  the  haemoptysis 
is  very  profuse,  the  blood  may  pour  out  of  the  mouth  in  a  stream  and  rapidly 
prove  fatal  ;  when  haemoptysis  has  occurred,  the  sputum  may  be  blood-stained 
for  several  days  afterwards  ;    at  first  it  is  bright  red,  but  subsequently  becomes 


294 


HMMA  TEMESIS 


darker  and  assumes  a  brownish,  tinge.     For  a  tabular  summary  of  the  points 
of  distinction  between  hsematemesis  and  hEemoptysis  see  Hemoptysis. 

Having  arrived  at  the  conclusion  that  the  patient  is  suffering  from  heemat- 
emesis,  the  next  point  is  to  determine  the  cause. 


Bleeding  from  the  mouth  and  throat 
Malingering. 


Causes  of  Hematemesis 

A.  Swallowed  Blood. 

Epistaxis 
Haemoptysis 

B.  Diseases  of  the  (Esophagus  : — 

Epithelioma 

Aortic  aneurysm  rupturing  into  the  oesophagus 

Rupture  of  varicose  oesophageal  veins 

Mediastinal  growth  perforating  the  oesophagus  and  aorta 

Foreign  body  perforating  the  oesophagus  and  aorta. 

C.  Diseases  ol  the  Stomach : — 

Acute  gastritis 

Chronic  gastritis 

Toxic  gastritis 

Corrosive     poisons,     such     as 
strong  acids  or  alkalies 

Gastrointestinal  irritants,  such 
as  arsenic,  phosphorus,  anti- 
mony 

D.  Diseases  of  the  Duodenum  : — 

Ulcer 
Pancreatico-duodenal  fistula 

E.  Portal  Obstruction  : — 

Cirrhosis  of  the  liver 
Pylephlebitis   (adhesive) 
Pressure  on  the  portal  veins 
Chronic  heart  and  lung  disease 
Some  cases  of  enlarged  spleen. 
Acute  Febrile  Diseases  : — • 


Ulcer 

Gastrostaxis 
Haemorrhagic  erosions 
Carcinoma 
Injuries 
Atheroma 

Abdominal  aneurysm  opening  into 
the  stomach. 


Gall-stone    ulcerating 
denum 


quite  rarely. 


into    the    duo- 


F. 


Dengue 
Cholera 
Acute  yellow  atrophy. 


Hodgkin's  disease 
Chlorosis  (?) 
Pernicious  ansmia. 


Malignant  variola 

Malignant  scarlet  fever 

Malaria 

Yellow  fever 
Blood  Diseases : — 

Purpura. 

Scurvy 

Haemophilia 

Leukaemia 
Miscellaneous : — 

Chronic  Bright's  disease 

Following  abdominal  operation. 

It  may  be  said  at  once  that  there  are  only  three  common  causes  of  profuse 
haematemesis,  namely,  gastrostaxis,  gastric  ulcer,  and  cirrhosis  of  the  liver.  The 
differential  diagnosis  between  these  is  by  no  means  always  easy.  The  older 
the  patient  and  the  greater  the  history  of  alcoholism,  the  more  likely  is  the 
symptom  to  be  due  to  cirrhosis  of  the  hver  ;  at  this  stage  of  the  malady  there 
may  be  neither  jaundice  nor  ascites,  but  the  liver  may  be  felt   enlarged  and 


G. 


H. 


HMMA  TEMESIS  295 


unduly  firm,  and  the  spleen  may  also  be  palpable.  Hasmatemesis  in  a  young, 
ansemic  woman  is  more  likely  to  be  due  to  gastrostaxis  than  to  ulcer,  whereas  in 
older  patients,  especially  in  males,  gastric  or  duodenal  ulcer  is  the  probable 
diagnosis  if  cirrhosis  can  be  excluded.  The  distinction  between  gastrostaxis 
and  gastric  ulcer  often  becomes  one  of  opinion  only  unless  operation  is  resorted 
to.  The  longer  the  preceding  history  of  gastric  symptoms,  and  the  more 
definitely  localized  the  epigastric  pains,  the  more  likely  does  ulcer  become. 
The  diagnosis  is  often  arrived  at  quickly  enough,  but  sometimes  a  routine 
discussion  of  all  the  possible  causes  is  required  :  so  that  we  will  take  each  of  the 
above  groups  in  turn. 

A.  Swallowed  Blood. 

Epistaxis. — If  there  is  obvious  bleeding  from  the  nose  as  well  as  hsematemesis, 
the  probability  would  be  that  some  of  the  blood  had  trickled  down  the  posterior 
nares  into  the  pharynx,  and  had  been  swallowed  and  subsequently  vomited.  It 
should  be  remembered,  however,  that  the  two  commonest  causes  of  epistaxis 
in  adults  are  cirrhosis  of  the  liver  and  chronic  interstitial  nephritis,  so  that  the 
possibility  of  bleeding  having  occurred  from  the  stomach  as  well  as  from  the 
nose  would  have  to  be  considered.  If  a  moderate  degree  of  epistaxis  has  taken 
place  during  the  night,  blood  may  have  been  swallowed  unconsciously.  In 
some  cases  in  which  no  blood  has  come  from  the  anterior  nares,  examination 
may  reveal  blood  trickling  from  the  posterior  nares,  and  the  epistaxis  may 
become  evident  if  the  patient  blows  his  nose. 

HcBinoptysis. — When  blood  comes  from  the  air-passages,  some  of  it  may  flow 
back  into  the  pharynx  and  be  swallowed,  especially  if  the  haemorrhage  occurs 
during  sleep.  If  the  patient  has  a  cough,  or  expectorates  blood-stained  sputum 
and  presents  signs  of  chronic  pulmonary  disease,  the  possibility  of  swallowed 
blood  must  be  considered  as  a  cause  of  the  hsematemesis,  though  difficulties 
may  arise  in  forming  a  correct  conclusion,  for  cirrhosis  of  the  liver,  for  instance, 
is  not  infrequently  complicated  by  phthisis,  and  so  on. 

Bleeding  from  the  Mouth  and  Throat.- — The  gums,  tongue,  and  fauces  should 
be  examined  carefully,  as  blood  from  any  of  these  sources  may  be  swallowed 
and  later  vomited.  Bleeding  from  the  gums  is  most  likely  to  occur  when  they  are 
spongy,  as  in  scurvy  or  mercurial  stomatitis. 

Malingering. — The  possibility  of  blood  having  been  drunk  in  secret  and 
afterwards  vomited  with  intent  to  deceive  must  be  considered  in  some  cases 
when  no  cause  can  be  found  to  account  for  its  occurrence.  Should  fraud  be 
suspected,  it  may  generally  be  detected  by  careful  observation.  The  red 
corpuscles  should  be  examined  microscopically  in  case  the  oval  corpuscles  of 
a  bird  may  reveal  their  extraneous  source. 

B.  Diseases  of  the  (Esophagus. 

Epithelioma. — Haemorrhage  is  rare  in  the  commonest  form  of  epithelioma  of 
the  oesophagus  which  leads  to  an  annular  stricture,  but  it  may  occur  as  the 
result  of  the  ulcerative  form  of  the  disease  from  erosion  of  small  blood-vessels, 
the  amount  of  blood  which  is  brought  up  being  small.  When  the  ulceration  is 
deeper  and  more  extensive,  it  may  finally  lead  to  perforation  of  a  larger  vessel, 
even  the  aorta,  a  condition  which  causes  sudden,  profuse,  and  rapidly  fatal 
haemorrhage.  The  diagnosis  of  this  cause  does  not,  as  a  rule,  give  rise  to  much 
difficulty.  Dysphagia  is  the  earliest  symptom  in  nearly  all  the  cases,  and  it  is 
generally  progressive  unless  a  good  deal  of  ulceration  occurs  to  re-open  the 
passage.  The  first  difficulty  is  in  swallowing  ordinary  food,  then  soft  food 
will  not  go  down,  and  finally,  as  the  growth  closes  up,  even  fluids  are  regurgitated 
as  soon  as  an  attempt  is  made  to  swallow.  The  food  which  is  thus  regurgitated 
may  be  tinged  with  blood.     Rapid  emaciation  is  associated  with  the  dysphagia. 


296  HMMATEMESIS 


the  abdomen  becomes  flat  and  retracted,  and  in  some  cases  hard  and  enlarged 
cervical  glands  may  be  felt.  Pain  may  be  felt  at  any  attempt  to  take  food,  or 
it  may  be  persistent  and  severe.  One  or  other  recurrent  laryngeal  nerve  is 
involved  in  some  cases,  causing  paresis  or  paralysis  of  the  corresponding  vocal 
cord.  There  may  be  some  difficulty  in  differentiating  this  condition  from  an 
aneurysm  of  the  aorta  pressing  on  the  oesophagus,  and  here  the  value  of  ;i^-rays 
in  examining  the  chest  is  very  great.  Even  without  using  any  bougie,  the 
fact,  and  the  site  of  oesophageal  stenosis  can  be  demonstrated  by  watching  the 
passage  of  capsules  containing  bismuth  oxycarbonate,  whilst  an  aortic  aneurysm 
which  obstructs  the  oesophagus  is  nearly  always  large  enough  to  present  a 
distinctive  pulsatile  ;r-ray  shadow. 

Aneurysm  of  the  Thoracic  Aorta  opening  into  the  (Esophagus . — An  aneurysm  of 
the  descending  thoracic  aorta  compressing  the  oesophagus,  may  finally  erode 
and  open  into  it,  with  profuse  and  fatal  haematemesis.  Such  cases  may  be  very 
difficult  to  distinguish  from  epithelioma  of  the  oesophagus,  and  the  danger  of 
passing  a  bougie  is  obvious.  Hence  the  great  value  of  the  ;ir-rays,  as  mentioned 
just  now.  An  aneurysm  situated  in  such  a  position  that  it  can  exert  pressure 
on  the  oesophagus,  is  more  likely  to  give  rise  to  subjective  symptoms  than  to 
physical  signs.  Syphilis  has  such  an  important  bearing  on  its  causation  that 
positive  evidence  of  lues,  especially  if  treatment  has  been  insufficient,  would 
be  in  favour  of  a  diagnosis  of  aneurysm.  Syphilitic  stricture  of  the  oesophagus 
may  be  disregarded,  for  there  is  no  authentic  case  on  record.  Pain  in  the  back 
is  much  more  constant  and  severe  in  aneurysm  than  in  epithelioma,  and  it  is 
liable  to  sharp  and  paroxysmal  exacerbations.  The  bulge  is  generally  too  far 
along  the  aorta  to  cause  paralysis  of  the  left  vocal  cord.  Tracheal  tugging  will 
be  absent,  and  the  pulses  and  pupils  equal.  The  presence  of  pulsation  and  a 
bruit  in  the  back  over  the  seat  of  pain,  would  of  course  point  to  an  aneurysm, 
but  these  are  very  exceptional  signs.  The  most  common  effect  of  aneurysm 
of  the  descending  thoracic  aorta  is  to  obstruct  the  left  main  bronchus,  and  lead 
to  pain  in  the  left  side  of  the  thorax  behind,  with  impairment  of  percussion  note, 
together  with  crackling  rales,  and  deficient  voice  sounds,  vesicular  murmur, 
and  tactile  vocal  fremitus  in  the  left  lower  lobe.  These  pulmonary  effects  of 
aneurysm  in  this  part  of  the  aorta  should  never  be  forgotten. 

Rupture  of  Varicose  (Esophageal  Veins. — Varicose  veins  occur  in  the  lower  end 
of  the  oesophagus  as  a  result  of  portal  obstruction,  especially  that  form  which  is 
due  to  cirrhosis  of  the  liver,  and  the  rupture  of  such  veins  is  often  followed  by 
profuse  haematemesis.  It  is,  however,  practically  impossible  to  determine 
whether  the  blood  comes  from  the  lower  end  of  the  oesophagus  or  from  the 
stomach,  so  that  the  diagnosis  resolves  itself  into  one  of  cirrhosis  of  the  liver. 

Mediastinal  Growth  perforating  the  (Esophagus  and  Aorta. — Hsmatemesis  from 
this  cause  is  exceptionally  rare,  for  mediastinal  growth  is  by  no  means  a  common 
disease,  and  vomiting  of  blood  is  an  infrequent  complication  of  it.  Haemorrhage 
may  occur,  however,  if  the  growth  compresses  and  erodes  the  oesophagus.  It 
is  most  likely  to  be  mistaken  for  thoracic  aneurysm  or  epithelioma  of  the 
oesophagus.  The  tendency  of  new  growth  to  compress  and  invade  the  large 
veins,  leading  to  oedema  of  the  neck  and  upper  extremities,  cyanosis,  and  dilated 
superficial  veins,  is  characteristic,  and  serves  to  distinguish  it  from  aneurysm, 
in  which  severe  venous  obstruction  is  much  rarer.  The  following  case  of 
mediastinal  sarcoma  perforating  the  oesophagus  and  aorta  is  an  example  of 
hsmatemesis  from  this  cause  : — 

Michael  H.,  aged  30,  was  admitted  for  dyspnoea  and  pain  in  the  chest.  He  had 
suffered  from  several  attacks  of  what  had  been  considered  to  be  haemoptysis,  similar  to 
that  of  phthisis,  the  first  occurring  seven  months  before  his  admission.  He  was  found 
to  have  impairment  of  note,  with  diminished  breath-sounds,  over  the  whole  of  the  left 


H^MA  TEMESIS  297 


side  of  his  cliest.  About  a  month  after  his  admission  he  suddenly  brought  up  a  large 
quantity-  of  blood,  and  died.  At  the  post-mortem  examination,  the  stomach  and 
duodenum  were  full  of  blood.  There  was  a  large  sarcomatous  mediastinal  growth,  which 
had  surrounded  the  lower  end  of  the  oesophagus,  trachea,  and  aorta.  The  wall  of  the 
cBSophagus  at  the  level  of  the  bifurcation  of  the  trachea  had  been  destroyed,  and  the 
aorta  was  perforated  at  the  origin  of  the  left  subclavian  artery,  so  that  a  direct  com- 
munication between  the  oesophagus  and  the  aorta  had  been  established. 

Foreign  Body  perforating  the  (Esophagus  and  Aorta. — Copious  haemorrhage 
which  may  cause  death  may  be  produced  as  a  result  of  a  foreign  body,  such  as 
a  pin,  fish-bone,  or  tooth-plate,  perforating  both  the  oesophagus  and  some  large 
vessel,  or  even  the  aorta.  A  history  of  such  a  foreign  body  being  swallowed, 
followed  by  a  feeling  of  discomfort  in  the  oesophagus,  would  suggest  such  a 
condition,  which  might  be  confirmed  by  the  use  of  ;v-rays,  bougies,  or  the 
oesophagoscope. 

C.  Diseases  of  the  Stomach. 

Acute  Gastritis. — The  mucous  membrane  of  the  stomach  in  this  disease  is 
congested,  and  small  haemorrhages  and  erosions  may  be  present.  They  can  be 
seen  clearly  with  the  gastroscope.  The  haemorrhage  which  occurs  is  slight,  in 
the  form  of  streaks  of  blood  mixed  with  mucus  in  the  vomit,  and  it  hardly  merits 
the  appellation  haematemesis.  Acute  gastritis  is  caused  most  frequently  by 
errors  in  diet,  irritating  or  decomposing  foods,  alcohol,  corrosive  or  irritant 
poisons,  or  sepsis  from  septic  teeth,  stomatitis,  or  pyorrhoea  alveolaris.  The 
chief  symptoms  are  :  a  feeling  of  discomfort  and  tenderness  in  the  epigastrium, 
nausea,  eructations,  vomiting,  constipation  ;  and  in  children,  diarrhoea,  headache, 
a  feeling  of  depression,  furred  tongue,  foul  breath,  and  concentrated  urine. 

Chronic  Gastritis. — The  mucous  membrane  of  the  stomach  may  be  thickened 
and  congested  with  haemorrhagic  erosions  scattered  over  its  surface.  The 
vomit  usually  consists  of  a  good  deal  of  mucus,  and  occasionally  a  little  blood. 
It  may  follow  acute  gastritis,  but  most  frequently  is  caused  by  the  continual 
and  excessive  ingestion  of  alcohol,  tea,  coffee,  and  irritating  and  indigestible 
articles  of  diet.  The  main  symptoms  are  :  Tenderness  in  the  epigastrium 
aggravated  by  the  taking  of  food,  nausea,  vomiting — especially  in  the  early 
morning  if  due  to  alcohol — flatulence,  foul  breath,  a  furred  tongue  indented  by 
the  teeth  at  the  edges,  constipation,  concentrated  urine,  and  a  slight  degree  of 
pyrexia. 

Toxic  Gastritis  due  to  Corrosive  Poisons. — Strong  acids  or  alkalies  destroy  the 
mucous  membrane  of  the  stomach  as  well  as  injure  that  of  the  mouth,  throat, 
and  oesophagus.  More  or  less  constant  vomiting  of  blood  and  blood-stained 
mucus  is  one  of  the  most  prominent  symptoms,  and  it  may  be  associated 
with  intense  pain  in  the  mouth,  throat,  and  abdomen,  dysphagia,  pain 
and  tenderness  behind  the  lower  end  of  the  sternum  or  in  the  epigastrium, 
distention  of  the  abdomen,  collapse,  and  a  rapid,  feeble  pulse.  The  urine  may 
contain  blood  and  albumin  and,  if  the  poison  is  oxalic  acid,  crystals  of  oxalate 
of  lime.  If  corrosive  poisoning  is  suspected,  an  inspection  of  the  mouth  and 
pharynx  will  show  signs  of  corrosion,  and  an  examination  of  the  vomit  will 
furnish  evidence  of  the  nature  of  the  poison. 

Arsenic. — The  mucous  membrane  of  the  stomach  is  red,  inflamed,  partly 
detached,  and  covered  with  blood-stained  mucus.  The  chief  symptoms  are 
nausea,  violent  and  incessant  sickness,  burning  pain  in  the  epigastrium, 
diarrhoea,  faintness,  and  depression.  The  vomit  is  usually  a  brownish,  turbid 
fluid,  mixed  with  mucus  and  streaks  of  blood.  Later,  there  may  be  severe 
diarrhoea,  with  rice-water  stools.     Arsenic  may  be  detected  in  the  vomit. 

Phosphorus,  antimony ,  and  other  irritant  poisons  may  also  cause  inflammation 
of  the  mucous  membrane  of  the  stomach,  and  lead  to  slight  haematemesis. 


298  h.t:ma  temesis 


Gastric  Ulcer. — Haematemesis  is  the  most  important  sj-mptom  of  gastric  ulcer, 
though  it  occurs  in  only  about  50  per  cent  of  the  cases  both  in  the  acute  and 
chronic  forms  of  the  disease,  in  the  former  being  due  to  the  erosion  of  small 
vessels,  and  in  the  latter  to  the  ulcerative  process  extending  to  and  opening 
up  larger  gastric  vessels,  and  occasionally  even  the  pancreatic  or  splenic  artery. 
The  amount  of  blood  varies  within  wide  limits.  If  the  quantit}^  is  small,  or 
if  it  is  graduall}^  poured  out  into  the  stomach,  it  may  remain  there  a  sufficient 
time  for  the  acid  gastric  juice  to  act  on  it  and  convert  the  hsemoglobin  into 
hsmatin,  a  condition  which  gives  to  the  vomit  the  characteristic  dark-brown 

coffee-grounds  "  appearance.  In  some  cases  the  blood  is  not  vomited  but 
appears  in  the  stools  as  melaena.  If  a  medium  or  large  vessel  is  eroded,  the 
bleeding  may  be  very  copious,  a  quart  or  more  of  blood  being  vomited,  either 
liquid  and  arterial  in  colour  or  in  large  red  clots.  A  profuse  haemorrhage  causes 
sudden  pallor,  a  feeling  of  faintness,  restlessness,  syncope,  and  a  rapid,  feeble 
pulse.  It  is  rarely  fatal  unless  a  large  vessel  such  as  the  splenic  artery  has  been 
eroded.  Occasionally,  haematemesis  is  the  first  intimation  of  the  presence  of  a 
gastric  ulcer,  but  in  the  majority  of  cases  there  are  other  symptoms  and  signs 
which  have  preceded  it.  Clinically  it  is  a  disease  which  was  formerly  said 
to  occur  most  frequently  in  females,  especially  of  the  servant  class,  between 
the  ages  of  twent}^  and  thirty,  though  not  a  few  cases  diagnosed  as  gastric 
ulcer  are  probably  examples  of  gastrostaxis,  or  bleeding  from  a  spongy, 
oozing  mucosa,  without  any  definite  and  macroscopic  ulceration.  An  analysis 
of  loi  fatal  cases  showed  59  males  and  42  females.  Like  duodenal  ulcer,  it 
seems  to  be  commoner  in  the  North  of  England  than  in  the  South,  and  in  mining 
and  manufacturing  rather  than  in  rural  districts.  In  addition  to  haemat- 
emesis, the  signs  most  characteristic  of  gastric  ulcer  are  abdominal  pain,  nausea, 
vomiting,  and  melaena.  Pain  is  felt  in  the  epigastrium  just  below  the  ensiform 
cartilage  ;  it  usually  begins  a  few  minutes  after  the  ingestion  of  food,  but 
in  some  cases  is  not  experienced  until  an  hour  or  two  afterwards.  Pain  may 
also  be  felt  in  the  back,  between  the  tenth  dorsal  and  first  lumbar  spines.  Its 
character  and  intensity  are  very  variable,  but  it  is  usually  severe.  Hyperaesthesia 
of  the  skin  and  tenderness  on  pressure  in  the  epigastrium  may  also  be  present. 
Vomiting  may  come  on  immediately  after  food  is  taken,  or  may  be  deferred 
for  an  hour  or  two,  being  preceded  usually  by  a  good  deal  of  pain.  The  vomit 
has  a  very  acid  taste  and  an  abnormally  acid  reaction.  Melaena  follows 
haematemesis  ;  occasionally  it  may  precede  it,  and  rarely  occurs  independently. 
The  tongue  in  the  majority  of  cases  is  clean,  red,  nioist,  and  steady'. 

Hffimatemesis  from  this  cause  is  sometimes  difficult  to  differentiate  from 
that  due  to  cirrhosis  of  the  liver  or  carcinoma  of  the  stomach. 

There  is  more  or  less  anaemia  ;  the  points  of  distinction  between  gastric  ulcer 
and  anaemic  vomiting  are  discussed  on  page  40. 

Gastrostaxis  (see  Anjemia,  p.   40). 

HcBmorrhagic  erosions  are  probabty  the  earliest  stage  of  gastric  ulcer,  though 
they  may  not  develop  bej^ond  the  phase  of  minute  erosions.  They  may  be  the 
actual  cause  of  gastrostaxis,  and  perhaps  the  distinctions  between  gastrostaxis, 
haemorrhagic  erosions,  and  multiple  small  gastric  ulcers  are  differences  of  degree 
and  not  of  kind.  There  are  certain  conditions,  however,  especially  acute 
malignant  fevers,  purpura,  infective  endocarditis,  and  similar  septic  states, 
in  which  a  general  tendency  to  subcutaneous  and  submucous  haemorrhages 
leads  to  multiple  small  gastric  erosions,  which  produce  haematemesis,  without 
being  directl}-  related  to  ordinary  gastric  ulcer. 

Carcinoma. — Haematemesis  is  a  less  frequent  and  important  sign  of  carcinoma 
of  the  stomach  than  of  gastric  ulcer,  for  it  occurs  in  but  a  little  over  20  per 
cent  of  the  cases,  and  even  then  is  generally  slight.     Bright-red  blood  is  rarely 


H.EM  A  TEMESIS  299 


seen  in  the  vomit,  for  the  slow  ooze  from  the  ulcerated  surface  of  the  growth 
allows  the  blood  to  remain  in  contact  with  the  gastric  juice  and  develop  the 
so-called  "  coffee-grounds  "  appearance.  About  60  per  cent  of  the  cases  occur 
between  the  ages  of  forty  and  sixty.  The  chief  symptoms  and  signs  of  the 
disease  are  :  pain  in  the  epigastric  region,  nausea,  vomiting,  anorexia,  loss  of 
weight  and  strength,  pyrexia,  anasmia,  cachexia,  and  the  presence  of  an  abdom- 
inal tumour. 

Pain  is  one  of  the  earliest  symptoms,  but  it  varies  considerably  in  degree  and 
position.  It  is  most  frequently  referred  to  the  epigastrium,  but  is  not  as  a 
rule  so  severe  as  in  gastric  ulcer.    ' 

Vomiting  is  another  early  symptom  which  varies  in  frequency  and  character 
according  to  the  position  of  the  growth.  When  the  pylorus  is  involved  and 
stenosed,  the  stomach  dilates  and  a  large  quantity  of  frothy,  brownish  vomit  is 
evacuated  every  two  or  three  days  ;  in  cases  of  diffuse  carcinoma  the  capacity 
of  the  stomach  is  diminished,  and  a  small  quantity  may  be  vomited  two  or  three 
times  a  day  ;  when  the  growth  is  situated  at  the  cardiac  orifice,  the  symptoms 
resemble  those  of  epithelioma  of  the  oesophagus,  and  the  food  immediately  after 
swallowing  is  regurgitated  rather  than  vomited  ;  whilst  in  cases  of  growth 
which  involve  neither  of  the  orifices  of  the  stomach,  there  may  be  no  vomiting, 
or  if  present  it  may  have  no  special  characteristics,  the  symptoms  being  mainly 
those  of  dyspepsia  or  gastritis.  A  chemical  analysis  of  the  vomit  may  show 
deficiency  of  hydrochloric  acid  and  the  presence  of  lactic  acid  ;  but  the  value 
of  this  test  is  limited.  The  growth  may  be  seen  with  the  aid  of  the  gastro- 
scope.  The  loss  of  weight  and  strength  are  usually  progressive,  and  they  are 
amongst  the  most  constant  and  characteristic  signs  of  the  disease.  Anaemia  of 
the  secondary  chlorotic  type  with  a  low  colour-index  may  be  so  prominent  a  sym- 
ptom that  a  primary  anaemia  may  be  suspected  until  a  careful  blood  examination 
has  been  made.  A  very  careful  investigation  of  the  abdomen  must  be  made,  for 
in  about  70  per  cent  of  the  cases  a  tumour  may  be  felt,  though  it  is  to  be  hoped 
that  the  gastroscope  will  lead  to  the  diagnosis  of  carcinoma  ventriculi  before 
this  stage  is  reached,  and  when  surgical  cure  is  still  possible.  The  position  and 
character  of  the  tumour  vary  according  to  the  part  of  the  stomach  which  is 
involved.  Pyloric  growth  may  cause  the  abdomen  to  be  distended  as  a  result 
of  gastric  dilatation,  and  a  movable  tumour  may  be  felt  above  the  umbilicus, 
near  the  middle  line  and  to  the  right  of  it.  When  the  cardiac  orifice  is  in- 
volved, there  may  be  no  tumour  to  be  felt  and  the  same  applies  to  the  small 
"  indiarubber-bottle  "  stomach  of  diffuse  carcinoma  ventriculi.  Tumours  of  the 
body  of  the  stomach  may  be  felt  in  the  epigastrium,  or  below  the  left  costal 
margin. 

Injuries. — Haematemesis  may  follow  blows,  stabs,  or  gunshot  wounds  in  the 
epigastric  region,  or  the  passage  of  instruments  or  foreign  bodies,  such  as  a  broken 
thermometer,  into  the  stomach.  The  history  and  the  evidence  of  any  such 
occurrence  would  make  the  diagnosis  sufficiently  obvious. 

Atheroma  in  association  with  arteriosclerosis,  or  granular  kidney  and  high 
blood-pressure,  may  lead  to  haematemesis  in  very  exceptional  cases  by  causing 
weakness  and  rupture  of  small  gastric  vessels.  Such  a  diagnosis  should  be 
made  with  extreme  caution,  even  when  other  symptoms  and  signs  of  atheroma 
are  present,  for  haematemesis  as  the  direct  result  either  of  heart  disease,  lung 
disease,  Bright's  disease,  or  affections  of  the  blood-vessels,  is  exceedingly  rare. 

Abdominal  Aneurysm  opening  into  the  Stomach. — Aneurysm  of  the  abdominal 
aorta  is  uncommon.  The  sac  may  rupture  into  the  stomach,  however,  and  lead 
to  a  sudden,  profuse,  and  fatal  attack  of  haematemesis.  The  chief  diagnostic 
signs  are  :  an  abdominal  tumour,  with  distinct  expansile  pulsation  and  severe 
pain,  both   in   the    abdomen  and  in  the  back,  over  the  site  of  the  bulge  in   a 


300  HmMA  TEMESIS 


patient  who  has  suffered  from  syphihs  and  has  been  accustomed  to  repeated  and 
violent  muscular  exertion. 

D.  Diseases  of  the  Duodenum. 

Duodenal  Ulcer. — Hsematemesis  is  caused  in  the  same  manner  in  this  disease 
as  in  gastric  ulcer,  viz.,  by  the  erosion  of  small  duodenal  blood-vessels  or  by  the 
ulcerative  process  spreading  to  and  opening  larger  and  deeper  blood-vessels 
outside.  The  ulcers  are  in  the  first  part  of  the  duodenum  in  a  very  large 
proportion  of  cases.  They  are  about  eight  times  as  common  in  men  as  in  women. 
Some  of  the  symptoms  are  similar  to  those  of  gastric  ulcer,  viz.,  hsematemesis, 
melaena,  abdominal  pain  and  tenderness,  anaemia,  and  vomiting.  Hsematemesis, 
however,  is  not  so  frequent  as  it  is  in  gastric  ulcer  ;  it  is  generally  less  marked 
than  is  the  melsena,  and  the  latter  may  occur  independently  of  hcematemesis 
or  before  it.  In  the  acute  form  of  the  disease,  there  may  be  a  copious  intestinal 
haemorrhage  in  an  apparently  healthy  person,  accompanied  by  acute  pallor  and 
followed  by  the  evacuation  of  a  mixture  of  black  altered  blood  and  bright  arterial 
blood  from  the  rectum.  The  more  the  bleeding,  the  greater  the  tendency  for 
the  blood  passed  to  be  still  bright  red.  There  may  be  no  pain  at  all,  but  more 
often  it  is  considerable  ;  it  is  deep-seated  in  the'  upper  part  of  the  abdomen, 
below  the  tip  of  the  ninth  right  rib,  more  to  the  right  of  the  middle  line  than  is 
that  of  gastric  ulcer,  and  usually  its  onset  is  two  or  three  hours  after  the 
ingestion  of  food.  One  point  about  this  pain  that  is  almost  pathognomonic 
is  the  way  in  which,  coming  on  when  the  patient  is  beginning  to  get  hungry 
— "  hunger  pain  " — it  is  often  entirely  reheved  by  taking  food.  Vomiting  is 
another  important  symptom  which  may  be  very  troublesome,  though  in  some 
cases  it  is  entirely  absent. 

Gall-stones  Ulcerating  through  from  the  Gall-bladder  into  the  Duodenum. — • 
Haemorrhage  may  occur  if  a  large  gall-stone  ulcerates  through  from  the  gall- 
bladder into  the  duodenum,  and  may  cause  haematemesis  and  melaena.  Previous 
attacks  of  pain  occasioned  by  the  gall-stone  might  lead  to  a  diagnosis  of  gastric 
or  duodenal  ulcer  ;  but  if  the  pain  was  colicky  in  character  and  was  associated 
with  tenderness  and  enlargement  of  the  liver,  pain  over  the  gall-bladder,  and 
jaundice,  it  would  point  to  the  presence  of  a  gall-stone.  The  diagnosis  might  be 
confirmed  by  the  discovery  of  the  stone  in  the  faeces,  or,  in  the  case  of  a  larger 
calculus,  by  the  occurrence  of  acute  intestinal  obstruction  frora  its  impaction 
in  the  small  intestine.  As  a  cause  of  haematemesis,  this  condition  is  naturally 
very  rare. 

E.  Portal  Obstruction. 

As  a  result  of  obstruction  to  the  fiow  of  blood  through  the  portal  system  of 
veins,  passive  congestion  and  haemorrhagic  erosion  of  the  mucous  membrane 
of  the  stomach  and  varicose  gastric  and  oesophageal  veins  may  be  produced. 
Haematemesis  may  then  arise  through  oozing  of  blood  from  the  congested  mucous 
membrane  or  from  an  actual  escape  of  blood  in  the  case  of  haemorrhagic  erosion 
or  the  rupture  of  one  of  the  varicose  veins. 

The  signs  which  are  common  to  portal  obstruction  in  addition  to  haematemesis 
are  :  nausea,  vomiting,  ascites,  oedema  of  the  legs,  albuminuria,  and  the  presence 
of  dilated  and  tortuous  superficial  abdominal  veins  ;    the  chief  cause  is  : — 

Cirrhosis  of  the  Liver. — This  disease  is  one  of  the  commonest  and  most 
important  causes  of  profuse  haematemesis,  and  it  is  often  difficult  to  diagnose 
from  gastric  ulcer  or  carcinoma  of  the  stomach.  Haematemesis  may  be  one  of 
the  earliest  symptoms,  and  it  is  frequently  profuse  and  very  liable  to  recur, 
though  it  is  seldom  fatal.  There  may  be  a  history  and  the  signs  and  symptoms 
of  chronic  alcoholism  :  morning  sickness,  loss  of  appetite,  especially  for  break- 
fast, epistaxis,  melaena,  cramps  in  the  legs  at  night,  bottle-nose,  dilated  stellate 


HMMATEMESIS  301 


venules  on  the  cheeks,  ascites,  jaundice,  dilated  and  tortuous  superficial  abdom- 
inal veins.  The  liver  may  be  enlarged,  its  surface  being  rough  and  hard,  and 
its  edges  irregular  and  beaded.  The  spleen  may  be  enlarged  as  a  result  of  the 
portal  obstruction,  but  in  adults  rarely  attains  to  such  an  enormous  size  as  it 
does  in  the  splenomegalic  variety  of  cirrhosis  in  children  and  young  adults.  In 
distinguishing  this  disease  from  carcinoma  of  the  stomach,  it  is  very  important 
to  determine,  if  possible,  the  absence  of  a  stomach  tumour  and  of  large  nodules 
projecting  from  the  surface  of  the  liver. 

Adhesive  Pylephlebitis. — Non- suppurative  thrombosis  of  the  portal  vein  is  a 
very  rare  condition,  and  it  is  difficult  to  diagnose.  It  may,  however,  give  rise 
to  sudden  and  profuse  heematemesis.  It  is  distinguished  from  other  forms  of 
portal  obstruction  by  the  relatively  sudden  onset  of  ascites,  hsematemesis, 
melasna,  and  enlargement  of  the  spleen,  and  by  an  absence  of  signs  and  sym- 
ptoms of  cirrhosis  of  the  liver  and  other  causes  of  portal  obstruction. 

Pressure  on  the  Portal  Vein. — Hcematemesis,  when  due  to  this  cause,  is 
generally  associated  with  ascites  and  intense  jaundice,  since  the  common  bile- 
duct  is  liable  to  be  compressed  as  well  as  the  portal  vein  on  account  of  their 
close  proximity  to  each  other.      (See  Jaundice.) 

Some  cases  of  Enlarged  Spleen. — Hsmatemesis  is  a  fairly  common  symptom  in 
cases  of  enlarged  spleen,  even  when  the  enlargement  is  not  associated  with 
cirrhosis  of  the  hver  or  leukaemia.  Osier  explains  the  occurrence  as  being  due 
to  the  "  intimate  relation  between  the  vasa  brevia  and  the  splenic  circulation." 
(See  Spleen,  Enlargement  of.) 

F.  Acute  Febrile  Diseases. 

Malignant  Variola. — Haematemesis  occurs  in  about  a  third  of  the  cases  of 
hasmorrhagic  small-pox.  It  is  associated  with  cutaneous,  subcutaneous,  and 
submucous  hemorrhages,  hasmaturia,  epistaxis,  melaena,  and  bleeding  from  the 
gums.  The  sudden  initial  rigor,  intense  backache  and  headache,  severe  vomiting, 
epigastric  pain,  cutaneous  haemorrhages,  and  the  diffuse  hypercemic  rash  with 
small  punctiform  haemorrhages  which  appears  first  in  the  groins  and  lower 
part  of  the  abdomen,  would  point  to  a  diagnosis  of  hasmorrhagic  or  black 
small-pox,  if  such  a  case  occurred  during  an  epidemic  of  the  disease. 

Malignant  Scarlet  Fever. — In  the  hjemorrhagic  form  of  scarlet  fever,  haemat- 
emesis may  occur  ;  but  haematuria,  epistaxis,  and  cutaneous  haemorrhages  are 
more  frequent.  The  sudden  and  severe  onset,  the  very  high  temperature, 
the  extremely  rapid  and  feeble  pulse,  headache,  deUrium,  and  the  appearance 
of  the  characteristic  rash  on  the  second  day,  would  point  to  scarlet  fever. 

Yellow  Fever. — "  Black  vomit"  due  to  the  presence  of  altered  blood  is  one  of 
the  most  characteristic  features  of  this  disease.  Hyperaemia  and  catarrhal 
swelhng  of  the  mucous  membrane  is  the  only  change  which  is  found  in  the 
stomach.  It  is  essentially  a  disease  of  tropical  and  sub-tropical  countries.  The 
onset  is  sudden,  with  a  chill,  headache,  and  severe  pain  in  the  back  and  Limbs. 
The  face  is  flushed,  and  very  soon  jaundice  appears.  After  the  first  day  the 
pulse-rate  drops,  so  that  with  a  temperature  of  103°  F.  or  104°  F.  the  pulse  may 
be  only  70  or  80.  Albuminuria  is  another  early  symptom  which  may  appear 
on  the  third  day.  In  addition  to  the  black  vomit,  there  may  be  cutaneous 
petechiae  and  bleeding  from  the  gums.  It  is  often  difficult  to  distinguish  from 
malignant  malaria,  though,  in  the  early  stages  in  malaria,  jaundice,  albuminuria 
and  haematuria  are  extremely  rare,  whilst  an  examination  of  the  blood  may 
reveal  the  presence  of  malarial  parasites. 

Cholera  may  be  associated  with  haematemesis  sometimes.  The  sudden  onset 
of  acute  gastrointestinal  symptoms,  the  rapidly  repeated  rice-water  stools,  and 
the  epidemic  nature  of  the  maladv,  all  point  to  the  diagnosis,  which  may  be 
confirmed  by  recovering  the  vibrio  from  the  motions  bacteriologically. 


302  H^MA  TEMESIS 


Acute  Yellow  Atrophy  of  the  Liver. — HEematemesis  is  the  commonest  form  of 
haemorrhage  in  this  rare  disease.  Women  between  twenty  and  thirty  are 
affected  more  frequently  than  men,  especially  during  and  just  after  pregnancy. 
It  sometimes  follows  fright  and  mental  emotion.  The  first  symptoms  are 
indistinguishable  from  catarrhal  jaundice,  viz.,  malaise,  loss  of  appetite, 
nausea,  vomiting,  and  jaundice.  The  vomiting  soon  becomes  intractable, 
the  jaundice  increases,  and  drowsiness,  restlessness,  and  delirium  supervene. 
The  vomit  is  black,  and  ma}^  resemble  treacle,  its  appearance  being  due  to 
altered  blood.  Melgena,  epistaxis,  and  subcutaneous  petechise  may  be  noticed. 
The  tongue  becomes  dry  and  brown,  the  liver  dullness  diminishes,  the  urine 
shows  characteristic  changes  in  the  marked  diminution  in  the  amount  of  urea 
and  the  presence  of  bile  pigment,  whilst  leucin  and  tyrosin  crystals  in  it  are 
an  important  diagnostic  sign  of  this  disease. 

G.  Blood  Diseases. 

Purpura  HcBmorrhagica. — Hsemorrhage  from  the  stomach  is  rare  in  this  disease. 
Hsematemesis  may  occur,  however,  as  a  result  of  blood  derived  from  the  mucous 
membrane  of  the  nose  or  mouth  being  swallowed.  As  purpura  is  a  symptom 
rather  than  a  disease  in  the  majority  of  cases,  before  making  a  diagnosis  of 
purpura  hsemorrhagica  or  idiopathica,  those  diseases  which  lead  to  symptomatic 
purpura  must  be  excluded  first.  In  scurvy,  the  spongy  gums,  the  distribution 
of  the  cutaneous  haemorrhages  around  the  hair  sacs,  and  the  anaemia  and  debility, 
which  are  out  of  proportion  to  the  loss  of  blood,  are  characteristic  diagnostic 
points.  The  possibility  of  an  acute  specific  fever  may  be  excluded  by  the 
absence  of  an  acute  onset  of  a  high  temperature.  An  examination  of  the  blood 
must  also  be  made,  to  exclude  pernicious  anaemia  and  leukaemia  ;  and  blood 
cultures  may  be  required.     (See  Anemia  ;   and  Purpura.) 

Scurvy. — Haematemesis  is  uncommon,  only  occurring  in  severe  and  well- 
marked  cases,  so  that  the  diagnosis  is  not  difficult.  The  swollen  and  spongy 
gums,  anaemia,  cutaneous  haemorrhages  around  the  hair  sacs,  and  subcutaneous 
indurations,  in  a  patient  who  is  found  to  have  been  living  on  a  diet  deficient  in 
quantity  and  in  vegetables,  would  point  to  scurvy. 

HcBmophilia — Out  of  334  cases  analyzed  by  Grandidier,  there  were  only 
fifteen  examples  of  haemorrhage  from  the  stomach.  Epistaxis,  bleeding  from 
the  mouth,  and  haemorrhage  into  the  joints  are  the  earliest  and  the  coramonest 
manifestations  of  the  disease.  The  association  of  haematemesis  with  hemor- 
rhage from  other  parts,  and  with  haemorrhage  into  joints  in  particular,  in 
a  patient  whose  near  male  relations  show  a  tendency  to  bleed  on  the  shghtest 
provocation,  would  point  to  haemophilia.  There  are  no  pathognomonic  blood 
changes. 

Leukczmia. — Haemorrhages  from  and  into  various  parts,  especially  epistaxis, 
are  common  in  this  disease.  Haematemesis  may  be  the  actual  cause  of 
death.  Its  association  with  enormous  enlargement  of  the  spleen  is  by  no 
means  pathognomonic  of  leukaemia,  for  the  two  conditions  may  be  present 
in  chronic  malaria,  splenic  anaemia,  and  splenomegalic  cirrhosis.  An  accurate 
diagnosis  cannot  be  made  until  the  blood  has  been  examined  and  a  high 
degree  of  leucocytosis  found  (100,000  to  1,000,000  white  blood  corpuscles  per 
c.  mm.),  with  a  large  proportion  of  myelocytes  in  the  case  of  spleno-medullary 
leukaemia  and  a  high  percentage  of  lymphocytes  (90  per  cent)  in  lymphatic 
leukaemia. 

Hodgkin's  Disease. — In  the  late  stages  of  this  disease  there  is  a  tendency  to 
haemorrhage  from  and  into  various  parts  of  the  body,  e.g.,  epistaxis,  bleeding 
from  the  mouth,  cerebral  haemorrhage,  and  rarely  haematemesis.  There  should 
be   little  difficulty   in    making  a  diagnosis,   as    haematemesis   would    be    a   late 


HMMA  TEMESIS  303 


symptom,  the  characteristic  features  of  the  disease  consisting  of  enlargement  of 
the  glands — especially  the  cervical  group,  enlargement  of  the  liver  and  spleen, 
with  progressive  and  ultimately  severe  anaemia  of  simple  chlorotic  type,  except 
for  the  occurrence  of  occasional  myelocytes  and  basophile  corpuscles  in  blood 
films.  The  disease  may  prove  fatal  in  a  few  weeks  or  months,  but  the  patient 
often  survives  for  several  years. 

Chlorosis. — It  is  difficult  to  determine  whether  hasmatemesis  occurring  in  an 
anaemic  woman  under  thirty,  is  due  to  gastric  ulcer  or  to  gastrostaxis  (p.  40). 
That  chlorosis  has  something  to  do  with  heematemesis,  apart  from  the  formation 
of  macroscopic  ulcers,  is  probable  ;  it  is  also  probable  that  chlorosis  predisposes 
to  gastric  ulcer.  The  precise  nature  of  the  symptom  in  a  chlorotic  girl  is  very 
difficult  to  determine  therefore,  some  observers  diagnosing  gastric  ulcer  where 
others  prefer  to  label  the  condition  gastrostaxis.  The  former  withhold  solid 
food  longer  than  the  latter,  and  are  perhaps  inclined  to  recommend  operation 
more  readily  ;  these  are  the  main  grounds  for  striving  to  draw  a  clear  distinction 
between  the  two  conditions. 

Young  women  suffering  from  chlorosis  are  usually  well  nourished.  The  skin 
may  have  a  greenish  tinge  and  the  sclerotics  a  distinct  bluish  appearance. 
(Edema  of  the  feet,  dyspnoea,  palpitation,  and  amenorrhcea  are  prominent 
symptoms  ;  but  the  diagnosis  cannot  be  made  with  any  certainty  imtil  the  blood 
has  been  examined.  It  is  pale  and  thin  ;  the  red  blood-corpuscles  are  reduced 
in  number,  but  rarely  are  under  3,000,000  per  c.  mm.,  the  average  size  of 
the  red  blood-corpuscles  is  below  normal,  the  haemoglobin  is  reduced  much 
more  in  proportion  than  are  the  red  blood-corpuscles,  so  that  the  colour- 
index  is  low,  being  as  a  rule  about  0-5  or  under  ;  the  white  blood-corpuscles 
are  not  increased,  and  the  differential  leucocyte  count  is  almost  normal. 
Seeing  that  amenorrhcea  and  hasmatemesis  are  both  liable  to  occur  in 
anaemic  girls,  the  gastric  haemorrhage  has  sometimes  been  regarded  as  vicarious 
menstruation  ;  there  is  little  evidence  to  support  this  view  of  its  pathology, 
however,  and  when  the  bleedings  recur,  the  attacks  do  not  show  any  kind  of 
monthly  regularity. 

Pernicious  AncBmia. — Hasmatemesis  is  a  very  rare  symptom  in  pernicious 
anaemia  ;  when  it  occurs,  the  difficulty  in  distinguishing  between  this  disease 
and  carcinoma  of  the  stomach  is  much  increased.  A  correct  diagnosis  cannot 
be  made  until  the  blood  has  been  examined.  A  great  diminution  in  the  number 
of  red  blood-corpuscles  to  1,000,000  or  less  per  c.  mm. — the  haemoglobin  being 
also  reduced,  but  not  in  proportion  to  the  red  blood-corpuscles,  so  that  the  colour 
index  is  high — an  increase  in  the  average  size  of  the  red  blood-corpuscles,  and  the 
presence  of  megaloblasts,  would  point  to  pernicious  anaemia.  The  urine  contains 
pathological  urobihn. 

Malarial  Cachexia. — Anasmia  and  enlargement  of  the  spleen  may  follow 
repeated  attacks  of  malaria,  and  severe  haematemesis  may  be  a  prominent 
symptom.  In  making  the  diagnosis,  the  history  of  residence  abroad,  of  attacks 
of  ague,  and  the  condition  of  the  blood,  must  be  relied  on.  A  normal  or  a 
diminished  number  of  leucocytes,  with  a  relative  increase  in  the  large  mono- 
nuclear cells  beyond  15  per  cent,  is  strong  presumptive  evidence  of  a  previous 
malarial  infection. 

H.  Miscellaneous. 

Chronic  Interstitial  Nephritis. — Haematemesis  occasionally,  but  very  rarely, 
occurs  in  this  disease.  Its  association  with  anasmia,  thickened  and  tortuous 
superficial  arteries,  high-tension  pulse,  hypertrophy  of  the  heart,  albuminuric 
retinitis,  polyuria,  and  urine  of  low  specific  gravity  containing  a  variable 
quantity  of  albumin  and  renal  tube-casts,  would  point  to  chronic  interstitial 


304 


HMMA  TEMESIS 


nephritis  as  the  cause.     It  is  most   important  that  the  blood-pressure  should 
be  measured  instrumentallyj  and  not  guessed  at  by  palpation. 

Following  Abdominal  Operations. — Hsematemesis  may  occur  after  severe 
abdominal  operations,  independently  of  any  injury  to  the  stomach  or  duodenum. 
Should  death  occur,  no  obvious  lesion  can  be  found  in  the  stomach  to  account 
for  it  in  the  majority  of  cases.  The  reason  of  the  occurrence  of  such  an  alarming 
symptom  remains  a  mystery  in  many  cases,  but  in  some  infective  conditions, 
such  as  appendicitis,  multiple  minute  ulcers  have  been  found.       Herbert  French. 

H.ff:MATOPORPHYRINURIA.^(See  Urine,  Abnormal  Coloration  of.) 

H.ffiMATURIA. — Blood  may  appear  in  the  urine  as  the  result  of  traumatism, 
of  disease  in  some  portion  of  the  urinary  tract,  or  of  other  organs  involving 
the  urinary  apparatus,  and  in  a  few  general  diseases  of  other  parts  of  the  body. 
The  blood  may  be  present  in  large,  small,  or  microscopic  amounts,  it  may 
continue  for  days  or  even  weeks  together,  or  may  appear  suddenly  and  without 
apparent  cause,  and  disappear  completely  for  a  variable  period.  Further, 
it  may  be  present  in  the  urine  either  as  corpuscles  or  as  haemoglobin,  and 
it  is  necessary  to  distinguish  between  the  two  conditions.  In  hsemoglobinuria 
the  urine  is  dark  brown  from  the  presence  of  methaemoglobin,  and  any  deposit 
is  found  to  consist  of  brownish  debris  (see  HyEMOGLOBiNURiA).  Occasionally 
the  colouring  matter  of  the  blood  may  escape  from  the  corpuscles  if  the  stained 
urine  has  been  retained  for  any  length  of  time  in  the  bladder,  when  crenated  or 
disintegrated  corpuscles  will  be  found  on  microscopic  examination  of  the 
sediment  from  a  specimen. 

The  following  list  gives  the  chief  causes  of  heematuria  : — 


i. h.^maturia    from    affection    of    some    part    of    the 

Urinary    Organs. 


A.  Renal  Causes. 

Profuse. 
Malignant  tumours  of  the  kidney  : 

Nephroma 

Embryoma 

Carcinoma 

Sarcoma 
Innocent   tumours — papilloma    of 

pelvis 
Injuries  of  the  kidney 
Calculus 
Tuberculosis 

B.  Ureteric  Causes — Calculus  in  the  ureter. 

C.  Vesical  Causes. 

Profuse. 
Villous  tumour 
Papilloma 

Villus-covered  carcinoma 
Prostatic    adenoma    or    car- 
cinoma 


Slight. 
Calculus 
Tuberculosis 
Renal  mobility 
Hydronephrosis 
Polycystic  disease 
Traumatism 
Oxaluria 

Nephritis,  acute  and  subacute 
Drugs  :      turpentine,     carbolic 
acid,  cantharides 


Slight. 
Epithelioma 
Tuberculosis 
Calculus 
Acute  cystitis 
Bilharzia  hsematobia 
Traumatism 


D.  Urethral  Causes Acute  urethritis.  Impaction  of  calculus,  Traumatism 


HEMATURIA  305 


II. HvEMATURIA    FROM    DISEASE    OF    THE    NEIGHBOURING    VlSCERA 

INVOLVING    THE    URINARY    ORGANS. 

Carcinoma  of   the  uterus,  vagina,  or  rectum 

Acute  appendicitis 

Acute  salpingitis 

Pelvic  abscess 

Dysenteric  or  tuberculous  ulceration  of  the  intestine 

III. — HEMATURIA    IN  General  Diseases. 

Renal    infarction    in  endocarditis 

Arteriosclerosis 

Leukaemia 

Purpura  and  scurvy 

Haemophilia 

Acute  fevers,  malaria,  small-pox,  and  yellow  fever 

In  considering  the  diagnosis  of  a  case  presenting  haematuria  as  a  symptom, 
it  is  seldom  that  there  are  not  other  symptoms  present,  such  as  pain,  tumour, 
or  increased  frequency  of  micturition,  which  will  point  to  one  or  other  organ  as 
the  source  of  the  bleeding  ;  but  in  some  cases  haematuria  may  be  the  only 
symptom.     The  following  points  will  often  help  in  the  differential  diagnosis  : — 

The  Colour  of  the  Urine. — If  the  urine  is  stained  a  bright  red  colour,  the 
haemorrhage  is  most  likely  to  arise  from  the  bladder  or  lower  urinary  tract. 
Dark-coloured  blood  in  the  urine  may,  however,  be  due  to  the  retention  of  blood 
in  the  bladder  for  some  time,  or  from  the  large  amount  present  in  the  urine. 

The  Distribution  of  the  Blood  in  the  Urine  during  Micturition. — If  the  urine 
during  micturition  is  only  tinged  with  blood  during  the  final  expulsive  efforts, 
or  if  the  terminal  urine  is  stained  more  deeply  than  the  rest,  the  source  of  the 
haematuria  is  almost  certainly  in  the  bladder.  If  the  first  urine  passed  is  blood- 
stained and  the  remainder  clear,  the  bleeding  is  probably  from  the  urethra  or 
prostate,  whereas  if  the  urine  is  evenly  stained  with  blood  throughout,  it  suggests 
that  the  source  of  haemorrhage  is  in  the  kidneys,  although  a  vesical  lesion  which 
causes  more  than  a  slight  haemorrhage  may  also  give  rise  to  a  deeply  blood-stained 
urine  throughout  micturition. 

The  Quantity  of  Blood  Present  in  the  Urine. — The  passage  of  a  large  quantity 
of  blood  in  the  urine,  in  the  absence  of  traumatism,  is  always  suggestive  of  some 
form  of  growth  in  the  bladder  or  kidney.  Papillomata  and  villus-covered 
carcinomata  in  the  bladder  may  cause  sudden  profuse  haemorrhage  without  pain 
or  other  symptom,  whilst  equally  profuse  haemorrhage  may  arise  from  a 
malignant  tumour  in  the  kidney  which  has  invaded  the  renal  pelvis.  The 
examination  of  any  clots  of  blood  passed  in  the  urine  may  occasionally  afford 
useful  information  in  the  determination  of  the  seat  of  haemorrhage.  The  urine 
should  be  poured  into  a  large  fiat  tray  containing  water,  and  the  clots  floated 
out,  when  some  may  show  the  triangular  or  pyramidal  shape  indicating  their 
formation  in  the  renal  pelvis,  or  others  the  thin,  worm-like  form  with  tapering 
or  decolorized  ends  from  their  formation  in  the  ureter.  Any  clots  formed  in  the 
bladder  are  of  flat,  disc-like  character,  and  are  often  broken  up  in  their  passage 
through  the  urethra.  The  pyramidal  or  vermicular  clots  are  distinctive  of 
renal  haemorrhage,  and  their  passage  down  the  ureter  is  accompanied  by  the 
same  acute  renal  colic  that  is  caused  by  renal  calculus. 

If  the  quantity  of  blood  is  increased  by  movement  or  exercise,  suspicion  of 
renal  stone  or  growth  will  arise.     In  a  recent  case,  profuse  haematuria  occurred 
after  three  successive  railway  journeys,  when  the  lesion  found  at  operation  was 
an  early  carcinoma  of  one  kidney  which  had  recently  invaded  the  renal  pelvis. 
D  20 


306  HEMATURIA 


The  Association  of  other  Elements  from  the  Urinary  Organs  with  Blood  in 
the  Urine. — Microscopical  examinatioo  of  the  deposit  obtained  by  centrifuging 
a  specimen  of  urine  may  reveal  cellular  elements  distinctive  of  the  renal  pelvis 
or  vesical  mucous  membrane  or  epithelial,  granular,  and  blood-casts  from  the 
renal  tubules  [Plate  I.),  which  may  help  in  the  diagnosis  in  a  case  of  haematuria. 
The  presence  of  a  number  of  urinary  crystals  in  a  urine  of  acid  reaction  will 
point  to  renal  calculus.  Occasionally,  small  pieces  of  growth  may  be  passed 
in  the  urine  from  the  delicate  villous  papilloma  or  villus-covered  carcinoma  of 
the  bladder,  and  more  rarely  may  be  found  plugs  of  muco-pus  from  a  caseous 
tuberculous  cavity  in  the  kidney. 

The  association  of  pus  with  blood  in  the  urine  does  not  give  much  assistance 
in  the  determination  of  the  seat  of  the  bleeding.  Both  pus  and  blood  will  often 
be  present  in  either  calculus  or  tuberculosis  of  the  kidney  or  bladder,  and  may 
both  be  present  with  vesical  growth  or  with  prostatic  enlargement. 

The  Amount  of  Albumin. — If  the  amount  of  albumin  in  the  urine  is  in  excess 
of  that  which  would  be  due  to  the  amount  of  blood  present,  the  bleeding  is 
probably  renal  in  origin. 

The  Reaction  of  the  Urine  is  of  very  slight  assistance  in  the  determination 
of  the  source  of  bleeding  in  a  case  of  hsematuria.  It  may  be  stated  in  a  general 
sense,  that  blood  in  an  acid  urine  is  more  likely  to  be  derived  from  the  kidney 
than  from  the  bladder.  This,  however,  is  liable  to  be  misleading,  for  blood 
may  be  present  in  an  acid  urine  in  a  case  of  vesical  calculus  or  growth,  whereas, 
on  the  other  hand,  there  may  be  blood  in  alkaline  urine  in  a  case  of  renal 
calculus  as  well  as  in  pathological  conditions  of  the  bladder. 

The  association  of  unilateral  lumbar  pain,  situated  in  the  angle  between  the 
last  rib  and  the  border  of  the  erector  spinae  muscle,  passing  forwards  above 
the  iliac  crest  into  the  groin,  with  occasional  attacks  of  colic,  would  suggest 
a  renal  lesion,  whilst  haematuria,  accompanied  by  increased  frequency  of  mic- 
turition or  by  penile  pain  immediately  following  micturition,  would  indicate 
vesical  disease.  Equally  important  is  it  to  take  into  consideration  the  age  of 
the  patient ;  thus,  in  a  young  adult,  continued  slight  haematuria  with  increased 
frequency  of  micturition  are  highly  suggestive  of  tuberculous  disease  of  the 
bladder  or  kidney,  whereas  slight  haematuria  in  a  more  elderly  patient  suggests 
vesical  carcinoma  or  calculus.  At  any  age,  severe  haematuria  may  be  present 
with  a  villous  tumour  of  the  bladder,  or  in  a  patient  more  advanced  in  years, 
with  renal  growth  or  prostatic  enlargement. 

Further  evidence  of  the  source  of  the  haemorrhage  may  be  obtained  upon  the 
physical  examination  of  the  patient.  This  should  be  carried  out  systemati- 
cally, and  not  only  should  the  urinary  organs  be  examined,  but  any  evidence  of 
disease  elsewhere  in  the  body,  as  in  the  heart,  lungs,  blood,  liver,  or  pelvic 
organs,  sought  for.  Each  kidney  should  be  examined  bimanually,  one  hand 
being  placed  in  the  angle  made  by  the  last  rib  and  the  margin  of  the  erector 
spinae  muscle,  and  the  other  in  front,  immediately  below  the  costal  margin  ; 
the  patient  is  then  directed  to  breathe  deeply  whilst  pressure  is  maintained  by 
the  two  hands,  when  an  enlarged  or  unduly  mobile  kidney  may  be  felt  to  descend, 
or  may  be  grasped  on  deep  inspiration.  Any  pain  or  undue  tenderness  on 
either  side  should  be  noted,  especially  any  sharp,  pricking  pain  experienced  by 
the  patient  if  the  anterior  hand  be  suddenly  depressed,  a  sign  which  is  said  by 
Jordan  Lloyd  to  be  indicative  of  renal  stone. 

Examination  of  the  bladder  by  palpation  in  the  suprapubic  area  may  elicit 
pain  in  acute  inflammatory  conditions,  or  may  give  evidence  of  a  distended  bladder 
in  a  case  of  haematuria  from  prostatic  obstruction ;  but  much  more  knowledge 
may  be  gained  by  a  thorough  rectal  examination.  For  this  purpose  the  patient 
should  assume  the  knee-elbow  position,  when  the  examining  finger  can  explore  not 


HEMATURIA  307 


only  the  prostate,  but  the  vesiculae  seminales,  the  lower  end  of  each  ureter,  and 
the  bladder  base,  as  well  as  the  lateral  pelvic  wall.  The  prostate  may  show 
adenomatous  enlargement,  or  may  be  infiltrated  with  primary  carcinoma — 
which  has  recently  been  shown  to  be  far  from  uncommon, — when  the  gland  will 
present  marked,  firm,  rounded  nodules,  and  will  often  be  immovable.  Search 
should  be  made  for  any  nodules  in  the  prostate  or  vesicles,  or  of  thickening  of 
the  lower  end  of  the  ureter,  suggestive  of  tuberculous  disease,  or  of  thickening 
or  infiltration  in  the  bladder  base,  which  may  often  be  felt  in  a  case  of  vesical 
carcinoma.  Examination  in  the  lateral  pelvic  space  may  show  infiltration  of  the 
pelvic  lymphatics,  or  enlargement  of  the  lymphatic  glands  in  a  case  of  carcinoma 
of  the  bladder  or  prostate.  Examination  of  the  testes  should  always  be  made. 
A  nodule  in  either  epididymis  may  be  evidence  of  tuberculous  disease,  which 
mav  have  spread  to  the  urinary  organs,  but  care  must  be  taken  not  to  mistake 
a  nodule  dating  from  a  gonorrhoeal  epididymitis  for  one  due  to  tuberculous 
disease. 

Great  assistance  may  be  obtained  by  the  use  of  the  cystoscope  {Plates  V  and 
VI).  Needless  to  say,  the  greatest  gentleness  must  be  used  in  carrying  out  any 
instrumentation^  to  avoid  any  further  haemorrhage,  which  would  obscure  a  view 
by  the  cystoscope,  and  if  any  bleeding  is  present,  an  attempt  should  be  made  to 
arrest  it  by  irrigation  of  the  bladder  with  silver  nitrate  i-iooo,  or  with  adrenalin 
solution  of  the  same  strength.  If  the  bleeding  is  profuse,  it  is  probablv 
impossible  to  obtain  a  satisfactory  view  of  the  interior  of  the  bladder,  but  with 
even  moderate  haemorrhage  going  on,  a  rapid  distention  of  the  bladder  may 
produce  a  medium  clear  enough  to  obtain  a  view  which  will  show  the  seat  of 
haemorrhage.  Thus  in  renal  haematuria  blood-stained  urine  may  be  seen  to 
be  emitted  from  one  ureteric  orifice  {Plate  V,  Fig.  A)  and  clear  urine  from 
the  other  before  the  medium  is  too  obscured  ;  or  with  vesical  haemorrhage  a 
vesical  tumour  may  be  seen.  Even  slight  haemorrhage  will,  however,  rapidly 
render  the  medium  in  the  bladder  too  hazy  to  obtain  a  satisfactory  examina- 
tion of  any  minute  changes  in  the  vesical  wall,  such  as  tuberculous  disease. 
Hence  it  is  better,  if  possible,  to  undertake  any  cystoscopic  examination  in  the 
interval  between  attacks  of  bleeding,  when  the  bladder  can  be  thoroughly 
examined  and  any  pathological  lesion  found.  If  no  evidence  is  obtained  in 
this  way,  a  further  examination  may  be  conducted  during  an  attack  of  bleeding. 

ft  remains  to  consider  the  main  causes  of  haematuria. 

I. H.^MATURIA    FROM   AFFECTION   OF    SoME    PaRT   OF   THE    URINARY   TRACT. 

A .  Renal  Causes. 

The  Malignant  Tutnours  of  the  Kidney,  nephroma,  embryoma,  carcinoma,  and 
sarcoma,  are  all  associated  with  profuse  haematuria  at  intervals.  The  nephro- 
mata  are  the  most  common  ;  they  arise  in  the  adrenal  rests  found  in  the  cortical 
portions  of  the  kidney,  and  are  of  comparatively  slow  growth.  The  embrvomata 
may  occur  in  small  children  or  in  elderly  persons,  whilst  the  true  carcincmata  and 
sarcomata  are  much  more  uncommon.  These  tumours  cause  an  aching  in  the 
loin,  and  may  lead  to  considerable  enlargement  of  the  kidney  before  any 
haematuria  occurs.  In  the  progressive  grow^th  of  the  tumour,  the  renal  pelvis 
is  gradually  involved  and  haematuria  is  evoked.  This  is  usually  severe  in  t^^e, 
so  that  clots  may  be  formed  in  the  calyces  of  the  renal  pelvis  or  in  the  ureter 
and  cause  the  typical  pain  of  renal  colic  in  their  descent  of  the  latter.  The 
renal  tumour  usually  maintains  the  shape  of  the  kidney,  but  in  some  cases 
may  present  a  nodular  form.  Hence  profuse  haematuria,  wath  clots  of  pyramidal 
or  worm-like  shape,  associated  with  renal  enlargement,  is  strongly  suggestive 
of  renal  malignant  growths. 


3o8  '  HEMATURIA 


The  only  common  form  of  innocent  tumour  in  the  kidney  is  that  of  a  papilloma 
of  the  renal  pelvis.  This  gives  rise  to  profuse  hsematuria  and  to  renal  enlarge- 
ment, which  in  this  instance  is  due  to  hydro-  or  haemato-nephrosis  from  the 
obstruction  to  the  ureter  by  the  papillary  growth  or  by  blood-clot.  Thus  the 
renal  tumour  may  be  variable  in  size.  Papillomata  of  the  mucous  membrane  of 
the  renal  pelvis  are  occasionally  accompanied  by  similar  growths  in  the  ureter, 
and  may  also  show  a  similar  growth  at  the  ureteric  orifice  upon  inspection  of 
the  bladder. 

Injuries  to  the  Kidney  may  cause  haematuria  ;  the  diagnosis  is  usually  obvious. 
The  history  of  the  accident,  of  a  blow  or  squeeze  applied  to  the  lumbar  region, 
associated  with  haematuria,  would  point  to  an  injury  to  the  kidney.  There 
may  be  renal  enlargement,  but  this  must  be  diagnosed  from  an  extravasation  of 
blood  in  the  perinephric  tissues  from  the  rupture  of  the  renal  cortex.  Com- 
paratively slight  injury  to  the  loin  may  produce  haematuria  from  a  small  lesion 
in  the  renal  tissues,  whilst  in  some  cases  there  is  no  sign  or  recollection  of  external 
violence.  In  any  case  of  haematuria  following  traumatism,  it  is  essential  to 
diagnose  an  injury  to  the  kidney  from  injury  to  the  urethra  or  bladder.  In 
urethral  injury  the  tube  may  be  merely  contused,  or  partially  or  wholl}^  ruptured  ; 
blood  may  be  found  at  the  urethral  meatus  or  may  be  marked  in  the  first  portion 
of  any  urine  that  may  be  passed,  whilst  if  the  urethra  be  entirely  divided,  signs 
of  commencing  extravasation  of  urine,  with  inability  to  micturate,  will  appear. 

DESCRIPTION    OF    PLATE    V. 

Bladder  Appearances  seen    through    the    Cystoscope. 

Fig.  A. — Blood-stained  urine  issuing  from  the  ureter. 
Fig.   B. — Purulent  urine  issuing  from  the  ureter. 
Fig.    C— Congestion  around  a  ureteric  orifice   in  calculous  pyelitis 
Fig.  D. — The  retracted  ureter  common  with  descending  renal  tuberculosis. 
Fig.  E. — Tuberculous    ulceration    around    the    ureteric   orifice    in    descending 
renal  tuberculosis. 

Fig-s.  D  and  E  are  from  sketches  kindlv  supplied  by  Dr.  C.  F.    Walters,  pf  Clifton. 

If  the  bladder  be  injured,  blood  may  be  present  in  any  urine  drawn  off  ;  or  in  a 
rupture  of  the  bladder  involving  the  peritoneal  coat  fluid  may  be  found  in  the 
abdominal  cavity.  The  length  of  time  between  the  last  passage  of  urine  and 
the  occurrence  of  the  accident  should  be  ascertained,  and  a  catheter  passed  ; 
very  gentle  irrigation  of  the  bladder  with  sterile  fluid  should  be  carried  out  in 
any  suspected  rupture  of  the  viscus,  to  see  if  the  amount  of  fluid  run  into  the 
bladder  is  duly  returned.  At  the  same  time,  a  thorough  examination  should  be 
made  of  the  bony  pelvis  for  any  sign  of  fracture,  which  is  frequently  the  cause 
of  direct  injury  to  the  bladder  or  urethra. 

In  Renal  Calculus  the  bleeding  is  seldom  profuse,  is  usually  associated  with 
a  small  amount  of  pus,  and  frequently  is  increased  after  any  exertion  or  by 
the  jolting  of  a  journey.  The  subject  of  a  renal  stone  will  usually  complain 
of  pain  in  one  loin  of  a  constant  aching  character,  which  will  remain  of  this 
character  so  long  as  the  stone  remains  embedded  in  the  renal  tissues,  in  which 
condition  slight  haematuria  is  often  present.  When,  however,  the  calculus  pro- 
jects into  or  is  free  in  the  renal  pelvis,  the  urine  also  contains  a  small  quantity 
of  pus,  and  attacks  of  renal  colic  come  on,  characterized  by  very  acute  pain  in 
the  loin,  passing  forwards  and  downwards  to  the  groin,  upper  part  of  the  thigh, 
and  testicle  of  the  same  side,  and  accompanied  by  frequent  desire  to  pass  urine. 
The  calculus  may  be  passed  into  the  bladder  along  the  ureter,  may  become 
impacted  in  the  course  of  the  ureter,  or  may  remain  in  the  renal  pelvis,  in 
which  case  successive  attacks  of  renal  colic  may  occur.     The  previous  passage 


PL  A  TE      V. 

BLADDER   APPEARANCES   SEEN   THROUGH   THE   CYSTOSCOPE 


Fig.  D. 


Cojiyriglit 


Fig.  E. 

]l'.    Thornton  Shiells,  del. 


l.NDE.V     111-      DI,\GNOSIS 


H.TiMATURTA 


309 


of  a  small  calculus  per  urethram,  following  an  attack  of  renal  colic,  is  an 
important  point  in  the  history  of  such  a  patient,  but  in  any  case  an  examination 
by  skiagraphy  should  be  carried  out,  when  a  calculus  may  be  proved  present  in 
the  kidney  (Fig.  97).  A  calculus  in  the  kidney  may  attain  a  size  too  large  to 
become    engaged    in  the    upper    end    of   the    ureter,   when    renal    colic    will   be 


I^ig:  97, — Skiagram  of  a  calculus  in  a  dropped  left  kidney. 
(By  Dr.  Alfred  C.  Jordan.) 


absent,   or  it  may  cause   hydronephrosis,    renal    abscess,    or    pyonephrosis,    of 
which  symptoms  may  be  present. 

Renal  Tuberculosis,  apart  from  the  miliary  form  of  children,  is  not  uncommon 
as  a  primary  disease  of  one  kidney.  The  patients  affected  are  usually  young 
adults,  who  complain  of  a  constant  aching  in  one  loin,  with  occasional  attacks 
of  more  acute  pain  resembling  renal  colic.  At  the  onset  of  the  disease,  when 
the    foci    are    limited    to    the    renal   tissues,    there    is    no    change  in   the  urine 


3IO  HEMATURIA 


beyond  the  occasional  presence  of  albumin ;  but  as  it  advances  the  foci 
coalesce  and  form  a  softened  area  which  opens  into  the  renal  pelvis,  when  there 
is  a  constant  discharge  of  small  quantities  of  pus  and  blood  in  the  urine.  The 
liberation  of  tuberculous  material  into  the  renal  pelvis  and  ureter  causes  infection 
of  the  mucous  lining  of  these  passages,  and  is  marked  almost  constantly  by 
increased  frequency  of  micturition  during  both  the  day  and  the  night,  even 
before  any  tuberculous  infection  has  occurred  in  the  bladder.  These  cases  are 
often  mistaken  for  renal  calculus,  but  in  any  case  of  persistent  slight  hasmaturia 
or  pyuria  a  careful  search  should  be  made  for  tubercle  bacilli  in  the  urine.  It 
should  be  noted  also  that  a  skiagram  may  show  a  distinct  shadow  produced 
by  a  tuberculous  focus  in  the  kidney,  but  its  outline  differs  from  that  due  to 
a  calculus  in  its  indefinite  border.  In  renal  tuberculosis  the  haematuria  is 
rarely  increased  by  exertion  on  the  part  of  the  patient,  as  is  frequently  the  case 
with  calculus,  and  pain  in  the  loin  is  less  mitigated  by  rest  in  bed. 

In  Renal  Mobility,  haematuria  is  certainly  uncommon,  but  occasionally  occurs. 
In  the  case  of  a  patient  with  markedly  increased  renal  mobility,  haematuria  may 
follow  any  exertion,  such  as  hunting  or  dancing.  Renal  mobility  is  so  common, 
however,  that  the  occurrence  of  haematuria  should  in  any  case  arouse  suspicion 
of  some  other  lesion  of  the  urinary  tract,  and  a  thorough  examination  both  of 
the  bladder  (by  the  cystoscope)  and  of  the  kidney,  should  be  made  before  any 
attempt  at  fixation  is  undertaken.     Movable  kidney  may  be  entirely  painless 

DESCRIPTION    OF    PLATE    VI. 

Bladder   Appearances   seen   through   the    Cystoscope. 

Fig.   F. — Pedunculated  carcinoma   of  the  bladder. 
Fig.    G. — Pedunculated  bald  carcinoma  of  the  bladder. 
Fig.  H. — Uric  acid  calculus  in   the  bladder. 

Fig.    I. — Appearance  at  the  urethral  orifice  in  bilateral  adenomatous  enlarge- 
ment of  the  prostate. 
Fig.  K. — Bilharzia  haematobia. 

J^ig.   G  is  from  a  sketch  by  ])r.    }l'alte?-s,  and  Fig,    K  is  ri:J>roduccd  by  kina 
pertnission  of  Mr.  H.   A.    Wilson. 

and  give  rise  to  no  symptoms  whatever,  or  may  cause  lumbar  aching  or  attacks 
of  acute  pain  resembling  renal  colic  (Dietl's  crises).  It  frequently  causes  gastro- 
intestinal disturbance  from  the  drag  upon  the  duodenum  in  relation  to  it,  and 
occasionally  also  polyuria  and  increased  frequency  of  micturition.  The  kidne}^ 
can  be  felt  to  be  movable,  but  care  must  be  taken  not  to  mistake  other  abdominal 
swellings  for  a  kidney  (see  Kidney,  Enlargement  of). 

Hydronephrosis  occasionally  gives  rise  to  haematuria,  and  the  combination  of 
renal  tumour  and  haematuria  would  suggest  a  growth  in  the  kidney.  The  blood 
from  a  hydronephrotic  kidney,  however,  is  very  rarely  copious,  and  the  other 
symptoms  of  hydronephrosis  would  distinguish  the  two,  in  particular  inter- 
mittency  with  corresponding  changes  in  the  amount  of  the  urine. 

Polycystic  disease  of  the  kidneys  is  commonly  accompanied  by  haematuria  in 
the  later  stages  of  the  disease.  It  occurs  in  early  childhood  or  in  adult  life,  and 
is  most  commonly  bilateral,  forming  an  enlargement  of  each  kidney  which  may 
reach  large  dimensions,  although  on  the  other  hand  a  tumour  may  onl}'  be  felt  on 
one  side.  In  the  early  stages  the  diagnosis  is  difficult  ;  but  later,  pain,  bilateral 
tumour,  haematuria,  and  signs  of  renal  inefficiencj'  will  be  present.  The  renal 
tumour  caused  by  polycystic  disease  is  smooth  and  rounded,  but  differs  from 
hydronephrosis  in  that  fluctuation  can  seldom  be  obtained.  Bilateral  hydro- 
nephrosis will  be  diagnosed  from  polycystic  disease  by  the  finding  of  some 
lesion  obstructing  the  normal  urinary   flow,    such  as  stricture  of  the  urethra. 


PLATE      VI. 

LADDER      APPEARANCES      SEEN      THROUGH      THE      CYSTOSCOPE 


Fig.  I. 


Cojiyright 


Fig.  K. 

W.   Thornton  Shiclls,  del. 


INDEX     OF     DIAGNOSIS 


HEMATURIA  311 


prostatic  or  vesical  disease,  or  carcinoma  of  the  pelvic  organs  invading  the 
ureters. 

Oxaluria  (q.v.)  may  give  rise  to  a  slight  hematuria.  The  passage  of  large  num- 
bers of  oxalate  crystals  in  the  urine  occurs  in  some  patients,  especially  after  a 
diet  containing  rhubarb,  gooseberries,  or  tomatoes,  and  is  often  accompanied 
by  dyspepsia.  An  examination  of  the  urine  on  successive  days  will  demonstrate 
the  condition.  The  aching  in  one  loin  and  the  presence  of  envelope  crystals  in 
the  urine,  may  simulate  renal  stone,  but  the  absence  of  a  shadow  in  a  skiagram 
will  disprove  the  latter. 

Acute  Nephritis  is  accompanied  by  haematuria,  but  is  usually  obvious  by  the 
sudden  onset  of  the  disease,  by  the  history  of  some  specific  fever,  or  of  a  chill, 
and  by  the  subcutaneous  oedema.  The  urine  is  scanty  and  of  high  specific 
gravity,  and  contains,  in  addition  to  blood  discs,  hyaline  and  epithelial  tube- 
casts,  many  renal  epithelial  cells,  and  abundant  albumin.  There  are  some 
cases  of  acute  nephritis  in  which  no  oedema  occurs,  and  then  the  abundance  of 
renal  tube-casts  in  the  urine  affords  the  main  evidence  as  to  the  diagnosis. 

B.  Ureteric  Calculus  may  cause  hematuria,  either  during  the  descent  of  the 
stone  or  when  the  latter  becomes  arrested  in  the  duct  without  causing  complete 
obstruction  to  the  flow  of  urine.  The  diagnosis  is  usually  easy  from  the  history, 
and  the  character  of  the  pain,  accompanied  by  the  increased  desire  to  micturate  ; 
but  in  some  cases  on  the  right  side  it  may  be  mistaken  for  acute  appe-ndicitis. 
The  previous  history  of  the  passage  of  a  calculus  or  of  renal  symptoms  of  stone 
will  usually  be  elicited.     A  skiagram  should  be  obtained. 

C.  Vesical  Causes. — The  profuse  haematuria  of  a  papilloma,  villous  tumour, 
or  of  a  villus-covered  carcinoma  of  the  bladder,  frequently  occurs  without 
any  other  symptom.  The  haemorrhage  may  come  on  suddenly  without  any 
exciting  cause ;  it  may  last  a  variable  time,  and  then  entirely  disappear,  or 
continue  as  a  slight  haematuria  for  some  days.  With  the  carcinomatous  form 
there  may  be  some  increased  frequency  of  micturition  in  the  absence  of 
bleeding,  but  in  either  variety  the  clotting  of  blood  in  the  bladder  may  cause 
urgent  desire  to  micturate  or  even  retention  of  urine.  A  rectal  examination 
may  give  evidence  of  infiltration  of  the  base  of  the  bladder  or  of  the  pelvic 
lymphatics  in  the  malignant  form,  but  it  is  only  rarely  that  an  innocent 
tumour  is  large  enough  to  be  felt  by  the  rectum.  In  the  intervals  betw-een 
ha3morrhages,  a  cystoscopic  examination  will  demonstrate  the  presence  of  a 
vesical  growth  [Plate  VI,  Figs.  F  and  G).  It  should  be  noted  that  the  common 
situation  for  a  vesical  tumour  is  at  the  base  of  the  bladder,  in  close  proximity 
to  a  ureteric  orifice  ;  this  latter  may  be  actually  obstructed,  or  dragged  upon 
by  the  growth  in  such  manner  as  to  cause  renal  distention  or  actual  hydro- 
nephrosis, so  that  a  vesical  tumour  may  give  rise  to  renal  pain  and  tumour, 
and  in  this  way  may  be  readily  mistaken  for  a  renal  growth.  This  difficulty 
will  be  overcome  by  a  cystoscopic  examination  of  the  bladder. 

Prostatic  enlargement  of  the  adenomatous,  or  more  frequently  of  the  carcino- 
matous variety,  maj^  cause  haematuria.  The  age  of  the  patient  (54  or  more), 
the  increased  frequency  and  difficulty  in  micturition,  the  evidence  obtained  by 
a  rectal  examination  and  by  catheterization,  suffice  to  diagnose  the  disease. 
The  haematuria  of  prostatic  enlargement  is  often  profuse,  and  may  be  an  early 
symptom  of  the  disease  ;  but  on  careful  enquiry  it  will  usually  be  found 
that  there  has  been  for  some  months  a  gradually  increasing  frequency  of 
micturition. 

Vesical  Epithelioma  occurs  in  elderly  patients,  and  cause?  slight  but  fairly 
constant  haematuria.  For  haemorrhage  to  take  place  from  a  vesical  epithelioma, 
there  must  be  ulceration  of  the  surface  of  the  growth,  and  other  symptoms  will 
be  present,   namely,   increased   frequency  of  micturition  both  day  and  night. 


31- 


HMMATURIA 


penile  pain  following  the  act  of  micturition,  and  p^'uria.  The  blood  often  occurs 
as  a  few  drops  at  the  termination  of  urination,  or  may  be  mixed  throughout  the 
act.  Usually  a  vesical  epithelioma  is  situated  on  the  base  of  the  bladder,  and 
may  be  felt  as  a  distinct  infiltration  per  rectum. 

Vesical  Tuberculosis  gives  rise  to  exactl}^  the  same  symptoms  as  an  epithe- 
Uoma,  but  it  occurs  commonly  in  young  adults.  Persistent  slight  haematuria 
and  pyuria  in  a  young  patient  will  always  suggest  tuberculous  disease,  and  a 
very  careful  search  should  be  made  in  the  centrifugalized  urine  for  tubercle 
bacilli,  whilst  other  evidence  of  tuberculous  disease,  especially  in  the  testes, 
vesiculas  seminales,  and  prostate,  should  be  looked  for.  Difficulty  may  arise  in 
the  diagnosis  between  vesical  and  renal  tubercle,  for  in  the  latter,  persistent 
haematuria  and  pyuria,  together  with  increased  frequency  of  micturition,  may 
be  present.  With  renal  tubercle  will  usually  be  found  some  renal  enlargement 
and  pain,  the  ureter  may  be  felt  to  be  thickened,  and  the  blood  in  the  urine 
will  not  be  more  apparent  at  the  end  than  during  the  rest  of  micturition,  unless 
the  bladder  is  also  affected.     Renal  tuberculosis  is  more  commonly  a  primary 

disease  in  the  urinary  organs 
than  vesical,  but  either  may 
occur  in  the  progress  of  the 
disease  of  the  other  organ. 
When  a  tuberculous  nodule, 
in  a  vesicle  or  the  prostate 
ulcerates  into  the  bladder, 
a  sharp  attack  of  haematuria 
may  result.  Great  assist- 
ance may  be  gained  in  the 
diagnosis  of  urinary  tuber- 
culosis b}^  a  careful  cysto- 
scopic  examination  [Plate 
V,  Fig.  E). 

Vesical  Calculus  also 
causes  slight  haematuria, 
usually  as  a  few  drops  in 
the  terminal  urine  of  mic- 
turition. The  subject  of  a 
calculus  in  the  bladder 
which  is  unaccompanied  by 
cystitis  will  complain  of 
increased  frequency  of  mic- 
turition during  the  day  or 
during  exercise,  but  is 
usually  free  from  micturition  during  the  night.  There  is  pain  of  a  pricking 
character  in  the  glans  penis  after  micturition,  and  there  may  be  a  history  of 
sudden  stoppage  of  the  stream  during  the  act.  The  patients  are  usually  men, 
and  there  may  be  a  history  of  previous  calculi  or  of  the  kidney  having  been 
found  to  be  unduly  movable.  The  stone  may  be  felt  with  a  sound,  or  better 
still,  seen  by  a  cystoscope,  when  small  calculi  which  may  be  missed  with  a 
sound  may  be  diagnosed  with  certainty  [Plate  VI,  Fig.  H).  The  ;r-rays  are 
also  useful  in  detecting  the  stone  in  many  cases  [Fig.  98). 

If  the  calculus  has  caused  cystitis,  there  will  be  in  addition  pyuria  and 
nocturnal  micturition. 

Acute  Cystitis  is  accompanied  by  haematuria;  but  the  other  symptoms,  such 
as  vesical  tenesmus,  suprapubic  pain,  and  pyrexia,  together  with  pyuria  and  a 
cause  for  the  condition,  will  point  to  the  disease. 


J^ig:  98. — Skiagram  of  a  composite  (oxalate  and  phosphate) 

vesical  calculus.    C,  calculus  ;  R,  rectum  ;  S,  sj-mphysis  pubis. 

{By  Dr.  Alfred  C.  Jordan.) 


HEMATURIA  313 


Bilharzia  hcsmatobia  causes  slight  hagmaturia,  and  gives  rise  to  symptoms 
very  similar  to  vesical  tuberculosis.  The  discovery  of  the  typical  ova  in 
the  urine  (see  Fig.  13,  p.  93),  together  with  a  history  of  residence  in  an 
affected  district,  notably  Egypt  or  certain  parts  of  South  Africa,  will  make 
the  diagnosis  clear.  The  cystoscopic  appearance  in  the  bladder  of  small, 
glistening  yellow  nodules  and  small  areas  of  raised  granulation  tissue,  is 
distinctive  of  the  disease  {Plate   VI,  Fig.  K). 

D.   Urethral  Causes. 

Acute  Urethritis  may  cause  blood  to  appear  in  the  urine  from  the  acute  con- 
gestion of  the  urethral  mucous  membrane,  both  in  gonorrhoeal  and  septic 
infections.  The  history  and  the  presence  of  an  acute  urethral  discharge  make 
the  diagnosis  evident. 

The  Impaction  of  a  Calculus  in  the  urethra  causes  some  bleeding  from  direct 
injury  to  the  urethral  mucous  membrane.  There  is  usually  retention  of  urine, 
so  that  true  hsematuria  may  not  occur ;  but  the  history  of  sudden  stoppage  of 
the  stream  of  urine  during  micturition,  with  acute  penile  pain,  together  with 
the  previous  history  of  renal  or  vesical  stone,  will  usually  make  the  diagnosis 
clear.  It  is  not  uncommon  in  male  children.  The  calculus  may  be  felt  from, 
the  outside  in  the  course  of  the  urethra,  often  at  or  near  the  meatus,  or  easily 
seen  by  an  endoscopic  examination. 

II. H.EMATURIA     FROM     DISEASE     OF     THE    NEIGHBOURING     ViSCERA     INVOLVING 

THE  Urinary  Organs. 

The  direct  spread  of  carcinoma  of  the  pelvic  organs  may  in  its  progress 
involve  the  bladder,  and  is  of  not  uncommon  occurrence  in  the  later  stages 
of  carcinoma  of  the  uterus,  vagina,  rectum,  or  pelvic  colon.  The  infiltration 
of  the  bladder  wall  before  actual  ulceration  has  occurred,  is  usually  indicated 
by  vesical  irritability,  followed  by  ulceration  and  haematuria,  together  with 
the  passage  of  urine  by  the  vagina  or  faecal  matter  in  the  urine.  Occurring 
as  a  late  stage  of  carcinomatous  disease,  there  is  usually  little  difficulty  in 
the  diagnosis. 

Haematuria  may  occur  during  an  attack  of  acute  appendicitis  from  the  direct 
spread  of  the  inflammatory  process  to  the  vesical  wall.  In  some  cases  in 
which  the  inflamed  appendix  turns  downwards  over  the  pelvic  brim,  it  may 
become  adherent  to  the  bladder,  or  an  abscess  may  form  in  immediate  relation 
to  the  bladder  wall.  The  localized  inflammation  of  the  vesical  mucous  membrane 
causes  haematuria,  whilst  the  sudden  appearance  of  a  quantitj^  of  pus  in  the 
urine  has  been  noticed  when  an  appendicular  abscess  has  ruptured  into  the 
bladder.  The  history  of  acute  pain  low  down  in  the  right  iliac  fossa,  the 
pyrexia,  and  general  symptoms  of  peritoneal  inflammation  before  any  urinary 
symptom  was  noted,  will  point  to  the  disease  ;  a  rectal  examination  may 
reveal  the  inflammatory  process  in  the  right  pelvic  region. 

Acute  Salpingitis  or  Pelvic  Abscess  may  similarly  cause  haematuria  from 
direct  inflammatory  extension  to  the  vesical  wall,  but  this  is  rarer  than  in 
appendicitis. 

Tuberculous  and  Dysenteric  Ulceration  of  the  Intestine  have  both  caused 
haematuria  by  the  adhesion  of  the  bowel  to  the  fundus  of  the  bladder  and  the 
subsequent  inflammatory  condition  of  the  mucous  membrane.  In  a  case  of 
slight  haematuria,  a  cystoscopic  examination  showed  a  localized  area  of  intense 
congestion  at  the  fundus  of  the  bladder  without  any  other  vesical  lesion,  and 
on  opening  the  abdomen,  a  coil  of  small  intestine,  obviously  ulcerated  by  tubercle, 
was  found  adherent  to  the  peritoneal  aspect  of  the  bladder.  In  most  cases  the 
symptoms  due  to  the  intestinal  disease  would  be  apparent. 


314  HEMATURIA 


III. HiEMATURIA    IN    GENERAL    DISEASES. 

The  sudden  plugging  of  a  renal  vessel  by  embolism  {renal  infarction))  is  not 
uncommon  in  cases  of  endocarditis,  and  may  be  accompanied  by  hsematuria. 
The  embolism  is  most  commonly  seen  in  infective  endocarditis,  during  the 
course  of  which  sudden  pain  is  felt  in  the  loin,  followed  by  haematuria.  The 
occurrence  of  acute  endocarditis  in  the  course  of  acute  septic  processes,  such  as 
acute  osteomyelitis,  pneumonia,  or  acute  rheumatism,  is  not  uncommon,  and 
will  usually  be  diagnosed  before  there  is  any  evidence  of  renal  embolism.  On 
the  other  hand,  there  are  certain  cases  of  chronic  heart  disease  in  which  the  first 
evidence  of  infected  endocarditis  having  developed  may  be  the  occurrence  of 
sudden  haematuria  ;  and  in  some  such  cases  there  may  be  difficulty  in  excluding 
acute  Bright's  disease,  because  around  each  infarct  there  is  local  acute  inflamma- 
tion, and  therefore  the  urine  will  contain  tube-casts  as  well  as  blood  ;  the  discs 
should  be  examined  for  optic  neuritis,  and  if  there  is  pyrexia  with  progressive 
enlargement  of  the  spleen,  infective  endocarditis  will  suggest  itself. 

LeukcBtnia  may  be  accompanied  by  haematuria  ;  but  the  enlargement  of  the 
spleen,  general  symptoms  of  anaemia,  and  the  total  and  differential  blood 
counts,  will  point  to  a  diagnosis. 

Scurvy  and  the  various  forms  of  Purpura  [q.v.)  may  each  be  accompanied  by 
haematuria,  but  the  general  symptoms  of  each  disease  are  usually  well  marked 
before  haematuria  occurs.  In  infantile  scurvy,  the  evidence  of  subperiosteal 
haemorrhages  should  be  looked  for,  whereas  in  purpura  there  will  be  other 
obvious  hagmorrhagic  lesions.  R.  H.  Jocelyn  Swan. 

HEMOGLOBINURIA. — Haemoglobinuria  differs  from  haematuria  in  that  the 
blood-pigment  is  passed  in  solution  in  the  urine  apart  from  red  corpuscles.  In 
many  cases  of  haemoglobinuria  small  numbers  of  red  corpuscles,  or  the  ghosts 
of  them,  may  be  found  microscopically  ;  but  so  far  as  these  red  corpuscles 
go  they  constitute  haematuria  in  association  with  the  haemoglobinuria  ;  the 
essential  part  of  the  latter  is  the  passage  of  the  blood  pigment  dissolved  out 
of  the  red  corpuscles.  It  gives  the  same  chemical  tests  as  ordinary  blood  ; 
spectroscopically  it  is  almost  as  common  to  find  the  bands  of  methaemoglobin 
{Fig.  22,  p.  95)  as  those  of  oxyhaemoglobin  {Fig.  17,  p.  95)  ;  by  the  addition 
of  ammonium  sulphide  the  spectrum  is  changed  to  that  of  reduced  haemoglobin 
{Fig.  18,  p.  95),  and  by  the  further  addition  of  a  few  drops  of  concentrated 
caustic  soda,  that  of  alkaline  haematin  {Fig.  20,  p.  95)  is  produced.  The 
diagnosis  depends  upon  the  discovery  of  blood  pigments  in  the  urine,  whilst 
the  microscope  shows  no  red  corpuscles,  or  these  are  so  few  in  number  as  to 
be  out  of  all  proportion  to  the  pigment.  It  is  important  that  the  urine  should 
be  examined  fresh,  for  otherwise,  owing  to  the  disintegration  of  red  cells  after 
they  have  been  passed  as  such,  it  is  possible  to  mistake  for  haemoglobinuria  that 
which  is  really  haematuria. 

To  the  naked  eye,  the  urine  may  be  only  just  tinged  with  a  colour  that 
suggests  blood  pigment,  or  it  may  be  absolutely  blood  red,  brown,  murky,  or 
even  black,  as  in  the  tropical  blackwater  fever.  It  is  seldom  clear  ;  but  clouded 
by  mucus,  casts,  amorphous  masses  of  pigment,  and  debris. 

Haemoglobinuria  results  from  any  condition  which  leads  to  haemoglobinaemia 
by  laking  the  red  corpuscles  within  the  living  vessels.  It  has  been  produced 
in  animals  experimentally  by  the  injection  of  various  haemolytic  sera  and  other 
substances.  It  may  occur  in  man  as  the  result  of  the  oral  administration  of 
certain  chemical  substances  such  as  potassium  chlorate,  pyrogallic  acid,  naphthol, 
urotropine,  and  possibly  quinine  ;  after  the  inhalation  of  certain  toxic  gases, 
notably  carbon  monoxide,  carbon  bisulphide,  naphtha  vapour,  arseniuretted 
hydrogen  ;    after  the  transfusion  of  certain  foreign  sera  which  were  formerly 


HMMOGLOBINURIA  315 


employed  instead  of  saline  infusions  ;  after  frostbite  and  extreme  exposure  to 
cold  ;  after  severe  burns  ;  after  large  internal  extravasations  of  blood,  especially 
those  within  the  abdominal  cavity  ;  in  a  few  cases  in  which  pregnancy  is  associated 
with  toxasmic  symptoms  ;  in  some  new-born  infants,  occasionally  in  an  obscure 
epidemic  form  ;  in  association  with  certain  functional  disorders  of  the  vasomotor 
system,  especially  Raynaud's  disease,  factitious  urticaria  and  angio-neurotic 
oedema  ;  after  very  long-sustained  excessive  physical  exertions  and  fatigue  ;  in 
association  with  severe  forms  of  microbial — or  presumably  microbial — toxaemia, 
especially  malaria  and  blackwater  fever,  and  to  a  much  less  extent  in  severe  syph- 
ilis, typhoid  fever,  scarlet  fever,  acute  pyogenic  septicaemia,  generalized  anthrax, 
yellow  fever,  and  other  tropical  fevers  ;  Henoch's  purpura ;  in  certain  cases  of 
nephritis  ;  and  in  that  remarkable  affection  known  as  paroxysmal  haemoglobinuria. 

Although  the  above  list  may  appear  formidable,  as  a  matter  of  fact  the  differ- 
ential diagnosis  between  the  different  diseases  mentioned  in  it  will  seldom  depend 
solely  upon  the  presence  or  absence  of  haemoglobinuria.  The  chief  importance  of 
the  latter,  indeed,  lies  first  in  the  necessity  of  not  mistaking  it  for  haematuria,  and 
secondly  in  that  its  occurrence  is  a  sign  that  considerable  haemolysis  is  taking  place 
and  that  the  prognosis  is  proportionately  less  good.  It  is  enough  if  the  fact 
that  it  may  be  a  complication  of  any  of  the  above  conditions  is  borne  in  mind. 

The  question  of  whether  blackwater  fevev  is  due  to  the  effects  of  quinine  in 
a  patient  whose  blood  is  already  susceptible  to  haemolysis  on  account  of  malaria, 
or  whether  the  blackwater  is  due  to  a  distinct  and  specific  malady,  has  not  yet 
been  settled  ;  the  diagnosis  is,  however,  generally  obvious,  the  geographical 
circumstances  under  which  the  disease  develops  pointing  to  its  nature. 

Paroxysmal  hcsmoglobinuria  is  rare  ;  but  in  Great  Britain  it  is  probably  the 
commonest  cause  of  considerable  hemoglobinuria  without  symptoms  of  extreme 
illness.  It  may  affect  adolescents  or  grown-up  people,  males  or  females  ;  it  has 
probably  several  different  ultimate  causes  ;  amongst  the  latter,  however,  previous 
syphilis  stands  out  pre-eminently,  and  probably  heredity  is  also  a  factor.  Males 
are  affected  rather  than  females.  The  remarkable  feature  of  the  malady  is  the 
way  in  which  an  attack  can  be  brought  on,  almost  at  will,  by  certain  immediate 
causes,  of  which  the  most  potent  is  exposure  to  cold,  others  being  excessive 
exercise  or  mental  excitement.  Sometimes  the  exposure  has  to  be  considerable 
before  haemoglobinuria  results  ;  on  the  other  hand,  it  may  be  impossible  for  the 
patient  to  keep  his  hands  immersed  in  cold  water  for  any  length  of  time  without 
an  attack  ensuing.  The  urine  may  look  like  blood,  and  the  output  of  pigment, 
together  with  considerable  albuminuria,  persists  for  a  day  or  two  as  a  rule  ;  the 
attack  may  be  unaccompanied  by  other  symptoms,  but  sometimes  there  is  a 
shivering  attack  or  an  actual  rigor  with  rise  of  temperature,  and  a  general  feeling 
of  illness,  necessitating  rest  in  bed.  Sooner  or  later,  if  repeated  attacks  occur, 
the  patient  becomes  severely  anaemic,  with  all  the  symptoms  that  result  from 
such  anaemia.  The  diagnosis  may  be  very  difficult  at  the  time  of  the  first  attack, 
but  it  is  relatively  easy  when  the  attacks  recur,  especially  when  there  is  distinct 
relationship  to  some  definite  immediate  cause,  such  as  exposure  to  cold,  to  undue 
fatigue,  or  mental  excitement.  The  main  mistake  to  avoid  is  a  diagnosis  ox 
haematuria,  such  as  a  villous  tumour  of  the  bladder  might  cause.  The  way  to 
obviate  this  error  is  to  employ  both  the  microscopic  and  the  spectroscopic  tests 
for  blood,  much  pigment  and  few  corpuscles  pointing  to  haemoglobinuria. 

Herbert  French. 

HEMOPTYSIS. — The  term  haemoptysis  literally  means  blood-spitting,  but 
clinically  it  is  restricted  to  the  expectoration  of  blood  derived  from  the  lungs, 
bronchi,  or  trachea,  to  the  exclusion  of  the  spitting  of  blood  derived  from  the 
mouth,  nose,  or  pharynx.  Some  observers  would  include  blood  coming  from 
ulceration  of  the  larynx  under  the  heading  of  haemoptysis,  others  would  not,  so 


3i6  HMMOPTYSIS 


that  the  meaning  of  the  term  is  arbitrary.     For  practical  purposes  it  is  simpler 
to  include  the  larynx  as  a  source  for-  haemoptysis. 

The  differential  diagnosis  resolves  itself  into  two  main  portions,  namely, 
(I)  A  determination  of  whether  the  symptom  has  really  been  haemoptysis  in  the 
restricted  sense,  or  whether  the  blood  has  been  derived  from  the  mouth,  nose, 
or  pharynx  on  the  one  hand,  or  the  stomach  on  the  other  ;  and  (II)  If  true 
haemoptj'sis  has  really  occurred,  a  determination  of  its  exact  cause  in  the  parti- 
cular case. 

I. — The  Distinction  between  True  and  Spurious  Hemoptysis. 

True  haemoptysis — that  is  to  say,  haemorrhage  from  the  lungs,  bronchi,  trachea, 
or  larynx — can  sometimes  be  distinguished  at  once  from  the  spitting  of  blood 
derived  from  the  nose,  mouth,  or  pharynx.  The  occurrence  of  epistaxis 
bleeding  gums,  sore  throat,  ulcerative  stomatitis,  epithelioma  linguae,  injury 
to  the  mouth,  gingivitis  from  a  carious  tooth,  or  from  pyorrhoea  alveolaris, 
pharyngitis,  septic  conditions  of  the  antrum  of  Highmore,  or  frontal,  ethmoidal, 
or  sphenoidal  air-cells,  or  rarer  conditions,  such  as  lupus  of  the  palate  or 
pharynx,  sarcoma  of  the  tonsil  or  of  the  basisphenoid,  may  generally  be  detected 
by  a  careful  examination  of  the  nose,  mouth,  gums,  and  phar\mx  ;  moreover, 
the  blood  in  these  conditions  is  usually  mixed  with  saliva,  watery,  and  perhaps 
non-aerated.  It  is  very  important,  however,  to  be  decidedly  guarded  in  con- 
cluding that  blood  comes  from  the  mouth,  nose,  or  throat,  and  not  from  the 
lungs  ;  and  a  careful  examination  for  tubercle  bacilli  should  be  carried  out  in 
every  such  case,  lest  the  early  stage  of  phthisis  should  be  missed. 

The  distinction  between  haemoptysis  and  haematemesis  is  often  easy  enough, 
but  sometimes  very  difficult.  The  history  may  help,  or  the  patient's  own 
sensations  may  make  him  certain  that  he  coughed  up  the  blood,  and  did  not 
vomit  it.     The  following  is  a  summary  of  the  points  of  distinction  : — 

Hemoptysis.  H.ematemesis. 

1.  The  patient  coughs  the  blood  up  i.  The  blood  is  vomited 

2.  Part  of  the  blood  is  often  frothy  2.  The  blood  is  not  frothy 

3.  The  blood  may  occur  by  itself,  but  it  is  3.  The  blood  may  occur  by  itself,  but  it  is 

often  mixed  with  sputa,  recognizable  often  mixed  with  vomit,  recognizable 

microscopically  by  the  presence  of  food  particles 

4.  The  blood  is  alkaline  in  reaction  4.  The    blood    may    be    alkaline    if    it    is 

abundant,  but  it  is  often  acid  from 
admixture  with  gastric  juice 

5.  Tubercle    bacilli    or    elastic    fibres    may  5.  Tubercle  bacilli  will  be  absent 

be  detected 

6.  There    may    be    a    previous    history    of  6.  There   may  be   a   definite  history,  with 

acute  rheumatism,   or  of  cough'  and  or    without    physical   signs,   pointing 

night  sweats,  indicative    of  heart   or  to  a  gastric  lesion  or  to  cirrhosis  of 

lung  disease,  confirmed  by  abnormal  the  liv'er 
cardiac  or  pulmonary  physical  signs 

7.  Before  the  blood  is  coughed  up,   there  7.  Before   the  blood  is  brought   up   there 

is     often    a    sense      of      tickling    or  may  be  a  feeling  of  sickness,  nausea, 

gurgling    in    the     throat,     which     is  oppression       in       the       epigastrium, 

always  very  suggestive  of  true  haemo-  faintness,  and  giddiness 
ptysis 

8.  The  motions  are  not  altered  afterwards  8.  The  motions  are  often  tarry  afterwards 

unless  the  blood  has  been  abundant 
and  much  of  it  has  been  swallowed, 
when  they  may  be  tarry  as  in 
haematemesis 

9.  Blood-stained    sputa    may    be    expec-  9.  There  are  usually  no  sputa 

torated    for    several    days    after    a 
severe  attack 
10.  A  history  of  cough  10.  A  history  of  abdominal  pains  after  food. 


HEMOPTYSIS 


317 


Notwithstanding  all  these  points  of  distinction,  however,  it  may  be  very- 
difficult  to  avoid  being  misled,  unless  the  patient  can  be  kept  under  observation 
for  a  time  ;  moreover,  haematemesis  may  be  caused  by  haemoptysis,  especially 
when  the  bleeding  takes  place  in  the  night,  the  blood  being  swallowed  as  soon  as 
it  gets  into  the  pharynx  whilst  the  patient  remains  asleep  and  quite  unconscious 
of  the  occurrence.  The  frequency  with  which  haemoptysis  occurs  during  the 
night  when  the  patient  is  at  rest  is  remarkable  ;  but  in  the  majority  of  instances 
the  incidence  of  bleeding  excites  coughing,  and  the  patient  wakes. 

Malingering  by  the  production  of  blood-spitting  by  gum-sucking  is  diagnosed 
upon  circumstantial  evidence.  It  has  sometimes  happened  that  a  patient 
has  produced  the  blood  of  fowls  with  the  statement  that  this  has  been  coughed 
up — a  fallacy  that  can  be  detected  by  examining  the  red  cells  under  the 
microscope. 

II. — Determination   of  the  Cause  of  the  Hemoptysis. 

Having  arrived  at  the  conclusion  that  a  patient  has  had  haemoptysis,  the  next 
point^is  to  ascertain  the  cause  of  this  very  important  symptom  in  the  particular 
case.  It  may  be  said  at  once  that  by  far  the  commonest  causes  of  haemoptysis 
are  phthisis  on  the  one  hand  and  mitral  stenosis  upon  the  other.  The  heart  and 
lungs  need  particular  examination  therefore,  and  the  family  and  personal  history, 
both  as  to  acute  rheumatism  or  chorea,  and  as  to  consumption,  may  assist. 
If  there  are  no  abnormal  physical  signs  in  the  thorax,  it  does  not  follow  that 
phthisis  is  absent — even  phthisis  with  cavitation  may  exist  without  any  definitely 
abnormal  physical  signs  being  detected ;  microscopical  examination  of  the 
sputum,  therefore,  both  for  tubercle  bacilli  and  for  elastic  fibres,  should  never  be 
omitted,  especially  after  the  haemoptysis  has  ceased  ;  repeated  examinations 
may  be  required  if  the  first  proves  negative. 

Although  these  are  the  commonest,  there  are  a  great  many  other  causes,  as 
the  following  tables  indicate  : — 

A.  Haemoptysis  due  to  Changes  in  the   Lungs  : — 


Phthisis  : 

[a]  Early 
(6)   Later 

Cirrhosis    of     lung  :     pneumono- 
coniosis  : 
(fl)    Knifegrinder's  lung 

[b)  Stonemason's  lung 
Cardiac  disease,  especially  mitral 

stenosis 
Violent    coughing    efforts,    as    in 

whooping-cough  or  bronchitis 

or  emphysema 
Injury  : 

(a)  Blows  upon  the  chest  wall, 

without  rib  fracture 

[b)  Fractured  rib 

(c)  Exploratory  needling  of  the 

chest 

[d)  At  the  end  of  paracentesis 

thoracis. 
Lobar  pneumonia 
Bronchopneumonia 


8.  Septic  pneumonia,  with  or  with- 

out abscess 

9.  Gangrene  of  the  lung 

10.  Infarction  of  the  lung  : 

{a)   Embolic 
{b)   Thrombotic 

11.  Neoplasm   of   the   lung,    whether 

primary  or  secondary  : 

(a)  Sarcoma 

(b)  Carcinoma 

12.  Sporotrichosis  of  the  lung  : 

{a)   Aspergillosis 

[b)  Actinomycosis 

(c)  Other  forms 

13.  Aortic  aneurysm  pressing  on  and 

opening  into  the  lung 

14.  Hydatid  cyst 

15.  Primary  atheroma  of  the  pulmo- 

nary arterioles 

16.  Empyema  bursting   through   the 

lung 

17.  Hepatic  abscess  bursting  through 

the  diaphragm  into  the  lung. 


3i8 


HEMOPTYSIS 


B.  Haemoptysis  due  to  Changes  in  the  Bronchioles,  Bronchi,  or  Trachea 


1.  Bronchitis  : 

{a)   Acute 
(6)    Chronic 
(c)    Plastic 

2.  Bronchorrhoea 

3.  Bronchiectasis 

4.  Aortic  aneurysm  opening  into  the 

trachea  or  a  bronchus 

5.  Ulceration    of   the    trachea   or    a 

bronchus  : 
{a)   Tertiary  syphilitic 
(b)   Malignant 

(i)   Primary    epithelioma 
of  bronchus 


calcareous  bronchial  gland. 
6.   Parasitic  infection  by  the  Disto- 
wia  pulmonale  westermanni 
C.  Haemoptysis  due  to  Changes  in  the  Larynx  :  — 


{d) 


(ii)   Invasion  of   a  bron- 
chus  by   a   medias- 
tinal sarcoma,  lym- 
phosarcoma, oesoph- 
ageal     epithelioma, 
or  other  neoplasm. 
Secondary  to  a  foreign  body, 
such  as  a  button,  a  fruit- 
stone,  a  tooth,  etc.  ;    or  to 
a  tracheotomy  tube 
Secondary   to   a  caseous  or 


D. 


Acute  laryngitis 
Tuberculous  ulceration 
Syphilitic  ulceration 
Malignant  ulceration  : 

(a)   Epitheliomatous 

(&)    Sarcomatous 
Post-typhoidal  ulceration 
Post-diphtheritic  ulceration  i 

Haemoptysis  due  to  Changes  in  the  Blood  : 


7.  Injury  to  the  larynx,  by  a  blow, 
a  throat  grip,  a  cut  throat, 
intubation,  or  operation 

8.  Lupus  of  the  larynx 

9.  Variolous  ulceration 

10.  Leprosy  of  the  larynx 

1 1 .  Angioma  of  the  larynx 


1.  Purpura  and  its  various  causes  [q.v.] 

2.  Scurvy 

3.  SplenomeduUary  leukaemia 

4.  Lymphatic  leuicaemia 

5.  Pernicious  anaemia 

E.  Doubtful  Causes  of  Haemoptysis  :— 

1.  Granular  kidney 

2.  Arteriosclerosis 

3.  Vicarious  menstruation 


6.  Hodgkin's     disease     or     lymph- 

adenoma 

7.  Malignant  types  of  specific  fevers, 

such  as  variola  or  measles 

8.  Haemophilia 


4.  Recurrent  haemoptysis  in  arthritic 
subjects  (Andrew  Clark) 

5.  Haemoptysis  in  apparently  sound 
and   healthy  young  subjects. 

Copious  Haemoptysis  has  only  two  causes,  namely  rupture  of  an  aortic  aneurysm 
into  trachea,  bronchus,  or  lung  ;  and  rupture  of  an  aneurysm  of  a  pulmonary 
arteriole  in  a  phthisical  vomica.  The  former,  when  once  it  causes  severe  haemo- 
ptysis, nearly  always  proves  immediately  fatal  ;  the  latter  may  also  cause  rapid 
death,  but  sometimes  the  severe  bleeding  stops,  and  recovery  may  ensue.  In 
either  case,  however,  there  is  often  a  stage  of  slight  or  premonitory  bleeding  for 
days,  weeks,  or  even  months  before  the  final  and  possibly  fatal  rupture  occurs. 

There  are  some  causes  of  haemoptysis  in  the  above  list  about  which  little  need 
be  said.  The  whole  of  Group  E,  for  instance,  is  open  to  much  doubt ;  it  is  true 
that  apparently  sound  young  subjects  may  have  transient  haemoptysis,  and 
never  develop  phthisis  ;  on  the  other  hand,  a  certain  proportion  of  such  cases 
do  become  consumptive  later,  so  that  the  presumption  is  that  in  all  of  them 
the  haemoptysis  really  has  a  tuberculous  origin,  cure  resulting  rapidly  in  some, 
but  not  in  others.  Particular  care  should  be  taken  in  the  examination  of  the 
sputum  and  of  the  chest  by  the  ordinary  physical  methods,  and  perhaps  by  the 
;ir-ray3  also,  and  even  although  the  cause  of  the  haemoptysis  may  not  be  precisely 
determined,  the  patient  would  be  well  advised  to  live  as  healthily  as  possible, 


HAEMOPTYSIS 


319 


lest  a  further  stage  of  phthisis  should  develop.  The  same  applies  to  so-called 
vicarious  menstruation  ;  and  in  not  a  few  cases  in  which  the  hcemoptysis  has 
been  attributed  to  the  arthritic  diathesis,  to  arteriosclerosis,  or  to  renal  lesions, 
the  lesion  may  really  be  an  intercurrent  infection  of  the  lung  by  tubercle  bacilli 
even  in  middle-aged  or  elderly  people. 

Causes  in  Group  D  seldom  give  rise  to  extensive  spitting  of  blood  from  the 
lungs,  though  there  may  be  much  epistaxis,  bleeding  from  the  gums,  and  so  on. 
The  diagnosis  between  the  different  conditions  in  this  group  will  be  found  else- 
where. 

Phthisis  is  by  far  the  commonest  cause  of  haemoptysis.  It  may  be  the  very 
first  sign  of  the  disease,  it  may  be  the  last,  or  it  may  occur  at  any  intermediate 
stage.  The  amount  of  blood  brought  up  is  very  variable.  The  sputum  may  be 
only  streaked  with  blood,  or  a  pint  or  more  may  stream  from  the  mouth.  In 
advanced  stages  of  phthisis  the  diagnosis  is  not  difficult.  There  is  the  history 
of  cough,  loss  of  appetite  and  weight,  night  sweating,  and  expectoration  ;  there 
are  the  wasting  and  flattening  of  the  chest  wall,  especially  above  and  below  the 
clavicles,  often  more  on  one  side  than  the  other  ;  the  deficient  movement  on 
respiration,  the  unequal  tactile  vocal  fremitus,  the  impairment  of  note,  over  one 
upper  lobe  more  than  over  the  other,  with  the  bronchial  breathing,  consonating 
rales,  bronchophony  and  pectoriloquy  at  one  apex,  with  signs  of  similar  but  less 
advanced  disease  at  the  other.  Detection  of  pus  cells,  tubercle  bacilli,  and 
perhaps  elastic  fibres  in  the  sputum,  is  conclusive.  Haemoptysis  may,  however, 
be  the  earliest  evidence  of  phthisis  ;  the  diagnosis  is  then  difficult,  for  the  physical 
examination  may  not  reveal  any  abnormal  signs.  Particular  stress  may  be  laid 
upon  greater  prominence  of  one  clavicle  than  of  the  other,  prolongation  of  the 
expiration,  and  the  constant  presence  of  one  or  more  apical  clicks,  or  rales, 
perhaps  brought  out  only  on  voluntarily  coughing.  In  some  cases,  the  mottled 
shadows  seen  with  the  ;ir-rays  may  assist  the  diagnosis  {Fig.  27,  p.  120), 
although,  taken  by  themselves,  they  may  be  misleading  ;  tubercle  bacilli  may  be 
found  in  the  sputa  quite  early,  so  that  a  careful  examination  even  of  the  most 
insignificant  amount  of  sputum  must  always  be  made  before  a  definite  and 
reliable  opinion  as  to  the  cause  of  the  haemoptysis  can  be  given.  The  actual 
cause  of  the  haemoptysis  in  phthisis  is  not  constant.  In  the  early  stages  of  the 
disease  it  may  be  the  result  of  a  local  inflammatory  hyperaemia  with  rupture  of 
the  capillaries  ;  the  amount  of  blood  expectorated  is  then  usually  small,  and  it 
may  amount  only  to  streaking  of  the  sputum.  A  little  later,  small  vessels  may 
themselves  become  inflamed  and  softened,  or  directly  invaded  by  the  tuberculous 
process,  consequently  rupturing  if  any  extra  strain  is  suddenly  put  upon  them, 
— for  instance,  during  attacks  of  coughing.  This  may  lead  to  a  more  profuse 
haemoptysis  even  quite  early  in  the  disease.  When  the  malady  is  more  advanced, 
the  caseation  and  the  breaking  down  of  lung  tissue  may  lead  to  softening  of 
the  external  wall  of  a  considerable  branch  of  the  pulmonary  artery,  resulting 
in  an  aneurysmal  bulge,  which,  if  thrombosis  does  not  occur  within  it,  will 
sooner  or  later  rupture,  and  cause  a  profuse  and  probably  fatal  haemorrhage. 

Cirrhosis  of  the  Lung — Pneumonoconiosis,  Miners'  Phthisis — is  a  particular 
variety  of  fibrosis  due  to  the  inhalation  of  irritating  particles,  especially  amongst 
workers  at  certain  occupations.  Coal  miners  seldom  get  it  ;  although  their  lungs 
become  packed  with  carbon — anthracosis — these  particles  do  not  seem  to  inflame 
the  tissues.  Knife-grinders  suffer  from  it — siderosis  ;  so  do  workers  in  certain 
limestone  quarries,  rock-drilling  gold  mines,  and  diamond  mines — silicosis.  The 
chief  point  in  the  diagnosis  is  the  history  as  to  occupation  ;  there  is  much  doubt 
as  to  whether  these  conditions  are  not  really  of  a  chronic  tuberculous  nature, 
and  tubercle  bacilli  should  be  looked  for  in  all  these  cases.  The  haemoptysis  is 
far  less  frequent  and  less  abundant  than  it  is  in  ordinary  cases  of  phthisis. 


320  HEMOPTYSIS 


Mitral  Stenosis  is  the  second  commonest  cause  of  haemoptysis.  Other  forms 
of  heart  disease  seldom  lead  to  it  direct,  though  mitral  regurgitation  may  do  so 
occasionally,  and  so  may  aortic  stenosis  or  regurgitation  when  they  have  caused 
secondary  mitral  regurgitation.  Congenital  heart  disease,  unlike  the  acquired 
forms,  is  so  liable  to  lead  to  phthisis  that  any  haemoptysis  associated  with  it 
would  arouse  suspicions  of  the  latter.  Fungating  endocarditis  may  also  cause 
haemoptysis,  but  as  the  result  rather  of  the  septic  state  than  of  the  valvular 
lesion.  Mitral  stenosis  is  the  chronic  valvular  heart  disease  par  excellence  to 
produce  haemoptysis,  and  it  may  do  so  either  when  there  is  complete  compensa- 
tion or  when  there  is  evidence  of  failure.  When  compensated,  the  right  ventricle 
pumps  blood  into  the  lungs  with  vigour,  and  the  stenosis  of  the  mitral  valve 
may  be  so  great  that  there  is  a  great  rise  of  pressure  in  the  pulmonary  vessels. 
This  is  indicated  clinically  by  the  great  accentuation  or  marked  reduplication 
of  the  second  sound  in  the  second  left  intercostal  space  close  to  the  sternum.  At 
the  impulse,  which  is  often  not  materially  displaced,  the  first  sound  will  have 
a  slapping  character,  and  it  will  generally  be  preceded  by  a  shorter  or  longer 
presystolic  rumbling  bruit.  The  latter  is  so  short  sometimes  that  it  may  be 
overlooked,  but  there  may  be  a  history  of  chorea  or  rheumatism  to  assist  the 
diagnosis,  and  the  accentuated  pulmonary  second  sound  will  arouse  suspicion 
in  other  cases,  particularly  if  the  precordial  impairment  of  resonance  is  increased 
upwards  and  to  the  right,  but  not  much  to  the  left.  The  result  of  the  great  rise 
of  blood-pressure  in  the  lungs  is,  that  some  of  the  capillaries  rupture  from  time 
to  time  ;  the  resultant  haemoptysis  alarms  the  patient,  but  it  is  really  no  sign  of 
danger  ;  sometimes  patients  have  this  haemoptysis  whenever  the  heart  is  at  its 
best,  losing  it  again  when  any  failure  threatens.  Far  different  is  it  when  blood- 
spitting  occurs  in  failing  cases  of  mitral  stenosis  ;  it  is  then  generally  due  to 
infarction  or  to  pulmonary  "  apoplexy."  The  infarction  is  less  often  due  to 
embolism  from  an  ante-mortem  clot  in  the  right  auricular  appendix  or  other 
part  of  the  right  side  of  the  heart  than  it  is  to  thrombosis,  which  results  as  follows  : 
atheromatous  degeneration  of  the  pulmonary  arterioles  is  brought  about  by  the 
greatly  increased  tension  within  them  ;  rupture  of  small  branches  of  such 
degenerated  pulmonary  arterioles  gives  rise  to  "  apoplexies,"  and  the  altera- 
tion in  the  tunica  intima  due  to  the  atheroma,  together  with  the  deficient  rate 
of  blood-flow,  strongly  predispose  to  thrombosis  and  consequent  infarction. 
An  embolic  infarct  occurs  suddenly,  and  causes  acute  pain  in  the  corresponding 
part  of  the  thorax,  orthopnoea,  increased  cyanosis,  dyspnoea,  and  haemoptysis  ; 
a  thrombotic  infarct  arises  gradually,  and  causes  haemoptysis  without  the  other 
symptoms. 

Violent  Coughing  efforts,  as  in  whooping  cough,  or  emphysema  and  bronchitis, 
may  cause  such  pressure  of  the  fraenum  linguae  against  the  teeth  as  to  abrade  its 
surface  and  lead  to  the  expectoration  of  blood-streaked  salivary  sputum — 
spurious  haemoptysis  ;  it  is  said  that  they  can  also  produce  true  haemoptysis  ; 
this  is  possible,  but  before  blood-spitting  in  any  given  case  is  attributed  merely 
to  violence  of  coughing,  every  care  should  first  be  taken  to  exclude  both  tubercle 
and  heart  disease. 

Injury  to  the  Chest  is  not  an  uncommon  cause  of  blood-spitting.  There  need 
have  been  no  fracture  of  a  rib — a  severe  blow  on  the  thorax  sometimes  suffices. 
The  only  difficulty  in  the  diagnosis  is  to  be  sure  that  the  injury  is  the  sole  cause, 
and  that  it  has  not  merely  been  the  final  factor  in  producing  haemorrhage  from 
a  latent  tuberculous  focus  or  an  aneurysm. 

In  Lobar  Pneumonia  the  amount  of  blood  expectorated  is  slight  in  the  majority 
of  cases  ;  the  sputum  is  thick,  viscid,  tenacious,  and  generally  there  is  no  more 
blood  than  will  give  it  a  rusty  or  russet-brown  colour.  It  may,  however,  be 
bright  red,  and  in  a  few  cases  copious  enough  to  be  in  itself  alarming.       The 


HEMOPTYSIS 


321 


difficulty  is  to  distinguish  it  from  phthisis,  or  from  lobar  pneumonia  superposed 
upon  phthisis.  The  diagnosis  is  often  obvious  enough  ;  but  sometimes,  notwith- 
standing the  acute  onset,  the  continued  fever,  the  high  ratio  of  the  respiration 
to  the  pulse-rate,  the  viscidity  of  the  sputum,  the  presence  of  capsulated  diplo- 
cocci  in  it,  the  abnormal  physical  signs,  and  the  absence  of  chlorides  from  the 
urine,  serious  doubt  remains  until  the  subsequent  course  of  the  case  has  been 
watched.  When  the  ;tr-rays  can  be  utilized  at  the  bedside,  a  skiagram  may 
sometimes  serve  to  differentiate  batween  phthisis  {Fig.  27,  p.  120)  and  lobar 
pneumonia  {Fig.  99). 

Bronchopneumonia  is  a  rare  cause  of  haemoptysis,  because  it  is  seen  mainly 
in  children  at  an  age  when  no  spitting  occurs.  In  older  patients,  broncho- 
pneumonia is  generally  either  influenzal,  or  else  due  to  the  inhalation  of  septic 
particles  from  the  mouth  after 
operations  under  anaesthetics,  or 
in  association  with  such  diseases 
as  epithelioma  of  the  tongue,  or 
otitis  media  with  lateral  sinus 
thrombosis.  Septic  broncho- 
pneumonia is  diagnosed  by 
reason  of  its  being  a  lung  com- 
plication of  some  other  malady 
likely  to  give  rise  to  it.  Influ- 
enzal bronchopneumonia  is  apt 
to  cause  characteristic  sticky 
rales  at  the  bases,  with  less 
pyrexia  but  more  asthenia  than 
is  the  case  with  lobar  pneu- 
monia ;  and  the  minute  Bacilli 
influenzcB  may  be  found  in  the 
sputum  in  large  numbers.  If 
the  signs  are  apical  rather  than 
basal,  it  will  be  very  difficult 
to  be  sure  that  the  condition 
is    not    tuberculous,   except  by 

watching  the  case,  and  finding  that  rapid  and  complete  resolution  and  re- 
covery ensue. 

Gangrene  of  the  Lung,  due  to  whatever  cause,  is  characterized  by  the  extreme 
stench  of  the  breath  and  sputa.  The  only  conditions  which  can  produce  similar 
stench  are  foetid  decomposition  of  the  retained  sputum  in  bronchiectatic  cavities 
or  old  phthisical  vomicae,  or  similar  decomposition  in  the  pus  of  an  empyema 
which  has  ruptured  through  the  lung,  and  which  is  only  able  to-  empty  out  its 
contents  periodically.  Gangrene  of  the  lung  can  be  differentiated  from  all  these 
by  the  quantity  of  pulmonary  elastic  fibres  that  may  be  found  in  the  sputum, 
the  absence  of  clubbed  fingers,  and  by  the  history  being  much  shorter  than 
would  probably  be  the  case  with  the  others. 

Infarction  of  the  Lung,  embolic  and  thrombotic,  has  already  been  mentioned 
in  connection  with  heart  disease,  its  most  frequent  cause.  It  only  remains  to 
add  that  it  may  also  occur  as  the  result  of  embolism  secondary  to  thrombosis 
of  systemic  veins,  infective  endocarditis  of  the  pulmonary  or  tricuspid  valves, 
or  from  primary  thrombosis  in  some  blood  diseases,  such  as  leucocythaemia.  A 
large  embolus  causes  sudden  death  without  haemoptysis  ;  a  smaller  one  may 
give  rise  to  sudden  acute  pain  in  some  part  of  the  chest,  and  a  local  patch  of 
crepitant  rales  with  a  pleuritic  rub,  and  perhaps  impairment  of  percussion  note 
with  bronchial  breathing.     Haemoptysis  associated  with  such  physical  signs  and 


Fig.  99. — Skiagram  of  lobar  pneumonic  consolidation 
of  left  lung  (A);  normal  right  lung  (B);  gastric  gas 
bubble  (C)';  liver  (D).      (By  Dr.  .Alfred  C.  Jordan?) 


322  HAEMOPTYSIS 


accompanied  by  evidence  of  endocarditis  or  venous  thrombosis  would  suggest 
infarct  as  the  cause  of  it.  Difhcultj^  arises  mainly  when  there  is  no  obvious 
phlebitis  in  the  case,  when  the  vein  affected  is  deep-seated  in  the  pelvis, — for 
instance,  after  childbirth  or  some  operation.  The  diagnosis  is  not  so  difficult 
when  there  have  been  repeated  sudden  acute  pains  in  different  parts  of  the  chest, 
each  followed  bv  a  little  pyrexia  and  sometimes  b}^  haemopt^'sis,  due  to  repeated 
small  emboli. 

Carcinoma  and  Sarcoma  of  the  Lung  are  usualh'  secondary.  The  diagnosis 
is  sometimes  obvious,  sometimes  very  obscure  indeed.  The  primary  seat 
of  the  growth  ma}''  be  near  the  lung,  for  instance  in  a  bronchus,  the  oesophagus, 
or  breast,  or  the  mediastinal  glands  ;  or  it  may  be  distant,  in  the  stomach, 
or  a  bone,  and  so  on.  The  sputum  may  be  merely  blood-tinged,  or  it  ma\^  be 
dark  like  red-currant  jelly  ;  occasionally  the  haemorrhage  is  profuse.  A  large 
number  of  cases  of  malignant  disease  in  the  lung  are  accompanied  bj^  pleuritic 
effusion,  and  unless  the  existence  of  a  primary  neoplasm  elsewhere  is  known, 
growth  may  not  at  first  be  suspected.  If  aspiration  is  performed,  the  fluid  is 
generally  found  to  contain  blood  ;  indeed,  the  discovery  of  blood-stained  pleural 
fluid  at  a  first  tapping  of  a  case  that  is  not  absolutely  acute,  is  always  very 
suggestive  of  neoplasm.  Increasing  varicosity  of  the  veins  on  the  chest  wall,  with 
reversal  of  the  blood  current  in  them,  also  points  to  intrathoracic  growth  ob- 
structing the  superior  vena  cava.  The  neoplasms  may  also  stenose  a  bronchus, 
leading  to  unilateral  deficiency  of  movement  and  tactile  vocal  fremitus,  impair- 
ment of  note,  and  deficient  or  absent  breath  sounds,  with  or  without  faint 
bronchial  breathing  and  crackling  rales  ;  whilst,  accompanying  these  physical 
signs,  no  tubercle  bacilli  would  be  found  in  the  sputum,  and  yet  the  weakness 
and  emaciation  would  be  progressive.  Particles  of  the  new  growth  have  been 
detected  microscopically,  either  in  the  sputum  or  in  the  pleural  effusion,  in  many 
of  these  cases. 

Sporotrichoses  of  the  Lung  are  being  recognized  with  increasing  frequency. 
Hitherto  they  have  generally  been  mistaken  for  phthisis.  They  are  due  to 
various  moulds  of  the  nature  of  Actinomyces,  Aspergillus  niger,  and  others,  and 
the  diagnosis  .depends  upon  bacteriological  investigations  of  the  sputum  by 
cultural  methods.  When  no  tubercle  bacilli  can  be  detected  on  repeated  examina- 
tion in  the  ordinarj^  wav,  the  possibility  of  sporotrichosis  should  be  borne  in  mind, 
particularly  if  the  patient's  occupation  leads  to  contact  with  vegetable  products 
such  as  hay  or  straw,  grain,  bird  foods,  or  even  cotton,  as  in  the  case  of  seam- 
stresses and  tailors. 

Aortic  Aneurysm  far  less  often  opens  into  the  lung  itself  than  it  does  into  a 
bronchus  ;  the  symptoms  are  similar  in  either  case,  and  if  the  history  is  long  the 
diagnosis  will  alreadv  have  been  made  on  account  of  some  other  symptom  than 
hjemoptysis,  especiallv  pain  in  the  chest  or  in  the  back.  The  ;ir-rays  are  a 
valuable  means  of  deciding  the  diagnosis  (Fig.  74,  p.  236).  Two  points  are 
worthy  of  particular  attention,  and  these  are  :  first,  that  the  rupturing  of  an 
aortic  aneurj^sm  into  a  bronchus,  with  copious  and  rapidly  fatal  hemoptysis, 
may  be  the  very  first  sign  that  anything  is  wrong  ;  and  secondh-,  that  in  not  a 
few  cases  there  may  have  been  slight  haemoptysis  and  blood- streaking  of  the 
sputum  for  weeks  or  months  before  the  fatal  rupture  ensues  ;  these  preliminary 
slight  attacks  of  haemoptysis  are  probably  due  to  erosion  of  small  vessels  in  the 
wall  of  the  bronchus,  and  if  the  aneurysm  is  partiall}'  obstructing,  say,  the  left 
upper  bronchus,  so  as  to  produce  impairment  of  note  over  the  left  apex,  with  a 
few  rales  there,  and  haemoptysis,  it  is  clear  that  a  mistaken  diagnosis  of  phthisis 
might  readily  be  made.  Tubercle  bacilli  will  be  persistently  absent  from  the 
sputum,  there  will  very  likely  be  a  previous  history  of  syphiHs,  hard  manual 
work,  and  perhaps  drinking  ;  without  the  A^-rays  to  show  the  pulsating  shadow 


HEMOPTYSIS 


323 


of  the  aneurysm,  however,  the  correct  diagnosis  may  be  missed,  and  even  when 
the  fatal  rupture  occurs,  the  condition  may  still  be  erroneously  attributed  to 
phthisis,  unless  a  post-mortem  examination  is  made. 

Hydatid  Cysts  are  much  rarer  in  Europe  than  in  Australia  and  Xew  Zealand  ; 
those  of  the  lung  are,  as  a  rule,  secondary  to  hydatid  of  the  liver.  They  may 
give  rise  to  neither  signs  or  symptoms  ;  on  the  other  hand,  they  maj^  cause 
haemoptysis,  and  phthisis  may  be  simulated.  The  ;i;-rays  are  very  efficient  in 
detecting  their  spherical  shadows  (Fig.  100).  The  blood  may  exhibit  eosino- 
philia. 

Primary  Atheroma  of  the  Pulmonary  Arterioles  is  so  rare  as  to  be  undiagnosable. 
There  is  no  relationship  between  systemic  and  pulmonary  atheroma,  and  the 
commonest  cause  of  the  latter  is  mitral  stenosis,  as  described  above. 


J^i^.  loo. — Skiagram  of  a  hydatid  cyst  of  the  thorax,  occupying  the  position 
of  the  upper  lobe  of  the  left  lung. 

Empyema  bursting  through  the  Lung  may  or  may  not  cause  haemoptysis  ; 
the  main  features  of  the  case  will  generally  be  an  obscure  febrile  illness  subsequent 
to  pneumonia,  followed  by  a  sudden  eruption  of  pus  from  the  respiratory^  passages, 
and  a  repetition  of  a  similar  copious  expectoration  of  pus  at  intervals  ;  in  many 
cases  there  are  comparatively  few  abnormal  physical  signs,  for  had  the  empyema 
not  been  hidden  away  deeply  in  the  thorax,  its  existence  would  have  been 
diagnosed  earlier,  and  it  would  have  been  relieved  by  operation  before  it  burst 
into  the  lung. 

A  Hepatic  Abscess  that  has  burst  through  the  lung  is  apt  to  give  rise  to  anchovy- 
sauce-coloured  sputum  which  is  characteristic  ;  no  amoebae  may  be  discovered, 
and  the  pus  will  very  likely  be  sterile  ;  the  diagnosis  is  generally  based  upon  the 
history  of  residence  in  the  tropics,  possibh^  of  an  attack  of  amoebic  dysentery-, 


324  HEMOPTYSIS 

and  of  hepatic  symptoms,  pyrexia,  and  rigors  previous  to  the  expectoration 
of  the  blood-stained  pus.  The  abscess  occurs  on  the  right  side  more  often 
than  on  the  left,  and  there  may  be  the  typical  dome-shaped  dullness  at  the 
base  of  the  right  lung. 

Haemoptysis  due   to   changes  in  the   Bronchioles,  Bronchi,  and  Trachea,  as 

distinct  from  changes  in  the  lung,  have  to  some  extent  been  incidentally  con- 
sidered with  the  latter. 

Bronchitis  should  never  be  diagnosed  as  the  cause  for  haemoptysis  in  a  particular 
case  until  phthisis  and  mitral  stenosis  have  been  thoroughly  excluded. 

Bronchorrhcea  is,  in  most  respects,  only  a  variety  of  bronchitis. 

Bronchiectasis  may  be  associated  with  some  slight  degree  of  haemoptysis 
sometimes,  or  when  the  bronchiectasis  is  due  to  prolonged  partial  obstruction  of 
a  bronchus  by  a  thoracic  aneurysm,  there  may  be  copious  and  fatal  haemoptysis, 
as  described  above.  Bronchiectasis  seldom  occurs  apart  from  fibrosis  of  the 
lung  ;  indeed,  fibroid  lung  is  commoner  than  bronchiectasis  ;  when  fibrosis 
and  bronchiectasis  occur  together  and  affect  one  lung  in  particular,  the  diagnosis 
is  relatively  easy,  for  there  is  deficiency  of  bulk,  movement,  and  resonance, 
tactile  vocal  fremitus,  vesicular  murmur,  and  voice  sounds  over  the  affected  lung ; 
the  heart  is  materially  displaced  towards  that  side  ;  numerous  loud  crackling 
rales,  with  or  without  bronchial  breathing,  bronchophony,  and  pectoriloquy,  will 
be  heard  over  scattered  patches  of  the  affected  lung,  whilst  in  the  intervening 
areas  there  will  be  little  to  be  heard  at  all  ;  the  rales  will  be  brought  out  best 
when  the  patient  coughs  ;  the  lung  on  the  other  side  may  give  relatively  normal 
signs.  Clubbing  of  the  fingers  may  be  extreme.  The  diagnosis  of  fibroid  lung 
and  bronchiectasis  itself  is  not  complete,  however,  until  the  precise  cause  of  the 
latter  has  been  ascertained  ;  sometimes  so  complete  a  diagnosis  is  not  possible. 
The  following  is  a  list  of  the  chief  causes  of  the  condition  : — 

1 .  Causes  in  the  lung  : — 

Congenital  atelectasis  Pneumonoconiosis 

Recurrent    attacks    of  Chronic  tuberculosis 

bronchopneumonia 
Delayed   resolution    of 

lobar  pneumonia 

2.  Causes  which  act  by  partially  stenosing  a  bronchus  : — 

[a).   Causes  within  the  bronchus  : — 

A  foreign  body 

Inspissated  bronchitic  mucus. 
(b) .    Causes  m  the  wall  of  the  bronchus  : — 

Syphilitic  stenosis 

Primary  epithelioma, 
(c).   Invasion  of  the  bronchus  from  without  : — 

Aortic  aneurysm 

Mediastinal  new  growth 

Hodgkin's  or  lymphadenomatous  glands 

Caseous  bronchial  glands 

A  hypertrophied  left  auricle  in  some  cases  of  mitral  stenosis. 

3.  Causes  which  have  long  compressed  the  lung  from  the  pleural  side  : — 


Sporotrichosis 

Recurrent  bronchitis  (doubtful). 


Pleuritic  effusion 
Pleural  effusion 
Thick  pneumonic  lymph 
Empyema 


Pericardial  effusion 
Ascites 

Subdiaphragmatic  abscess 
Hepatic  tumour 


A  large  heart  |  Splenic  tumour. 


HEMOPTYSIS  325 


There  will  be  no  need  to  discuss  each  of  these  here  ;  if  the  different  possibilities 
are  kept  in  mind,  a  probable  diagnosis  can  be  made  fairly  easily  in  most  cases. 
The  only  bronchial  causes  of  haemoptysis  that  need  be  dealt  with  further  are 
syphilitic  ulceration  and  infection  by  the  Distoma  pulmonale. 

Syphilitic  Disease  of  a  Bronchus  is  a  tertiary  lesion  of  gummatous  nature,  and 
as  it  heals  it  causes  bronchial  stenosis  and  consequent  fibrosis  of  the  lung,  with 
or  without  bronchiectasis.  It  will  hardly  be  diagnosed  unless  there  are  other 
very  definite  means  of  knowing  that  the  patient  has  had  syphilis,  and  is  still 
suffering  from  its  tertiary  effects  ;  ar\d  even  then  care  must  be  taken  to  exclude 
the  possibility  of  the  luetic  patient  having  developed  phthisis.  The  influence 
of  iodide  of  potassium  in  such  a  case  does  not  afford  conclusive  evidence  one 
way  or  the  other,  for  even  though  the  syphilitic  lesion  heals,  it  leaves  behind  it 
the  fibrous  steno.sis  of  the  bronchus. 

The  Distoma  Pulmonale  Westermanni  is  very  unlikely  to  be  the  cause  of 
haemoptysis  in  any  patient  who  has  not  been  resident  in  China,  Japan,  or 
Formosa.  History  of  residence  in  those  countries,  on  the  other  hand,  would 
suggest  the  diagnosis,  confirmation  of  which  would  be  afforded  by  examination 
of  the  sputum  for  the  parasites  or  their  ova. 

The  differential  diagnosis  of  Haemoptysis  due  to  changes  in  the  Larynx 
depends  mainly  on  two  things  :  the  history  of  the  case,  and  the  condition  seen 
locally  with  the  laryngoscope.  The  history  and  course  are  the  chief  factors 
in  diagnosing  acute  simple  laryngitis,  post-typhoidal,  post-diphtheritic,  or 
variolous  ulceration  of  the  larynx,  or  conditions  due  to  injury  of  the  larynx  by  a 
blow,  a  hand-grip,  a  cut  throat,  or  intubation  or  other  operation.  Leprous 
ulceration  of  the  larynx  seldom,  if  ever,  occurs  in  any  patient  who  has  not  lived 
in  leprous  lands,  and  who  has  not  for  a  long  time  exhibited  subcutaneous  and 
cutaneous  evidence  of  his  disease.  Of  the  remaining  five  conditions  given  in 
the  list,  namely,  tuberculous,  syphilitic,  and  malignant  ulcerations,  lupus,  and 
angioma  of  the  larynx,  the  last  two  are  very  rare  indeed,  though  both  may  be 
diagnosable  by  their  laryngoscopic  appearance,  particularly  if  there  is  also  lupus 
of  the  face  on  the  one  hand,  or  a  tendency  to  cutaneous  or  buccal  blood-oozing 
nasvi  on  the  other.  Between  the  remaining  three  conditions  there  mav  be  some 
doubt  for  a  time,  but  if  it  can  be  seen  that  the  ulceration  is  extensive  and  yet 
unilateral,  it  is  probably  epitheliomatous  ;  if  tubercle  bacilli  are  present  in  the 
sputum,  if  there  are  apical  lung  signs,  and  if  multiple  shallow  ulcers  can  be  seen 
along  the  epiglottis,  as  well  as  in  the  larynx,  tuberculous  ulceration  is  probable — 
it  practically  never  occurs  except  secondary  to  pulmonary  tubercle,  though  the 
latter  may  be  slight  and  may  remain  in  abeyance,  whilst  the  laryngeal  tubercle 
advances  rapidly  ;  syphilitic  laryngitis  may  be  diagnosed  by  exclusion,  but  if 
there  is  a  tendency  to  healing,  with  marked  deformity,  after  extensive  bilateral 
destruction  of  the  laryngeal  and  neighbouring  tissues,  and  if  there  is  decided 
collateral  evidence  of  tertiary  syphilis,  including,  perhaps,  a  positive  serum 
reaction,  the  diagnosis  may  often  be  made  directly.  The  chief  difficulty  arises 
in  cases  in  which  there  may  be  both  syphilis  and  tubercle  at  the  same  time. 
This  brings  us  back  once  more  to  the  fact  that,  once  it  has  been  decided  that 
true  haemoptysis  has  occurred,  the  next  step  is  to  examine  carefully  the  sputum 
and  the  chest  for  signs  of  tubercle,  and  not  to  diagnose  any  other  condition 
until  both  tubercle  and  mitral  stenosis  have  been  excluded.  Herbert  French. 

HEMORRHAGE  FROM  GUMS.— (See  Bleeding  Gums.) 
HAEMORRHAGE  FROM  LUNG.— (See  H/emoptysis.) 
HEMORRHAGE,  GASTRIC— (See  H^matemesis.) 

D  21 A 


326  HEADACHE 


HEMORRHAGE,  INTESTINAL (See  Blood  per  Anum  ,  and  Meljena.) 

HEMORRHAGE,  NASAL.— (See  Epistaxis.) 

HEMORRHAGE,  RETINAL.— (See  Ophthalmoscopic  Appearances.) 

HEMORRHAGE,  SUBCUTANEOUS.— (See  Purpura.) 

HEMORRHAGE,  URINARY (See  Hematuria.) 

HEMORRHAGE,  UTERINE,  and  HEMORRHAGE,  VAGINAL.—  (See 
Menorrhagia;  Metrorrhagia;  Metrostaxis.) 

HEMOTHORAX.— (See  Chest,  Bloody  Effusion  in.) 

HALTING. — (See  Gait,  Abnormalities  of.) 

HEADACHE  is  one  of  the  commonest  symptoms  met  with  in  medical  practice, 
and  the  various  conditions  with  which  it  is  associated  are  exceedingly  numerous, 
as  the  list  given  below  amply  demonstrates. 

Headache  may  be  the  first  symptom  calling  attention  to  the  existence  of 
grave  organic  disease,  and  the  correct  diagnosis  of  the  cause  of  this  symptom  is 
obviously  of  the  greatest  importance.  Too  often,  unfortunately,  treatment  of 
a  headache  precedes  a  careful  investigation  as  to  its  cause,  and  an  increased  risk 
may  be  thereby  incurred  bj^  the  patient  through  the  delay  in  recognizing  some 
one  of  its  more  serious  causes. 

The  explanation  of  the  mode  of  production  of  the  pain  known  as  headache  is 
not  easy,  seeing  that  the  brain  substance  itself  is  insensible  to  mechanical  stimu- 
lation. The  meninges  are  supplied  with  sensory  nerves,  and  abnormal  stimuli 
received  therefrom  reach  the  cortex  and  give  rise  to  the  impression  of  pain. 
Abnormal  states  of  the  intracranial  blood-vessels  may  cause  pain,  which  is  more 
difficult  of  explanation,  as  it  is  uncertain  that  they  have  any  sensory  nerve- 
supply.  It  seems  probable  that  the  headache  produced  by  increased  vascular 
tension  is  a  pressure  effect  acting  on  the  brain  as  a  whole,  or  on  its  coverings 
the  meninges. 

The  scope  of  this  article  does  not  allow  further  discussion  of  this  part  of  the 
subject.  Certain  general  hnes  of  diagnosis  may  be  laid  down.  The  closest 
attention  should  be  paid  to  the  character,  situation,  and  time  of  occurrence 
of  the  pain,  and  also  to  accompanying  symptoms. 

The  character,  whether  throbbing,  paroxysmal,  or  affected  hy  movement  or 
position.  Headaches  associated  with  alimentary  disturbance,  and  raised  blood- 
pressure,  are  often  throbbing  in  character,  are  reheved  by  rest  in  a  recumbent 
position,  and  are  increased  on  movement.  Severe  paroxysmal  attacks  would 
suggest  a  neuralgia. 

The  situation.  This  may  be  frontal,  vertical,  occipital,  or  unilateral,  and  in 
cases  of  organic  disease  of  the  cerebrum  may  be  an  important  indication  and  an 
aid  in  localizing  the  situation  of  the  lesion.  In  renal  disease,  the  headache 
associated  with  chronic  uraemia  is  usually  frontal,  but  may  be  occipital.  It  is 
vertical  in  constipation,  the  "  bilious  "  headache.  It  may  be  unilateral  in 
migraine,  tumour,  abscess,  middle-ear  disease;  or  occipital  in  cerebellar  disease. 
Occipital  headache  may  also  be  simulated  by  myalgia  in  the  muscles  and  tendons 
of  the  nape  of  the  neck. 

Time  of  occurrence. — Headache  associated  with  organic  disease  of  the  brain 
or  its  meninges  often  persists  or  becomes  worse  at  night,  and  may  wake  the 
patient  from  his  sleep,  whereas  that  due  to  toxic  and  functional  causes  is  relieved 
by  rest  in  a  horizontal  position.     Grave  suspicion  of  the  organic  nature  of  the 


HEADACHE  327 


headache  should,  therefore,  attend  a  case  in  which  pain  in  the  head  disturbs 
the  patient's  sleep  at  night.  A  headache  experienced  on  rising  in  the  morning 
may  be  due  to  a  stuffy,  ill-ventilated  room,  or  to  the  slighter  degrees  of  com- 
bined astigmatism  and  hypermetropia,  or  to  faulty  adjustment  of  the  pillows. 
Pillows  piled  too  high  may  cause  interference  with  the  cerebral  circulation 
and  result  in  headache.  Persistent  morning  headache  may  be  associated  with 
chronic  nephritis,  and  careful  observation  should  therefore  be  made  of  the 
patient's  urine.  Evening  headaches  are  most  commonly  due  to  mental  over- 
work, or  eyestrain^  especially  w^here  some  visual  defect  exists. 

For  the  purposes  of  classification  it  is  convenient  to  divide  the  causes  of  head- 
ache into  three  main  groups  : — {A)  Organic  disease  (brain,  intracranial  vessels, 
meninges,  skull,  special  sense  organs)  ;  iB)  Toxic  states ;  (C)  Functional  condi- 
tions. 

A.  Causes  due  to  Organic  Disease. 

These  may  be  classified  anatomically  as  follows  : — • 

1.  Diseases  of  the  brain  ;— 

Concussion  Cysts 

Tumours  Hydrocephaly 

Abscess  Disseminated  sclerosis 

Gumma  General  paralysis  of  the  insane. 

2.  Diseases  of  intracranial  vessels  : — 

Haemorrhage   (rupture)  Aneurysm 

Thrombosis  Syphilitic  endarteritis 

Embolism  Arteriosclerosis. 

3.  Diseases  of  the  meninges: — ■ 

Meningitis,  various  forms —  Syphilis — meningeal   type 

localized  or  diffuse  Tumours. 

Pachymeningitis 

4.  Diseases  of  the  skull  : — 

(    Innocent 

Tumours      '    ,t  t  ^   I    Primary 

I    Malignant  ^    „  / 

I  °  I    Secondary. 

Tertiary  syphilis 

Suppuration  or  new  growi;h  in  frontal,  antral,  or  mastoid   sinuses 

Suppuration  or  tumour  in  the  orbit 

Dental  diseases. 

5.  Diseases  of  special  sense  organs  : — • 

Eye — errors  of  refraction,  iritis,  glaucoma,  etc. 

Ear — middle-ear  disease. 

Nose — adenoids,  polypi,  nasopharyngeal  catarrh.      Inflammation  of 

one  of  the  accessory  air  sinuses — frontal,  ethmoidal,  sphenoidal ; 

empyema  of  a  frontal  sinus. 

Headache  in  Organic  Cerebral  Disease. 

Time  of  occurrence. — Organic  cerebral  disease  should  be  strongly  suspected 
if  a  history  of  recurrent  nocturnal  headache  be  obtained. 

Severity. — The  pain  is  often  intense,  and  sometimes  paroxysmal  in  character. 

Situation. — This  may  give  some  clue  as  to  the  existence  of  an  organic 
lesion.  In  cases  of  cerebral  tumour  the  pain  may  be  unilateral  or  frontal,  or 
occipital  with  a  cerebellar  lesion.  In  middle-ear  and  mastoid  disease  with 
unilateral  headache  and  localized  tenderness,  occipital  headache  may  be  one  of 
the  earliest  symptoms  of  meningitis. 

Associated   Signs   and  Symptoms. — One   or   more  of  the   following  signs   and 


328  HEADACHE 


symptoms  may  present  themselves  at  an  early  period  in  cases  of  headache  due 
to  organic  cerebral  disease,  and  their  early  recognition  is  of  great  importance  : — 


Optic  neuritis 

Irregularity  in  force  and  frequency 

of  the  pulse 
The  onset  of  drowsiness 
Fits. 


Vomiting — ^that  is  of  the  "cerebral 
type  "  (see  Vomiting)  :  it  usually 
bears  no  relation  to  food,  and  is 
not  preceded  by  nausea 

Inequality  of  the  pupils 

Squint 

Tapping  the  skull  over  the  site  of  the  pain  may  reveal  local  tenderness. 

The  onset  of  any  of  these  signs  associated  with  headache  would  point  to  the 
existence  of  some  organic  lesion,  such  as  are  enumerated  above.  As  in  many 
of  these  conditions  the  diagnosis  is  unattended  with  difficulty,  it  will  suffice  to 
direct  attention  to  a  few  of  them. 

The  headache  occasionally  met  with  in  disseminated  sclerosis  is  sometimes 
paroxysmal  and  accompanied  by  vomiting,  and  is  most  frequently  situated  in 
the  back  of  the  head  and  neck.  The  absence  of  optic  neuritis  and  the 
presence  of  the  special  signs  of  disseminated  sclerosis  should  lead  to  a  correct 
diagnosis. 

Cerebral  hemorrhage,  thrombosis,  and  embolism  are  often  followed  by  headache 
of  varying  severity.  In  cerebral  aneurysm  a  rhythmic  beating  or  pulsation  is 
sometimes  felt,  and  rushing  noises  are  heard,  more  particularlj^  when  the  internal 
carotid  is  involved. 

Advanced  arteriosclerosis  of  the  cerebral  arteries  is  sometimes  attended  by 
very  severe  headache  accompanied  by  vomiting  ;  and  cases  have  been  described 
presenting  features  closely  resembling  those  of  cerebral  tumour.  In  arriving  at 
the  diagnosis  instrumental  measurement  of  the  blood-pressure  is  all-important. 

In  meningitis,  especially  in  the  epidemic  cerebrospinal  and  the  post-basal 
varieties,  the  character  of  the  headache  is  significant.  It  is  usually  very  intense, 
is  occipital,  and  even  at  an  early  stage  may  be  attended  by  stiffness  of  the  neck 
and  retraction  of  the  head.  The  examination  of  the  cerebrospinal  fluid  obtained 
by  lumbar  puncture  is  of  great  importance  in  determining  the  presence  of 
meningitis  (see  Retraction  of  the  Head). 

Special  Sense  Organs. — Eye.  Headaches  due  to  errors  of  refraction,  glaucoma, 
iritis,  etc.,  are  generally  frontal  or  temporal.  A  slight  error  of  refraction  may 
cause  what  appears  to  be  a  disproportionately  severe  headache,  particularly  in 
children.  This  headache  is  frontal,  occurs  mostly  in  the  evening  or  after  school 
hours,  and  is  often  attended  by  a  burning,  pricking  or  watering  of  the  eyes. 
Correction  of  the  defect  by  suitable  glasses  settles  the  diagnosis  by  curing  the 
headache. 

B.  Toxic  Causes. 

These  may  be  subdivided  into  two  groups,  one  in  which  the  toxic  influence 
is  acquired  from  without,  or  is   exogenous ;  the  other  in  which  the  disturbing 
,  element  or  toxin  is  produced  within  the  body,  and  is  of  endogenous  origin. 

1.  Of  exogenous  origin  : — 

Foul  air,  as  in  close,  ill-ventilated  rooms 

Poisonous  gases,  CO.,,  CO,  chloroform,  ether,  etc. 

Drugs,  e.g.  quinine,  iron  in  some  individuals,  salicylates,  opium. 

Alcohol  Tobacco  Lead  poisoning. 

2.  Of  endogenous  origin  : — 

Uraemia  Gout 

Cholaemia  Diabetes 

Gastro-intestinal  disturbances  :  dyspepsia,  constipation 

Toxasmias  :  specific  fevers,  pyrexia  in  phthisis,  suppuration,  etc. 


HEADACHE  329 


As  regards  the  toxic  causes  of  headache  Httle  further  need  be  said  as  to  the 
diagnosis  of  the  exogenous  poisons. 

Urczmia  is  classed  for  purposes  of  convenience  as  a  condition  due  to  endo- 
genous bodies,  or  substances  produced  within  the  body.  It  stands  out  as 
one  of  the  most  important  causes  of  headache,  and  special  attention  must  always 
be  given  to  ensure  its  recognition.  Uremic  headaches  may  be  met  with  in  all 
degrees  of  severity,  from  a  slight  frontal  headache  felt  on  rising  in  the  morning 
to  an  intense  vertical  or  general  cephalalgia.  Other  ursemic  manifestations  may 
be  present,  such  as  vomiting,  drowsiness,  dyspnoea,  affections  of  vision,  and 
retinal  changes.  The  examination  of  the  urine  in  all  cases  of  headache  should 
never  be  neglected,  as  regards  its  specific  gravity,  the  presence  of  albumin, 
blood  and  casts. 

C.  Functional  Causes  : — 

/   high,    in    arteriosclerosis    and    renal 

Abnormal   blood- pressure    -,  . 

low,     in     anaemia,     morbus     cordis, 

I        Addison's  disease 

Venous  congestion 

Excessive  mental  strain 

Pressure  on  the  head — heavy  hats,  carrying  weights  on  the  head 

Persistent  noises — ''  gun  headache  " 

Sea-sickness — movement  of  boat,  train 

Menstruation 

Hysteria — ("  clavus  hystericus  ") 

Migraine 

Epilepsy 

Eye  strain,  "  academy  headache  " 

Sunstroke. 

High  blood-pressure  is  often  a  cause  of  headache,  usually  of  a  throbbing 
character,  accompanied  by  a  sense  of  fullness  of  the  head.  The  headache 
tends  to  come  on  towards  evening  and  after  meals.  The  vascular  condition 
should  be  ascertained  by  means  of  some  suitable  apparatus  for  estimating 
blood-pressure. 

Headache  associated  with  low  blood-pressure  (cerebral  anaemia),  as  in  some 
forms  of  morbus  cordis  and  anaemia  with  feeble  cardiac  action,  is  relieved  by 
rest  in  the  horizontal  position  and  cardiac  tonics  such  as  digitalis  and  iron. 

Venous  congestion  may  cause  headache.  This  is  also  met  with  in  heart 
disease  with  failing  compensation.  It  may  also  account  for  the  headache 
felt  on  rising  in  the  morning  as  the  result  of  sleeping  with  pillows  too  high 
or  too  low. 

The  "clavus  hystericus  "  is  a  boring  pain  felt  in  the  vertex  and  in  hysterical 
states. 

Headache  in  migraine  is  often  unilateral,  though  quite  commonly  bilateral, 
and  it  is  frequently  accompanied  by  vomiting.  Transitory  visual  disturbance 
usually  precedes  the  headache. 

In  epilepsy  headache  is  of  frequent  occurrence  in  the  post-epileptic  state,  and 
it  should  be  borne  in  mind  tha,t  it  may  also  follow  the  slight  manifestations  of 
petit  mal. 

After  sunstroke,  chronic  headache,  usually  vertical,  may  persist  for  months, 
and  the  same  apphes  to  many  head  injuries. 

It  is  sometimes  difficult  to  distinguish  between  headache,  which  implies  pain 
inside  the  skull,  and  neuralgia,  which  is  pain  felt  in  the  peripheral  course  of  a 


330  HEADACHE 


nerve  trunk  (see  Pain  in  the  Face).  Neuralgia,  if  of  wide  distribution,  may 
simulate  headache.  Careful  examination  may  be  necessary  to  decide  whether 
the  supposed  headache  may  not  in  reality  be  a  neuralgia.  The  local  distri- 
bution, the  often  intense  and  paroxysmal  character  of  the  pain,  the  presence 
of  "  tender  spots,"  the  existence  of  some  definite  exciting  cause  such  as  dental 
caries,  should  point  to  the  diagnosis  of  neuralgia.  u.  Morlcy  Fletcher. 

HEART,  ENLARGEMENT  OF.— (See  Enlargement  of  the  Heart.) 

HEART  IMPULSE,  DISPLACED. — The  apex  beat,  which  is  the  lowest  and 
outermost  point  at  which  the  cardiac  impulse  can  be  felt,  is  situated  in  the  normal 
adult  chest  in  the  fifth  left  intercostal  space,  one-half  to  one  inch  internal  to 
the  mammillary  line.  It  may  be  impossible  to  define  the  position  of  the  apex 
beat  even  in  health,  on  account  of  increased  thickness  of  the  chest  wall,  either 
due  to  muscular  development  or  to  excess  of  fat ;  or  in  the  female  on  account 
of  a  large  mamma.  A  similar  difficulty  arises  when  the  cardiac  impulse  is 
feeble ;  when  the  heart  is  overlapped  by  the  left  lung,  as  in  pulmonary 
emphj'sema  ;  or  when  pericardial  effusion  is  present. 

In  children,  the  apex  beat  is  situated  further  to  the  left  than  in  adults.  Speak- 
ing generally,  it  is  outside  the  mammillary  line  during  the  first  three  3'ears  of 
life,  in  the  mammiUaxy  line  from  the  fourth  to  the  tenth  j'ears,  and  it  gradually 
reaches  the  adult  position  by  the  age  of  fifteen  years. 

In  many  patients  ^rith  displacement  of  the  apex  beat  of  the  heart,  the  cause 
is  obvious,  as  in  the  case  of  a  cardiac  lesion,  chronic  renal  disease  and  arterial 
sclerosis,  disease  of  the  lungs  and  pleurae,  thoracic  tumour,  or  abdominal  enlarge- 
ment. The  conditions  which  produce  displacement  of  the  cardiac  impulse  can 
be  classified  under  the  following  two  headings  : — 

A .  When  the  bulk  of  the  Heart  is  in  the  Normal  Position. 

1.  Diseases  of  the  heart : 

(a).  Valvular  (c).  Pericardial. 

(b).  Myocardial 

2.  Changes  in  the  heart  secondary  to  : 

(a).  Diseases  of  the  lungs,  such  as  emphysema,  fibrosis,  etc. 

(6).  Arterial  sclerosis  and  chronic  renal  disease 

(c).  Anaemia  and  any  debilitating  conditions  which  affect  chiefly  the  right 

ventricle 
{d).  Toxic  conditions  producing  changes  in  the  myocardium,  as  in  specific 

infectious  diseases 
(e).  Muscular  exertion. 

B.  When  the  whole  Heart  is  Displaced. 

1.  Changes  in  the  lungs  : 

(a).  Contraction  of  one  lung  or  a  portion  of  it 

(fe).  Enlargement  of  one  lung,  as  in  pneumonia,  emphj'sema, 

(c).  New  growth  of  lung. 

2.  Changes  in  the  pleurcB  : 

(a).  Pleuris}^  with  effusion,  empyema,  pneumothorax 
(b).  New  growth  of  pleura. 

3.  Other  thoracic  tumours — new  growth,  aneurj-sm. 

4.  Deformities  of  the  chest  wall,  as  the  result  of  scoliosis. 

5.  Changes  in  the  abdomen  —  ascites,  t^-mpanites,  abdominal  tumour,  and 
pregnancy. 

6.  Transposition  of  the  heart. 


HEART     IMPULSE,     DISPLACED  331 

To  distinguish  between  these  two  groups  is  usually  not  difficult,  for  when  the 
bulk  of  the  heart  is  in  the  normal  position,  and  the  apex  beat  is  displaced  beyond 
the  left  mammary  line,  the  area  of  cardiac  dullness  is  found  to  be  increased,  not 
only  to  the  left,  but  also  to  the  right  of  the  sternum,  and  in  an  upward  direction. 
This  increase  is  found  in  all  cases  in  which  there  is  a  general  enlargement  of 
the  heart,  provided  that  the  organ  is  not  overlapped  by  an  emphysematous 
lung.  If  both  lungs  are  emphysematous  and  the  cardiac  apex  is  displaced  out- 
wards, although  the  size  of  the  heart  cannot  be  estimated  by  percussion,  yet  the 
bulk  of  the  heart  may  confidently  be  presumed  to  be  in  the  normal  position. 

The  presence  of  a  cardiac  lesion,  arterial  sclero.sis,  or  chronic  renal  disease, 
helps  to  confirm  the  view  that  the  abnormal  position  of  the  apex  beat  is  due  to 
an  increase  in  the  bulk  of  the  heart,  and  not  to  a  displacement  of  the  organ  as  a 
whole.  The  examination  of  the  pulse  gives  valuable  information  ;  if  it  be 
of  high  tension  and  is  sustained,  or  if  the  pulse  is  of  the  "  water-hammer  "  type, 
it  indicates  that  the  displaced  apex  beat  is  due  to  enlargement  of  the  left  ven- 
tricle, and  that  probably  there  is  no  displacement  of  the  heart.  The  blood- 
pressure  is  increased  in  arterial  sclerosis  and  in  renal  disease,  and  must  therefore 
be  estimated,  for  it  gives  additional  evidence  that  the  displaced  apex  beat  is 
part  of  a  general  enlargement  of  the  heart.  The  examination  of  the  urine  must 
never  be  omitted,  for  if  there  be  polyuria,  with  a  small  trace  of  albumin,  low 
specific  gravity,  and  hyaline  and  granular  casts,  the  presence  of  chronic  inter- 
stitial nephritis  is  ascertained,  and  this  will  account  for  the  enlargement  of  the 
heart,  and  any  displacement  of  the  apex  beat  downwards  and  to  the  left. 

The  presence  of  a  cardiac  bruit  is  of  great  value  in  determining  that  the  dis- 
placed apex  is  due  to  morbid  changes  in  the  heart ;  but  the  absence  of  a  bruit 
does  not  necessarily  mean  that  the  displaced  apex  beat  is  unassociated  with 
cardiac  disease.  The  enlargement  of  the  left  ventricle,  due  to  arterial  degenera- 
tion or  chronic  interstitial  nephritis,  may  not  be  accompanied  by  any  bruit, 
unless  dilatation  becomes  so  great  that  mitral  regurgitation  supervenes.  The 
characters  of  any  of  the  cardiac  sounds  are  frequently  altered  in  dilatation  and 
hypertrophy  of  the  left  ventricle.  Thus,  the  aortic  second  sound  may  be  accen- 
tuated on  account  of  the  increased  arterial  tension,  and  the  second  sound  over 
the  base  of  the  heart  may  be  reduplicated  on  account  of  the  aortic  and  pulmonary 
valves  not  closing  synchronously.  The  first  sound  is  frequently  louder  and 
more  prolonged  in  hypertrophy  of  the  ventricles,  due  to  an  increase  in  the 
muscular  element  of  the  sound,  and  the  greater  force  with  which  the  auriculo- 
ventricular  valves  are  closed.  In  simple  dilatation  of  the  ventricles,  the  first 
sound  is  often  slightly  accentuated,  but  is  usually  sharper  and  shorter. 

In  the  second  class  of  cases,  in  which  the  whole  heart  is  displaced,  the  cause 
of  the  displacement  is  usually  easy  to  ascertain.  The  chest  is  frequently 
asymmetrical,  for  there  will  be  either  bulging  of  the  chest  wall  on  the  side  from 
which  the  heart  is  displaced,  or  some  shrinking  on  the  side  to  which  it  is  drawn. 

When  the  heart  is  displaced,  examination  by  percussion  may  show  that 
resonance  is  present  where  normally  there  is  cardiac  dullness.  Thus,  when  the 
right  lung  is  emphysematous  and  the  heart  is  pushed  over  to  the  left  in  conse- 
quence, the  resonance  of  the  right  lung  may  be  found  extending  to  the  left  of 
the  sternum.  A  similar  absence  of  cardiac  dullness  is  found  on  the  other  side 
of  the  chest  when  the  heart  is  pushed  to  the  right  in  emphysema  of  the  left  lung. 
It  is  not  always  so  easy  to  determine  the  boundaries  of  the  heart  when  the  dis- 
placement is  due  to  the  presence  of  a  pleural  effusion,  as  there  is  dullness  over 
the  effusion  which  may  be  continuous  with  the  cardiac  dullness.  In  such  a  case, 
however,  the  dullness  over  the  base  of  the  lung  is  not  only  in  front,  but  is  likely 
to  be  found  behind  as  well.  There  are  also  signs  of  compression  of  the  lung  by 
the  effusion,  such  as  absence  of  breath-  and  voice-sounds  and  the  existence  of 


332  HEART    IMPULSE,     DISPLACED 

tubular  breathing,  and  skodaic  resonance.  .Egophony  may  be  heard  at  the 
upper  level  of  the  fluid,  and  when  present  it  is  very  suggestive  of  pleuritic 
effusion.  WTien  the  heart  is  drawn  over  to  one  side  by  the  contraction  of  the 
lung,  as  in  fibrosis,  there  is  impaired  resonance  upon  percussion  over  the  fibrosed 
lung,  continuous  with  the  cardiac  dullness.  The  boundaries  of  the  heart  may 
be  difficult  to  define  by  percussion,  but  over  the  fibrosed  lung,  breath-sounds 
are  present,  tubular  in  character,  vocal  fremitus  and  resonance  are  increased, 
and  crackling  rales  and  other  adventitious  sounds  may  be  heard.  \Vhen  the 
heart  is  drawn  over  in  this  manner  by  fibrosis  of  one  lung,  the  resonance  over  the 
healthy  lung  will  be  found  to  extend  across  the  middle  line,  and  thus  invade  the 
normal  position  of  cardiac  dullness.  Examination  of  the  chest  by  means  of 
the  AT-rays  usually  helps  to  determine  the  position  of  the  heart ;  but  large 
tumours,  pleuritic  effusions,  etc.,  produce  shadows  which  may  be  continuous 
with  that  of  the  heart.  The  pulsations  of  the  heart  are  generally  well  seen, 
especially  in  children,  and  indicate  its  position. 

The  changes  in  the  abdomen,  causing  displacement  of  the  heart  upwards,  are 
not  likely  to  be  overlooked,  because  there  must  be  a  considerable  amount  of 
abdominal  enlargement  before  the  heart  can  be  raised  by  it ;  and  therefore,  if 
displacements  of  the  apex-beat  are  due  to  ascites,  tympanites,  abdominal 
tumours,  or  pregnane}-,  the  causes  are  all  of  such  a  marked  degree  or  in  such  an 
advanced  stage,  that  they  are  easily  recognizable.  ^Vhen  the  heart  is  displaced 
as  the  result  of  marked  changes  in  the  lungs  and  pleurae,  intrathoracic  tumours, 
or  abdominal  enlargements,  the  causes  of  the  displacement  are  usually  found 
first  on  account  of  the  symptoms  and  physical  signs  they  produce  ;  the 
alteration  in  the  position  of  the  apex  beat  is  then  a  confirmatory  sign. 

In  the  first  group,  in  Avhich  the  bulk  of  the  heart  is  in  the  normal  position, 
the  direction  in  which  the  apex  beat  is  displaced  is  of  some  diagnostic  value. 
It  is  displaced  downwards  and  to  the  left  in  hypertrophy  of  the  heart,  especially 
when  it  affects  chiefl}^  the  left  ventricle.  In  mitral  regurgitation  the  apex  beat 
is  displaced  outwards  and  to  the  left,  whereas  in  lesions  of  the  aortic  valves 
the  displacement  is  to  the  lelt  and  downwards,  so  that  the  apex  beat  is 
commonly  situated  in  the  sixth  intercostal  space.  In  both  these  conditions  the 
left  ventricle  is  enlarged,  but  Avith  mitral  regurgitation  the  right  side  of  the  heart 
becomes  enlarged  early  in  the  disease,  and  the  apex  is  displaced  much  more 
outwards  than  downwards.  ^Vhen  the  right  ventricle  is  alone  enlarged,  as  in 
pulmonary  emphj-sema,  the  displacement  of  the  apex  beat  is  directly  to  the 
left,  and  not  dowuAvards  at  aU. 

The  varying  enlargement  of  the  two  ventricles  may  be  fairly  gauged  by 
watching  the  position  of  the  apex.  It  is  raised  and  displaced  slightly  to  the 
left  by  any  cause  which  increases  the  height  of  the  diaphragm,  such  as  ascites, 
tympanites,  abdominal  tumours,  and  pregnancy.  The  cardiac  impulse  is  also 
raised  in  pericardial  effusions.  There  are,  however,  a  considerable  number  of 
cases  of  displaced  apex  beat,  with  the  bulk  of  the  heart  in  the  normal  position,  in 
which  it  is  difficult  to  ascertain  the  cause  of  the  displacement.  This  is  especially 
so  in  young  adults,  in  Avhom  the  apex  beat  may  be  found  to  be  displaced 
slightly  outwards  without  any  apparent  cause.  If  the  subject  be  a  young  and 
muscular  man,  who  otherwise  seems  in  good  health,  the  condition  is  probably 
due  to  hypertrophj'  of  the  left  ventricle  as  the  result  of  excessive  athletic  exercise 
or  of  some  arduous  muscular  work.  The  history  would  confirm  this  view.  If, 
on  the  other  hand,  the  patient  is  not  a  muscular  individual,  the  displacement 
may  still  be  due  to  strain,  but  some  other  cause  should  always  be  looked  for, 
and  in  the  absence  of  any  obvious  cardiac  lesion,  pericardial  adhesions  must  not 
be  forgotten  :  these  may  be  very  slight,  and  produce  very  few  symptoms  except 
a  slight  enlargement  of  the  heart. 


HEMIANOPSIA  333 


In  young  girls,  the  apex  beat  is  often  situated  in  the  mammary  line,  and  this 
displacement  is  associated  with  chlorosis  and  other  debilitating  conditions  -which 
produce  dilatation  of  the  conus  arteriosus.  The  apex  beat  is  not  only  displaced 
outwards,  but  is  also  raised.  The  diagnosis  is  confirmed  by  finding  that  the 
cardiac  dullness  is  increased  in  an  upward  direction,  and  by  the  presence  of  a 
functional  systolic  bruit  in  the  pulmonary  area  and  a  bruit  de  diable  in  the  neck. 

In  elderly  people,  in  whom  there  is  no  valvular  disease  of  the  heart,  the  apex 
may  be  displaced,  not  only  as  the  result  of  hypertrophy  of  the  left  ventricle 
secondary  to  renal  disease  and  arterial  sclerosis,  and  as  the  result  of  enlargement 
of  the  right  ventricle  secondary  to  pulmonary  emphysema  ;  but  also  as  the  result 
of  myocardial  degeneration.  The  last  condition  may  be  difficult  of  diagnosis, 
but  when  there  is  no  evidence  of  valvular  disease,  emphysema,  chronic  renal 
disease,  arterial  sclerosis,  or  anything  causing  displacement  of  the  heart  as  a 
whole,  it  must  always  be  suspected  ;  for  myocardial  degeneration  occurs  more 
frequently  than  is  generally  suspected.  When  the  apex  beat  is  displaced  out- 
wards as  the  result  of  myocardial  degeneration,  certain  symptoms  frequently 
accompany  it,  such  as  dyspnoea  upon  exertion,  attacks  of  syncope,  palpitation, 
and  oedema  of  the  legs.  The  pulse  is  feeble  and  irregular,  and  on  examination 
of  the  heart,  the  impulse  is  feeble,  a  gallop  rhythm  is  frequently  present,  and  a 
soft  systolic  bruit  audible  at  the  apex. 

Another  form  of  uniform  cardiac  hypertrophy  that  needs  special  mention  is 
that  which  results  from  long-continued  drinking  of  large  quantities  of  fluid, 
particularly  beer — the  beer-drinker's  heart.  J .  E.  H.  Sawyer. 

HEART  SOUNDS,  ACCENTUATION  OF.  —  (See  Accentuation  of  Heart 
Sounds.) 

HEART  SOUNDS,   REDUPLICATION  OF (See   Reduplication   of    Heart 

Sounds.) 

HEARTBURN,  or  Pyrosis,  is  an  indication  of  excessive  acidity  of  the  gastric 
contents.  This  may  be  due  either  to  excessive  secretion  of  acid  (hyperchlorhydria, 
or  hypersecretion) ,  or  to  abnormal  fermentation  of  the  food  leading  to  the  produc- 
tion of  organic  acids  (lactic,  acetic,  butyric,  etc.).  The  diagnosis  between  these 
different  causes  must  depend  upon  a  consideration  of  the  other  signs  and 
symptoms  present,  and  upon  the  results  yielded  by  a  test  meal  (see  Indigestion). 
It  is  possible  that  heartburn  may  also  be  produced  by  the  escape  of  normal 
gastric  contents  into  the  lower  end  of  the  oesophagus,  as  the  result  of  a  relaxed 
condition  of  the  cardiac  sphincter.  This  can  only  be  inferred  from  the  absence 
of  any  other  cause  for  the  symptom.  Robert  Hutchison. 

HEMERALOPIA.— (See  Vision,   Defects   of.) 

HEMIANESTHESIA.— (See  Sensation,  some  Abnormalities  of.) 

HEMIANOPSIA  —  or,  as  it  is  sometimes  called,  hemiopia  or  hemianopia — 
means  inability  to  see  objects  in  one  half  of  the  field  of  vision.  It  is  generally, 
but  arbitrarily,  restricted  to  cases  in  which  this  defect  is  due  to  changes  else- 
where than  in  the  retina  or  disc.  It  is  not  a  common  condition,  but  it  some- 
times escapes  recognition  because,  whichever  half  of  the  visual  field  has  become 
blind,  good  vision  remains  at  the  central  part,  and  even  the  patient  himself  may 
not  ahvaj-s  be  conscious  of  his  defect  until  some  accident,  such  as  running  into 
objects  in  broad  daylight,  draws  his  attention  to  it.  To  map  out  the  blind  area 
with  accuracy,  an  instrument  known  as  the  perimeter  is  required. 

It  is  possible  to  get  hemianopsia  in  one  eye  only,  but  this  is  very  rare  apart 
from  functional  conditions  or  migraine. 


334 


HEMIANOPSIA 


When  both  eyes  are  afiected,  the  bhndness  may  affect  either  :  (i)  Correspond- 
ing halves  of  the  field  of  vision — bilateral  homonymous  hemianopsia — spoken  of 
as  right  if  neither  eye  can  see  objects  in  the  patient's  right-hand  half  of  the  field 
of  vision  [Figs.  103  and  104),  and  as  left  if  in  the  left  half  ;  or  (2)  Opposite 
halves  of  the  field  of  vision — almost  invariably  the  temporal  halves,  and 
referred    to    as    bilateral   temporal  hemianopsia  {Fig.  102). 

These  are  the  only  two  varieties  that  are  of  clinical  importance.  They  are 
generally  not  the  only  symptoms  in  the  case,  but  they  sometimes  serve  to 
localize  certain  cranial  lesions  with  accuracy. 


J^/^.  loi. — A  diagram  illustrating  the  con- 
nections of  the  optic  nerves  and  tracts,  the  3rd 
cranial  nerves,  and  the  occipital  cortex.  A, 
3rd  nerve  going  to  left  eye  ;  B,  ditto  to  right 
eye  ;  C,  relay  of  cells  in  optic  thalamus  and 
superior  corpus  quadrigeminum  ;  D,  left  occi- 
pital cortex,  which  sees  objects  in  the  right 
half  of  the  field  of  vision  ;  E,  right  occipital 
cortex,  which  sees  objects  in  the  left  half  of  the 
field  of  vision. 


Fig:  102. — A  diagram  showing  how  a  tumour 
of  the  pituitary  body  affecting  the  decussating 
fibres  at  the  optic  chiasma  prevents  impulses 
passing  from  the  nasal  half  of  either  retina  to 
the  corresponding  cortex  or  to  the  correspond- 
ing 3rd  nucleus.  Hence  bilateral  temporal 
hemianopsia  and  absence  of  pupil  reaction 
to  light  thrown  on  the  nasal  half  of  either 
retina. 


I.  Bilateral  Homonymous  Hemianopsia  has  a  variety  of  causes,  affecting  one 
or  other  of  three  main  sites,  namely  :  («)  one  optic  tract  ;  (b)  the  posterior 
limb  of  one  internal  capsule  ;  or  (c)  the  optic  radiations  or  one  occipital  region 
at  or  near  the  cuneus.  In  any  of  these  sites  the  pathological  lesion  may  be 
either  vascular — thrombosis,  haemorrhage,  embolism,  or  intermittent  closure  ; 
or  a  neoplasm,  such  as  a  gumma,  a  tuberculous  nodule,  an  inflammatory 
swelling,  or  a  gliomatous,  carcinomatous,  or  sarcomatous  nodule.  The  first 
step  is  to    locate    the   site  of   the  lesion  ;    its   nature  will    then  be  more  easily 


HEMIANOPSIA 


335 


determined,  because  in  the  internal  capsule  a  hccmorrhage,  thrombosis,  or  em- 
bolism of  the  middle  cerebral  artery  is  the  commonest  cause  of  the  symptom ;  a 
neoplasm,  or  an  abscess,  is  probably  its  commonest  cause  in  the  occipital  cortex, 
though  an  abscess,  or  rupture  or  occlusion  of  the  posterior  cerebral  artery  would 
also  be  thought  of  ;  in  the  optic  tract  it  is  as  often  as  not  gummatous,  or  in 
some  other  way  syphilitic. 

2.  Bilateyal  Temporal  Hemianopsia. — There  is  only  one  spot  at  which  a  single 
lesion  can  produce  this  condition  ;  this  is  at  the  central  part  of  the  optic  chiasma 
where  the  fibres  from  the  nasal  half  of  each  eye  are  decussating.     The  three  com- 


Fig:  103. — .-V  diagram  showing  how  a  lesion 
of  the  left  optic  tract  causes  blindness  of  the 
right  half  of  the  field  of  vision  of  each  eye. 
and  also  prevents  the  pupils  from  reacting  in 
response  to  a  ray  of  light  falling  on  the  blind 
half  of  either  retina. 


Fig.  I04. — A  diagram  showing  how  a  lesion  of 
the  left  optic  radiations  or  of  the  visual  portion  of 
the  left  occipital  cortex  causes  blindness  of  the 
right  half  of  the  field  of  vision  of  each  eye,  but 
does  not  prevent  the  pupils  from  reacting  in 
response  to  a  ray  of  light  falling  on  the  blind  half 
of  either  retina. 


monest  causes  of  this  rare  lesion  are  :  {a)  Hypertrophy  of  the  pituitary  body,  a 
condition  which  also  leads  to  acromegaly,  so  that  it  is  important  to  test  for  bilateral 
temporal  hemianopsia  in  every  case  of  acromegaly,  and  it  will  be  found  in  a 
certain  number  ;  {b)  Callus,  resulting  from  a  fracture  of  the  base  of  the  skull 
through  the  basi-sphenoid  bone  ;  (c)  A  gumma  or  other  tumour  in  this  region. 
The  differential  diagnosis  between  these  three  groups  will  generally  be  obvious 
enough  when  the  variety  of  ha;mianopsia  has  been  established. 

In  order  to  decide  the  locality  of  the  lesion  it  is  essential  in  the  first  place  to 
determine  whether  a  pencil  of  light  falling  upon  that  part  of  the  retina  which 


3  3  6  HEM  I A  NO  PS  I A 


cannot  see  is  able  to  evoke  a  reflex  contraction  of  the  pupil.  This  requires  careful 
testing  in  a  dark  room,  with  a  small  pencil  of  light  directed  towards  different 
portions  of  the  eye  at  the  observer's  will  by  a  suitable  mirror  or  lens.  Anatomical 
considerations  make  it  obvious  that  if  the  optic  tract  is  destroyed  there  is  no 
path  by  which  the  light  impulses  from  the  non-seeing  portions  of  retina  can 
reach  the  oculomotor  nucleus,  so  that  there  will  be  no  reflex  movement  of  the 
pupil  in  response  to  light  {Fig.  103).  If,  on  the  other  hand,  the  optic  tract  is 
intact,  the  lesion  being  in  the  posterior  limb  of  the  internal  capsule,  or  in  the 
optic  radiations  or  the  cuneus,  the  same  hemianopsia  results,  but  the  pupils  react 
to  light  stimuli  falling  upon  the  blind  halves  of  the  retinae  {Fig  104). 

If  the  light  reflex  is  lost  the  lesion  is  at  once  located  to  the  optic  tract,  pro- 
vided there  is  no  obvious  trouble,  such  as  cataract,  or  locomotor  ataxy,  or 
iritic  adhesions,  to  prevent  the  reaction.  If,  on  the  other  hand,  the  light  reflex 
remains,  the  lesion  must  be  in  one  of  the  three  other  places  mentioned,  and  in 
determining  this  the  history  may  help  considerably.  If  there  has  been  an 
apoplectic  seizure  in  an  elderly  person,  haemorrhage  in  the  region  of  the  internal 
capsule  is  likely,  and  there  will  often  be  both  hemiparesis  and  hemiparsesthesia 
at  the  same  time.  In  a  younger  person  suffering  from  heart  disease,  a  somewhat 
similar  history  would  point  to  embolism  involving  the  posterior  limb  of  the 
internal  capsule.  If,  on  the  other  hand,  there  has  been  a  slow  onset,  with 
increasing  headache,  vomiting,  and  giddiness,  then  a  neoplasm  or  gumma 
affecting  the  optic  radiations  or  one  occipital  pole  will  not  be  unlikely. 

If  the  patient  is  unable  to  see  things  in  the  right  halves  of  his  fields  of  vision, 
the  lesion  will  b=!  in  his  left  optic  tract,  left  internal  capsule,  left  optic  radiations, 
or  left  cuneus,  as  the  case  may  be,  and  vice  versa. 

Hemianopsia  due  to  migraine  or  to  intermittent  closure  of  cerebral  vessels 
will  be  distinguished  from  that  due  to  the  other  causes  by  its  presence  on  some 
occasions  and  its  absence  on  others. 

Irregular  or  partial  forms  of  hemianopsia  result  from  irregular  or  partial 
lesions  in  the  optic  tract  or  other  regions  mentioned  above.  The  differential 
diagnosis  is  then  more  difficult,  though  it  is  made  upon  the  same  lines  as  those 
described  above.  From  a  diagnostic  point  of  view  it  is  fortunate  perhaps  that 
hemianopsia,  when  it  occurs  at  all,  is  generally  definite,  and  either  bilateral 
temporal  or  bilateral  homonymous.  Herbert  French. 

HEMIPLEGIA  signifies  loss  of  motor  power  in  the  limbs  of  one  side  ;  the 
face,  especially  its  lower  half,  being  frequently  affected  at  the  same  time.  In 
the  great  majority  of  cases  the  face  is  paretic  on  the  same  side  as  the  affected 
arm  and  leg,  but  there  is  one  important  exception  to  this,  namely  when  the 
lesion  is  in  one  side  of  the  pons  Varolii,  when  there  is  paralysis  of  the  face  upon 
the  same  side  as  the  lesion,  and  of  the  arm  and  leg  upon  the  opposite  side — a 
condition  known  as  crossed  hemiplegia.  The  lesion  in  most  cases,  however,  is 
in  or  near  the  internal  capsule,  less  often  in  the  motor  cortex,  of  the  opposite 
side  to  that  which  is  hemiplegic.  There  may  or  may  not  be  hemiansesthesia 
at  the  same  time,  and  in  rare  cases,  when  the  lesion  is  far  back  in  the  internal 
capsule,  there  may  also  be  Hkmianopsia  (^.u.).  When  the  cause  lies  in  the  internal 
capsule,  the  paralyzed  m^uscles  may  be  either  flaccid  or  spastic,  but  they  do  not 
as  a  rule  exhibit  the  athetotic  and  other  involuntary  movements  that  cortical 
lesions  may  give  rise  to  (see  Contractions).  When  a  patient  has  difficult}- 
in  speech  associated  with  hemiplegia  it  is  important  to  distinguish  dysarthria 
from  aphasia  (see  Speech,  Abnormalities  of).  Lesions  of  the  internal 
capsule  often  produce  difficulty  in  using  the  tongue,  which  renders  speech 
mechanically  difficult  (dysarthria) — a  very  different  thing  from  the  aphasia  or 
difficulty  in  uttering  the  correct  words  when  the  mechanism  for  the  movements 


HEMIPLEGIA  337 


of  the  tongue  is  unaffected.  True  aphasia  associated  with  hemiplegia  suggests 
a  lesion  at,  or  close  to  Broca's  area  of  the  cortex  on  the  left  side,  and  is  therefore 
far  less  common  with  left-sided  than  with  right-sided  hemiplegia. 

The  fact  of  hemiplegia  is  generally  not  difficult  to  determine,  though  in  some 
cases  there  may  be  so  slight  a  weakness  that  doubts  arise  as  to  whether  there  is 
any  hemiplegia  at  all.  The  routine  examination  of  such  a  patient  will  generally 
detect  a  little  inequality'  in  the  degree  to  which  the  eyes  can  be  closed  firmly,  a 
slight  difference  in  the  depth  of  the  two  naso-labial  folds  when  the  patient  opens 
his  hps  with  his  teeth  clenched,  a  greater  difference  than  previously  between  the 
two  hand-grips,  as  measured  by  the  dynamometer,  slightly  brisker  radial  and 
ulnar  wrist-jerks,  or  tricipital  and  bicipital  elbow-jerks  upon  the  affected  side, 
inequality  of  the  knee-jerks  with  a  tendency  to  exaggeration  upon  the  paretic 
side,  with  corresponding  extensor  plantar  reflex  and  increased  Achillis  jerk  or 
even  ankle-clonus.  All  these  changes  will  be  pronounced  in  cases  where  the 
hemiplegia  is  more  definite,  though  if  the  patient  be  seen  within  a  short  time  of 
the  onset  of  hemiplegia  from  cerebral  heemorrhage,  the  tendon  and  other  reflexes 
— which  will  presently  be  exaggerated  should  the  patient  survive — may  for  the 
time  being  be  decreased  or  even  unobtainable  upon  the  affected  side. 

Stress  is  often  laid  upon  the  presence  or  absence  of  rigidity  in  connection  with 
hemiplegia,  particularh'  according  as  the  rigidity  comes  on  early  or  late  in  the 
case.  This  helps  less,  however,  in  the  diagnosis  than  it  does  in  the  prognosis. 
A  few  cases  of  hemiplegia  are  flaccid  throughout,  though  this  is  uncommon  if 
the  patient  survives  and  the  hemiplegia  persists  ;  in  cases  of  hemiplegia  due  to 
cerebral  haemorrhage  early  rigidity  generally  suggests  a  smaller  hasmorrhage  than 
does  early  flaccidity  followed  by  rigidity  ;  so  variable  is  this,  however,  that  the 
point  is  of  less  value  than  has  sometimes  been  supposed. 

It  is  difficult  to  classify  the  causes  of  hemiplegia  satisfactorily,  but  the  follow- 
ing is  a  summary  or  list  of  those  discussed  : — 

A. — The    Commoner    Causes    of    Hemiplegia. 

1.  Hemiplegia  of  moderately  Rapid  Onset. 

Cerebral  haemorrhage 

Syphilitic  endarteritis  of  a  middle  cerebral  artery 

Thrombosis  of  a  middle  cerebral  artery. 

2 .  Hemiplegia  of  Sudden  Onset. 

Embolism  of  the  middle  cerebral  artery,  generally  due  to  mitral  stenosis, 
or  to  fungating  endocarditis. 

3.  Hemiplegia  dating  from  Birth,  or  from  infancy,  and  resulting  from  :■ — 


Injury 

Congenital  malformation 

Acute  encephalitis 


Sinus  thrombosis 
Meningococcal  meningitis. 


Granted  that  a  patient  is  suffering  definitely  from  hemiplegia,  the  exact 
cause  of  the  symptom  has  to  be  determined.  One  may  say  at  once  that  the 
diagnosis  is  easy  in  a  very  large  proportion  of  cases.  Hemiplegia  of  moderately 
rapid  onset  in  a  patient  over  fifty  years  of  age  is  almost  certainly  due  to  cerebral 
hcsmorrhage,  particularly  when  it  is  associated  with  coma  of  rapid  but  not  instan- 
taneous onset,  when  there  is  a  high  blood-pressure  and  enlargement  of  the 
heart,  with  a  ringing  aortic  second  sound,  with  or  without  albuminuria  or  other 
evidence  of  granular  kidney  or  arteriosclerosis.  If  the  hemiplegia  has  been  of 
gradual  onset  in  a  young  adult,  particularly  if  one  limb  is  very  much  more 
affected  than  the  rest  of  that  half  of  the  body,  if  there  had  been  premonitory 
symptoms  for  some  hours,  or  even  days,  before  the  paresis  became  marked,  and 
D  22 


338  HEMIPLEGIA 

if  there  has  been  no  loss  of  consciousness,  the  great  probabihty  is  that  the 
patient  is  suffering  from  syphilitic  endarteritis  of  the  middle  cerebral  artery,  with 
or  without  secondary  thrombosis.  The  diagnosis  may  be  confirmed  by  a  history 
of  syphilis,  by  the  occurrence  of  cutaneous  ulcers  or  other  syphilitic  lesions,  or 
by  a  positive  Wassermann's  serum  reaction. 

If  the  patient  is  young,  if  the  hemiplegia  has  been  of  absolutely  sudden 
onset,  generally  without,  but  sometimes  with,  loss  of  consciousness,  the  proba- 
bility of  embolism  of  the  middle  cerebral  artery,  secondary  to  mitral  stenosis  or  to 
fungating  endocarditis,  will  be  considerable,  and  the  diagnosis  will  generally  be 
confirmed  by  physical  examination  of  the  heart,  and  by  enquiry  into  the  history 
as  regards  acute  rheumatism,  chorea,  or  other  rheumatic  affections.  In  cases  of 
fungating  endocarditis  there'  may  have  been  emboli  elsewhere,  the  spleen  will 
generally  be  palpable,  and  there  will  probably  be  some  pyrexia  with  progressive 
anaemia   and  a  tendency  to  subcutaneous  and  retinal  haemorrhages. 

If  the  patient  has  been  hemiplegic  from  birth  or  from  early  infancy,  the 
probability  is  that  there  has  either  been  an  injury  to  the  opposite  side  of  the 
brain  at  birth,  or  congenital  malformation  of  that  side,  or  acute  inflammation  of 
it  after  birth — the  result  perhaps  of  acute  encephalitis,  sinus  thrombosis,  or  even 
meningococcal  meningitis  which  has  recovered.  It  is  particularly  in  these 
infantile  cases  that  hemiathetosis  is  liable  to  be  associated  with  the  hemiplegia. 

Although  the  above  are  by  far  the  commonest  causes  of  hemiplegia  at  the 
different  age-periods,  it  is  possible  for  them  to  overlap  as  regards  age  incidence  ; 
and  one  occasionally  sees  fatal  cerebral  haemorrhage,  apparently  of  the  senile 
type,  in  persons  not  much  over  twenty  ;  similarly,  syphilitic  thrombosis  of  the 
middle  cerebral  artery  may  not  occur  until  after  fifty ;  fungating  endocarditis 
followed  by  cerebral  embolism  may  occur  at  any  age,  though  it  is  commonest 
in  young  persons  ;  the  same  applies  to  cerebrospinal  meningitis.  The  diagnosis 
will  be  indicated,  if  at  all,  by  other  symptoms  than  the  hemiplegia.  In  doubtful 
cases  considerable  assistance  may  be  derived  from  lumbar  puncture  and 
analyses  of  the  cerebrospinal  fluid  :  the  following  are  some  of  the  main  points 
in  which  the  latter  may  differ  from  the  normal  under  various  pathological 
conditions  : — 

Appearance. — Cerebrospinal  fluid  is  normally  quite  clear  and  free  from  colour, 
so  that  in  a  test-tube  it  may  be  difficult  to  distinguish  it  from  water  ;  when 
there  are  inflammatory  changes  in  the  central  nervous  system,  particularly  in  all 
the  acute  forms  of  meningitis,  the  fluid  becomes  opalescent,  turbid,  purulent,  or 
even  fibrinous  ;  and,  instead  of  being  colourless,  it  may  develop  a  yellow  or 
reddish-brown  colour. 

Specific  Gravity. — Its  normal  specific  gravity  is  low,  lying,  as  a  rule,  between 
1-004  ^•iid  1-007.  I't  may  retain  a  normal  specific  gravity  even  in  diseased 
conditions,  for  instance  in  cases  of  general  paralysis  of  the  insane  ;  but  if  there 
are  inflammatory  changes,  such  as  ineningitis,  the  specific  gravity  is  liable  to  be 
increased. 

Tension. — Normally  the  fluid  drops  out  through  the  lumbar-puncture  needle 
at  the  rate  of  60  drops  per  minute.  If  it  exudes  at  a  lower  rate  than  this  no 
definite  deduction  can  be  drawn,  for  it  may  be  that  the  tube  is  partly  occluded  ; 
but  if  the  rate  of  outflow  is  higher  than  one  drop  per  second,  it  indicates  a  condi- 
tion of  hyper-tension  due  to  disease  such  as  meningitis,  cerebral  tumour, 
haemorrhage,  or  abscess. 

Reaction. — Cerebrospinal  fluid  is  always  alkaline  whether  in  health  or  in 
disease. 

Cryoscopy.—Th.e  normal  freezing  point  of  the  cerebrospinal  fluid  is  — 0-55°  C.  ; 
in  disease  it  may  be  either  above  or  below  this  ;    generally  speaking,  the  greater 


HEMIPLEGIA  339 

the  diminution  in  the  freezing  point  the  more  Ukely  is  acute  organic  disease  to  be 
present  in  the  central  nervous  system. 

Sugar. — -The  amount  of  reducing  substance  in  normal  cerebrospinal  fluid,  esti- 
mated by  the  reduction  of  Fehling's  solution,  is  approximately  1-5  parts  per 
1, 000  ;  in  diabetes  mellitus  this  is  more  or  less  increased  ;  what  the  figures  are 
in  other  conditions  has  not  yet  been  established  fully,  but  there  is  some  evidence 
to  show  that  the  sugar  is  materially  decreased  in  dementia  prascox. 

Urea. — Urea  in  cerebrospinal  fluid  amounts  normally  to  1-5  parts  per  1,000  ; 
the  disease  in  which  there  is  any  material  increase  in  this  is  uraemia,  and  the 
excess  of  urea  in  cerebrospinal  fluid  in  this  condition  is  sometimes  an  important 
point  in  the  differential  diagnosis  in  cases  of  coma. 

Proteids. — There  is  little  if  any  coagulable  proteid  in  normal  cerebrospinal 
fluid  ;  careful  analyses  have  shown  that  no  albumin  is  present,  but  that  there 
are  traces  of  globulin  ;  in  diseased  conditions,  particularly  thosv  associated  with 
inflammation  within  the  cranium  or  spinal  canal,  there  are  albumin,  more  globulin 
than  normal,  and  often  some  nucleo-proteid. 

Choline. — Some  stress  was  laid  at  one  time  upon  the  supposed  fact  that 
choline  platino-chloride  crystals  were  obtainable  from  the  cerebrospinal  fluid 
when  acute  nervous  degeneration  was  taking  place,  and  not  in  health,  but  there 
is  considerable  evidence  to  show  that  the  tests  employed  were  unreliable, 
so  that  the  general  opinion  now  is  that  deductions  drawn  from  analyses  for 
choline  are  entirely  erroneous,  even  when  the  choline  periodide  crystals  are  tested 
for  instead  of  the  platino-chloride. 

Cytological  Examination. — The  normal  fluid  is  practically  free  from  cells, 
although,  owing  to  the  impossibility  of  avoiding  slight  injury  to  vessels  by  the 
introduction  of  the  lumbar-puncture  needle,  a  few  red  corpuscles  are  generally 
found  in  the  centrifugalized  deposit,  and  a  few  leucocytes  corresponding  to  the 
numbers  that  would  be  expected  in  the  blood  represented  by  the  red  cells.  It 
is  probable  that  cerebrospinal  fluid  obtained  quite  free  from  any  blood  contami- 
nation would  be  practically  free  from  leucocytes.  Quite  otherwise  is  it  in 
certain  diseases — not  only  in  acute  lesions,  such  as  meningitis,  but  also  in 
chronic  degenerations,  such  as  general  paralysis  of  the  insane.  It  is  important 
to  examine  the  centrifugalized  deposit,  not  merely  for  the  presence  or  absence 
of  leucocytes,  but  also  for  the  different  relative  proportions  of  polymorpho- 
nuclear cells  and  of  lymphocytes.  A  considerable  number  of  polymorpho- 
nuclear cells  generally  indicates  bacterial  infection  of  the  subarachnoid  space  by 
some  organism  other  than  the  tubercle  bacillus,  especially  streptococci,  staphy- 
lococci, pneumococci,  and  meningococci.  Some  degree  of  polymorphonuclear 
excess  may,  however,  accompany  the  characteristic  lymphocytosis  of  a  few  cases 
of  tuberculous  meningitis.  Mononuclear  proliferation — that  is  to  say  lympho- 
cytosis— indicates,  as  a  rule,  a  subacute  or  chronic  inflammatory  or  degenerative 
condition  ;  it  almost  invariably  accompanies  syphilitic  lesions  of  the  central 
nervous  system,  particularly  general  paralysis  and  tabes  dorsalis  ;  it  is  also  to 
be  expected  in  tuberculous  meningitis,  and  in  sleeping  sickness.  It  is  not,  how- 
ever, pathognomonic  of  any  of  these,  for  it  has  been  observed  also  in  entirely- 
different  conditions,  such  as  herpes  zoster,  acute  anterior  poliomyelitis,  some 
cases  of  cerebral  tumour,  lymphatic  leukaemia,  chloroma,  and  even  mumps. 
Although  lymphocytosis  generally  indicates  chronic  mischief,  and  polymorpho- 
nuclear leucocytosis  acute  infection,  in  the  later  stages  even  of  acute  microbial 
infections  mononuclear  cells  may  be  more  numerous  in  the  cerebrospinal  fluid 
than  are  the  polymorphonuclears. 

Bacteriological  Examination. — Normal  cerebrospinal  fluid  is  absolutely  sterile. 
In  pathological  conditions  it  ma^^  be  examined  bacteriologically  in  various  ways, 
including  direct  staining  of  films  made  from  the  centrifugalized  deposit,  cultural 


340  HEMIPLEGIA 

methods,  and  inoculation  into  animals.  The  most  important  organisms  that 
have  been  found  are  the  pneumococcus,  streptococcus,  bacillus  tuberculosis, 
meningococcus  (Weichselbaum's  Diplococcus  tntracellularis  meningitidis), 
pneumobacillus,  bacillus  typhosus,  and,  probably  as  a  terminal  infection  only, 
the  staphylococcus  and  the  Bacillus  coli  communis.  The  cerebrospinal  fluid 
may  be  used  for  testing  for  Wassermann's  reaction  for  syphilis  by  complement 
fixation,  though  this  is  better  carried  out  upon  blood  serum.  The  Treponema 
pallidum  {SpirochcBta  pallida)  has  been  found  in  the  cerebrospinal  fluid  in  at 
least  one  case,  but  it  again  is  more  hkely  to  be  detected  in  the  local  syphiUtic 
lesions.  The  only  protozoon  at  all  constantly  met  with  in  the  cerebrospinal 
fluid  in  disease  is  the  Trypanosoma  gambiense  in  cases  in  which  the  trypano- 
somiasis has  reached  the  stage  of  sleeping  sickness. 

B. — Less    Usual    Causes    of    Hemiplegia. 

General  paralysis  of  the  insane 

Borderland  sufficiency  of  the  cerebral  circulation  in  old  people  (intermittent 

claudication) 
Cerebral  tumour,  with  or  without  hasmorrhage  into  it 
Cerebral  abscess 

Stab  or  bullet  wound  injuring  the  spinal  cord  in  the  cervical  region 
Hemichorea 
Meningitis,  whether  tuberculous,  suppurative,  posterior-basal,  or  epidemic 

cerebrospinal 
Disseminated  sclerosis 
Caisson  disease 
Hysteria. 

Amongst  the  less  usual  causes  of  hemiplegia  it  is  perhaps  worthy  of  particular 
mention  that  general  paralysis  of  the  insane  sometimes  attracts  little  or  no  atten- 
tion until  a  seizure  of  some  kind  occurs,  this  seizure  not  infrequently  being 
epileptiform,  and  sometimes  producing  a  hemiplegia  closely  simulating  that 
due  to  cerebral  hsemorrhage.  The  diagnosis  may  remain  uncertain  until  the 
course  of  the  case  can  be  followed,  but  Wassermann's  serum  reaction,  and  the 
lymphocytosis  in  the  cerebrospinal  fluid,  may  each  serve  to  point  to  the  true 
nature  of  the  case.  Another  feature  is  the  very  rapid  rate  of  temporary  recovery 
exhibited  by  some  patients  ;  deeply  comatose  and  hemiplegic  when  seen  upon 
the  day  of  seizure,  nearly  all  the  S3^mptoms  may  have  disappeared  by  the  next 
morning  in  a  way  that  would  be  unusual  were  they  due  to  a  haemorrhage  of 
sufficient  size  to  cause  so  deep  a  coma. 

In  quite  old  people,  that  is  to  say  those  over  eighty  years  of  age,  incomplete 
hemiplegia  may  occur  rapidly  but  transiently  over  a  period  of  years,  in  such  a 
way  as  to  suggest  during  the  first  attack  or  two  that  there  has  been  an  actual 
extravasation  of  blood  within  the  brain.  The  rapidity  with  which  the  hemi- 
plegic symptoms  may  disappear,  and  the  way  in  which  they  may  recur  and  yet 
disappear  again  each  time,  render  it  probable  that  these  patients  are  not  suffering 
from  the  effects  of  recurrent  small  haemorrhages,  but  from  a  condition  of  partial 
occlusion  of  their  cerebral  vessels  by  atheroma  to  such  an  extent  that,  whereas 
the  circulation  is  just  sufficient  for  the  needs  of  the  brain  at  one  time,  it  is  just 
insufficient  at  other  times  ;  the  result  being  that  when  the  insufficiency  of 
cerebral  circulation  is  most  in  evidence,  weakness  of  a  hemiplegic  type  ensues,  to 
disappear  when  rest  in  bed  restores  the  cerebral  circulation  to  a  sufficiency 
again.  Cases  of  this  kind  have  been  spoken  of  as  suffering  from  intermittent 
claudication,  as  though  the  vessels  could  alternately  dilate  and  close  up  spon- 
taneoush'  ;    but  there  is  evidence  to  show  that  there  are  no  efficient  vasomotor 


HEMIPLEGIA  341 

nerves  in  the  cranial  vessels,  so  that  the  theory  of  borderland  sufficiency  of 
circulation  through  atheromatous  vessels  is  more  probable  than  that  of  inter- 
mittent claudication. 

Cerebral  tumour  or  cerebral  abscess  may  produce  hemiplegia  by  infiltrating 
either  the  cerebral  cortex  or  the  pyramidal  tract  directly,  or  by  these  becoming 
involved  in  the  softening  around  the  tumour  or  the  abscess  ;  in  most  cases  there 
will  be  a  history  of  weeks  or  months  of  headache,  giddiness,  and  effortless 
vomiting,  with  or  without  signs  of  irritation  previous  to  the  paralysis  ; 
ophthalmoscopic  examination  will  frequently  reveal  optic  neuritis  of  the  choked 
disc  type  (Plate  VII,  Fig.  K),  and  in  the  abscess  cases  there  will  generally  be 
a  predisposing  cause,  particularly  otitis  media.  It  is  well  known,  however, 
that  either  a  tumour  or  an  abscess  within  the  cranium  may  be  latent  for 
months,  and  in  some  such  cases  symptoms  may  come  on  acutely,  especially 
if  there  has  been  haemorrhage  into  a  softening  tumour.  Ordinary  cerebral 
haemorrhage  may  be  simulated  in  this  way,  but  if  well  marked  optic  neuritis  is 
found  in  both  eyes,  it  is  probably  not  a  haemorrhage  only.  The  existence  of 
pyrexia  is  not  by  itself  evidence  of  abscess,  for  haemorrhage  near  the  internal 
capsule,  or  in  the  motor  cortex,  often  leads  to  some  rise  of  temperature  for  the 
time  being,  wliilst  pontine  haemorrhage  is  not  infrequently  associated  with 
hyperpyrexia,  and  in  not  a  few  cases  of  intracranial  abscess  pyrexia  is  con- 
spicuously absent. 

Injury  to  the  Spinal  Cord  in  the  Cervical  Region  is  a  very  rare  cause  of  paralysis 
of  the  arm  and  leg  upon  the  same  side  ;  first,  because  trauma  here  is  extremely 
liable  to  damage  more  than  half  the  cord  ;  and,  secondly,  because  the  injury 
must  involve  the  lower  part  of  the  cervical  enlargement  if  the  arm  is  to  be  para- 
lyzed, and  it  is,  therefore,  very  liable  indeed  to  interfere  with  the  subsidiary 
respiratory  centres,  and  thus  prove  rapidly  fatal.  Occasionally,  however, 
either  a  knife  stab  or  a  bullet  wound  on  one  side  of  the  neck  produces  hemiplegia 
with  evidence  of  unilateral  paralysis  of  the  diaphragm  as  observed  when  the 
patient's  abdominal  respiratory  movements  are  watched  in  a  good  hght.  It  has 
sometimes  been  asserted  that  the  patient  will  have  aucesthesia,  not  of  the  same, 
but  of  the  opposite  side  of  the  body  :  in  practice  this  is  not  generally  the  case, 
the  hemiplegia  and  the  hemianaesthesia  being  on  the  same  side  as  the  lesion  in 
at  least  some  instances. 

Children  of  a  rheumatic  tendency,  who  are  subject  to  chorea,  sometimes 
present  the  movements  of  the  latter  upon  one  side  of  the  body  only— hemi chorea  ; 
both  before  the  actual  movements  appear  and  after  they  have  ceased  there  is 
apt  to  be  considerable,  and  occasionally  extreme,  weakness  of  the  affected  side  ; 
so  much  so  that  some  intracranial  lesion  may  be  suspected,  unless  there  has  been 
clear  evidence  of  the  existence  of  chorea. 

Occasionally,  weakness  of  a  hemiplegic  nature  may  be  the  first  symptom  of 
meningitis,  whether  tuberculous,  suppurative,  posterior  basal,  or  epidemic 
cerebrospinal  ;  sometimes,  upon  post-mortem  examination  a  definite  unilateral 
softening,  or  a  tuberculous  nodule  affecting  the  pjrramidal  fibres  may  be  found 
to  account  for  this  ;  but  more  often  the  appearances  seen  after  death  fail  to 
explain  why  there  should  have  been  unilateral  paretic  symptoms.  In  the  earlier 
stages  the  diagnosis  may  be  quite  obscure,  but  sooner  or  later  the  paresis  becomes 
bilateral,  and  the  course  of  the  disease  indicates  meningitis  beyond  doubt, 
especially  if  there  are  convulsions,  vomiting,  and  optic  neuritis.  Choroidal 
tubercles  may  be  detected  in  some  cases  {Plate  VIII,  Fig.  W),  and  the 
cerebrospinal  fluid  may  be  examined  cytologically  and  bacteriologically. 

Disseminated  Sclerosis  is  a  very  slowly  progressive  disease,  in  which  during  the 
earlier  stages  the  foci  of  sclerosis  are  few  and  quite  irregularly  distributed,  so 
that  Avhereas  in  the  later  stages  ataxy,  intention  tremor,  more  or  less  spasticity 


342  HEMIPLEGIA 

with  increased  knee-jerks,  extensor  plantar  reflexes,  ankle-clonus,  and  staccato 
speech,  are  to  be  expected,  these  are  only  present  when,  in  the  course  of  years, 
numbers  of  sclerotic  foci  have  accumulated  in  the  spinal  cord  and  brain  ;  long 
previous  to  this  there  have  been  irregular  symptoms,  amongst  which  may  be 
mentioned  hemiplegia  ;  the  diagnosis  at  this  stage  is  often  a  matter  of  opinion 
only,  though  if  the  patient  can  be  watched  over  a  sufficient  length  of  time  the 
nature  of  the  case  ultimatelj^  becomes  obvious. 

The  symptoms  of  caisson  disease  are  due  to  the  liberation  of  definite  air  bubbles 
in  the  nervous  system,  and  what  the  symptoms  will  be  depends  entirely  on 
where  these  bubbles  are ;  in  most  instances  they  are  widely  scattered,  so  that 
bilateral  paralyses  are  more  common  than  unilateral ;  it  is  possible,  however, 
for  caisson  disease  to  produce  hemiplegia  if  a  relatively  large  air  bubble  becomes 
hberated  in  or  near  the  internal  capsule.  The  diagnosis  depends  upon  the 
history  and  occupation. 

Hysteria  may  be  responsible  for  almost  any  form  of  nerve  symptom,  hemi- 
plegia being  not  an  uncommon  variety.  There  is  no  wasting,  except  that  which 
may  be  due  to  disuse  ;  the  knee-jerks  may  be  exaggerated,  but  the  plantar 
reflexes  will  remain  flexor,  and  there  is  no  ankle-clonus  ;  the  face,  as  a  rule,  is 
unaffected  ;  if  the  patient,  hang  flat  upon  her  back,  is  asked  to  raise  her  legs 
from  the  bed,  she  will  raise  the  sound  leg,  but  not  that  which  is  paretic  ;  whereas, 
in  a  case  in  which  there  is  incomplete  paralysis  of  one  leg  due  to  organic  lesions 
of  the  upper  neurone  upon  one  side,  an  attempt  to  raise  the  leg  in  this  way 
often  leads  to  the  paretic  leg  being  lifted  as  well  as  the  other.  The  sex  and 
age  of  the  patient,  her  previous  history,  and  the  presence  possibly  of  other 
functional  nerve  symptoms,  especially  globus  hystericus,  hysterical  aphonia, 
or  the  distribution  of  anaesthesia  of  the  glove  or  stocking  type,  woiild  indicate 
the   diagnosis.  Herbert  French. 

HICCOUGH. — Hiccough  is  a  symptom  which  far  more  often  than  not  has  no 
clinical  significance,  resulting,  as  it  does  even  in  the  healthiest  people,  from 
excessive  laughter,  from  the  stimulation  of  certain  reflex  spots,  especially  about 
the  chin,  from  tickling,  or  even  coming  on  spontaneously  without  any  obvious 
cause  at  all. 

Occasionally,  however,  hiccoughing  may  be  so  persistent  or  may  reach  so 
alarming  a  degree,  that  it  becomes  of  clinical  importance.  The  patients  may  be 
divided  into  two  groups,  namely,  those  in  whom  there  is  already  severe  illness, 
and  those  who  are  not  obviously  ill.  Of  the  former  group  there  are  two  main 
types  —  the  Alcoholic  and  the  Peritonitic.  No  difficult}^  of  diagnosis  arises 
between  these  two  ;  the  drunken  person's  hiccough  has  a  character  of  its  own. 
The  patient  who  has  an  acute  abdominal  condition  associated  with  hiccough 
will  have  presented  grave  symptoms  long  before  hiccough  sets  in,  the  diagnosis 
often  having  been  arrived  at  by  urgent  laparotomj-.  Hiccough  in  these  cases 
does  not  serve  to  distinguish  between  acute  peritonitis  due  to  whatever  cause, 
acute  haemorrhagic  pancreatitis,  acute  intestinal  obstruction  from  any  cause,  or 
acute  post-operative  dilatation  of  the  stomach  ;  its  occurrence  and  persistence, 
however,  indicate  a  ver}^  grave  prognosis. 

When  persistent  or  recurrent  hiccough  is  a  troublesome  symptom  in  a  patient 
who  is  not  obviously  ill — so  troublesome  that  something  more  than  a  simple 
hiccough  has  to  be  thought  of — three  main  types  of  malady  will  suggest  them- 
selves, namely  : — 

1.  Hysteria  or  neurosis. 

2.  Mediastinal  irritation  of  vagi  or  phrenic  nerves,  e.g.,  by  caseous  lymphatic 
glands. 

3.  Degenerative  changes  in  the  medulla  oblongata. 


HICCOUGH 


343 


None  of  these  three  types  is  at  all  common,  and  their  diagnosis  during  life  is 
often  a  matter  of  opinion. 

Functional  Hiccough  is  a  remarkable  malady  hardly  to  be  mistaken.  The 
patient  is  generally  a  girl  between  15  and  25  years  of  age,  and  she  may  hiccough 
persistently  throughout  her  waking  hours  for  weeks,  at  the  rate  of  two  or  three 
times  a  minute.  She  will  sleep  well,  and  the  hiccough  stops  during  sleep.  She 
will  eat  well,  but  may  hiccough  during  meals  in  a  most  distressing  way.  She 
will  have  exaggerated  knee-jerks,  brisk  flexor  plantar  reflexes,  and  she  will  be 
amenable  to  treatment  by  suggestion.  Whether  treated  or  not,  the  hiccough 
will  cease  in  time,  though  it  may  persist  on  and  off  for  weeks  ;  often  it  will  be 
noticed  to  have  come  in  the  place  of  some  other  neurosis,  and  when  it  goes  it  may 
be  replaced  by  other  functional  nerve  symptoms. 

Irritation  of  a  Vagus  or  Phrenic  Nerve  by  something  in  the  mediastinum 
causes  recurrent  attacks  of  intractable  hiccough  only  in  rare  cases.  In  a  child, 
the  least  uncommon  cause  is  tuberculous  caseation  of  bronchial  and  mediastinal 
glands  ;  these  seldom  obstruct  a  bronchus  or  in  other  mechanical  ways  afford 
evidence  of  their  presence  ;  but  they  may  be  associated  with  periodic  attacks 
of  febrile  illness  in  a  patient  who  looks  delicate,  and  who  has  been  in  the  habit 
of  drinking  much  milk  ;  and  there  may  be  evidence  of  chronic  enlargement  of 
the  glands  elsewhere,  particularly  those  in  the  neck  or  in  the  abdomen.  In  an 
adult  the  least  uncommon  causes  are  either  malignant  or  lymphadenomatous 
deposits  in  the  mediastinum,  or  else  fibrous  mediastinitis.  The  former  may  be 
indicated  by  reason  of  there  being  symptoms  of  a  primary  growth  in  the  oeso- 
phagus or  elsewhere,  or  by  progressive  varicosity  of  the  veins  of  the  chest  wall, 
or  signs  of  recent  and  increasing  obstruction  to  a  bronchus  ;  chronic  mediastinitis 
has  generally  been  preceded  by  repeated  attacks  of  pleurisy  and  pericarditis, 
especially  in  those  subject  to  acute  rheumatism.  Hiccough  is  an  exceptional 
symptom  in  these  cases. 

Finally,  if  hiccough  is  due  to  degeneration  or  softening  of  the  medullary 
centres,  it  will  almost  certainly  be  associated  with  other  symptoms  of  cerebral 
or  spinal  mischief  ;  in  a  young  adult  there  might  be  a  suggestive  history  of 
syphilis  or  chronic  alcoholism,  whilst  in  an  older  person  there  would  be  thickened 
and  tortuous  arteries,  a  high  tension  pulse,  an  enlarged  heart,  arcus  senilis, 
possibly  albuminuria  in  an  abundant  urine  of  low  specific  gravity — signs  of 
senile  degenerative  changes.  Herbert  French. 

HIPPUS. — (See  Pupil,  Abnormalities  of  the.) 

HUSKINESS.— (See  Speech,  Abnormalities  of.) 

HYPERESTHESIA.— (See  Sensation,  Abnormalities  of.) 

HYPERIDROSIS. — ^(See  Sweating,  Abnormalities  of.) 

HYPERPYREXIA. — The  point  at  which  pyrexia  becomes  hyperpj^rexia  is 
arbitrary  ;  by  some  it  is  fixed  at  105°  F.,  by  others  at  106°  F.  It  may  occur 
occasionally  in  many  different  diseases,  but  it  is  seldom  itself  of  diagnostic 
significance.  The  patient  will  nearly  always  have  exhibited  other  symptoms  or 
signs  pointing  to  the  diagnosis  ;  therefore  the  following  list  of  maladies  in  which 
hyperpyrexia  may  occur  needs  little  discussion  : — 

A .  Fevers  of  microbial,  or  probably  of  microbial,  origin : — 


Lobar  pneumonia  Septicsemia 

Bronchopneumonia   '  Erysipelas 

Scarlatina  ;  Typhoid  fever 

Pyemia  \  Typhus  fever 


Malignant    endocarditis 
General  tuberculosis 
Tetanus 
Tuberculous  meningitis 


344  HYPERPYREXIA 

Fevers  of  microbial,  or  probably  of  microbial,  origin : — -continued. 


Posterior  basal  meningitis 
Epidemic  cerebrospinal 

meningitis 
Suppurative  meningitis 
Malaria 

Relapsing  fever 
Cholera 


Dysentery 

Yellow  fever 

Rheumatic  fever 

Chorea  insaniens 

Uraemia  due  to  ascending  nephritis 

Pyelitis. 


B.  Lesions  of  the  Central  Nervous  System  : — 

Cerebral  haemorrhage,  especially  pontine,  or  into  one  optic  thalamus 

Fractured  skull,  with  contusion  of  the  brain 

Cerebral  softening 

Cerebral  tumour  or  abscess,  especially  tumour  of  the  pons  Varolii 

Fractured  spine,  especially  in  the  lower  cervical  or  upper  dorsal  regions 

Acute  mj'elitis  after  injury. 

C.  Affections  that  are  less  easy  to  classify  : — 

After  burns  or  scalds 


Heat  stroke  or  sunstroke 
Infantile  convulsions 
Delirium  tremens 


Uraemia  other  than  that   due  to 

septic  nephritis 
Acute  yellow  atrophy  of  the  liver. 


D.  Hysteria. 

There  are,  however,  certain  small  points  about  hyperpyrexia  that  may  be 
important  in  diagnosis. 

Acute  rheumatism  is  often  stated  to  be  a  prominent  cause  of  it ;  as  a  matter 
of  fact,  hyperpyrexia  is  excessively  rare  in  acute  rheumatism,  so  that  should  it 
occur  in  a  case  that  has  been  regarded  as  rheumatic  fever,  the  diagnosis  should 
be  very  carefully  revised  lest  it  really  be  septicemia. 

In  children  the  physical  signs  alone  may  leave  one  in  doubt  as  to  whether 
there  is  bronchitis  only,  or  broncho-pneumonia,  or  even  general  tuberculosis  of 
the  lungs  ;  the  occurrence  of  hyperpyrexia  generally  indicates  that  there  is  more 
than  bronchitis  ;  if  the  patient  is  not  particularly  livid,  bronchopneumonia  is 
more  likely  than  general  tuberculosis  ;  the  latter  becomes  the  more  probable 
the  more  ill  the  patient  is,  out  of  proportion  to  the  physical  signs.  Occasion- 
ally h^^perpyrexia  occurs  in  an  infant  or  child  after  a  fit,  without  any  definite 
cause  being  assignable  either  for  the  convulsion  or  for  the  high  temperature, 
and  without  any  serious  consequence  resulting. 

In  tuberculous  meningitis  h^^perpyrexia  is  generally  terminal ;  in  posterior- 
basal  meningitis,  on  the  other  hand,  it  sometimes  occurs  periodically  and 
transiently,  producing  acute  upward  "  spikes  "  upon  a  temperature  curve  that 
is  not  otherwise  very  high  ;  these  pyrexial  "  crises,"  as  they  have  been  called, 
point  to  posterior-basal  rather  than  to  the  more  serious  tuberculous  meningitis. 

Hyperpyrexia  may  sometimes  serve  as  the  chief  point  in  distinguishing  pontine 
hcBmorrhage  or  heat-stroke  from  other  forms  of  coma,  such  as  acute  alcoholism 
or  opium  poisoning  ;  in  the  latter,  the  temperature  is  below  normal.  The  circum- 
stances of  the  case,  such  as  climatic  conditions  or  occupation,  will  generally  serve 
to  distinguish  between  heat-stroke  and  pontine  haemorrhage. 

After  an  injury  to  the  back — for  instance,  by  a  fall  in  the  hunting  field — the 
occurrence  of  hyperpyrexia  sometimes  serves  to  exclude  the  diagnosis  of  a  mere 
bruising,  and  to  point  to  the  gravity  of  the  condition — a  fractured  or  dislocated 
spine  near  the  cervical  region,  or  acute  traumatic  myelitis  or  softening  of  the 
upper  part  of  the  spinal  cord. 

The  diagnosis  of  the  other  diseases  mentioned  in  the  above  list  is  not  much 
assisted  by  the  occurrence  of  hyperpyrexia. 


HYPOTHERMIA  345 

It  only  remains  to  add  a  word  or  two  about  hysteria  and  high  temperatures. 
There  can  be  no  doubt  that,  in  exceptional  cases,  nearly  all  of  which  are  of 
the  female  sex,  the  mercury  in  the  clinical  thermometer  does  actually  rise  to  a 
very  high  figure  without  there  being  any  corresponding  illness  in  the  patient. 
Malingerers  have  sometimes  learned  a  trick,  such  as  rubbing  the  bulb  of  the 
thermometer,  to  produce  enough  friction  heat  to  send  the  mercury  up  ;  but 
quite  apart  from  malingering,  there  are  females  in  whom,  for  some  reason 
that  is  not  yet  understood,  the  mercury  really  does  record  temperatures  that 
are  not  those  of  the  internal  tissues.  Readings  have  been  taken  simultaneously 
in  the  mouth,  armpits,  and  rectum,  all  possibility  of  malingering  being  excluded 
by  special  precautions  ;  all  the  thermometers  registered  hyperpyrexia.  The 
diagnosis  is  generally  made  by  the  fact  that  the  readings  are  so  high  that  they 
must  be  unreal ;  the  following  have  been  recorded  in  various  cases :  107°, 
108°,  111°,  113°,  ii5'8°,  116-4°,  117°.  i20-8°,  122°,  127°,  128°,  and  even  131°  F. 
In  most  of  these  patients  the  symptoms  were  slight,  though  sometimes 
there  have  been  flushings,  headache,  restlessness,  and  various  functional  nerve 
symptoms,  or  even  delirium  and  convulsions.  Unless  it  is  at  once  obvious 
that  the  patient  is  not  really  ill,  there  must  always  be  difficulty,  danger,  and 
anxiety  in  arriving  correctly  at  the  diagnosis  of  hysterical  hyperpyrexia  ;  the 
nature  of  the  case  may  remain  in  doubt  until  the  course  and  result  have 
been  watched.  Herbert  French. 

HYPERTROPHY  OF  THE  HEART. —  (See  Enlargement  of  the  Heart.) 

HYPOTHERMIA. — This  signifies  a  condition  of  subnormal  temperature,  and 
generally  speaking  it  is  assumed  to  refer  to  the  temperatures  registered  by  the 
thermometer  in  the  mouth.  Rectal  temperatures  do  not  always  coincide  with 
those  of  the  mouth,  but  the  clinical  significance  of  variations  in  rectal  temperatures 
is  not  yet  fully  understood. 

From  a  diagnostic  point  of  view  hypothermia  is  not  often  a  symptom  of  great 
importance,  but  there  are  at  least  two  points  about  it  that  require  special  mention. 
In  the  first  place,  coma  due  to  opium  poisoning  may  be  closely  simulated  by 
coma  due  to  pontine  haemorrhage ;  in  both  there  are  bilateral  loss  of  movement, 
pinpoint  pupils,  and  few  other  symptoms  ;  with  opium  poisoning,  however, 
the  temperature  becomes  subnormal,  whilst  with  pontine  haemorrhage  it  tends 
to  rise  to  the  level  of  hyperpyrexia,  so  that  the  thermometer  may  be  the  means 
of  diagnosing  between  them.  In  the  second  place,  patients  suffering  from 
chronic  valvular  heart  disease,  with  symptoms  of  impending  or  actual  failure  of 
compensation,  very  commonly  suffer  from  hypothermia.  This  is  a  point  that 
is  not  always  sufficiently  emphasized  ;  not  a  few  cases  of  heart  disease  having 
for  their  normal  temperature  base-line  not  98'4°  F.,  but  97°  F.,  or  even  96°  F. 
It  follows,  that  a  patient  whose  normal  temperature  is  96°  F.  really  has  over  two 
degrees  of  fever  when  his  temperature  reaches  98-4°  F  ;  he  may  develop  fungating 
endocarditis  upon  the  top  of  his  chronic  valve  lesion,  and  yet  his  temperature 
may  not  rise  materially  above  98 '4"  F.  The  fact,  therefore,  that  hypothermia 
is  a  common  feature  in  heart  cases  has  great  importance,  for  it  indicates  the 
necessity  for  regarding  even  slight  rises  above  98 '4°  F.  with  greater  seriousness 
in  them  than  in  other  cases. 

For  the  rest,  hypothermia  is  not  a  symptom  that  helps  much  in  diagnosis, 
and  it  will  suffice  to  indicate  its  chief  causes  which  are  as  follows  : — 

Chronic  debilitating  maladies,  such  as  : — 


Chronic  valvular  heart   disease 
Addison's  disease 
Diabetes  mellitus 
Myxcedema 


Cretinism 
Arteriosclerosis 

Chronic   nephritis^  with  or  without 
urasmia. 


346  HYPOTHERMIA 

Coma  due  to  poisons,  particularly  : — ■ 


Opium 
Alcohol 
Chloral 


Anaesthetics 
Carbolic  acid 
Oxalic  acid. 


Increased  intracranial  pressure  in  certain  cases  of  : — 


Cerebral  abscess 
Cerebral  tumour 
Cerebellar  abscess 


Cerebellar  tumour 
Cerebral  haemorrhage. 


These  same  lesions,  especially  if  they  involve  either  the  pontine  or  the 
subthalamic  regions,  or  if  they  affect  the  corpus  striatum,  may  produce 
pyrexia  or  even  Hyperpyrexia  [q.v.)  instead  of  hypothermia,  so  that  the 
inconstancy  of  the  latter  symptom  detracts  considerably  from  its  value  in 
differential  diagnosis  in  these  cases. 

Convalescence  after  certain  fevers  ;  for  instance  : — 

Pneumonia  |       Typhoid  fever  |       Relapsing  fever. 

Shock  after  severe  injury,  or  after  a  serious  operation. 
Collapse  due  to  loss  of  fluid  from  the  tissues  from  such  conditions  as  : — 
Severe  vomiting,  whatever  the  Peritonitis 

cause  Intestinal  obstruction 

Severe    diarrhoea,    choleraic    or  Haemorrhage, 

otherwise 
Exposure,  especially  in  the  case  of  a  child. 

In  the  morning,  in  cases  of  intermittent  pyrexias  of  the  septic  or  hectic 
types.  It  is  important  that  the  temperature  should  have  been  taken  both 
night  and  morning  before  the  low  figures  for  the  morning  are  assumed  to 
indicate  continued  hypothermia  ;  indeed,  very  low  readings  in  the  earlier  part 
of  the  day,  in  a  patient  whose  malady  is  not  at  once  obvious,  may  arouse 
suspicion  of  a  tuberculous  lesion  which  further  investigation  may  confirm. 

Herbert  French. 
ICTERUS.— (See  Jaundice.) 

IMPOTENCE. — Strictly  speaking,  impotence  includes  any  condition,  whether 
in  the  male  or  in  the  female,  that  prevents  the  performance  of  coitus  ;  by  common 
consent  it  has  come  to  be  restricted  to  inability  on  the  part  of  the  male.  It  is 
not  synonymous  with  sterility  ;  the  latter,  in  the  male,  implies  absence  of  the 
spermatozoa  necessary  to  fecundation  ;  a  man  may  be  sterile  without  being 
impotent,  or  impotent  without  being  sterile  ;  he  may  also  be  both  impotent  and 
sterile. 

There  are  three  main  groups  of  conditions  which  lead  to  impotence,  namely  : — 

I. — Mechanical  defect,  such  as  congenital  or  acquired  malformation  of  the 
penis,  absence  of  the  penis,  carcinoma,  elephantiasis,  and  so  on.  These  need 
not  detain  us,  for  their  diagnosis  is  generally  obvious  on  inspection  ;  one  need 
only  say  that  even  considerable  deformities  of  the  genital  organs  are  by  no 
means  necessarily  associated  with  impotence. 

2. — Entire  Absence  of  Penile  Erections  :  as  the  result  either  of  some  organic 
disease  of  the  nervous  system,  or  of  some  general  constitutional  condition  ;  one 
may  mention  particularly  the  following  : — 


Locomotor  ataxy 

Ataxic  paraplegia 

General  paralysis  of  the  insane 

Primary  spastic  paraplegia 

Disseminated  sclerosis 


Amyotrophic  lateral  sclerosis 
Transverse  softening  of  the  cord 
Plumbism 

Compression    of    the   lower    part 
of  the  cord 


INCONTINENCE     OF    FMCES 


347 


Dementia 

Diabetes  mellitus 

Senility 

Atrophy  of  the  testicles  from  injury 

or   from   severe    orchitis,    gonor- 

rhoeal  or  otherwise 


Pernicious  anaemia 
Malarial  cachexia 
Syphihtic  cachexia 
Cancerous  cachexia 
Phthisical  cachexia 
Exhaustion  from  excesses. 


There  is  little  need  to  discuss  these  further  here,  for,  providing  they  are  borne 
in  mind,  they  will  readily  be  diagnosed  as  the  result  of  a  careful  routine  examina- 
tion of  the  nervous  system,  urine,  lungs,  and  so  on.  One  need  only  add  that 
impotence  may  be  an  early  symptom  in  ataxic  paraplegia,  disseminated  sclerosis, 
and  phthisis,  and  that  the  diagnosis  may  seem  to  be  neurasthenia  only  until  the 
case  has  been  watched. 

3. — Impotence  due  to  Inability  to  obtain  Erections  at  the  right  time. — 
This  is  a  very  common  form  of  the  symptom  ;  the  patients  are  generally  told 
they  are  suffering  from  neurasthenia  ;  and  so  they  are,  of  a  particular  sort. 
This  is  psychical  or  nervous  impotence  :  strong  erections  may  be  present  at 
inopportune  times,  there  may  be  emissions  during  sleep,  and  yet  at  the  very 
moment  when  sexual  intercourse  is  intended  the  erection  is  either  quite  absent 
or  imperfect.  Sometimes,  owing  to  extreme  irritabihty,  emission  occurs  on  so 
little  excitation  that  it  takes  place  before  insertion  is  complete,  the  rigidity 
of  the  penis  relaxing  almost  at  once,  so  that  completion  of  coitus  becomes 
impossible.  Temporary  impotence  of  this  kind  is  not  at  all  uncommon  during 
the  first  few  days  or  weeks  of  married  life,  especially  if  the  wedding  has  been 
preceded  immediately  by  particularly  hard  business  strain  or  mental  overwork 
preparatory  to  the  honeymoon.  The  diagnosis  is  arrived  at  partly  by  the 
history,  partly  by  the  negative  result  of  careful  physical  examination  of  all  the 
systems,  especially  the  nervous  and  pulmonary  ;  early  phthisis  is  often 
accompanied  by  inabilitj^  to  obtain  penile  erection  ;  but  the  final  criterion  is 
the  effect  of  time.  Where  there  is  no  organic  cause  for  the  symptom,  normal 
coitus  will  occur  presently  if  the  patient  ceases  to  be  over-anxious  about  it. 

Herbert  French. 

IMPULSE,  DISPLACED  CARDIAC— (See  Heart  Impulse,  Displaced.) 

INCONTINENCE  OF  F.flECES. — Evacuation  of  the  contents  of  the  rectum 
without  voluntary  control  or  initiation  may  occur  under  several  distinct  con- 
ditions, the  investigation  of  which  may  yield  results  of  great  diagnostic 
importance. 

In  healthy  persons  the  reflex  relaxation  of  the  sphincter  ani  which  is  necessary 
for  defaecation  takes  place  only  at  the  bidding  of  the  will.  Some  healthy  persons 
are  better  able  to  resist  an  imperative  call  to  stool  than  others,  and  it  happens 
occasionally  that  an  individual  who  is  poorly  endowed  with  the  power  of  inhibiting 
the  reflex  may  suffer  from  an  incontinence  of  faeces  when  the  stimulus  evoked 
by  irritating  contents  of  the  bowel  is  overpoweringly  strong.  The  individual 
would  be  conscious  of  the  accident,  which  would  be  of  rare  occurrence,  and 
examination  would  reveal  no  abnormality.     Children  often  suffer  in  this  way. 

Mechanical  incontinence  of  fasces  results  from  injuries  or  diseases  of  the 
rectum  or  perineum,  such  as  carcinoma,  in  which  the  outlet  of  the  bowel  is  no 
longer  guarded  by  an  efficient  sphincter.  Local  inspection  and  digital  examina- 
tion of  the  parts  will  suffice  to  discover  the  cause  of  such  incontinence. 

In  conditions  of  coma  or  partial  unconsciousness,  from  whatever  cause  arising, 
reflex  emptying  of  the  bowel  may  occur  at  intervals,  particularly  if  aperients 
are  administered.  Digital  examination  of  the  rectum  in  such  cases  will  reveal 
a  normal  sphincter  which  closes  on  the  observer's  finger. 


348  INCONTINENCE     OF    FMCES 

Injuries  or  diseases  of  the  central  nervous  system  above  the  sacral  region  of 
the  cord,  if  they  interfere  with  impulses  passing  from  the  cortex  to  the  lumbo- 
sacral enlargement,  but  do  not  cause  serious  sensory  disturbance  in  the  perineal 
area,  lead  to  an  unstable  condition  to  which  the  term  "  precipitancy  of  defaeca- 
tion  "  is  applied.  In  these  circumstances,  the  patient  is  usually  constipated, 
but  the  call  to  stool,  when  it  comes,  spontaneously  or  as  the  result  of  aperient 
medicine,  is  imperative,  and  finds  the  patient  powerless  to  resist  or  delay  the 
act.  The  examination  of  such  a  person  discloses  a  normal  sphincter;  but,  in 
all  probability,  some  degree  of  spastic  paraplegia  with  brisk  tendon  jerks  and 
extensor  plantar  responses  will  be  found,  and  inquiry  will  elicit  the  history  of 
precipitate  micturition.  Moreover,  the  patient  will  be  conscious  of  the  acts  of 
defaecation  and  micturition.  This  association  of  signs  and  symptoms  is  common 
enough  in  cases  of  partial  injury  to  the  spinal  cord,  in  cases  of  old  dorsal  myelitis, 
of  disseminated  sclerosis,  of  syringomyelia,  etc.  Somewhat  similar  "  explosive 
diarrhoea  "  is  also  a  prominent  feature  of  certain  cases  of  carcinomatous  stricture 
of  the  sigmoid  colon. 

With  more  serious  disease  of  the  central  nervous  system  above  the  sacral 
region,  the  impulses  conveying  the  need  for  defsecation  do  not  reach  the  brain, 
and  the  act  takes  place  in  a  reflex  manner  without  the  knowledge  of  the  patient. 
Under  these  circumstances,  paraplegia  with  sensory  disturbance  over  the  sacral 
segmental  areas  will  help  to  localize  the  site  of  the  lesion.  The  tone  of  the 
sphincter  ani  may  be  little  below  normal  or  quite  unimpaired. 

Disease  or  injury  leading  to  destruction  of  the  sacral  cord  or  of  the  cauda 
equina  is  distinguished  by  the  fact  that  incontinence  of  faeces  is  associated 
with  an  insensitive  relaxed  sphincter  and  with  serious  motor,  sensory,  trophic, 
and  reflex  disturbances  in  the  lower  extremities.  When  the  fseces  are  small 
and  fluid  they  escape,  more  or  less  continuously,  through  the  gaping  anal 
aperture.  On  the  other  hand,  they  sometimes  tend  to  accumulate  in  dry  masses 
too  large  to  pass  the  portal  without  assistance.  The  patient  is  unconscious  of 
the  accumulation,  unconscious  of  soiling,  and  insensitive  to  the  exploring  finger. 

It  will  be  understood  from  the  above  statements  that  for  the  purpose  of  dia- 
gnosis it  is  necessary,  in  all  cases  of  fascal  incontinence,  not  only  to  inquire  into 
the  exact  features  of  the  incontinence,  the  presence  or  absence  of  a  call  to  stool, 
the  tendency  to  constipation  or  precipitancy,  the  ability  to  feel  the  passage  of 
motions,  etc.,  but  to  supplement  the  knowledge  gained  in  this  way  by  a  local 
examination,  especially  of  the  sphincter  ani,  and  an  investigation  of  the  motor, 
sensory,  and  reflex  conditions  in  the  lower  extremities.  E.  Farquhar  Buzzard. 

INCONTINENCE   OF  URINE. — (See  Micturition,  Abnormalities  of.) 

INCO-ORDINATION.— (See  Ataxy.) 

INDICANURIA.  —  Indican  in  the  urine  is  mainlj^  due  to  the  formation  of 
indol  in  the  intestine  as  the  result  of  putrefactive  changes  in  the  products  of 
tryptic  digestion  of  proteids.  The  indol  so  formed  is  absorbed  from  the  bowel, 
and  converted  in  the  liver  into  relatively  innocuous  potassium  indoxyl  sulphate, 
or  indican.  This  is  tested  for  by  oxidizing  it  to  indigo,  the  blue  colour  of  which 
is  characteristic.  Almost  any  oxidizing  agent  could  be  utilized  for  the  test, 
but  the  difficulty  is  that  even  slight  excess  of  the  reagent  destroys  the  indigo. 
A  brown  ring  appearing  at  the  junction  of  the  urine  and  the  acid,  when  testing 
for  albumin  with  nitric  acid  that  is  slightly  fuming,  generally  indicates  a  consider- 
able degree  of  indicanuria.  To  be  certain  of  this,  Jaffe's  bleaching  powder  test 
is  usually  employed.  There  are  several  ways  of  using  it.  Fresh  solution  of  cal- 
cium hypochlorite  is  essential.  To  about  20  c.c.  of  urine  add  3  c.c.  of  chloroform 
and  3  c.c.  of  hydrochloric  acid  of  medium  strength  ;   the  colourless  chloroform 


INDIGESTION  349 


sinks  to  the  bottom  of  the  mixture  ;  a  drop  of  the  calcium  hypochlorite 
solution  is  now  added  and  the  test  tube  deliberately  inverted  once  or  twice  ;  a 
second  drop  is  added,  and  so  on,  the  colour  of  the  chloroform  being  watched  the 
while.  If  indican  is  present,  it  becomes  oxidized  to  indigo,  which  is  dissolved  out 
by  the  chloroform  so  that  the  latter  changes  from  colourless  to  blue,  and  the 
depth  of  indigo-blue  colour  in  the  chloroform  affords  a  rough  measure  of  the 
amount  of  indican  in  the  urine.  The  main  precaution  to  be  taken  is,  not  to  add 
the  hypochlorite  solution  too  rapidly,  for  excess  of  it  discharges  the  colour  of 
the  indigo. 

Indican  being  an  ethereal  sulphate,  it  is  present  in  excess  under  the  same 
circumstances  as  an  excess  of  ethereal  sulphates.  At  one  time  it  was  thought 
that  much  useful  clinical  information  as  to  the  condition  of  the  intestines  could 
be  learned  from  its  occurrence.  It  is  true  that  any  circumstances  that  are 
likely  to  increase  the  putrefactive  changes  in  the  proteid  in  the  bowel  are  also 
likely  to  increase  the  amount  of  indican  in  the  urine  ;  marked  indicanuria  is 
generally  found  in  cases  of  chronic  constipation,  intestinal  obstruction,  diarrhoea, 
typhoid  fever,  dilated  stomach,  peritonitis,  acute  enteritis  or  colitis,  appendicitis, 
membranous,  tuberculous  or  ulcerative  colitis,  acute  and  chronic  dysentery, 
cholera,  intussusception,  and  carcinoma  coli.  It  affords  no  assistance  in  dia- 
gnosing between  one  and  another  of  these  various  affections,  however.  Moreover, 
.it  may  occur  when  there  is  decomposition  of  albumin  elsewhere  in  the  body 
than  in  the  bowel ;  for  instance,  in  gangrene  of  the  lung,  gangrenous  empyema, 
putrid  bronchitis,  bronchiectasis,  or  advanced  pulmonary  tuberculosis. 

Recently,  since  the  rage  for  treatment  by  various  lactic-acid-producing  bacilli 
has  set  in,  it  has  been  urged  that  this  treatment  is  most  indicated  when  there 
are  relatively  large  quantities  of  ethereal  sulphates  in  the  urine  ;  the  degree  of 
indicanuria  affords  some  indication  of  the  amount  of  ethereal  sulphates  present, 
so  that,  broadly  speaking,  it  is  said  that  the  occurrence  of  indicanuria  is  a  point 
in  favour  of  treatment  by  lactic-acid  bacilli  and  their  products.  The  difficulty 
is  that  a  considerable  number  of  perfectly  healthy  individuals  pass  quite  large 
quantities  of  indican  in  their  urine.  There  are  some  who  contend  that  even 
these  healthy  persons  are  really  suffering  from  intestinal  putrefactive  changes 
without  knowing  it ;  this  is  possible,  but  from  the  patient's  point  of  view 
it  is  tantamount  to  saying — what  is  indeed  almost  true — that  indicanuria  has 
no  real  diagnostic  or  clinical  significance.  Herbert  French. 

INDIGESTION — It  is  important  to  remember  that  "  indigestion  "  is  a  sym- 
ptom, and  not  a  disease  ;  and  if  a  patient  complains  of  this,  one  should  enquire 
more  particularly  as  to  the  exact  nature  of  the  abnormal  sensations  present,  e.g., 
pain,  fullness,  flatulence,  vomiting,  etc.  The  diagnostic  indications  furnished  by 
each  of  these  symptoms  is  considered  separately  (see  Vomiting  ;  Pain  in  the 
Epigastrium;  Fullness;  Flatulence:  etc.),  but  it  may  be  convenient 
here  to  offer  some  general  guidance  as  to  the  methods  of  arriving  at  a  diagnosis 
in  cases  in  which  "  indigestion,"  in  one  or  other  of  its  aspects,  is  the  chief 
complaint. 

I. — Simulation   of  Dyspepsia   by  other  Conditions. 

At  the  outset  one  should  never  forget  that  a  patient  may  describe  his  case 
as  one  of  indigestion,  although  he  is  not  really  suffering  from  any  primary 
affection  of  the  stomach  at  all ;  and  mistakes  can  only  be  avoided  by  subjecting 
every  such  case  to  a  thorough  physical  examination  of  all  the  organs,  and  not 
confining  it  to  the  abdomen.  If  the  possibility  of  error  is  borne  in  mind,  it  is 
not  usually  difficult  to  avoid  ;  and,  accordingly,  it  will  be  sufficient  to  enumerate 
briefly  the  chief  conditions  to  be  thought  of.     These  are  : — 


350  INDIGESTION 


1.  The  Vomiting  of  Pregnancy. — The  possibility  of  pregnancy  should  always 
be  present  to  the  mind  when  one  is  consulted  by  a  young  woman  who  complains 
of  vomiting  and  indigestion,  and  the  other  signs  and  symptoms  of  pregnancy 
(amenorrhcea,  fullness  of  the  breasts  with  areolar  pigmentation,  enlargement 
of  the  uterus,  etc.)  looked  for. 

2.  Cerebral  Vomiting. — In  children,  particularly,  vomiting  of  cerebral  origin 
may  be  mistaken  for  dyspepsia.  Incipient  meningitis  and  tumour  are  the 
commonest  causes  of  such  vomiting.  The  former,  in  its  earliest  stage,  may  be 
very  difficult  to  diagnose  with  certainty,  but  the  presence  of  signs  of  cerebral 
irritation  (e.g.  photophobia,  squint,  irritability,  headache,  Kernig's  sign,  etc.) 
should  make  one  suspicious  ;  paralyses,  headache,  and  optic  neuritis  point  to 
tumour. 

3.  Uraemia  may  masquerade  as  "indigestion,"  characterized  by  loss  of  appetite 
and  vomiting  (uraBmic  gastritis).  The  presence  of  the  "  ursemic  odour  "  in  the 
breath,  of  high  arterial  tension,  and  of  albuminuria  and  albuminuric  retinitis, 
should  be  looked  for.  It  must  be  remarked,  however,  that  albumin  may  be 
absent  from  the  urine  in  undoubted  cases  of  uraemia. 

4.  Phthisis. — In  cases  of  early  phthisis,  indigestion  may  be  the  chief  sj^mptom 
of  which  the  patient  complains,  nausea  and  vomiting  being  often  present. 
This  can  be  excluded  by  a  careful  examination  of  the  chest  and  of  the  sputum, 
which  should  never  be  omitted,  especially  in  j^oung  subjects. 

5.  The  Gastric  Crises  of  Tabes  are  apt  to  be  mistaken  for  dyspepsia. 
Paroxysmal  vomiting  of  great  violence  is  the  usual  form  they  assume,  and  they 
may  simulate  gastric  ulcer  or  other  organic  affections  of  the  stomach.  If  the 
knee-jerks  be  absent  and  the  pupils  immobile  to  light,  the  diagnosis  is  easy, 
but  it  must  be  remembered  that  gastric  crises  may  occur  early  in  a  case  of  tabes 
before  the  usual  signs  of  disease  of  the  cord  have  manifested  themselves.  One 
should  enquire  in  such  a  case  for  a  history  of  lightning  pains,  and  for  any  trouble 
with  the  bladder.  It  is  said  also  that  the  blood-pressure  is  raised  during  a 
gastric  crisis,  whereas  it  is  lowered  in  all  other  cases  of  acute  vomiting.  This 
may  prove  of  diagnostic  value. 

6.  Nervous  or  Hysterical  Vomiting  may  also  simulate  dyspepsia.  The  diagnosis 
here  must  be  made  largely  by  the  method  of  exclusion.  The  patient  is  usually 
a  woman,  and  there  may  be  other  signs  of  hysteria  present. 

7.  In  Chronic  Intestinal  Obstruction,  the  abdominal  pains,  and  the  vomiting 
which  often  accompany  them,  maybe  described  by  the  patients  as  "indigestion." 
In  such  a  case  there  will  be  distention  of  the  abdomen,  often  with  visible  peris- 
talsis in  the  intestine,  and  a  histor}^  of  gradually  increasing  constipation.  A 
tumour  may  be  felt,  or  examination  with  the  sigmoidoscope  maj^  clear  up  the 
case. 

8.  Cholecystitis  is  very  apt  to  be  diagnosed  as  "  indigestion."  In  the  case  of 
middle-aged  or  elderly  women,  particularly,  who  complain  of  "  wind  "  and 
"  spasms,"  the  possibilitj'-  of  the  presence  of  gall-stones  should  always  be  thought 
of.     (See  Pain  in  the  Epigastrium  ;  and  Pain  in  the  Right  Hypochondrium.) 

g.  Chronic  Appendicitis  may  manifest  itself  chiefly  by  symptoms  which  point 
to  the  stomach  rather  than  to  the  vermiform  appendix  as  the  seat  of  the  disease. 
The  pain  in  such  a  case  may  have  the  character  of  a  typical  "  hunger-pain," 
and  be  relieved  by  alkalis  (see  Pain  in  the  Epigastrium).  In  children  who 
are  brought  to  one  for  "  indigestion,"  with  vague  abdominal  pains,  the  possi- 
bility of  appendicitis  should  be  specially  remembered. 

10.  Angina  Pectoris  in  one  of  its  forms  may  be  accompanied  by  much  flatu- 
lence, which  leads  the  patient  to  consult  his  doctor  for  "indigestion."  The 
occurrence  of  the  symptoms  upon  exertion,  the  characteristic  tendency  of  the  pain 
to  spread  into  the  left  arm,  and  the  frequent  presence  of  a  high  blood-pressure, 


INDIGESTION  351 


are  all  of  diagnostic  value.  Abdominal  angina,  in  which  the  pain  is  seated  in 
the  large  abdominal  blood-vessels,  may  be  more  difficult  to  differentiate.  Flatu- 
lence is  again  a  pronounced  feature  ;  but  there  may  also  be  vomiting,  and  even 
haematemesis.  Thickening  of  the  peripheral  blood-vessels  is  usually  present ; 
and  the  therapeutic  test  is  of  help,  the  pain  being  relieved  by  vasodilators,  and 
especially  by  diuretin. 

11.  Extra-abdominal  causes  of  Pain  are  often  put  down  by  patients  to  indiges- 
tion. Examples  of  these  are  pleurisy,  spinal  caries,  and  abdominal  aneurysm. 
(See  Pain  in  the  Epigastrium.) 

12.  Eructatio  Nervosa,  due  to  air- swallowing,  is  also  usually  described  as 
indigestion.     For  the  method  of  diagnosing  it,  see  Flatulence. 

II. — Functional  versus  Organic  Dyspepsia. 

Having  excluded  aU  these  possible  causes  of  error,  one  may  conclude  that 
one  has  to  deal  with  a  case  of  either  organic  or  functional  disease  in  the  stomach 
itself.  If  vomiting,  loss  of  flesh,  or  severe  prin  be  prominent  symptoms,  the 
disease  is  probably  organic  ;  if  these  be  absent,  and  the  affection  has  persisted 
for  some  time,  one  has  most  likely  to  do  with  a  functional  disorder. 

III. — Differential  Diagnosis  of  Organic  Dyspepsias. 

The  chief  organic  diseases  which  have  to  be  thought  of  are  :  (i)  Cancer, 
(2)  Ulcer,  (3)  Gastritis,  (4)  Obstructive  dilatation.  The  differential  diagnosis 
of  these  may  now  be  briefly  considered. 

I.  Career. — A  malignant  growth  in  the  stomach  may  be  situated  either  at 
the  cardiac  orifice,  in  the  body,  or  at  the  pylorus.  In  the  first  of  these  situations 
it  will  produce  difficulty  in  swallowing  (see  Dysphagia).  If  at  the  pylorus, 
it  will  result  in  dilatation  of  the  stomach  (see  below).  Growths  in  the  body 
are  those  which  are  most  difficult  to  diagnose. 

(a).  A  history  of  "indigestion  "  beginning  abruptly  in  a  patient  (oftenest  a 
man)  above  the  age  of  forty,  and  which  does  not  speedily  yield  to  simple  treat- 
ment, is  very  suspicious.  On  the  other  hand,  it  must  be  remembered  that  in  a 
considerable  number  of  cases  the  growth  starts  in  an  old  ulcer,  so  that  a  history 
pointing  to  this  may  also  be  in  favour  of  carcinoma. 

(6).  Steady  loss  of  weight,  and  the  early  appearance  of  anaemia,  point  to 
malignant  growth  ;  but,  on  the  other  hand,  the  absence  of  these  signs,  and 
even  a  temporary  gain  in  weight  under  treatment,  by  no  means  exclude  it. 

(c).  Loss  of  appetite,  and  especially  a  disinclination  for  meat,  are  usually 
early  symptoms.  Nausea  and  vomiting  supervene  later,  but  are  rarely  absent 
altogether.     Pain  may  be  present  early,  and  is  often  more  or  less  constant. 

{d).  A  steady  diminution  in  the  amount  of  h3-drochloric  acid  in  the  gastric 
juice,  with  the  presence  of  lactic  acid  and  of  Oppler-Boas  baciUi  in  the  gastric 
contents,  is  a  combination  pointing  strongly  to  carcinoma. 

It  is  therefore  upon  a  combination  of  these  symptoms  and  signs  that  the 
diagnosis  must  be  based  in  the  early  stage  (when  it  is  most  important  to  make 
it).  Later,  a  tumour  may  be  felt  below  the  left  costal  margin,  or  in  the  epigas- 
trium ;  enlarged  glands  may  appear  above  the  left  clavicle,  although  they  are 
exceptional  ;  and  there  may  be  signs  of  secondary  growths  in  the  liver,  or  at 
the  umbilicus.  When  ulceration  has  supervened,  traces  of  blood  may  be  found 
in  the  gastric  contents,  and  occult  blood  in  the  stools.      (See  page  197.) 

In  some  cases  of  carcinoma  of  the  body  of  the  stomach,  pronounced  anaemia 
is  one  of  the  earliest  and  most  striking  symptoms.  Such  cases  have  to  be 
diagnosed  from  pernicious  anaemia.  A  blood-count  will  usually  suffice  to 
distinguish   them,   for   in    gastric    carcinoma    the   red    cells    are   rarely   below 


352  INDIGESTION 


2,000,000  per  cubic  mm.,  -whereas  in  pernicious  anaemia  they  go  much  lower 
than  that ;  in  pernicious  ansemia,  also,  the  colour-index  is  about  i  or  above  it, 
in  carcinoma  it  is  less  than  i.  Megaloblasts  are  found  in  the  film  in  pernicious 
anaemia,  but  not  in  carcinoma. 

In  spite  of  all  that  has  been  said  above,  the  early  diagnosis  of  carcinoma  of 
the  stomach  is  a  matter  of  great  dif&cultj"  ;  and  it  may  be  justifiable  to  resort 
to  an  exploratory  operation  in  a  suspicious  case  which  does  not  clear  up  after 
a  few  weeks'  treatment. 

2.  Ulcer. — The  characteristic  symptom  of  ulcer  is  pain,  which  comes  on  after 
food,  and  is  reheved  by  vomiting,  which  is  usually  though  not  invariably 
present.     Haematemesis  is  strongly  confirmatory^,  but  is  often  absent. 

The  chief  sign  of  ulcer  is  a  localized  spot  of  tenderness  on  deep  pressure.  (See 
also  Pain  in  the  Epigastrium  ;   and  Tenderness  in  the  Epigastrium.) 

3.  Gastritis. — -Chronic  "  gastric  catarrh "  is  certainly  diagnosed  oftener 
than  it  should  be,  the  majority  of  cases  so  described  being  really  examples  of 
functional  dyspepsia.  The  symptoms  are  loss  of  appetite,  fullness  and  weight 
in  the  epigastrium,  depending  greatly  upon  the  kind  of  food  taken  ;  pain  is  not  a 
feature  of  gastritis  ;  nausea  is  common,  and  vomiting  may  occur  but  is  not 
usually  a  prominent  s^-mptom.  There  is  no  characteristic  physical  sign,  and 
a  diagnosis  cannot  be  made  with  certainty  without  the  use  of  the  stomach  tube. 
This  shows  :  (a)  Diminished  total  acidity,  or  even  complete  absence  of  gastric 
juice  ;  (b)  Excess  of  mucus  in  the  contents,  or  the  presence  of  mucus  on  washing 
out  the  fasting  stomach. 

Having  determined  the  presence  of  gastritis,  one  has  to  settle  whether  it  is 
primarj'  or  secondary.  Secondary  gastritis  may  occur  :  (a)  AMiere  there  is 
disease  of  the  heart,  causing  back-pressure  ;  (6)  In  cirrhosis  of  the  liver  ;  (c)  In 
chronic  renal  disease.  If  aU  of  these  can  be  excluded,  primary  gastritis  may  be 
diagnosed,  and  the  chief  causes  of  the  latter  looked  for.  These  are  :  (a)  Defective 
or  carious  teeth,  and  "  oral  sepsis  ;  "  (&)  Abuse  of  alcohol  or  tobacco,  or  the 
taking  of  irritating  or  "indigestible"  articles  of  food. 

4.  Dilatation. — One  has  to  determine  the  presence  of  dilatation,  and  then  to 
discover  its  cause. 

The  presence  of  dilatation  is  determined  :  (a)  By  showing  that  the  stomach 
is  enlarged  ;   and  (b)  By  proving  the  occurrence  of  stagnation  of  the  contents. 

[a).  Enlargement  of  the  stomach  may  be  inferred  when,  by  percussion,  the 
greater  curvature  is  found  to  reach  below  the  level  of  the  umbilicus,  the  lesser 
curvature  being  in  its  normal  position.  In  order  to  facilitate  percussion  it 
may  be  necessary-  to  inflate  the  stomach,  by  making  the  patient  swallow  90  gr. 
of  tartaric  acid,  followed  by  120  gr.  of  bicarbonate  of  soda. 

Examination  bv  the  ;i^-rays  after  a  bismuth  meal  is  of  help  in  obscure  cases 
{Fig.  105). 

The  presence  of  splashing  is  not  a  certain  sign  of  dilatation,  unless  it  be  present 
some  hours  after  a  meal. 

ip).  The  occurrence  of  stagnation  of  contents  is  proved  by  giving  the  patient 
an  evening  meal,  preferably  containing  some  easily  recognizable  food,  e.g., 
currants,  and  washing  out  next  morning.  If  food  residues  are  present  in  the 
washings,  stagnation  may  be  inferred. 

The  cause  of  dilatation  may  be  either  [a)  Some  obstruction  at  the  pjdorus  ; 
or  (6)   Primary  atony  of  the  stomach  wall. 

In  distinguishing  between  these,  the  historj-  ma}'  help.  Thus  the  occurrence 
in  the  past  of  symptoms  of  ulcer  points  to  a  cicatricial  stenosis  of  the  pjdorus. 
If  visible  peristaltic  waves  are  seen,  one  maj'  be  sure  of  the  existence  of  an  obstruc- 
tion. These  can  sDmetimes  be  elicited  b}'  massaging  the  stomach,  or  by  flicking 
the  surface  of  the  abdomen  with  a  wet  towel.     The  presence  of  actual  stagnation 


INDIGESTION 


3.53 


of  the  contents  is  also  strongly  in  favour  of  obstruction,  as  this  rarely,  if  ever, 
occurs  in  cases  of  atonic  dilatation.  Copious  vomiting  also  points  to  obstruction, 
as  it  is  exceptional  to  meet  with  this  symptom  in  atony. 

Assuming  that  obstructive  dilatation  has  been  diagnosed,  one  has  next  to 
determine  its  cause.  Here  one  has  to  distinguish  between  benign  and  malignant 
obsiniciion.  The  existence  of  a  history,  or  signs  and  symptoms  of  ulcer  (see 
above),  point  to  the  former  ;  the  general  symptoms  of  carcinoma,  to  the  latter. 
A  tumour  may  be  felt  in  either  case.  Examination  of  the  stomach  contents 
also  helps  in  the  differential  diagnosis.  The  presence  of  abundance  of  free  HCl, 
with  sarcinae  and  yeasts,  points  to  benign  stenosis  ;  diminution  or  absence  of 
HCl,  with  the  presence  of  lactic  acid  and  Oppler-Boas  bacilli,  to  malignancy. 

One  has  further  to  distinguish  dilatation  from  :  {a)  Gastroptosis  ;  and 
(b)    Hour-glass  stomach. 

{a).  In  gastroptosis,  percussion  (if  necessary  after  inflation)  will  show  that 
the  lesser  curvature  is  displaced 
downwards,  as  well  as  the  greater ; 
but  the  normal  distance  between 
the  two  curvatures — about  four 
inches — is  preserved. 

In  the  great  majority  of  cases 
of  gastroptosis  the  right  kidney 
is  more  or  less  freely  movable, 
and  this  affords  confirmatory 
evidence.  The  ;i;-rays  may  also 
be  of  help  {Fig.  105). 

{b).  Hour-glass  stomach  may  be 
diagnosed  by  the  following  signs: — 

(i).  If  the  stomach  be  washed 
out  with  a  known  quantity  of 
fluid,  e.g.  30  oz.,  it  will  be  found 
that  some  has  been  lost,  e.g.  6  oz., 
when  the  return  fluid  is  measured. 
Some  of  the  fluid  seems  to  dis- 
appear, in  fact,  as  if  it  had  flowed 
through  a  hole. 

(ii).  If  the  stomach  be  washed 
clean,  and  the  tube  passed  a  few 
minutes  later,  several  ounces  of 
fermenting  liquid  may  be  obtained, 
which  have  escaped  from  the 
pyloric  pouch. 

(iii) .  If  the  stomach  be  drained  apparently  dry,  a  splash  can  still  be  obtained 
over  the  pyloric  end  ("  paradoxical  dilatation  "). 

(iv).  If  the  stomach  resonance  be  carefully  percussed  out,  and  it  be  then 
inflated  with  tartaric  acid  and  soda,  as  described  above,  and  then  again  percussed, 
it  will  be  found  that  a  great  increase  in  resonance  has  occurred  at  the  cardiac 
end  only.  If  the  abdomen  be  watched  for  a  little,  the  pyloric  pouch  may  some- 
times be  seen  to  fill  gradually  and  become  prominent.  A  loud  gushing  sound 
can  also  be  distinguished  on  listening  with  the  stethoscope  over  the  site  of  the 
opening  between  the  two  pouches. 

IV. — Differential   Diagnosis  of  Functional  Dyspepsias. 

Assuming  that  all  the  above  forms  of  organic  disease  can  be  excluded,  one 
may  conclude  that  the  case  is  one  of  functional  dyspepsia. 

D  2^ 


/^7!^.  105. — Skiagram  showing  Ujl-  IjiMUuth  shadow  of 
a  dropped  and  dilated  stomach,  the  patient  being  in  the 
vertical  position.  C,  crest  of  le(t  ilium  ;  F,  finidus  of 
stomach  ;  p,  pylorus  ;  R,  twelfth  left  rib  ;  V,  vertebral 
column. — Bj>  D?-.  A.  C.  Jordan. 


354  INDIGESTION 


The  next  task  is  to  determine  what  particular  variety  of  functional  disorder 
one  has  to  deal  with.  In  attempting  to  do  this,  one  is  met  at  the  outset  bj^  the 
difficulty  of  classifying  functional  disorders  of  the  stomach. 

Three  forms  of  classification  may  be  adopted  :  (i)  Physiological,  (2)  Clinical, 
(3)   Etiological. 

1.  Physiological  Classification. — In  this  classification,  cases  of  functional 
dyspepsia  are  arranged  according  to  the  particular  function  or  functions  affected, 
thus : — 

(a).  Affections  of  secretion  : — 

(i)   Excess  =  Hypersecretion  and  hyperchlorhydria. 
(ii)   Defect  =  Achylia  and  hypochlorhj^dria. 
(b).  Affections  of  motility  : — 

(i)   Excess  =  Pyloric  spasm, 
(ii)   Defect  =^  Atony,  or  impaired  motility, 
(c).  Affections  of  sensation  : — 

Excess  =  Hypersesthesia  or  gastralgia. 
Any  of  these  may  be  present  alone,  or  two  or  more  may  exist  in  conjunction 
The  diagnosis  of  affections  of  secretion  and  motility  can  only  be  made  by  the 
aid  of  the  stomach  tube  (see  p.  355). 

For  the  diagnosis  of  hyperaesthesia  (gastralgia)  see  Pain  in  the  Epigastrium. 
The  above  is  undoubtedly  the  most  scientific  method  of  making  a  differential 
diagnosis  in  cases  of  functional  dyspepsia,  but  it  has  the  inconvenience  of  neces- 
sitating the  use  of  test  meals. 

2.  Clinical  Classification. — Clinically,  cases  of  functional  dyspepsia  may  be 
classified  into  certain  rough  groups  according  to  their  symptoms.     Thus  : — 

(a) .  Hypersthenic  dyspepsia,  which  is  probably  due  to  a  combination  of  hyper- 
secretion and  hyperaesthesia.  The  patient  is  usually  a  young  man,  otherwise 
healthy  ;  and  the  chief  symptom  is  pain  during  the  late  period  of  digestion  (see 
Pain  in  the  Epigastrium). 

(b).  Asthenic  dyspepsia. — This  is  due  to  impaired  motility  (atony),  with  or 
without  some  disorder  of  secretion.  The  patient  may  be  of  either  sex,  and  of 
any  age,  and  the  chief  symptoms  are  Flatulence  [q.v.)  and  Fullness  [q-v.).  It 
is  often  present  along  with  gastroptosis  (especially  in  women)  ;  and  there  may 
be  atonic  dilatation  of  the  stomach  (see  above) . 

(c).  Acid  dyspepsia. — This  is  an  ill-defined  group,  in  which  the  chief  symptom 
is  a  sensation  of  acidity,  or  the  presence  of  acid  eructations.  Some  cases  are 
really  examples  of  hyperchlorhydria,  with  or  without  the  presence  of  gastritis. 
In  others,  the  cause  is  the  production  of  organic  acids  by  fermentation.  Dia- 
gnosis can  only  be  made  by  aid  of  the  stomach  tube. 

Other  clinical  forms  of  dyspepsia  are  also  described,  e.g.,  "senile"  dj'spepsia 
(essentially  a  hypochylia),  "  gouty  "  dyspepsia  (the  same  as  the  "  acid  "  form), 
"  flatulent  "  dyspepsia  (usually  due  to  defective  motility),  and  others  ;  but  the 
use  of  such  terms  is  inaccurate,  and  should  be  avoided  as  far  as  possible. 

3.  Etiological  Classification, — Instead  of  attempting  to  distinguish  different 
forms  of  functional  dyspepsia,  one  can  regard  the  latter  as  an  aggregation  of 
symptoms  of  gastric  disorder  excited  by  different  causes,  and  classify  cases 
according  to  the  particular  exciting  cause  at  work.  This  method  is  simple  and 
convenient,  and  is  also  useful  for  purposes  of  treatment.  Adopting  it,  one  may 
say  that  functional  dyspepsia  may  be  induced  by  : — 

{a).  Dietetic  causes,  e.g.,  unsuitable  food,  hasty  meals,  the  tbuse  of  alcohol, 
tobacco,  etc. 

{b).  Physical  causes,  e.g.,  imperfect  chewing,  defective  teeth,  oral  sepsis,  over- 
fatigue, deficient  exercise,  etc. 

(c).  Mental  causes,  e.g.,  over- work,  a  studious  life,  etc. 


IXDIGESTION  355 


{d).  Emotional  causes,  e.g.,  shock,  worry,  etc. 

Anv  of  the  above  methods  is  useful,  the  essential  point  being  that  a  classifica- 
tion of  some  sort  should  be  adopted.  Probably  a  combination  of  the  first  and 
third  methods,  which  take  into  account  both  the  particular  disorder  which  is 
present,  as  well  as  the  cause  which  has  brought  it  about,  will  lead  to  the  best 
treatment. 

APPENDIX. 
^Methods  of  Ex.a.mining  the  Stomach. 

The  following  is  a  brief  account  of  some  special  methods  employed  in  examining  the 
stomach,  which  are  capable  of  being  carried  out  in  ordinary  practice  : — 

1.  Determination  of  size. — This  is  done  by  light  percussion,  or  by  percussion-ausculta- 
tion, with  or  without  pre\'ious  inflation.  The  position  of  the  lesser  and  greater  curvatures 
and  of  the  fundus  must  be  determined.  Inflation  is  performed  either  :  (a)  Through 
a  stomach  tube  connected  with  a  Higginson's  s\T:inge  :  or  (b)  By  making  the  patient 
swallow  go  gr.  of  tartaric  acid  dissolved  in  three  ounces  of  water,  followed  by  120  gr. 
of  bicarbonate  of  soda.  The  two  halves  of  a  seidlitz  powder  may  also  be  employed.  A 
considerable  degree  of  distention  can  also  be  brought  about  if  a  tumblerful  of  soda 
water  is  drunk,  and  the  patient  instructed  to  retain  the  gas  in  the  stomach  as  long  as 
possible. 

2.  Investigation  of  the  contents. — A  test  meal,  consisting  of  two  slices  of  dry  toast 
and  two  cups  of  tea  with  a  little  milk,  is  given  in  the  morning,  and  the  tube  passed  an 
hour  later.  The  tube  should  have  a  solid  end  and  one  bevelled  lateral  eye  close  to  it. 
The  sample  drawn  off  should  be  investigated  as  regards  : — 

(a).  Quantity. — Avery  small  result  containing  little  fluid  indicates  diminished  secretion 
(achyUa)  ;   an  abundant  and  very  liquid  yield  indicates  diminished  motility. 

ib).  Physical  characters. — The  presence  of  large  pieces  of  but  slightly  altered  food 
indicates  defecti\"e  secretion  and  digestion  ;  a  large  amount  of  liquid  with  a  granular 
deposit  shows  hypersecretion.  A  very  sour  odour  reveals  the  presence  of  organic  acids. 
\'iscidity  of  the  contents,  so  that  they  filter  slowly,  is  characteristic  of  the  presence  of 
mucus  in  excess. 
(c).  Acidity. 

(i)  Test  for  free  HCl. — Congo-red  paper  is  turned  blue,  methyl-orange  paper 
red,  if  free  HCl  be  present.  The  depth  of  colour  indicates  approximately  the 
amount  of  free  acid. 

(ii)    Total  Aciditv. — Ten  c.c.  of  the  filtered  contents  are  titrated  with  --  caustic 

10 

soda   solution,  two    or   three  drops  of   phenolphthalein    solution   being  used   as 

an  indicator.     A  pink  tinge  appears  as  soon  as  the  acidity  has  been  neutralized. 

The  result  is  expressed  in  terms  of  the  amount  of  caustic  soda  solution  required 

to  neutralize  100  c.c.  of  the  gastric  contents:  e.g.,  if  6  c.c.  neutralize  10  of  the 

contents,  then  the  acidity  is  60.     The  normal  acidity  is  between  40  and  70. 

(iii).  Organic  acids  need  only  be  tested  for  if  free  HCl  is  absent.     A  sour  odour 

of    the    contents  indicates  their  presence  ;    acetic  acid  and  butyric  acid   can   be 

recognized   by   the    odour  of  vinegar   or   rancidity   respectively  ;    lactic   acid  by 

adding  a  few  drops  of  the  contents    to  some    Ufelmann's  reagent  (equal  parts 

of  1-20  carbolic  and  weak  liq.  ferri  perchlor.)  in  a  test  tube.     A  bright  yellow 

colour  is  produced  if  the  acid  be  present. 

(d).  Ferments. — Rennin  can  be    tested  for  by  neutralizing  some  of  the  contents,  and 

trying  whether  the  addition  of  a  few  drops  to  a  Httle  milk  results  in  coagulation  when 

kept  warm  for  twenty  minutes. 

There  is  no  convenient    test   for   pepsin,  but  its  absence  may  usually  be  inferred  if 

there  is  no  rennin  present. 

(e).  Microscopical  characters. — Films  are  made  from  some  of  the  deposit,  and  stained 

with  dilute  gentian  violet.      Oppler-Boas  bacilli,  yeasts,  and  sarcinse  [Fig.  q2,   p.  267) 

should  be  looked  for.      The  first  occur  specially  in  cases  of  carcinoma  :    the  two  last 

in  benign  stenosis  of  the  pylorus. 

3.  Determination  of  motility.- — Impaired  motility  is  shown  by  the  presence  of  food 
residues  in  any  quantity  (say  about  4  ounces)  six-and-a-half  hours  after  an  ordinary 
dinner.  In  order  to  prove  the  presence  of  stagnation,  a  light  meal,  preferably  containing 
some  easily  recognized  food  (e.g.  currants)  should  be  given  in  the  evening,  and  the 
stomach  washed  out  next  morning.  If  food  be  found  in  the  washings,  stagnation  exists. 
If  there  be  no  food,  but  if  several  ounces  of  greenish  acid  fluid  are  obtained,  hyper- 
secretion is  present  ;   flakes  of  mucus  may  be  found  in  the  washings  in  gastritis. 

Robert  Hutchison. 
INEQUALITY  OF  THE  PULSES.— (See  Pulses,  Unequal.) 


356  INSOMNIA 


INEQUALITY  OF  THE  PUPILS.— (See  Pupil,  Abnormalities  of  the.) 

INSOMNIA  means  inability  to  obtain  the  normal  amount  of  sleep.  It 
includes  sleeplessness  and  broken  or  restless  sleep,  and  admits  of  no  closer 
definition  because  the  normal  amount  of  sleep  varies  so  widely  with  age,  habit, 
and  in  adults,  also  with  idiosyncrasy.  Thus,  out  of  the  twenty-four  hours,  an 
infant  at  one  month  will  sleep  for  twenty-one,  at  six  months  for  eighteen,  at 
twelve  months  for  fifteen  hours.  A  child  four  years  old  needs  twelve  hours' 
sleep,  the  schoolboy  of  twelve  needs  ten,  the  public-school  man  should  have 
nine.  The  average  hours  of  sleep  in  adult  life  are  said  to  be  eight  for  women, 
seven  for  men.  But  idiosyncrasy  may  cut  down  the  hours  necessary  in  certain 
people  to  no  more  than  three  or  four,  for  long  periods  and  without  any  impair- 
ment of  health  or  the  power  to  work.  Habit  may  train  neglected  children 
or  overworked  labourers  and  servants  to  get  on  with  short  hours  of  rest  and 
interrupted  sleep  that  would  speedily  make  an  ordinary  person  ill.  Insomnia 
is  a  symptom  indicating  that  something  is  amiss,  not  a  disease  per  se.  It  occurs 
in  a  great  many  acute  and  chronic  disorders,  but  in  the  majority  of  cases  it  is 
dependent  upon  functional  disturbances,  faulty  habits  or  hygiene,  an  ill-arranged 
regimen,  and  not  upon  organic  disease.  It  is  to  be  diagnosed  whenever  lack  of 
sleep  causes,  or  is  associated  with,  loss  of  health.  It  should  be  remembered 
that  most  patients  habitually  underestimate  the  amount  of  sleep  they  get, 
without  any  intention  to  deceive  ;  and  are  apt  to  complain  that  they  have  been 
awake  all  night,  when  in  point  of  fact  they  have  had  many  hours  of  sleep. 

The  chief  causes  of  insomnia  are  tabulated  below  in  three  main  groups, 
etiologically  : — 

1.  Faulty  Habits  or  Hygiene,  such  as — 

Some  sudden  change  in  the  routine  of  the  day  or  evening 

Exposure  to  undue  excitement  or  bad  atmosphere  before  retiring 

The  use  of  a  noisy,  airless,  or  overheated  bedroom 

The  use  of  too  many  bedclothes,   or  too   few 

Going  to  bed  on  too  full  or  too  empty  a  stomach 

Drinking  strong  tea  or  coffee  too  late  in  the  day 

The    over-use    of    tobacco. 

2.  Acute  Disorders,  such  as — 

Pain  due  to  any  cause,    inflammation,    injury,   etc. 

The  early  stages  of  fevers 

Acute  insanity,  meningitis,  delirium  tremens,  acute  nrania,  etc. 

Acute  nervous  exhaustion 

Gastro-intestinal  disorders,  dyspepsia,  constipation,  etc. 

3.  Clironic  Disorders,  such  as — 

Chronic   insanity   of   all    sorts,    neurasthenia 

Cerebral  syphilis,  intracranial  tumour 

Disease  of  the  heart,  valvular  or  myocardial 

Disease  of  the  lungs,  emphysema,  bronchitis,  asthma,  etc. 

Diseases  of  the   liver   or   kidneys 

Arteriosclerosis   and   high   blood-pressure,    hyperpiesis 

Anaemia,  primary  or  secondary 

Hysteria  and  malingering. 

The  closer  investigation  of  the  causes  of  insomnia  maj^  best  be  done  by  taking 
the  age  of  the  patient  into  consideration. 

Sleeplessness  in  an  Infant  is  most  often  due  to  indigestion,  hunger,  or  bodily 
discomfort  ;  in  rare  cases  it  is  evidence  of  nervous  instability  or  ear  or  brain 
disease.      Enquiry  into  the  methods  and  hours  of  feeding  the  infant  will  often 


INSOMNIA  357 


show  where  the  fault  lies  :  the  food  may  be  improper,  the  hours  of  feeding  too 
frequent,  the  practice  of  giving  the  bottle  or  breast  whenever  the  infant  cries 
may  have  been  followed,  or  the  habit  of  allowing  it  a  dummy  rubber  teat  to 
suck  at  all  hours.  The  artificially  fed  infant  is  likely  to  suffer  from  indigestion 
and  colic,  with  screaming,  drawing  up  of  the  legs,  and  rigid  abdomen  ;  the  breast- 
fed infant  will  more  often  fail  to  sleep  because  it  is  hungry.  In  many  cases  the 
infant  fails  to  sleep  because  it  is  in  discomfort  from  a  wet  napkin  or  bed,  from 
having  too  many  bed-clothes  and  being  overheated,  or  from  being  cold  ;  the 
bedroom  may  be  too  light  or  too  noisy.  In  not  a  few  instances  it  fails  to  sleep 
well  for  want  of  proper  training  ;  if  it  finds  that  it  will  be  fed  or  rocked  in  the 
arms  or  cradle  as  often  and  as  long  as  it  sees  fit  to  cry,  one  can  hardly  blame  it 
for  failing  to  realize  that  insomnia  is  objectionable.  When  the  infant  is  six 
months  old  or  more,  rickets  and  the  local  irritation  of  teething  are  common 
additional  causes  of  insomnia.  In  a  minority  of  cases  the  sleeplessness  is  due 
to  the  onset  or  presence  of  acute  or  chronic  disease,  or  to  the  indeterminate 
condition  described  as  nervousness  or  nervous  instability,  or  to  definite  mental 
deficiency  ;  careful  examination  of  the  infant  and  its  previous  history  should 
suffice  to  clear  up  the  diagnosis  in  these  cases.  As  the  treatment  of  sleeplessness 
in  an  infant  hardly  ever  demands  the  use  of  sedative  drugs,  but  consists  mainly 
in  rectifying  errors  of  diet,  hygiene,  or  up-bringing,  it  is  obvious  that  the  medical 
man  must  be  prepared  to  go  deeply  into  these  domestic  rather  than  medical 
matters. 

Sleeplessness  in  Children  is  largely  due  to  causes  similar  to  those  described 
above.  In  a  great  many  cases  it  is  due  to  indigestion,  with  which  may  be 
associated  flatulence,  teething,  and  the  presence  of  worms  in  the  intestine  ;  tea- 
drinking  is  a  common  cause  of  chronic  dyspepsia,  nervous  irritability,  and 
disturbed  sleep,  in  children  as  well  as  in  adults.  Many  children  sleep  ill  because 
they  are  put  to  bed  within  an  hour  or  so  of  a  late  tea  or  early  supper  of  too  solid 
a  character.  In  other  instances,  the  child  sleeps  badly  for  want  of  fresh  air  in 
the  bedroom,  waking  late  on  the  following  morning  in  a  headachy  and  irritable 
condition  and  with  little  appetite  for  breakfast.  Not  a  few  ill-fed  or  ansemic 
school-children  sleep  badly  during  term-time  because  they  are  over-worked  at 
school,  or  worried  about  their  lessons  or  their  place  in  the  class  without  being 
actually  overworked  ;  in  such  cases  the  distraction  afforded  by  games  is  likely 
to  be  more  successful  in  effecting  a  cure  than  treatment  by  rest.  It  is  only  in 
the  minority  of  instances  that  the  insomnia  is  due  to  disease,  whether  acute  or 
chronic,  such  as  adenoids,  enlarged  tonsils,  or  organic  disease  of  the  various 
viscera.  A  few  special  forms  of  insomnia  seen  in  childhood  caU  for  brief  mention. 
In  early  hip-disease  it  may  happen  that  sleep  is  disturbed  by  sudden  starting 
pains  ;  the  child  goes  off  to  sleep,  only  to  be  awakened  almost  at  once  by  sudden 
shooting  pains  in  the  affected  leg  or  hip.  Sleep  is  broken  by  fright  in  night- 
terrors  (see  Nightmares),  in  which  the  child  wakes  up  screaming  and  frightened, 
but  conscious  and  able  to  explain,  so  far  as  excitement  permits,  the  nature  of 
the  fright  ;  indiscretions  in  diet,  or  the  presence  of  adenoids  or  worms,  often 
explain  the  occurrence  of  such  night-terrors.  In  the  rarer  and  more  serious 
form  of  night-terror,  known  as  Pavor  nocturnus,  the  child  awakes,  screaming  and 
frightened,  but  not  fully  conscious,  and  unable  to  recognize  those  around  him. 
There  is  no  recollection  of  the  fright  next  day,  and  in  all  probability  the  pavor 
is  akin  to  epilepsy,  occurring  only  in  children  with  a  bad  family  history  of  nervous 
disease.  It  is  plain  from  what  has  been  said  above  that  the  diagnosis  of  the 
cause  of  sleeplessness  in  a  child  demands  the  scrutiny  of  the  daily  routine, 
diet,  and  sleeping-arrangements,  as  well  as  the  examination  of  the  child  itself. 
Sedative  drugs  are  practically  never  required  for  its  treatment,  except  in  the 
case  of  severe  acute  or  chronic  disease,  and  even  then  should  be  given  but  rarely. 
D  23A 


358  INSOMNIA 


Insomnia  in  Adults,  in  the  majority  of  cases,  is  due  to  faults  of  habit  or  hygiene 
similar  to  those  already  mentioned  in  the  case  of  children  ;  but  it  is  due  to  organic 
disease  of  one  sort  or  another  in  not  a  few  instances,  and  these  will  be  discussed 
later.  The  sleepless  adult  should  devote  much  thought  to  the  economy  and 
arrangement  of  his  bed  and  bedroom,  and  the  hours  he  keeps.  It  is  essential 
that  the  bed  should  be  comfortable — whether  the  mattress  be  hard  or  soft  is  a 
matter  of  taste  ;  many  people  sleep  better  with  a  high  pillow  than  with  a  low, 
and  if  a  high  pillow  is  not  agreeable,  the  same  effect  can  often  be  produced  by 
putting  blocks  two  or  three  inches  high  beneath  the  posts  at  the  head  of  the 
bed.  The  bedclothes  should  be  light  rather  than  heavy  ;  it  is  essential  that 
they  should  be  warm  enough  to  prevent  the  occurrence  of  cold  feet,  a  very 
common  cause  of  sleeplessness.  The  bed  should  not  be  placed  so  that  the 
sleeper  faces  the  light.  A  supply  of  fresh  air  throughout  the  night  is  essential, 
and  is  assured  if  the  room  is  heated  by  an  open  fire  :  stuffiness  and  overheating 
of  the  atmosphere  seem  almost  inseparable  from  heating  by  stoves,  hot  air,  hot 
water,  or  steam,  and  are  common  causes  of  sleeplessness.  The  hj-giene  of  the 
bedroom  having  been  attended  to,  the  habits  of  the  sleepless  patient  should  be 
passed  in  review.  Many  well-to-do  people  sleep  ill  because  they  go  to  bed  too 
soon  after  a  heavy  dinner  ;  a  few  because  they  go  to  bed  hungry.  Not  a  few 
find  that  they  sleep  badly  if  they  take  a  cup  of  coffee  after  dinner,  or  even 
drink  tea  in  the  afternoon  ;  others  sleep  Ul  if  they  indulge  in  brain-work  after 
dinner,  or  attend  exciting  public  meetings,  theatres,  concerts,  and  so  forth. 
It  is  known  that  bodily  and  mental  fatigue  promote  sleep,  and  some  patients 
with  insomnia,  solicit  sleep  and  aggravate  their  condition  by  pushing  fatigue 
to  the  point  of  exhaustion,  forgetting  that  over-fatigue  "often  produces  sleep- 
lessness. The  observance  of  fairly  regular  hours  for  work,  food,  and  sleep  is 
often  neglected  by  busy  men,  and  the  neglect  often  results  in  disturbance  of 
their  sleep.  Sudden  changes  in  the  mode  or  routine  of  daily  life,  or  alterations 
in  the  altitude  or  locality  inhabited,  may  result  in  acute  and  persistent 
insomnia.  It  is  to  the  investigation  of  these  and  similar  irregularities,  trifling 
as  many  of  them  maj'  appear,  that  one  must  look  in  diagnosing  the  cause  of 
insomnia  in  healthy  or  fairly  healthy  patients  ;  its  treatment  will  naturally 
turn  mainly  on  their  correction.  Healthier  habits  of  life  must  be  advised  ; 
the  use  of  sedatives  must  be  prohibited  entirely. 

In  the  case  of  adults  suffering  from  the  most  various  acute  disorders,  slight  or 
severe,  the  occurrence  of  insomnia  is  a  commonplace.  It  passes  off  with  the 
amelioration  of  the  disorder,  and  as  the  patient  is  no  doubt  able  to  give  an 
account  of  himself  and'  his  symptoms,  the  diagnosis  should  not  be  a  matter  of 
great  difficulty. 

But  it  is  often  otherwise  with  adults  suffering  from  insomnia  due  to  chronic 
disease  ;  the  sleeplessness  may  be  one  of  the  earliest  symptoms  of  illness,  or  the 
other  .symptoms  that  are  present  may  have  escaped  the  patient's  notice.  For 
example,  persistent  inability  to  sleep  is  often  a  prominent  and  early  feature  of 
nervous  or  mental  disease — melancholia,  mania,  general  paralysis,  hypochon- 
driasis, neurasthenia,  acute  nervous  exhaustion,  paralysis  agitans,  and  chronic 
alcoholism  may  heie  be  mentioned  ;  in  old  age,  senile  nocturnal  mania  may 
occur  as  a  very  troublesome  form  of  insomnia.  Inability  to  sleep  may  be  marked 
in  cases  of  cerebral  tumour  or  cerebral  syphilis.  Want  of  sleep  throws  a 
great  strain  on  the  nervous  system  generally,  and  so  is  a  prominent  factor  in 
the  production  of  insanity  ;  the  one  aggravates  the  other,  and  a  vicious  circle 
is  established.  In  heart  disease,  insomnia  is  frequently  a  distressing  feature  ;  the 
patient  often  has  to  sleep  propped  up  in  bed  because  of  breathlessness  whenever 
the  recumbent  position  is  adopted,  and  when  he  dees  get  off  to  sleep  he  is  often 
awakened  by  cardiac  palpitation  or  dyspnoea,  Avithin  a  few  minutes.      Restless 


IRRITABILITY  359 

nights  are  passed  and  sleep  is  much  impaired,  even  while  compensation  is  main- 
tained ;  when  compensation  fails  and  the  patient  becomes  bedridden,  the  condi- 
tion is  much  aggravated.  Patients  with  aortic  incompetence  and  much  cardiac 
hypertrophy  may  be  kept  awake  by  the  pulsating  shock  and  noise  of  their  own 
hearts.  Dyspnoea  is  a  common  cause  of  sleeplessness  in  many  diseases  of  the 
lungs,  just  as  it  is  in  severe  heart  disease.  Patients  with  bronchitis,  emphysema, 
spasmodic  asthma,  extensive  pulmonary  adhesions  or  pulmonar^^  tuberculosis, 
and  other  kindred  diseases,  often  pass  restless  nights  because  they  are  awakened 
bv  pulmonar\-  dyspnoea  soon  after  getting  off  to  sleep.  With  these  patients,  as 
with  those  suffering  from  heart  disease,  the  sitting  or  semi-recumbent  position 
at  night  is  often  imperative,  the  reasons  being  that  diaphragmatic  breathing 
is  easiest,  and  the  amplitude  of  the  diaphragmatic  movements  greatest  when  the 
patient  sits,  less  when  he  lies,  and  least  when  he  is  in  the  erect  position,  and 
that  these  patients  come  to  depend  in  the  last  resort  upon  their  diaphragmatic 
respiration.  Sleeplessness  is  frequent  in  cirrhosis  of  the  liver,  being  accompanied 
by  nocturnal  delirium  in  the  acute  and  the  severer  cases  ;  it  may  also  occur  in 
chronic  renal  disease.  It  is  often  a  persistent  and  distressing  feature  of  arterio- 
sclerosis and  high  blood-pressure,  with  hypertrophy  of  the  heart.  The  mechanism 
whereby  this  sleeplessness  is  produced  is  obscure  ;  but  from  the  fact  that  any 
treatment  that  lowers  the  blood-pressure — massage,  hot  baths,  high-frequency 
currents  of  electricity — cures  the  insomnia,  it  may  be  assumed  that  the  high 
arterial  pressure  acts  directly,  preventing  the  establishment  of  the  degree  of 
cerebral  anaemia  that  is  requisite  for  sleep.  But  it  must  be  noted  that  if  insomnia 
results  from  the  supply  of  too  much  blood  to  the  brain,  it  also  results  from  the 
supply  of  too  little  ;  hence  sleeplessness  occurs  in  grave  ancemia,  whether  primary 
or  secondary. 

In  conclusion,  it  may  be  noted  that  in  hysteria,  professions  of  obstinate 
insomnia  may  be  made  that  go  far  beyond  the  observed  facts  ;  and  that  the 
malingerer ,  claiming  not  to  have  slept  at  all  for  days  or  weeks,  may  urge  the 
sound  slumber  he  enjoys  in  hospital  as  an  argument  for  the  prolongation  of 
his  stay.  A.  J.  J  ex-Blake. 

IRIDOPLEGIA. — (See  Pupil,  Abnormalities  of  the.) 

IRRITABILITY. — It  is  not  very  often  that  irritability  can  be  regarded  as 
a  symptom  of  diagnostic  importance.  It  is  a  relative  condition,  varj'ing  in  its 
significance  with  the  individual,  and  more  especially  with  his  age.  Children, 
for  instance,  display  irritability  much  more  readily  than  adults  under  similar 
influences,  owing  to  incomplete  education  of  their  powers  of  control,  and  a  like 
distinction  may  be  drawn  between  different  persons  of  adult  age.  In  children, 
therefore,  varying  degrees  of  irritability  may  be  recognized  under  any  condition 
of  ill-health,  and  as  a  solitary  symptom  it  can  hardly  be  regarded  as  one  of  much 
import.  An  exception  may  perhaps  be  made  in  favour  of  the  steadily-increasing 
irritability  Avhich  is  sometimes  observed  as  a  prodrome  of  meningitis,  and  which 
may  be  sufficiently  remarkable  to  instigate  a  careful  look-out  for  other  early 
signs  of  that  disease,  such  as  vomiting,  headache,  strabismus,  and  head- 
retraction. 

In  regard  to  adults,  the  personal  disposition  is  longer  established  and  better 
recognized,  so  that  definite  alterations  in  temperament,  independent  of  obvious 
cause,  and  clearly  not  of  fleeting  character,  must  always  receive  attention  from 
the  medical  man  to  whose  notice  they  are  brought. 

Here  again  it  must  be  admitted  that  many  chronic  ailments,  especially  those 
which  entail  mental  or  physical  suffering,  may  be  associated  with  increased 
irritabilit}^  in  a  number  of  instances,  without  exciting  special  remark.      On  the 


36o  IRRITABILITY 


other  hand,  there  are  some  constitutional  or  metabolic  disturbances  which  are 
noted  for  the  irritability  to  which  they  may  give  rise.  Diabetes  mellitus  and 
chronic  nephritis  are  common  examples  of  this  kind,  and  the  examination  of  the 
urine  of  patients  in  whom  friends  have  observed,  or  who  may  even  themselves 
complain  of,  irritability,  should  never  be  neglected.  In  such  conditions  as 
jaundice.  Graves'  disease,  and  acromegaly,  other  symptoms  and  signs  are  more 
obvious  and  more  conclusive. 

Irritability  often  forms  part  of  a  neurasthenic  syndrome,  but  in  this  connection 
it  is  as  well  to  remember  that  the  same  symptom  may  be  present  in  the  early 
stages  of  general  paralysis  of  the  insane.  A  careful  investigation  of  other  mental 
changes,  of  the  condition  of  the  reflexes  and  pupils,  and,  if  suspicion  is  aroused, 
a  Wassermann  reaction  test,  should  be  carried  out  before  coming  to  a  definite 
diagnosis.  It  is  hardly  necessary  to  add  that  irritability  may  be  associated 
with  other  depressed  mental  states,  such  as  melancholia  and  epileptic  dementia. 
Finally,  chronic  intoxications,  and  especially  chronic  alcoholism  and  plumbism, 
may  be  responsible  for  great  irritability,  especially  in  the  earlier  hours  of  the  day. 

E.  Farquhar  Buzzard. 

IRRITABILITY  OF  THE  BLADDER. — (See  Micturition,  Abnormalities  of.) 

ITCHING.— (See  Pruritus.) 

JAUNDICE,  —  This  is  the  term  used  to  indicate  the  yellow  or  greenish 
coloration  of  the  skin,  conjunctiva,  mucous  membranes,  and  other  tissues  and 
fluids  of  the  body,  by  bile  pigment.     The  following  are  its  chief  signs  : — 

The  Skin. — The  colour  varies  from  a  light  sulphur  yellow  to  a  deep  orange, 
greenish,  and,  in  some  cases,  dark  olive  tint.  The  greenish  or  dark  olive  shade 
is  only  found  in  severe  cases  of  long  standing,  and  is  due  to  the  conversion  of 
bilirubin  into  biliverdin  and  choletelin  by  oxidation.  Intense  itching  is  often 
produced,  especially  if  the  jaundice  is  the  result  of  obstruction  of  the  bile-ducts  ; 
and  this  sometimes  leads  to  vigorous  scratching  and  the  production  of  scratch - 
m.arks,  blood-crusts,  and  sore  places. 

In  certain  cases,  after  some  time,  little  yellowish-white  or  light  yellowish- 
salmon-coloured  patches  of  soft  smooth  tissue  slightly  raised  above  the  surface 
of  the  surrounding  skin  may  appear  on  the  upper  eyelids  near  the  inner  canthi. 
These  patches  may  spread  until  the  eye  is  entirely  surrounded  by  this  altered 
skin.  A  similar  condition  may  also  occur  on  the  palmar  surface  of  the  hands 
and  fingers,  or  firm  rounded  nodules  varying  in  size  from  ;^  in.  to  \  in.  in 
diameter,  more  or  less  raised  above  the  level  of  the  surrounding  skin,  may 
develop  over  the  elbows,  knees,  or  in  other  places.  The  former  condition  is 
termed  xanthelasma  planum,  and  the  latter  xanthelasma  tuberosum. 

The  Eyes. — The  conjunctivae  are  yellow.  Care  must  be  taken  to  distinguish 
deposits  of  sub-conjunctival  fat  from  actual  coloration.  Occasionally  patients 
suffer  from  yellow  vision  (xanthopsia). 

The  Urine  may  present  almost  any  shade,  from  a  light  saffron-yellow  to 
yellowish-brown,  medium  brown,  dark  mahogany  brown,  greenish-brown,  or 
even  almost  black.  On  looking  across  the  upper  portion  of  the  urine  in  a 
specimen  glass  a  distinct  greenish  tinge  may  be  detected,  and  the  froth  which 
forms  at  the  top  on  shaking  possesses  a  distinct  yellowish  or  greenish  shade. 
It  stains  white  blotting-paper  and  linen  a  bright  yellow. 

As  a  general  rule,  when  jaundice  is  developing,  bile  pigment  can  be  detected 
in  the  urine  before  the  conjunctivae  become  yellow,  and  the  conjunctivae  become 
jaundiced  before  the  skin.  On  the  other  hand,  when  jaundice  is  leaving  a 
patient,  the  bile  pigment  first  disappears  from  the  urine,  whilst  the  skin  remains 
coloured  for  some  time  afterwards.     There  are  certain  special  cases,  indeed, 


JAUNDICE  361 

in  -which  the  skin  and  conjunctivcTc  exhibit  obvious  jaundice,  yet  there  is  no  bile 
pigment  in  the  urine.     This  condition  is  termed  acholuric  jaundice. 

Other  Secretions. — The  sweat  and  milk  of  women  who  are  nursing  may  be 
tinged  yellow.  Pleuritic,  pericardial,  or  peritoneal  effusions  may  be  similarly 
coloured.  The  tears,  saliva,  and  gastro-intestinal  secretions  are  not  affected 
in  this  manner,  nor  are  the  brain,  spinal  cord,  meninges,  or  cerebrospinal  fluid. 

The  Faeces. — In  cases  of  jaundice  due  to  obstruction  of  the  larger  ducts,  the 
iVcces  become  greyish-white  or  clay-coloured  from  lack  of  stercobilin,  and  they 
may  contain  an  excess  of  fat  which  by  decomposition  is  likely  to  give  the 
stools  a  verj'  offensive  smell.     The  bowels  are  usually  constipated. 

It  is  frequently  stated  that  the  pulse  is  apt  to  become  much  slower  than  normal, 
especialh^  in  cases  of  catarrhal  jaundice  without  pyrexia.  It  is,  however,  very 
rare  to  find  these  slow-pulse  cases  clinically  ;  more  often,  although  physiological 
experiments  show  that  bile  salts  tend  to  slow  the  heart  remarkably,  the  pulse- 
rate  is  accelerated,  especially  in  pyrexial  cases. 

Bruising. — There  is  a  marked  tendency'-  to  capillar^'  oozing  and  haemorrhage 
in  certain  cases  ;  this  is  important,  not  only  from  the  point  of  view  of  operations, 
but  also  because  of  the  ready  bruising  of  the  skin  which  might  be  mistaken  for 
evidence  of  violence. 

Cholaemia. — In  cases  of  severe  or  long-continued  jaundice,  cholasmic  symptoms 
ma}'  supervene,  namely,  stupor,  delirium,  convulsions,  coma,  and  very  possibly 
death. 

Jaundice  must  not  be  mistaken  for  other  conditions  which  cause  yellowness 
of  the  skin.  There  should  be  but  little  possibility  of  this,  provided  a  careful 
examination  is  made.  Shght  jaundice  and  pernicious  anaemia  are  perhaps  the 
two  conditions  that  may  most  readily  be  mistaken  for  each  other  ;  in  the  latter, 
however,  the  conjunctivae  are  generally  of  a  pearly  whiteness,  however  y-ellow 
the  skin  may  be  ;  and  if  the  urine  should  be  suspiciously  dark,  its  colour  will 
be  found  to  be  due  to  urobilin,  detected  by  its  spectroscopic  band  between  the 
E  and  F  lines  {Fig.  23,  p.  95),  whilst  tests  for  bile  pigments  would  be  negative. 
In  very  rare  cases  of  pernicious  anaemia  there  may  be  jaundice  also.  Acholuric 
jaundice  cases  are  probably  the  most  difficult  to  be  sure  of,  and  in  some  of 
these  the  diagnosis  becomes  a  matter  of  opinion. 

Having  decided  that  a  patient  is  suffering  from  jaundice,  the  next  step  is 
to  decide  the  cause  of  the  symptom.  The  following  is  a  list  of  the  chief  causes 
of  jaundice  : — 

CAUSES   OF   JAUNDICE. 

I.  Jaundic3  due  to  Obstruction  of  the  larger  Bile-ducts,  especially  of  the 
common  Bile-duct  :  — 

A.  Causes  within  the  Duct  :  — 

Gall  stones  j  !  Hydatid  cysts 

Inspissated  bile  j   Parasites ':  Distomata 

JAscarides. 

B.  Causes  affecting  the  Wall  of  the  Duct : — 

Catarrh    of    the    mucous   mem-         ,  Carcinoma  of  the  duct 

brane  of  the  duct  Cicatrization    following    ulcera- 

Catarrh   of    the   mucous   mem-         i  tion  of  the  duct 

brane    of    the   duodenum   in-         \  Congenital   obliteration   of    the 

volving   and   obstructing   the  duct, 

ampulla  of  ^'ater  ' 

Catarrh  of  the  pancreas  spread- 
ing to  and  involving  the  am- 
pulla of  Vater.  (Chronic  pan- 
creatitis) i 


362 


J  A  UN  DICE 


C.   Causes  compressing  the  Duct  from  outside  or  invading  it  from  outside  : — 


Peritoneal  adhesions 
Enlarged  portal  lymphatic  glands  : 
(a)   Secondary  nialignant 
{b)  Lymphadenomatous 
(c)   Tuberculous 
{d)   Leukaemic 
Tumours  of  the  liver 
,,  ,,         pancreas 

,,  ,,         duodenum 


Tumours  of  the  stomach 
colon 

right  kidney 
suprarenal  capsule 
ovaries 
uterus 
omentum 

Aneurj^sm  of  the  hepatic  artery. 


II.  Jaundice  without  Obstruction  of  the  larger  Bile-ducts  : — 

A.   Causes  associated  with  Disease  of  the  Liver  : — 


Carcinoma 
Cirrhosis 

Abscess    ,^°f,  .^  , 

( Multiple  or  pysemic 

Acute  yellow  atrophy 

B.  Jaundice  in  Acute  Fevers  :^ 
Malaria 

Typhus  I 

Typhoid  fever 

Pyaemia 

Pneumonia  i 

C.  Jaundice  due  to  Poisons  :— 
Phosphorus  I 
Arseniuretted  hydrogen  \ 

D.  Jaundice  due  to  Nervous  Causes  : — 
Mental  emotion  | 

E.  Jaundice  due  to   Unclassified  Causes 
Familial  jaundice  I 
Epidemic  infective  jaundice               | 


Passive   congestion   from    chronic 

heart  failure 
Syphilis 
Active  congestion. 


Weil's  disease 

Yellow  fever 

Relapsing  fever 

And  some  other  tropical  fevers. 


Toluylenediamine 
Snake  poison. 

Concussion. 

Icterus  neonatorum 
Icterus  gravis  of  children. 


THE    DIAGNOSIS. 

When  diagnosing  the  cause  of  jaundice  in  any  given  case,  it  is  of  the  greatest 
importance  to  consider,  not  only  the  degree  of  jaundice,  but  also  the  age  of  the 
patient,  the  history,  and  the  significance  of  any  other  symptoms  which  may  be 
present. 

Very  intense  jaundice  and  clay-coloured  motions  indicate  some  obstruction 
to  the  common  bile  duct,  of  which  the  commonest  causes  are  catarrh,  gall- 
stones, chronic  pancreatitis,  or  carcinoma. 

Jaundice  with  rigors  suggests  :  (i)  Infective  or  suppurative  cholangitis,  with 
or  without  suppurating  gall-bladder  from  gall-stones  or  from  carcinoma;  (2) 
Infective  or  suppurative  pylephlebitis,  especially  after  appendicitis  ;  (3)  Hepatic 
abscess  (single  or  pyaemic). 

Almost  all  the  different  causes  of  jaundice  may  also  cause  pyrexia,  so  that 
without  rigors  the  existence  of  pyrexia  does  not  assist  greatly  in  the  differential 
diagnosis.  That  cirrhosis  of  the  liver  and  carcinoma  of  the  liver  are  both  very 
apt  to  cause  evening  rises  of  temperature  to  as  much  as  100°  F.,  101°  F.,  or 
more,  is  a  fact  that  is  sometimes  overlooked. 

The  absence  of  pyrexia  in  a  jaundice  case  will  serve  to  exclude  such  conditions 


J  A  UN  DICE  363 

as  abscess,  pylephlebitis,  cholangitis,  acute  specific  fevers  such  as  typhoid  or 
Weil's  disease,  and  epidemic  infective  jaundice. 

Jaundice  with  enlargement  of  the  liver  may  occur  in  any  condition  of  obstruc- 
tion to  the  common  bile  duct,  and  in  congestion  of  the  liver,  cirrhosis,  carcinoma, 
syphilis,  abscess,  phosphorus  poisoning. 

Jaundice,  with  a  very  greatly  enlarged  gall-bladder,  especially  persistent 
jaundice  in  a  middle-aged  person,  suggests  carcinoma  of  the  head  of  the  pancreas. 
Gall-stones  seldom  cause  both  jaundice  and  a  large  gall-bladder  at  the  same 
time,  perhaps  because  the  infective  process  that  produces  the  gall-stones  also 
causes  peritoneal  adhesions  about  the  gall-bladder  which  tie  it  down  and  prevent 
it  from  expanding. 

The  diagnosis  is  very  often  almost  obvious.  For  instance,  jaundice  appearing 
in  an  infant  two  or  three  days  after  birth,  and  rapidly  disappearing  again,  is 
almost  physiological  (icterus  neonatorum).  Transient  jaundice  in  an  otherwise 
healthy  boy  or  girl  will  almost  certainly  be  catarrhal.  Jaundice  following  an 
acute  attack  of  colic  at  once  suggests  a  gall-stone.  Recurrent  attacks,  extending 
over  years,  are  not  likely  to  be  due  to  malignant  disease,  whereas  persistent 
and  deepening  jaundice  without  intense  pain  in  a  person  over  40  years  of  age^ 
who  has  been  wasting  and  has  only  been  ill  a  month  or  two,  suggests  malignant 
disease.  It  often  happens  that  the  primary  growth,  in  cases  of  secondary 
malignant  jaundice,  is  not  at  once  obvious,  and  it  is  important  not  to  omit  a 
rectal  examination  lest  there  be  a  rectal  carcinoma  that  is  itself  causing  no 
symptoms. 

A  few  words  may  now  be  said  about  each  of  the  main  causes  of  jaundice. 
I. — Obstruction  of  the  Common  Bile-duct. 

A.  Within  the  Duct. 

Gall-stones  may  give  rise  to  no  symptoms  so  long  as  they  remain  in  the  gall- 
bladder. They  vary  in  size  from  a  grain  of  sand  to  a  hen's  egg.  If  impacted 
in  the  cystic  duct,  distention  of  the  gall-bladder  may  follow,  but  there  is  no 
jaundice.  When  impacted  in  the  common  duct,  intense  jaundice  is  produced, 
and  some  enlargement  of  the  liver,  but  in  the  majority  of  cases  no  distention 
of  the  gall-bladder.  Before  impaction  of  the  calculus  takes  place  as  it  moves 
from  the  gall-bladder  along  the  ducts,  intense,  agonizing,  colicky  pain  is  produced, 
which  is  first  felt  in  the  epigastrium  and  right  hypochrondrium,  extending  thence 
to  the  back  of  the  lower  part  of  the  right  chest,  to  the  back  of  the  right  shoulder, 
and  it  may  be  so  severe  that  the  patient  becomes  collapsed.  Vomiting,  pyrexia, 
and  rigors  are  other  symptoms  which  are  frequently  associated  with  these 
attacks  of  pain.  The  latter  lasts  a  varying  time  according  to  what  happens  to 
the  calculus.  If  expelled  into  the  duodenum  the  severe  pain  ceases,  and  the 
gall-stone  may  be  found  in  the  faeces.  If  found,  it  should  be  carefully  examined, 
for  if  its  surface  is  faceted  it  indicates  that  other  gall-stones  are  present,  and 
points  to  the  likelihood  of  further  attacks  of  colic  and  jaundice  occurring. 

Jaundice  dependent  on  the  passage  of  gall-stones  usually  comes  on  about 
twelve  hours  after  the  commencement  of  the  attack  of  colic,  and  persists  for 
a  varying  period  according  to  the  length  of  time  the  calculus  remains  in  the 
duct.  Occasionally  jaundice  occurs  without  any  previous  colic.  Recurring 
attacks  of  jaundice  in  a  middle-aged  woman,  with  or  without  attacks  of  coUc 
are  almost  pathognomic  of  gall-stones  ;  only  one  other  disease  produces  precisely 
similar  symptoms,  namely,  chronic  pancreatitis.  In  the  latter,  however,  the 
jaundice  is  apt  to  persist  longer,  and  it  may  never  go  completely  away,  lessening 
between  the  attacks,  to  deepen  again  with  each  recurrence  of  the  acute  pan- 
creatic pain.      It  is  often  very  difficult  to  distinguish  gall-stones  from  chronic 


364  J  A  UNDICE 

pancreatitis  without  laparotomy,  and  yet  chronic  pancreatitis  is  curable  without 
any  operation.  The  absence  of  gall-stones  in  the  faeces,  and  the  presence  of  a 
positive  pancreatic  reaction  in  the  urine  (see  Cammidge's  Pancreatic  Reaction), 
would  point  to  chronic  pancreatitis  rather  than  to  gall-stones  ;  the  former  is 
distinguished  from  neoplasm  by  the  greater  amount  of  pain  it  causes  and  the 
longer  the  case  lasts. 

There  are  several  methods  of  detecting  pancreatic  disease,  most  of  which 
depend  upon  the  non-entry  of  the  pancreatic  juice  into  the  intestine.  The 
percentage  of  fat  in  the  stools  when  ordinary  quantities  are  given  by  the  mouth 
is  very  much  greater  when  the  pancreatic  juice  fails  than  when  the  bile  alone 
fails,  so  that  extremely  fatty  iridescent  stools  favour  a  diagnosis  of  pancreatitis 
or  pancreatic  neoplasm.  The  same  indication  is  afforded  when  the  faeces  contain 
a  large  number  of  undigested  muscle  fibres  ;  also  when  keratin-coated  capsules 
are  passed  undigested,  or  when  such  capsules  containing  methylene  blue  are 
given  without  the  urine  subsequently  turning  blue.  Other  tests  concern  the 
tryptic  activity  of  the  motions,  and  so  forth,  and  their  value  is  still  sub  judice. 

If  a  stone  remains  impacted  in  the  common  duct,  the  jaundice  is  intense  ; 
but  if  it  soon  passes  into  the  duodenum,  the  jaundice  is  slighter  and  transient. 

Inspissated  Bile  is  always  mentioned  as  a  cause  of  jaundice,  but  there  are 
no  distinguishing  signs  of  this  condition,  and  it  would  require  considerable 
boldness  on  the  part  of  the  physician  to  make  this  the  sole  diagnosis.  Thickening 
of  the  bile  may  occur  in  acute  fevers,  poisonings,  and  so  forth,  and  this  is 
possibly  the  cause  of  the  jaundice  in  many  of  the  cases  where  there  is  no  obstruc 
tion  to  the  large  bile- ducts  ;  but  a  diagnosis  of  "  inspissated  bile  "  by  itself 
would  clearly  be  incomplete  and  inadequate. 

Parasites. — A  hydatid  cyst  of  the  liver  may  happen  to  be  in  such  a  position 
as  to  stenose  the  common  bile-duct,  or  it  might  open  into  the  gall-bladder, 
cystic,  hepatic,  or  common  bile-ducts.  It  is,  however,  an  exceptionally  rare 
cause  of  jaundice,  and  it  could  seldom  be  diagnosed  unless  by  laparotomy. 

Distoma  hepaticum.  —  The  normal  habitation  of  this  parasite  is  the  bile- 
ducts  of  the  sheep  ;  it  is  sometimes  found  occupying  a  similar  position  in  man, 
though  in  England  this  is  of  extreme  rarity.  The  chief  symptoms  are  jaundice, 
ascites,  enlargement  of  the  liver,  vomiting,  pyrexia,  diarrhoea,  and  pain  in  the 
right  hypochondrium.  If  circumstances  should  suggest  this  infection,  the  vomit 
and  the  stools  should  be  examined  for  flukes,  and  the  stools  for  ova,  which  are 
constantly  present,  large,  brown,  and  operculated,  measuring  O"  1 3  by  "08  mm. 

Ascaris  lumbricoides  (round  worm). — This  parasite  inhabits  the  upper  part 
of  the  small  intestine  and  measures  from  15  to  45  cm.  in  length.  It 
seems  to  have  a  special  tendency  to  force  itself  into  small  orifices,  and  it  has 
been  recorded  as  becoming  impacted  in  the  common  bile-duct,  with  jaundice 
as  the  result.  The  worms  themselves  seldom  produce  symptoms,  and  unless 
they  are  actually  found  in  the  duct  they  could  never  be  diagnosed  with  certainty 
as  the  cause  of  jaundice.  Even  if  the  worms  or  their  ova  were  found  in  the 
patient's  faeces  it  would  be  a  bold  thing  to  diagnose  that  an  ascaris  impacted  in 
the  bile-duct  was  the  cause  of  the  jaundice. 

B.  Causes  affecting  the  Wall  of  the  Duet. 

Catarrh  of  the  Mucous  Membrane  of  the  Bile-duct  (catarrhal  jaundice). — This 
is  a  common  cause  of  jaundice — in  young  people  the  most  common  of  all.  It 
is  due  to  the  obstruction  caused  by  the  swelling  of  the  mucous  membrane, 
and  it  is  almost  impossible  to  distinguish  clinically  between  cases  in 
which  the  catarrh  is  confined  to  the  bile-ducts,  and  those  in  which  it  began 
in  the  duodenum  and  thence  extended  to  the  biliary  papilla.  It  is  usually 
preceded  by  gastro-intestinal  disturbances,  especially  epigastric  discomfort 
and  dyspepsia.     The  jaundice  develops  almost  suddenly  in  many  cases,  and  it 


J  A  UNDICE  365 

may  become  intense,  the  stools  being  clay-coloured  and  the  urine  dark  \vith 
bile  pigment.  There  may  be  a  slight  rise  of  temperature  at  first,  the  pulse  may 
be  less  accelerated  than  would  be  proportionate  to  the  temperature,  and  in 
quite  rare  cases  it  is  absolutely  slowed  down  to  40,  or  even  30  ;  the  liver  and 
spleen  may  be  slightly  enlarged,  the  tongue  furred  and  the  breath  foul  ;  loss 
of  appetite,  nausea,  constipation,  a  feeling  of  weight  and  discomfort  in  the  right 
hypochondriac  region,  may  also  be  prominent  symptoms.  In  mild  cases  the 
jaundice  is  slight  and  disappears  at  the  end  of  one,  two,  or  three  weeks  ;  some- 
times it  lasts  as  long  as  eight  weeks,  or  even  more.  In  considering  the  dia- 
gnosis, it  should  be  remembered  that  jaundice  in  a  child  or  young  adult  is  most 
likely  to  be  due  to  catarrh.  The  slightness  of  the  pain  helps  to  exclude  gall- 
stones and  chronic  pancreatitis,  and  malignant  disease  is  rendered  improbable 
if  the  jaundice  presently  clears  up,  and  if  the  patient  does  not  emaciate. 

Catarrh  of  the  Pancreatic  Ducts,  extending  to  the  ampulla  of  \'ater  and  so  to 
the  bile-ducts,  has  already  been  discussed  under  chronic  pancreatitis  above. 
It  differs  from  catarrh  starting  in  the  duodenum  or  in  the  bile-duct  by  being 
associated  with  periodic  attacks  of  colicky  epigastric  pain  resembling  gall- 
stone colic. 

Cicatrization  following  Ulceration  of  the  Duct. — Simple  fibrous  stricture  of 
the  bile-ducts  is  a  possible  but  rare  result  of  ulceration  due  to  gall-stones.  If 
the  cystic  duct  is  thus  stenosed,  distention  of  the  gall-bladder  without  jaundice 
follows  ;  if  the  hepatic  duct,  jaundice  and  enlargement  of  the  liver  without 
distention  of  the  gall-bladder  ;  and  if  the  common  duct,  intense  jaundice, 
enlargement  of  the  liver,  and  possibly,  but  not  necessarily,  distention  of  the 
gall-bladder.  It  is  practically  impossible  to  diagnose  between  this  condition 
and  impacted  gall-stones  during  life,  except  by  laparotomy. 

Congenital  Obliteration  of  the  Bile-ducts.  —  Jaundice  in  infants  is  almost 
always  transient,  icterus  neonatorum  developing  about  the  third  day  and  passing 
off  in  a  week  or  less.  If  an  infant  should  remain  persistently  jaundiced, 
a  grave  condition  is  almost  certainly  present,  though  only  a  post-mortem 
examination,  as  a  rule,  can  decide  whether  it  is  due  to  congenital  syphilis 
with  or  without  cirrhosis  and  pervious  ducts,  to  congenital  obliteration 
of  the  bile-ducts,  or  to  "  icterus  gravis,"  the  last  term  being  used  when  the 
child  dies  and  no  obvious  cause  for  the  jaundice  can  be  found  post  mortem. 
As  regards  congenital  obliteration  of  the  bile-ducts,  boys  are  more  frequently 
affected  than  girls.  Jaundice  may  be  present  at  birth  or  appear  on  the  second 
or  third  day,  or  even  as  late  as  the  fourteenth  day.  At  first  it  is  slight,  but  soon 
becomes  intense.  Constipation,  pale  motions,  bile  in  the  urine,  and  spontaneous 
haemorrhages — especially  from  the  umbilicus — are  the  most  prominent  symptoms. 
Death  may  take  place  in  two  or  three  weeks  when  haemorrhage  occurs,  but  if 
there  is  no  tendency  to  haemorrhage,  life  may  be  prolonged  for  six  or  seven  months. 
Increasing  jaundice,  colourless  motions,  bile-stained  urine,  and  spontaneous 
haemorrhages  would  point  to  some  condition  more  serious  than  icterus  neo- 
natorum. 

C.  Causes  Compressing  the  Duct  from  Outside  or  invading  it  from  Outside. 

When  compression  of  the  common  bile-duct  is  spoken  of,  the  term  invasion  of  it 
would  often  be  more  correct,  especially  when  the  so-called  compression  is  due 
to  secondary  deposits  of  malignant  disease  in  the  lymphatic  glands  in  the  portal 
fissure.  In  almost  all  cases  of  the  kind  jaundice  is  persistent,  and  it  is  often 
progressive,  although  there  may  be  slight  variations  in  its  depth. 

Enlarged  Glands  in  the  Portal  Fissure.  Secondary  Malignant  Glands. — The 
lymphatic  glands  in  the  portal  fissure  are  very  liable  to  become  enlarged  from 
deposits  of  secondary  growth  in  cases  of  abdominal  malignant  disease.  Jaundice 
with  or  Avithout  ascites  is  a  prominent  indication  of  such  a  condition,  and  when 


366  ■       JA  UN  DICE 

both  jaundice  and  ascites  are  present  in  a  case  of  malignant  disease  of  the  stomach 
or  intestine,  whether  the  hver  is  enlarged  or  not,  it  is  probable  that  there  are 
enlarged  malignant  glands  in  the  portal  fissure.  The  difficulty  of  diagnosis 
arises  in  cases  in  which  no  primary  growth  can  be  found.  In  a  fair  number  of 
these  it  is  either  in  the  rectum,  colon,  or  pancreas. 

Lymphadenomatous  Glands. — The  portal  glands  occasionally  become  enlarged 
in  cases  of  lymphadenoma  (Hodgkin's  disease),  or  lymphosarcoma,  with  a 
similar  result.  The  presence  of  enlarged  superficial  lymph  glands  and  enlarge- 
ment of  the  spleen  and  liver,  together  with  a  simple  anaemia  without  leucocytosis, 
would  suggest  this  diagnosis.  In  most  cases  of  lymphadenoma  in  which 
jaundice  occurs  it  is  a  late  symptom,  arising  long  after  the  correct  diagnosis  has 
already  been  made. 

Tuberculous  Glands. — Although  the  glands  in  the  portal  fissure  frequently 
become  caseous  in  cases  of  tuberculous  peritonitis  it  is  decidedly  rare  to  find 
that  their  enlargement  has  been  sufficient  to  compress  the  bile-duct  and  cause 
jaundice. 

Lymphatic  LeukcBniic  Glands. — The  visceral  glands  may  become  enormously 
enlarged  in  some  cases  of  lymphatic  leukaemia,  and  in  rare  instances  those  in 
the  portal  fissure  have  led  to  jaundice.  The  diagnosis  is  easy,  even  if  the  spleen 
and  superficial  lymphatic  glands  are  not  enlarged,  for  a  blood-count  would 
show  that  the  total  number  of  leucocytes  per  c.mm.  of  blood  was  raised  to 
anything  between  50,000  and  2,000,000  per  c.mm.,  whilst  the  differential 
leucocyte  count  would  show  a  very  great  preponderance  of  lymphocytes. 

Tumour  of  the  Liver. — Any  disease  which  causes  a  local  enlargement  of  the 
liver,  e.g.,  carcinoma,  sarcoma,  abscess,  gumma,  or  hydatid,  in  the  immediate 
neighbourhood  of  the  portal  fissure,  may  compress  the  common  bile-duct  and 
lead  to  jaundice.  On  account  of  the  close  relationship  between  the  bile-duct 
and  the  portal  vein,  ascites  is  equally  liable  to  be  produced.  The  association, 
therefore,  of  jaundice  and  ascites  with  a  local  enlargement  of  the  liver  would 
point  to  this  last-mentioned  condition  being  the  cause  of  the  two  former. 
In  many  such  cases,  however,  the  jaundice  is  really  due  to  deposits  in  the 
portal  lymphatic  glands  ;  for  if  the  latter  escape  there  may  be  very  large 
numbers  of  malignant  deposits  in  the  liver  without  there  being  any  jaundice 
at  all. 

Tumours  of  the  Pancreas. — A  tumour  of  the  head  of  the  pancreas  generally 
causes  jaundice  by  invading  the  orifice  of  the  common  bile-duct.  In  some  cases, 
situated  far  back  in  the  abdomen,  a  mass  can  be  felt  which,  on  account  of  its 
close  proximity  to  the  aorta,  may  present  distinct  transmitted  pulsation.  It 
may  prove  difficult,  without  artificially  inflating  the  stomach,  to  distinguish  it 
from  a  tumour  of  the  latter  or  of  the  liver.  A  pancreatic  tumour  is  situated 
behind  the  stomach,  and  does  not,  as  a  rule,  move  on  respiration,  though  if 
attached  to  the  portal  fissure  it  moves  with  the  liver.  Glycosuria  and  fatty 
stools  would  be  strong  evidence  in  favour  of  a  pancreatic  tumour,  even  if  no 
tumour  were  palpable.  The  tests  mentioned  on  page  364  could  be  employed  here 
too.  The  gall-bladder  is  very  apt  to  become  greatly  distended  ;  indeed,  persistent 
and  increasing  jaundice  with  decided  enlargement  of  the  gall-bladder  in  a  person 
of  the  cancer  age  are  probably  the  most  characteristic  symptoms  of  carcinoma 
of  the  head  of  the  pancreas. 

Tumours  of  the  Duodenum. — Primary  carcinoma  of  the  duodenum  is  very  rare, 
but  when  it  does  occur  it  usually  arises  in  the  immediate  neighbourhood  of  the 
biliary  papilla,  and  by  obstructing  the  common  bile-duct  causes  persistent 
jaundice,  with  progressive  emaciation. 

Tumours  of  the  Stomach. — A  carcinomatous  tumour  of  the  pyloric  end  of  the 
stomach  may  become  adherent  to  the  portal  fissure  and  cause  jaundice  by 


J  A  UNDICE  367 

compressing  the  common  bile-duct.  If,  however,  the  existence  of  a  gastric 
carcinoma  were  known  in  a  patient  who  developed  jaundice,  the  chances  would 
be  strongly  in  favour  of  the  latter  being  due  to  obstruction,  not  by  the  primary 
growth,  but  by  secondary  deposits  in  the  portal  lymph-glands.  It  should  also 
be  borne  in  mind,  however,  that  even  when  carcinoma  exists,  a  microbial 
catarrh  of  the  duodenum  may  cause  transient  non-malignant  jaundice. 

Tumours  of  the  Colon. — Carcinoma  of  the  hepatic  flexure  or  transverse  colon 
may  become  adherent  to  the  liver  and  cause  jaundic-3  by  compressing  the  common 
bile-duct.  It  may  be  difficult  to  distinguish  such  a  tumour  from  a  local  enlarge- 
ment of  the  liver  ;  but  constipation,  vomiting,  tympanitic  distention  of  the 
intestine,  and  the  passage  of  blood  per  rectum  would  point  to  a  growth  in  the 
colon.  In  most  of  such  cases,  however,  the  obstruction  to  the  bile-ducts  is 
not  by  the  primary  growth,  but  by  secondary  deposits  in  the  portal  glands. 
The  importance  of  rectal  examination  has  already  been  insisted  on. 

Tumours  of  the  Right  Kidney. — Large  tumours  of  the  right  kidney,  especially 
malignant  growths,  may  compress  the  bile-duct  and  cause  jaundice.  If  the 
tumour  becomes  adherent  to  the  liver  it  is  difficult  to  distinguish  it  from  an 
enlargement  of  that  organ,  as  the  liver  and  the  enlarged  kidney  would  move 
together  and  at  the  same  rate  during  respiration.  If  the  abdomen  is  bimanually 
palpated,  however,  the  loin  may  be  felt  to  be  filled  out  behind  ;  and,  in  front, 
the  edge  of  the  liver  may  be  distinguished  lying  over  the  front  of  the  tumour, 
and  it  may  be  possible  to  distinguish  a  vertical  band  of  colonic  resonance  over 
the  otherwise  dull  mass.  Hsematuria,  albuminuria,  and  pyuria  would  be 
additional  evidence   of  renal    disease. 

Transitory  attacks  of  slight  jaundice  are  not  uncommon  in  association  with 
movable  kidney.  This  is  possibly  due  to  compression  of  the  common  bile-duct 
by  the  kidney,  but  it  may  also  result  from  the  associated  enteroptosis  causing  a 
drag  on  the  duodenum,  and  a  kinking  of  the  common  bile-duct.  The  diagnosis 
of  movable  kidney  is  not  difficult,  the  position  and  the  mobility  of  the  tumour, 
and  the  curious  sickening  sensation  experienced  by  the  patient  when  it  is  com- 
pressed, being  sufficiently  characteristic. 

Tumours  of  the  Right  Suprarenal  Capsule. — Malignant  growth  of  the  right 
suprarenal  capsule  is  very  rare,  but  it  may  give  rise  to  an  enormous  tumour 
which  is  difficult  to  distinguish  from  a  renal,  or  even  in  some  cases  a  hepatic, 
enlargement.  IMalignant  disease  of  one  capsule  causes  no  symptoms  of  Addison's 
disease  if  the  other  remains  healthy. 

Ovarian  Tumours. — A  large  ovarian  cyst  may  extend  upwards  to  the  portal 
fissure,  compress  the  common  bile-duct,  and  cause  jaundice,  but  such  a  compli- 
cation is  rare  ;  indeed,  when  jaundice  is  associated  with  ovarian  tumour,  the 
suspicion  will  naturally  be  that  the  latter  is  malignant  and  that  there  are  second- 
ary deposits  in  the  glands  in  the  portal  fissure  obstructing  the  large  bile-ducts. 
Ascites  is  very  apt  to  be  present  at  the  same  time,  so  that  unless  the  existence 
of  an  ovarian  tumour  is  already  known,  or  unless  its  existence  can  be  determined 
by  abdominal,  vaginal,  or  rectal  examination,  there  may  be  much  difficulty 
in  determining  the  precise  cause  of  the  jaundice,  though  if  cirrhosis  of  the  liver 
can  be  excluded,  some  form  of  malignant  disease  will  probably  be  suspected. 

Tumours  of  the  Uterus. — A  large  tumour  of  the  uterus  may  cause  jaundice  in 
a  similar  manner  to  an  ovarian  tumour,  but  even  more  rarely. 

Tumours  of  the  Omentum. — A  large  omental  tumour  may  compress  the  bile- 
duct  and  thus  cause  jaundice,  but  it  is  an  exceedingly  rare  result  of  such  a 
condition.  Whether  malignant  or  tuberculous,  it  usually  lies  across  the  upper 
part  of  the  abdomen,  is  superficial,  and  moves  slightly  with  respiration.  If  it 
has  become  adherent  to  the  liver  it  may  be  difficult  to  distinguish  it  from  a  local 
enlargement  of  the  latter.     In  any  case,  the  jaundice  will  probably  be  diagnosed 


368-  J  A  UNDICE 

as  due  to  deposits — tuberculous  or  malignant — in  the  portal  glands,  rather  than 
to  the  omental  mass  itself. 

Aneurysm  of  the  Hepatic  Artery,  Cceliac  Axis,  or  Abdominal  Aorta. — An 
aneurysm  of  the  hepatic  artery  is  a  decidedly  rare  condition,  but  it  is  by  no  means 
unheard  of  in  cases  of  fungating  endocarditis  with  embolism.  Jaundice  is 
intense,  on  account  of  the  close  proximity  of  the  hepatic  artery  to  the  common 
bile-duct.  A  correct  diagnosis  would  be  almost  impossible  during  life,  especially 
in  view  of  the  fact  that  jaundice  may  occur  in  fungating  endocarditis  cases 
simply  from  the  inspissation  of  the  bile  that  results  from  the  toxaemia  and  fever. 

Aneurysm  of  the  coeliac  axis  or  upper  part  of  the  abdominal  aorta  is  also  a 
very  rare  cause  of  jaundice.  The  presence  of  an  abdominal  tumour  with  marked 
expansile  pulsation,  a  systolic  bruit  and  abdominal  pain,  are  the  most  important 
diagnostic  signs,  especially  if  they  occur  in  a  person  who  is  known  to  have  had 
syphilis. 

II. — Jaundice   without  Obstruction   of  the  larger  Bile-ducts. 

A.  Causes  associated  with  Disease  of  the  Liver. 

Carcinoma  of  the  Liver. — Jaundice  occurs  in  more  than  50  per  cent  of  the 
cases  of  malignant  disease  of  the  liver,  whether  secondary  or  primary  ;  it  is 
seldom,  however,  that  the  masses  in  the  liver  itself  cause  the  jaundice,  but  rather 
the  associated  deposits  in  the  portal  glands.  A  liver  may  contain  hundreds  of 
nodules  of  new  growth  without  there  being  either  jaundice  or  ascites  if  the  portal 
glands  escape.  Jaundice  brought  about  in  this  manner  is  permanent,  and  when 
the  common  duct  is  involved  is  intense.  The  skin,  which  at  first  is  a  deep 
orange,  becomes  greenish,  and  finally  the  dark  olive-green  tint  which  is  almost 
pathognomonic  of  jaundice  due  to  malignant  disease.  Increasing  jaundice 
in  a  patient  over  40  years  of  age,  who  has  been  ill  less  than  six  months, 
who  has  progressively  wasted  and  become  weaker,  and  whose  liver  is  enormously 
enlarged,  hard,  and  nodular,  points  without  much  doubt  to  malignant  disease, 
though  careful  search  may  be  required  before  the  primary  source  is  found. 
The  nodules  may  even  be  felt  to  be  umbilicated.  Primary  carcinoma  of  the 
liver  should  not  be  diagnosed  until  a  very  careful  physical  examination  has 
failed  to  furnish  evidence  of  the  primary  growth  in  some  other  organ. 

Cirrhosis. — In  many  cases  of  cirrhosis  of  the  liver  the  late  or  multilobular 
stage  of  the  disease  may  be  reached  without  there  having  been  any  jaundice 
at  all.  If  it  occurs  late  in  the  disease,  when  ascites  is  already  present,  the 
jaundice  is  usually  slight.  Ascites  is  the  most  constant  and  characteristic 
feature  at  this  late  stage  of  cirrhosis,  but  when  slight  jaundice  and  ascites  are 
associated  in  a  patient  who  gives  a  definite  history  of  alcoholism,  and  also 
has  symptoms  and  shows  signs  of  this  condition — nausea,  loss  of  appetite 
especially  for  breakfast,  morning  sickness,  attacks  of  cramp  in  the  legs  at 
night,  epistaxis,  h^matemesis,  melaena,  the  presence  of  dilated  venules  on  the 
cheeks,  acne  rosacea,  tremulous  tongue,  haemorrhoids,  and  a  hard  liver  with  a 
well-defined  and  beaded  edge — the  diagnosis  of  cirrhosis  of  the  liver  is  not  diffi- 
cult. Sometimes,  however,  jaundice  is  a  marked  feature  of  the  case  at  an  early 
stage,  when  the  organ  is  still  large  and  the  fibrosis  unilobular,  and  at  this  time 
ascites  is  conspicuous  by  its  absence.  In  most  of  these  cases  there  is  an  evening 
rise  of  temperature  to  about  foo"  F.  The  liver  is  considerably  enlarged,  its 
surface  is  smooth,  firm  perhaps,  and  tender,  and  its  edge  is  even  and  well-defined, 
reaching  to  the  level  of  the  umbilicus  or  even  below  it.  The  jaundice  may  pass 
ofif,  and  the  patient  survive  many  years  before  the  multilobular  ascitic  stage 
of  his  malady  is  reached  ;  on  the  other  hand,  if  the  jaundice  persists  and  deepens, 
the  prognosis  is  grave  ;  cholaemia  sets  in,  drowsiness  and  muttering  delirium 
passing  on  to  coma  and  death. 


J  A  UN  DICE  369 

There  is  a  peculiar  form  of  cirrhosis  of  the  liver  (Hanot's)  which  affects  several 
merabers  of  the  same  family,  and  whose  first  symptom  in  each  patient  is  jaundice. 
The  disease  appears  not  to  be  caused  by  alcohol,  syphilis,  or  malaria.  It  is 
possible  for  the  patient  to  live  many  years  with  more  or  less  jaundice  all  the 
time.  The  liver  is  enlarged  and  hard,  and  the  spleen  is  also  moderately  increased 
in  size.     The  diagnosis  is  arrived  at  by  enquiring  into  the  family  history. 

There  is  yet  another  particular  variety  of  cirrhosis  of  the  liver  which  occurs 
in  children  and  young  people,  and  is  characterized  by  enormous  enlargement 
of  the  spleen,  slight  enlargement  of  the  liver,  anaemia  without  leucocytosis, 
haematemesis,  clubbing  of  the  fingers,  jaundice,  and  stunted  growth.  It  differs 
from  Hanot's  cirrhosis  in  that  the  liver  is  smaller  and  the  spleen  larger,  and 
from  the  latter  feature  of  the  case  it  is  termed  splenomegalic  cirrhosis  (Taylor). 

Single  or  Tropical  Abscess. — In  cases  of  single  or  tropical  abscess  of  the 
liver,  intense  jaundice  is  rare,  and  it  is  only  likely  to  occur  when  the  abscess 
bulges  in  the  region  of  the  portal  fissure.  The  general  appearance  of  a 
patient  who  is  suffering  from  hepatic  abscess  may,  however,  be  mistaken  for 
jaundice,  because  the  complexion  is  sallow,  and  the  conjunctivae  may  even 
have  a  slightly  icteroid  tinge.     The  urine,  however,  seldom  contains  bile  pigment. 

It  is  a  disease  which  mostly  affects  people  who  have  resided  in  the  tropics, 
particularly  those  who  have  had  dysentery.  The  diagnosis  depends  on  the 
history  of  residence  abroad,  together  with  more  or  less  severe  symptoms,  such 
as  a  feeling  of  chilliness,  rigors,  intermittent  pyrexia,  profuse  sweating,  rapid 
pulse,  dull  heavy  pain  in  the  right  hypochondrium  and  under  the  right  shoulder 
blade,  vomiting,  dry  furred  tongue,  severe  prostration,  and  emaciation.  The 
physical  signs  vary  according  to  the  position  and  the  size  of  the  abscess.  Inter- 
mittent pyrexia  and  an  absence  of  signs  of  enlargement  of  the  liver  may  lead 
to  a  diagnosis  of  malaria,  but  a  blood  examination  should  settle  this  point. 
In  the  case  of  malaria,  protozoa  may  be  found  in  the  red  blood-corpuscles,  and 
after  the  initial  chill  there  is  a  diminution  in  the  number  of  leucocytes  with  a 
relative  lymphocytosis,  whereas  in  hepatic  abscess  there  would  be  a  poly- 
morphonuclear leucocytosis.  A  large  single  abscess  may  cause  a  fluctuating 
swelling  in  the  epigastrium  if  it  arises  in  the  left  lobe  ;  may  project  from  the  under 
surface  of  the  liver  and  simulate  an  enlarged  gall-bladder  ;  may  bulge  the  ribs  in 
the  lower  axillary  region  on  the  right  side  if  it  arises  from  the  right  lobe,  or  push 
the  diaphragm  upwards  and  simulate  an  empyema.  Should  the  abscess  open 
into  the  lung  the  dull  reddish  pus  expectorated  would  point  to  its  origin  in  the 
liver,  even  though  no  Amcebce  dy sentence  be  found  in  the  pus. 

Multiple  Abscesses  in  the  Liver. — Multiple  abscesses  of  the  liver  might  theor- 
etically arise  by  infection  through  any  one  of  four  different  channels,  namely, 
the  portal  vein,  the  bile-ducts,  the  hepatic  artery,  and  the  lymphatics.  In 
practice  only  the  first  two  are  important,  giving  rise  to  suppurative  pylephlebitis 
on  the  one  hand,  and  suppurative  cholangitis  on  the  other.  There  are  really 
no  sharp  lines  of  demarcation  between  non-suppurative  inflammations  of  these 
channels  on  the  one  hand  and  suppurative  ones  on  the  other.  Thus,  there  are 
all  intermediate  stages  between  simple  catarrh  of  the  ducts  and  acute  suppurative 
cholangitis  ;  and  there  are  similar  degrees  of  inflammation  in  the  case  of  the 
portal  venules.  Jaundice  is  almost  constantly  a  symptom  of  cholangitis  ;  and 
the  diagnosis  is  arrived  at  when  a  cause  for  cholangitis  exists,  such  as  gall-stones, 
carcinoma  of  the  gall-bladder,  empyema  of  the  gall-bladder  after  typhoid  fever, 
and  when  the  patient's  liver  enlarges  and  becomes  tender,  especially  if  rigors 
also  occur  from  time  to  time.  Suppurative  pylephlebitis  is  less  easily  diagnosed, 
and  indeed  it  is  often  overlooked  as  a  cause  for  an  obscure  febrile  illness  accom- 
panied by  rigors.  About  half  the  patients  who  have  it  develop  jaundice,  and 
one  very  important  point  is  that,  in  over  half  the  cases,  the  cause  of  the  infection 

D  24 


370  J  A  UXDICE 

of  the  portal  vein  is  a  recent  mild  attack  of  appendicitis.  If,  therefore,  a 
patient  who  has  recently  had  pains  or  discomfort  in  the  right  iliac  fossa  presenth^ 
begins  to  do  badly,  developing  p^-rexia  and  rigors  without  apparent  cause,  and 
if  that  patient  in  the  course  of  a  week  or  so  develops  a  tinge  of  jaundice  and  a 
sUghtly  enlarged  hver,  the  grave  diagnosis  of  infective  pylephlebitis  should 
suggest  itself  at  once. 

Acute  Yellow  Atrophy  of  the  Liver. — Jaundice  is  one  of  the  earUest  symptoms 
of  acute  yellow  atrophv  of  the  liver,  and  at  first  it  may  appear  that  the  patient 
is  suffering  from  catarrhal  jaundice.  At  the  commencement  it  may  be  slight, 
but  it  graduaUv  increases  in  intensity-  until  the  onset  of  nervous  s\Tnptoms, 
when  it  suddenlv  becomes  severe  and  the  skin  assumes  a  greenish  hue.  In  the 
earh-  stages  bile  pigment  may  be  found  in  the  urine,  but  towards  the  end,  when 
the  skin  becomes  green,  Gmehn's  reaction  cannot  be  obtained,  or  onlj^  a  trace 
of  pigment  can  be  detected.  The  striking  resemblance  between  this  disease 
and  that  producible  hj  poisons  suggests  that  in  it  there  is  that  varietA^  of  catarrh 
of  the  bile-ducts  which  Hunter  has  caUed  toxaemic — that  is,  a  catarrh  produced 
by  the  excretion  through  the  bile  of  injurious  products  which  cause  extensive 
degenerate  changes  in  the  hver  cells. 

This  is  an  exceptionally  rare  disease.  It  affects  females  under  30  years  of 
age  much  more  frequently  than  males,  and  in  a  good  many  cases  has  been 
preceded  bv  fright,  or  severe  mental  emotion.  It  usually  commences  in  the 
same  manner  as  an  attack  of  catarrhal  jaundice,  with  nausea,  vomiting,  loss 
of  appetite,  constipation,  and  pain  in  the  right  hypochondrium.  At  the  end  of 
two  or  three  weeks  a  sudden  change  occurs,  which  commences  with  severe 
vomiting,  headache,  restlessness,  followed  by  delirium,  convulsions,  and  coma. 
The  temperature  rises  to  101°  F.  or  102°  F.,  and  the  pulse  becomes  rapid.  The 
tongue  is  dr^-  and  brown.  There  is  a  tendency  to  haemorrhage  from  various  parts, 
e.g.,  epistaxis,  hgematemesis,  melsena,  and  metrorrhagia.  The  most  important 
diagnostic  signs  are  the  remarkable  diminution  of  urea  and  uric  acid,  and  the 
presence  of  leucin  and  tj-rosin,  in  the  urine;  also  the  rapid  diminution  in  the 
extent  of  the  hepatic  dullness  which  takes  place  after  the  development  of  the 
above-mentioned  ner\'ous  symptoms.  The  duration  of  the  disease,  in  the 
majority-  of  cases,  is  under  fourteen  days  from  the  time  of  the  sudden  change 
in  the  type  of  the  jaundice. 

Passive  Congestion  (nutmeg  liver). — Jaundice  occurs  in  severe  cases  of  passive 
congestion,  especially  as  the  result  of  long-standing  mitral  stenosis,  or  of  fibrosis 
of  the  lung,  with  ultimate  failure  of  the  right  side  of  the  heart.  It  is  usually 
but  an  icteric  tinge,  but  when  severe  its  association  with  C}-anosis  gives  a  curious 
dusky -green  tint  to  the  skin,  especially  that  of  the  face.  CEdema  of  the  legs 
and  ascites  are  also  present  as  a  rule.  The  liver  is  considerably  enlarged,  its 
edge  is  sharp  and  well  defined,  its  surface  smooth,  firm,  tender,  and  possibly 
pulsating.  Jaundice  from  this  cause  should  not  be  difficult  to  diagnose.  If 
in  a  chronic  heart  case  there  are  both  pvrexia  and  jaundice,  f ungating  endocarditis 
is  probable. 

Syphilis. — Congenital  syphilis  may  cause  jaundice  in  infants  or  young 
children  as  the  result  of  intralobular  fibrosis,  but  it  is  possible  for  the  latter  to 
be  extensive  without  there  being  any  jaundice,  and  even  where  the  latter  is 
present  it  is  usuallv  slight.  If  associated  with  uniform  enlargement  of  the  liver, 
wasting,  and  other  signs  of  congenital  SA-philis,  the  diagnosis  is  not  difficult. 

In  an  adult  it  is  possible  for  gummata  to  cause  jaundice  by  compressing  the 
ducts,  but  this  is  distinctly  rare.  The  local  enlargement  of  the  liver  and  pyrexia 
may  lead  to  a  diagnosis  of  abscess  or  of  secondary-  carcinoma.  A  careful 
examination  must  be  made  for  signs  of  s\-philis  ;  in  some  cases  it  is  not  until 
antis\-philitic  remedies  have  been  administered  and  the  effect  watched,  that  a 


J  A  UN  DICE  371 

correct  diagnosis  can  be  made.  If  there  are  any  active  lesions  of  the  skin  or 
mucous  membranes,  it  may  be  possible  to  detect  the  Spirochcsfa  pallida 
microscopically  (see  Plate  XII,  Fig.  J)  ;  or  the  patient's  serum  may  be 
examined  in  the  laboratory  for  Wassermann's  reaction. 

Probably  the  commonest  period  at  which  syphilis  may  be  directly  responsible 
for  jaundice  is  the  secondary  stage,  when  it  is  apt  to  cause  catarrh  of  many 
different  glandular  ducts,  including  those  of  the  liver.  The  symptoms  will  be 
very  like  those  of  simple  catarrhal  jaundice,  together  with  the  roseola,  the  sore 
throat,  the  pyrexia,  the  albuminuria,  and  other  signs  of  secondary  syphilis. 

Active  Congestion. — Active  congestion  of  the  liver  is  a  diagnosis  that  some 
observers  would  not  hold  with,  whilst  others  are  convinced  that  it  is  not  an 
uncommon  result  of  many  of  the  acute  fevers,  such  as  malaria,  and  that  it  may 
arise  from  insufficient  exercise,  especially  when  associated  with  alcoholism  and 
over-eating,  particularly  in  Europeans  who  live  in  the  tropics.  The  liver  is 
slightly  enlarged  and  tender.  The  chief  symptoms  are  slight  jaundice,  pain, 
and  a  feeling  of  fullness,  weight,  and  oppression  in  the  right  hypochondrium, 
which  sensations  are  much  increased  by  pressure  ;  also  pain  in  the  right  shoulder, 
a  bitter  taste  in  the  mouth,  nausea,  sickness,  a  furred  tongue  with  indented 
edges,  constipation,  and  scanty  high-coloured  urine.  There  may  be  a  tempera- 
ture of  102°  F.,  and  then  care  must  be  taken  to  distinguish  it  from  hepatic  abscess. 
An  absence  of  leucocytosis  would  be  in  favour  of  congestion  and  against  suppura- 
tion. If  due  to  malaria,  an  examination  of  stained  blood-films  should  demon- 
strate the  presence  of  malaria  parasites.  It  is  clearly  impossible  to  distinguish 
clinically  between  active  congestion  of  the  liver  and  catarrh  of  the  bile-ducts. 

B.  Jaundice  in  Acute  Fevers. 

Malaria. — Slight  jaundice  may  occur  in  long-continued  tertian  and  sestivo- 
autumnal  infections,  and  on  account  of  the  associated  irregular  pyrexia  it  may 
lead  to  a  mistaken  diagnosis  of  hepatic  abscess.  Microscopic  examination  of 
stained  blood-films,  and  the  discovery  of  the  characteristic  parasites  in  the 
red  blood-corpuscles  {Plate  XII),  are  the  most  conclusive  evidence  of  malaria. 
Jaundice  may  also  occur  as  a  result  of  malarial  cirrhosis. 

It  should  be  borne  in  mind  that  the  parasites  rapidly  disappear  from  the 
blood  in  cases  in  which  quinine  has  been  administered  recently.  It  is  important, 
therefore,  to  examine  blood-films  for  the  parasites  before  quinine  is  given,  and 
if  possible  at  the  very  commencement  of  an  ague  fit,  at  which  time  they  are 
at  their  most  typical  stage  of  development.  If  quinine  has  already  been  given, 
however,  there  will  still  be  presumptive  evidence  in  favour  of  malaria  if  there 
is  no  leucocytosis,  and  if  the  differential  leucocyte  count  shows  a  decided  increase 
in  the  proportion  of  large  hyaline  lymphocytes — up  to  1 5  per  cent  or  more. 

Typhus  Fever. — Jaundice  may  occasionally  occur  in  this  disease,  which, 
fortunately,  is  now  extremely  rare.  A  few  cases  have  been  seen  at  Guy's 
Hospital  during  the  last  few  years,  but  jaundice  was  not  noticed  in  any  of  them. 
The  onset  is  more  sudden,  and  the  prostration  occurs  earlier  and  is  more  marked, 
than  in  typhoid  fever.  A  slight  leucocytosis  may  occur  in  typhus.  The  rash 
appears  from  the  third  to  the  fifth  day,  and  consists  of  a  dusky  red  mottling — 
the  so-called  mulberry  rash — rose-coloured  papules  which  appear  on  the  abdomen 
and  chest,  together  with  a  certain  number  of  petechise — the  latter  not  being 
found  in  typhoid  cases.  The  fever  tends  to  terminate  by  crisis  rather  than  by 
lysis.     Widal's  reaction  is  negative. 

Typhoid  Fever. — Jaundice  is  a  rare  symptom  in  this  disease  ;  it  occurred  in 
only  three  out  of  Osier's  series  of  829  cases.  It  is  due  to  an  inflammation  of 
the  bile  passages  by  typhoid  bacilli.  The  gall-bladder  may  become  enlarged 
and  tender,  and  give  rise  to  a  typical  palpable  tumour,  though  this  may  also 
occur  in  typhoid  fever  without  there  being  any  jaundice  at  all.     It  occasionally 


372  J  A  UN  DICE 

arises  as  a  complication  in  the  course  of  the  disease,  or  it  may  be  a  sequela,  or 
again,  it  may  be  an  early  and  prominent  symptom  for  which  the  patient  seeks 
advice.  Cases  have  been  recorded  of  primary  typhoid  infection  of  the  gall- 
bladder and  bile-ducts  without  any  accompanying  ulceration  of  the  intestine. 
The  low  pulse  ratio,  when  compared  with  the  temperature,  e.g.,  a  pulse  of  90  with 
a  temperature  of  104°  F.,  the  presence  of  typical  rose-red  spots  on  the  abdomen, 
enlargement  of  the  spleen,  leucopenia,  and  a  positive  Widal's  reaction,  are  the 
most  important  signs  which  would  point  to  a  diagnosis  of  typhoid  fever. 

Pyomia  and  Septiccemia. — Jaundice  is  frequently  a  late  symptom  of  pyaemia, 
and  may  or  may  not  be  associated  with  the  presence  of  multiple  abscesses  in 
the  liver.  It  is  more  likely  to  occur  in  cases  of  portal  than  arterial  pyaemia. 
Rigors,  high  irregular  temperature,  rapid  pulse,  profuse  sweating,  rapid  emacia- 
tion, and  progressive  loss  of  strength,  are  symptoms  which,  if  developing  after 
parturition,  wounds,  or  operations,  would  point  without  much  doubt  to  a 
diagnosis  of  pyaemia.  In  some  instances  of  acute  septicaemia  due  to  streptococci, 
staphylococci,  and  perhaps  other  micro-organisms,  there  has  been  intense  jaundice 
of  the  skin  and  conjunctivae  of  a  peculiar  mustard-yellow  tint,  without  the  urine 
giving  a  positive  Gmelin's  test.  The  urine  may  or  may  not  be  discoloured — 
in  some  instances  it  looks  merely  concentrated,  in  others  it  looks  almost  like 
porter,  and  yet  it  gives  no  play  of  colour  to  the  nitric  acid  test  ;  the  cause  of 
this  would  seem  to  be  the  oxidation  of  the  pigment  before  it  reaches  the  urine  ; 
in  septic  cases  this  occurrence  of  acholuric  jaundice  is  a  very  remarkable 
and,  at  first  sight,  confusing  factor  in  the  case. 

Pneumonia. — Jaundice  occasionally  occurs  as  a  complication  of  pneumonia. 
It  varies  very  much  in  its  frequency  in  different  epidemics  of  the  disease.  It 
is  noticed  soon  after  the  initial  rigor,  but  is  rarely  intense.  It  is  most 
probably  due  to  engorgement  of  the  liver  and  catarrh  of  the  bile-ducts. 
Its  more  frequent  association  with  right  basal  pneumonia  is  suggestive. 
The  sudden  onset  with  a  rigor,  the  high  temperature,  the  rapid  respiration  rate, 
which  is  above  the  ordinary  temperature  and  respiration  ratio,  and  the  com- 
paratively slow  pulse,  e.g.,  T.  104°  F.,  R.  40,  P.  100,  the  characteristic  tenacious, 
russet-brown  sputum,  the  short  catchy  cough,  the  pain  in  the  side,  the  pleuritic 
rub,  and  the  signs  of  consolidation  of  the  lung,  the  hot  dry  skin,  the  deficiency 
of  chlorides  in  the  urine,  and  the  occurrence  of  herpes  facialis,  are  the  accom- 
panying indications  which  in  the  majority  of  cases  would  point  to  a  diagnosis 
of  pneumonia. 

Infections  or  Epidemic  Jaundice — Weil's  Disease. — This  disease  is  characterized 
by  a  sudden  onset,  with  pyrexia,  severe  pain  in  the  back  and  limbs,  headache, 
and  giddiness,  followed  in  a  day  or  two  by  jaundice,  enlargement  of  the  liver 
and  spleen,  and  signs  of  nephritis.  The  jaundice  becomes  intense  within  twenty- 
four  hours  of  its  onset.  The  temperature  rises  to  103°  F.  to  104°  F.,  and  the  pulse 
becomes  rapid.  Nephritis,  next  to  jaundice,  is  one  of  the  most  constant  features 
of  this  disease.  Males  between  1 5  and  30  are  most  frequently  affected,  and  it 
appears  to  have  some  direct  connection  with  insanitary  surroundings.  Butchers 
appear  to  be  particularly  susceptible.      It  is  practically  unknown  in  England. 

Yellow  Fever. — This  disease  in  some  respects  resembles  acute  yellow  atrophy 
of  the  liver,  but  the  liver  does  not  atrophy,  neither  does  the  spleen  enlarge,  and 
crystals  of  leucin  and  tyrosin  are  not  found  in  the  urine.  It  is  essentially  a 
disease  which  prevails  in  tropical  and  sub-tropical  countries,  especially  in  the 
West  Indies  and  Central  and  South  America.  The  incubation  period  is  from 
three  to  four  days,  and  the  onset  is  sudden,  with  rigors,  headache,  and  pain 
in  the  back  and  limbs.  The  bowels  are  constipated.  Jaundice  is  an  early 
symptom,  and  one  of  the  most  characteristic,  but  it  varies  in  intensity,  being 
much  more  severe  in  fatal  than  in  mild  cases.     The  temperature  rises  to  102°  F. 


J  A  UN  DICE  373 

or  103°  F.  ;  the  pulse  is  rapid  at  first,  but  may  fall  as  the  temperature  rises,  and 
this  is  looked  on  as  a  very  typical  sign  of  the  disease.  Albuminuria,  black 
vomit,  haemorrhage  from  the  gums  and  beneath  the  skin,  are  other  important 
symptoms.  A  sporadic  case  occurring  in  this  country  would  probably  be  looked 
upon  as  acute  yellow  atrophy  of  the  liver  unless  a  definite  history  of  exposure 
to  infection  was  obtainable.  It  may  be  difficult  to  distinguish  it  from  dengue 
and  pernicious  malaria.  From  the  latter  it  can  be  diagnosed  if  crescents  are 
discovered  in  the  blood  [Plate  XII,  Fig.  E.). 

Relapsing  Fever. — Jaundice  is  a  common  symptom  of  this  contagious  fever, 
which  is  prevalent  in  India,  and  is  liable  to  arise  in  other  countries  in  times 
of  famine.  Considerable  enlargement  of  the  liver  and  spleen,  and  a  good  deal 
of  abdominal  pain  and  tenderness,  are  present  in  the  majority  of  cases  ;  also 
epistaxis  and  haematemesis.  The  most  characteristic  feature  of  the  disease  is 
the  temperature,  which  rises  abruptly  to  104°  or  105°,  and  even  to  108°  F., 
remains  high  for  five  or  six  days,  and  then  suddenly  falls  to  normal  when,  after 
an  interval  of  about  a  week,  it  again  rises  and  remains  high  for  three  or  four 
days.  During  the  periods  of  pyrexia  the  SpirochcBta  ohermeieri  [Plate  XII, 
Fig.  I)  may  be  found  on  examining  blood-films  which  have  been  prepared  and 
stained  in  the  same  manner  as  for  the  detection  of  malaria  parasites.  The 
blood  examination  serves  to  distinguish  it  from  malaria. 

C.  Jaundice  due  to   Poisons. 

Phosphorus. — Jaundice  is  one  of  the  most  characteristic  symptoms,  but  by  no 
means  a  constant  one,  of  phosphorus  poisoning.  It  is  slight  at  first,  appearing 
on  the  second  or  third  day  in  severe,  but  in  mild  cases  not  until  the  end  of  the 
first  week,  or  even  later.  It  is  due  to  concentration  and  increased  viscidity  of 
the  bile,  leading  to  obstruction  of  the  smaller  ducts.  This  form  of  poisoning  is 
rare  in  this  country  since  the  stringent  law  regulating  the  manufacture  of 
matches  from  the  non-poisonous  form  of  the  drug  has  been  in  force.  In  the 
cases  which  do  occur,  the  phosphorus  has  been  taken  in  the  form  of  match- 
heads  or  rat  paste  with  suicidal  intent.  At  first  the  signs  are  those  of  acute 
irritant  poisoning  coming  on  soon  after  the  phosphorus  has  been  swallowed, 
viz.  :  nausea,  vomiting,  severe  burning  pains  in  the  epigastrium,  collapse, 
extreme  thirst,  rapid  feeble  pulse,  rapid  respiration,  and  tenderness  in  the 
epigastrium  and  right  hypochondriac  regions.  In  many  cases  that  receive  treat- 
ment early,  these  acute  irritant  symptoms  subside  in  a  day  or  two,  and 
recovery  results.  If  they  do  not  thus  subside,  however,  after  from  two  to  five 
days  the  symptoms  change,  the  vomit  becomes  black  or  brownish  from  the 
presence  of  blood,  jaundice  appears  and  rapidly  deepens,  the  liver  enlarges,  and 
headache,  drowsiness,  delirium,  convulsions,  and  coma  supervene,  followed  shortly 
by  death.  If  hepatic  enlargement  cannot  be  ascertained,  it  may  be  difficult 
to  distinguish  phosphorus  poisoning  from  acute  yellow  atrophy  of  the  liver. 
Haemorrhages,  although  common,  are  not  as  frequent  as  in  acute  yellow 
atrophy.  The  urine  is  concentrated  and  strongly  acid  ;  the  total  nitrogen  is 
first  reduced,  as  in  cases  of  starvation,  to  about  one-fourth  the  usual,  and 
then,  in  spite  of  the  fact  that  the  patient  can  retain  no  food,  it  rises  to  the 
usual  amount,  which  shows  that  there  must  be  a  considerable  destruction  of 
albuminous  tissue  taking  place.  Urea  forms  the  greater  part  of  the  total 
nitrogen,  but  towards  the  end  the  total  amount  of  ammonia  is  increased. 
Leucin  and  tyrosin  are  not  usually  found,  and  the  chlorides  are  diminished. 
The  condition  of  the  urine,  therefore,  forms  a  contrast  to  the  changes  which 
are  found  in  cases  of  acute  yellow  atrophy.  The  chief  indications  of  the  disease 
that  are  found  post  mortem  are  jaundice,  multiple  punctiform  haemorrhages, 
fatty  degeneration  of  the  liver,  kidneys,  and  heart,  -and  enlargement  of  the 
spleen. 


374  JAUNDICE 

Arseniiiretted  Hydrogen. — This  poison  causes  jaundice  in  a  similar  manner 
to  toluylenediamine,  through  extreme  concentration  of  the  bile.  According 
to  Hunter,  the  increase  of  bile  pigment  may  be  to  three  and  a  half  times-  more 
than  its  normal  amount.     The  bile  acids  are  diminished. 

Toluylenediamine. — This  drug  has  been  used  for  experimental  purposes,  and 
its  action  has  helped  to  prove  that  so-called  haematogenous  jaundice  is  really 
due  to  obstruction  of  the  smaller  ducts  through  increased  viscidity  of  the  bile. 
When  injected  into  dogs  this  poison  soon  produces  intense  jaundice.  It  causes 
destruction  of  blood,  and  the  haemoglobin  thus  liberated  increases  the  quantity 
and  viscidity  of  the  bile,  so  that  temporary  obstruction  of  the  smaller  ducts, 
followed  by  jaundice,  results. 

Snake  Poison. — Jaundice  is  a  common  result  of  snake-bite,  and  is  produced 
in  a  similar  manner  to  the  last  three  forms  described,  viz.  :  as  a  result  of  con- 
centration and  increased  viscidity  of  the  bile  leading  to  obstruction  of  the  smaller 
bile  ducts.     The  diagnosis  depends  upon  the  history. 

D.  Jaundice  due  to  Nervous  Causes. 

Icterus  Nervosa — Mental  Emotion. — Cases  are  on  record  of  jaundice  following 
almost  immediately  after  some  violent  mental  emotion,  but  they  are  of  extreme 
rarity.  Under  such  circumstances  the  jaundice  has  been  explained  as  being 
the  result  of  a  sudden  spasm  of  the  bile-ducts. 

In  another  class  of  these  cases  the  jaundice  does  not  appear  until  twelve  or 
fourteen  hours  after,  and  it  is  then  probably  due  to  catarrh  of  the  bile-ducts, 
associated  with  some  gastric  and  duodenal  catarrh,  for  it  is  well  enough  known 
that  severe  mental  emotion,  grief,  or  anxiety  may  give  rise  to  acute  dyspepsia. 
Jaundice  may  similarly  occur  after  concussion  of  the  brain.  Herbert  French. 

JERK,  ACHILLIS (See  Ankle-clonus.) 

JERK,  KNEE — (See    Knee-jerk.) 

JOINTS,  AFFECTIONS  OF  THE.— ft  will  be  well  to  place  these  in  two  groups : 
(i)  Acute  ;    (2)   Chronic. 

I.  Acute  Joint  Affections. — Arthritis  due  to  Rheumatic  Fever  is  the  most  frequent 
of  these.  The  patient  has  often  had  the  disease  before  ;  there  are  manifestations 
of  past  rheumatic  affection  of  other  parts  of  the  body  than  joints  ;  thus  the 
presence  of  organic  mitral  disease  is  of  great  help  in  the  diagnosis  of  a  doubtful 
case.  A  history  pointing  to  past  chorea,  several  attacks  of  tonsillitis,  pericarditis, 
or  rheumatic  erythema  or  nodules  will  help.  The  distinguishing  features  of  the 
arthritis  are  that  it  is  acute,  and  affects  first  and  chiefly  the  larger  joints, 
although  in  a  very  severe  case  even  the  joints  of  the  hand  and  fingers  may  be 
implicated  ;  it  does  not  occur  in  all  the  affected  joints  simultaneously,  but 
appears  in  one,  a  few  hours  after  in  another,  and  so  on.  As  the  arthritis  often 
only  lasts  a  few  days  in  any  one  joint,  in  some  it  may  have  passed  away  while 
others  are  being  affected.  The  pain  is  very  severe  and  is  greatly  increased  by 
any  jar  of  the  bed  ;  it  is  more  fleeting  than  the  arthritis,  but  like  it,  flits  from 
joint  to  joint,  hardly  ever  returning  to  the  same  joint  in  the  same  attack.  The 
swelling  of  the  joint  is  usually  only  slight  or  moderate  ;  it  is  due  to  synovial 
effusion,  never  suppurates,  generally  subsides  in  a  few  days,  and  usually  in  a  few 
days,  or  at  most  a  fortnight,  the  joint  returns  completely  to  its  normal  condition. 
Permanent  distortion  or  stiffness  of  the  joints  after  rheumatic  fever  occurs,  but 
it  is  highly  exceptional.  Often  there  is  a  faint  red  blush  over  the  joint  when 
first  affected. 

The  most  important  diagnostic  characteristics  of  this  arthritis  are  :  (i)  The 
fact  that  it  flits  from  joint  to  joint.     Never  diagnose  rheumatic  fever  so  long  as 


JOINTS,     AFFECTIONS     OF     THE  375 

only  one  joint  is  affected.  I  have  known  failure  to  remember  this  lead  to  a 
diagnosis  of  rheumatic  fever  in  traumatic  arthritis,  tuberculous  arthritis, 
arthritis  due  to  acute  necrosis  of  a  bone  near  a  joint,  and  acute  suppurative 
arthritis  ;  in  each  of  the  last  two,  the  niistake  has  cost  the  patient  his  life. 
(2)  The  arthritis  in  turn  quickly  leaves  joints  ;  failure  to  remember  this  has 
often  caused  septic  and  various  forms  of  infective  arthritis  to  be  called  rheumatic 
arthritis,  a  mistake  which  has  also  cost  lives.  The  drenching  sweats,  and  the 
relief  of  the  pain  by  salicylates,  are  very  characteristic  of  rheumatic  fever,  but 
septicasmia  causes  sweating.  The  sweating  of  rheumatic  fever  is  particularly 
liable  to  be  accompanied  by  minute  glassy  vesicles.  Finally,  the  arthritis  of 
rheumatic  fever  being  transient,  is  not  accompanied  by  muc^  arthritic  muscular 
atrophy.  Rheumatic  nodules,  which  are  rare,  but  when  present  are  seen  in 
young  boys  affected  with  rheumatic  fever  and  heart  disease,  are  almost  dia- 
gnostic, but  very  rarely  they  are  met  with  in  osteo-arthritis,  and  once  I  have 
seen  them  with  gonorrhoeal  arthritis. 

Septic  Arthritis  is  constantly  being  thought  to  be  rheum.atic  fever  :  a  bad 
mistake,  especially  for  the  patient.  In  septic  arthritis,  it  is  true,  several  joints 
may  be  affected  ;  but  it  may  be  one  only,  which  it  never  is  in  rheumatic  fever  ; 
further,  in  septic  arthritis  the  trouble  does  not  clear  up  in  one  joint  and  then 
pass  to  another  ;  a  joint  once  affected,  remains  affected  till  the  source  of  infec- 
tion is  removed  ;  the  soft  tissues  around  are  thickened  and  brawny,  quite  unlike 
rheumatic  fever,  and  if  the  colour  is  altered — which  is  not  often  the  case- — it  is 
dusky,  and  not  the  bright  red  of  rheumatic  fever.  Suppuration  often  occurs  :  in 
rheumatic  fever,  never.  Whether  or  not  suppuration  takes  place,  the  joint  often 
becomes  fixed,  which  is  excessively  rare  in  rheumatic  fever.  Then,  if  proper 
search  is  made,  the  source  of  infection  can  usually  be  found  ;  common  places  that 
are  overlooked  are  the  sockets  of  the  teeth,  and  the  vagina  and  uterus,  but  the 
source  may  be  anywhere,  e.g.,  septic  arthritis  maj^  follow  dilated  bronchial  tubes, 
cystitis,  prostatic  abscess,  a  boil  on  the  skin,  inflammation  of  the  nasal  cavities, 
and  perhaps  ulceration  of  the  intestine.  Sometimes  the  most  careful  seeking 
fails  to  find  the  source,  but  the  search  raust  not  be  given  up  readily.  The 
irregular  temperature,  usually  hectic,  the  leucocytosis,  sweats,  and  other  signs 
of  septicaemia  are  often  a  help. 

Pneumococcal  Arthritis. — This  is  rare  in  adults,  and  nearly  always  exists  as  a 
complication  of  acute  pneumonia.  It  may,  however,  be  found  Avithout 
evidence  of  pneumococcal  disease  in  any  other  part  of  the  body.  Generally  only 
one  joint  is  affected,  usually  the  knee,  less  often  some  other  large  joint,  such  as 
the  shoulder  or  elbow.  Often  there  is  a  history  of  recent  injury  to  the  part. 
The  patient  suddenly  feels  a  pain  in  the  joint  ;  within  a  few  hours  of  this  the 
temperature  is  raised  ;  the  joint  swells  rapidly,  is  very  painful  and  exquisitely 
tender  ;  yellowish-green  pus  quickly  forms.  The  diagnosis  is  obviously  easy 
if  the  patient  has  pneumonia,  but  may  be  difficult  if  he  has  not  ;  it  is  important 
to  come  to  a  diagnosis  early,  for  it  is  a  serious  disease,  and  if  allowed  to  go  far 
without  incision  and  drainage  the  patient  may  succumb  to  a  general  septicaemia. 
Pneumococcal  arthritis  is  the  commonest  form  of  infective  arthritis  in  children 
under  five  years  old.  Rarely  it  is  unassociated  with  any  other  pneumococcal 
lesion,  but  most  commonly  it  is  associated  with  pneumococcal  disease  of  either 
the  lungs  or  the  middle  ear.  As  in  adults,  it  is  confined  generally  to  one  large 
joint.  The  swelling  may  be  very  great,  and  extend  to  the  soft  tissues  beyond 
the  joint.  The  pain  is  less  than  in  adults,  and  redness  is  not  common.  Its 
possible  presence  must  be  remembered,  for  as  in  adults,  so  in  children,  it  is 
necessary  to  drain  the  joint  early.  The  child  has  a  raised  temperature,  and 
looks    ill. 

Typhoid  Arthritis. — There  are  two  varieties,  both  very  rare  :    (i)   That  which 


376  JOINTS,     AFFECTIONS     OF     THE 

precedes  the  typhoid  fever  ;  this  is  a  multiple  arthritis,  not  of  severe  degree, 
which  subsides  just  before  definite  symptoms  of  typhoid  show  themselves.  It 
is  impossible  to  diagnose  it  until  the  appearance  of  the  typhoid  fever.  (2)  This 
occurs  during  the  t}^hoid  fever  ;  one  or  many  joints  may  be  affected  ;  the 
arthritis  is  of  varying  severity  ;  it  may  subside  completely,  or  require  incision 
and  draining.  In  a  few  cases,  even  when  there  has  been  no  arthritis  during  or 
before  the  attack  of  typhoid  fever,  some  chronic  arthritis  may  appear  later  ; 
most  often  the  joints  and  ligaments  of  the  spine  are  affected,  and  during  the 
convalescence  from  his  fever  the  patient  complains  much  of  pain  and  stiffness 
of  his  spine  ;  he  is  then  said  to  have  a  typhoid  spine.  In  a  similar  way  the 
hip  may  become  stiff,  and  very  rarely  there  is  chronic  osteitis  of  the  head  and 
neck  of  the  femur. 

Scarlatinal  Arthritis. — This  affects  many  joints,  is  not  severe,  soon  subsides, 
and  is  easily  diagnosed  by  the  presence  of  the  scarlet  fever.  It  is  commonly 
known  as  scarlatinal  rheumatism,  a  bad  name  which  quite  gratuitously  assumes 
a  connection  between  this  arthritis  and  rheumatic  fever,  for  the  existence  of 
which  there   is  no  evidence. 

Arthritis  occurs  commonly  in  association  with  meningococcic  meningitis  and 
Malta  fever,  less  commonly  with  dysentery,  rarely  in  association  with  influenza, 
glanders,  small-pox,  measles,  and  diphtheria.  In  all  these  cases  the  presence  of 
the  principal  disease  determines  the  diagnosis. 

Goitorrhceal  Arthritis  is  often  called  gonorrhoeal  rheumatism,  but  this  phrase 
should  be  discarded,  for  there  is  no  association  between  gonorrhoea  and  rheumatic 
fever.  Gonorrhoeal  arthritis  is  frequently  overlooked.  I  have  repeatedly 
demonstrated  its  presence  when  the  family  physician  has  believed  its  existence 
impossible.  It  is  particularly  likely  to  be  missed  in  women.  I  have  met  with 
it  in  married  women  of  fifty  ;  it  is  probable  in  these  cases  that  they  are  infected 
by  their  husbands.  It  may  follow  gonorrhoeal  ophthalmia  and  even  ophthalmia 
neonatorum.  The  diagnosis  may  be  very  easy,  as  when  a  patient  is  seized  with 
an  acute  arthritis,  either  of  a  single  joint  or  of  several  joints,  while  he  or  she  is 
suffering  from  gonorrhoea.  If  it  is  possible  to  withdraw  a  little  fluid  from  the 
cavity  of  the  swollen  joint,  the  discovery  of  the  gonococcus  makes  the  diagnosis 
certain,  but  this  is  usually  quite  unnecessary,  and  unless  done  very  carefully 
may,  by  introducing  micro-organisms  from  without,  greatly  increase  the  damage 
to  the  joint.  Often  a  urethral  discharge  may  be  found,  though  sometimes  in 
long-standing  cases  of  gleet  it  is  very  slight ;  if  the  gonococcus  cannot  be  found 
in  the  discharge,  it  may  be  detected  in  a  swab  taken  from  the  posterior  urethra 
or  vagina.  If  in  women  it  is  thought  undesirable  to  excite  suspicion  by  taking 
a  vaginal  swab,  the  nature  of  a  doubtful  arthritis  may  be  determined  by  the 
wide  variations  of  the  opsonic  index  to  the  gonococcus. 

It  is  difficult  from  the  clinical  character  of  gonorrhoeal  arthritis  to  tell  it 
certainly  from  other  forms  of  arthritis.  Mistakes  happen  least  often  to  those 
who  constantly  think  of  the  possibility.  It  is  of  varying  degrees  of  acuteness ; 
in  the  chronic  cases  of  gleet  the  corresponding  arthritis  is  chronic,  but  in  the 
acute  cases  of  gonorrhoea  it  may  be  so  acute  that  I  have  more  than  once  known 
the  disease  called  rheumatic  fever.  '  Gonorrhoeal  arthritis  may  be  limited  to 
one  joint,  and  then  most  often  to  a  large  one,  especially  the  knee  ;  but  it  may 
be  multiple,  and  very  many  joints,  even  those  of  the  wrists,  hands,  and 
fingers,  may  be  implicated  ;  there  is  often  much  swelling  of  the  soft  tissues  around, 
and  this  is  more  responsible  for  the  swelling  than  is  the  effusion  in  the  joint. 
G  norrhoeal  arthritis  is  usually  very  painful.  The  sheaths  of  tendons  are  often 
inflamed  and  tender,  and  so  are  some  fasciae,  especially  the  plantar  fascia.  The 
patient  often  complains  of  pain  at  the  back  of  the  sole  of  the  foot,  and  in  a  chronic 
case  he  has  flat-foot.     There  is  no  variety  of  arthritis  in  which  muscular  atrophy 


JOINTS,     AFFECTIONS     OF     THE 


377 


is  more  striking.  I  have  known  a  severe  case  of  gonorrhceal  arthritis  of  the  hand 
called  progressive  muscular  atrophy.  When  gonorrhceal  arthritis  is  chronic 
throughout  the  whole  of  its  course,  and  is  limited  to  one  joint,  the  cause  of  the 
trouble  is  often  erroneously  set  down  to  tubercle.  Suppuration  is  very  rare. 
Some  cases  are  extremely  chronic,  and  may  lead  to  fibrous  ankylosis  with 
deformities,  but  with  our  modern  means  of  diagnosis  and  treatment  this  has 
become  exceptional.  Salicylates  have  no  decided  effect  either  upon  the  joint 
pains  or  upon  the  co-existent  pyrexia. 

All  the  acute  affections  hitherto  mentioned,  except  rheuraatic  fever,  are  often 
included  under  the  phrase  "  infective  arthritis,"  because  they  are  known  to  be 
due  to  infection  by  a  micro-organism  ;  but  this  is  a  loose  term  that  ought  only  to 
be  used  in  a  general  sense,  for  a  diagnosis  of  the  precise  cause  of  the  infection  is 
nearly  always  possible  if  care  be  taken. 

Sometimes  in  an  infective  arthritis  there  is  more  than  one  micro-organism 
at  work  to  cause  it  ;  thus,  in  the  late  stages  of  gleet,  various  micro- 
organisms flourish  in  the  diseased  urethra,  and  the  arthritis  may  be  due  to  a 
mixed  infection  in  which  the  gonococcus  is  not  the  preponderating  micro- 
organism ;  under  such  conditions  pus  may  form  in  the  joints.  Indeed,  I  have 
known  a  mixed  infection  of  gonococci  and  streptococci  from  the  genitals  of  a 
woman,  cause  in  her  a  very  severe  acute  arthritis  with  a  temperature  of  105°  F. 
In  exhausting  diseases,  e.g.,  typhoid  fever,  the  patient  may  suffer  from  a 
secondary  streptococcal  infection  which  may  cause  arthritis. 

Acme  Secondary  Arthritis. — By  this  is  meant  arthritis  due  to  spread  of  disease 
from  the  bone  in  the  neighbourhood  of  the  joint.  It  is  limited  to  one  joint ;  the 
most  acute  and  dangerous  form  is  that  which  follows  acute  osteomyelitis.  More 
than  once  I  have  known  this  called  rheumatic  fever  because  the  onset  has  been 


DIVOF 

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16 

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Z"'/^.  106. — Chart  showing  the  pyrexia  and' rapid  pulse  of  rheumatoid  arthritis. 

sudden  and  the  temperature  raised.  It  is  a  most  unfortunate  mistake,  for 
patients  suffering  from  this  form  of  arthritis  are  liable  to  die  quickly  from  general 
septicaemia,  to  prevent  which  the  joint  ought  to  be  opened  and  drained  at  once. 
The  mistake  may  usually  be  avoided  by  remembering  that  rheumatic  fever  dres 
not  affect  one  joint  only.  The  more  difficult  cases  are  those  in  which  more  than 
one  joint  is  acutely  diseased,  as  a  result  of  disease  of  the  ends  of  the  bones.  To 
avoid  this  mistake,  disease  of  the  bones  themselves  must  be  carefully  sought. 


378 


JOINTS,     AFFECTIONS     OF     THE 


Fortunately  for  diagnosis,  this  disease  of  several  joints  is  most  frequent  in  infants, 
and  in  them  severe  arthritis  due  to  rheumatic  fever  is  unknown.  It  is  called 
acute  arthritis  of  infants.  Disease  of  joints  may  be  secondary  to  an  abscess  in 
the  bone  or  to  tuberculous  disease  of  the  bone.  These  varieties  are  diagnosed  by 
discovering  the  underlying  disease  of  the  bones  ;  ;\r-rays  are  often  of  much  use. 
Rheumatoid  Arthritis. — The  first  attack  is  often  acute  :  therefore  the  disease  is 
best  considered  here.  The  name  is  bad  and  has  led  to  confusion  ;  it  owes  its 
origin  to  the  fact  that  the  disease  in  some  respects  resembles  rheumatic  fever  ; 
hence  the  name  implies  an  arthritis  resembling  that  of  rheumatic  fever.  It 
would  probably  lead  to  worse  confusion  to  invent  a  new  name,  so  the  present 
had  better  stand  until  the  micro-organism  causing  the  disease  has  been  discovered. 
The  first  attack  is  ushered  in  with  fever  ;  the  temperature  is  rarely  higher  than 
ioo°  or  ioi°  F.  in  the  evening  and  99°  or  100°  F.  in  the  morning.  This  fever 
lasts  from  three  to  six  weeks,  slowly  subsiding  towards  the  end  {Fig.  106).     The 


T'Vlu-.  107. — Acute  rheumatoid  arthritis  :  showing  the  spindle-shajjed  swelling  of  the 
joints  between  the  first  and  second  phalanges,  and  the  swelling  in  connection  with 
the  wrist  and  metacarpo-phalangeal  joints. 


pulse  is  generally  rapid,  out  of  proportion  to  the  fever,  the  hands  and  feet  sweat 
profusely,  patches  of  freckle-like  pigment  are  prone  to  appear  on  the  body. 
Most  of  the  patients  are  young  women.  The  pyrexia  is  less  severe  and  longer 
lasting  than  that  of  rheumatic  fever,  the  pulse  is,  considering  the  temperature, 
faster,  the  sweating  is  almost  confined  to  hands  and  feet,  pigment  is  frequent. 
Nor  are  the  differences  with  regard  to  the  arthritis  less  striking,  for  in  rheumatoid 
arthritis  the  characteristic  joints  to  be  affected  are  those  between  the  first  and 
second  phalanges,  and  as  it  is  an  affection  of  the  synovial  membranes,  and  also 
considerably  of  the  soft  tissues  around  the  joints,  quite  eairly  in  the  disease 
we  get  a  spindle-shaped  swelling  of  these  joints  {Fig.  107)  ;  but  soon  many  other 
joints  are  affected,  and  before  long  almost  every  joint  in  the  body  is  implicated, 
so  that  we  have  the  simultaneous  affection  of  a  great  many  joints.  The 
temporo-maxillary  joint  is  often  involved  ;  so  is  the  spine.     It  will  be  noticed 


JOINTS,     AFFECTIOXS     OF     THE 


379 


that  in  every  respect  the  arthritis  is  clinically  different  from  that  of  rheumatic 
fever.  The  joints  never  suppurate,  but  the  epitrochlear  gland  may  be  found 
enlarged.  Slowly  the  attack  subsides  ;  as  it  does  so,  passive  movements 
and  massage  should  be  undertaken,  for  if  not,  the  thickening  of  the  tissues 
around  the  joints  leads  to  their  fixation.  That  it  may  be  prevented  is 
shown  by  the  fact  that  the  jaw  only  becomes  fixed  very  rarely,  presumably 
because  of  its  frequent  movement.  There  is  never  any  endocarditis,  but 
the  arthritic  muscular  atrophy  is  often  extreme,  indeed,  as  extreme  as  in 
any  variety  of  arthritis.  In  a  few  months  a  second  attack  comes  on,  but 
both  the  general  symptoms  and  the  arthritis  are  less  severe  than  in  the  first ; 


J''ig'.  io8. — Severe   rheumatoid   arthritis  :     skiagram    of   the  hands,  showing  ulnar  deflection  but 
no   bonv  intra-articular  changes. 


then  a  few  months  later  another  less  severe  than  the  second,  and  so  on  until 
after  four,  five,  or  six  attacks  the  disease  Avears  itself  out.  In  the  later  stages, 
if  the  joints  have  been  allowed  to  become  stiff,  the  disease  is  often  confused  with 
osteo -arthritis  ;  but  rheumatoid  arthritis  occurs  in  younger  subjects,  and  there 
are  no  bony  outgrowths  [Fig.  io8),  except  in  a  few  cases  m  which  chronical!}^ 
thickened  fringes  of  sjmovial  membrane  have,  by  friction  during  movements 
of  the  joints,  worn  away  a  little  patch  of  cartilage,  exposed  and  irritated  the 
bone,  and  led  to  a  slight  outgrowth.  In  such  a  case  the  erosion  of  the 
cartilage  may  lead  to   bony  grating,   but   in  even  a  very  chronic  and  extreme 


38o 


JOINTS,     AFFECTIONS     OF     THE 


case  of  rheumatoid  arthritis,  in  which  the  joints  have  not  been  treated,  grating 
and  bony  outgrowths  are  quite  inconsiderable,  and  are  not  a  leading  feature 
as  in  osteo-arthritis.  Heberden's  nodes  [Fig.  109)  are  not  seen  in  rheumatoid 
arthritis.  The  spindle-shaped  swelling  of  the  phalangeal  joints  of  this  disease 
is  not  seen  in  osteo-arthritis.  The  joints  principally  affected  are  different  in 
the  two  diseases,  as  will  be  seen  on  reference  to  osteo-arthritis,  and  the  history 
is  entirely  different.  Formerly  some  importance  was  attached  to  the  trans- 
parency of  the  bones  to  the  Ar-rays  in  the  neighbourhood  of  the  affected  joints 
which  may  be  seen  in  rheumatoid  arthritis  [Fig.  no),  but  this  is  now  known 
to  be  visible  in  other  forms  of  arthritis.  The  ;tr-rays  are,  however,  of  use 
as  showing  the  bony  outgrowths  of  osteo-arthritis.  In  chronic  cases  of  both 
rheumatoid  arthritis  and  osteo-arthritis  ulnar  deflections  may  be  seen  [Fig.  108). 


Fig.  109. — Heberden's  nodosities  situated  on  terminal  phalanges  of  index  and  middle  fingers. 
(From  Arthriils  Deformans,  by  Llewellyn  Jones  Llewellyn.) 


Henoch's  Purpura. — This  disease  is  confined  to  children  between  infancy  and 
fifteen  years  old,  and  early  in  its  course  pain  and  slight  swelling  of  some  of  the 
large  joints,  with  a  little  elevation  of  temperature,  are  often  present.  As  in 
children  the  pyrexia  and  arthritis  of  rheumatic  fever  are  inconspicuous,  mistakes 
have  occurred  between  it  and  Henoch's  purpura,  but  the  pain  in  the  latter  is 
trivial.  The  attacks  of  abdominal  pain,  with  perhaps  vomiting  and  diarrhoea, 
are  characteristic,  and  so  is  the  purpura  {Fig.  m),  together,  in  many  cases,  with 
bleeding  from  some  internal  organ  :  hence  hsematuria,  haematemesis,  or  melaena. 
The  purpura  should  not  give  rise  to  any  difficulty  ;  rheumatic  purpura  is  un- 
known under  the  age  of  fifteen. 

Gout. — This  is  often  said  to  be  present  when  it  is  not.  The  most  certain  points 
in  the  diagnosis  of  gout  are,  first,  the  detection  of  urate  of  sodium,  usually  as 
white  hard  masses  in  connection  with  a  joint  [Fig.  112),  in  a  bursa,  or  as  a 


JOINTS,     AFFECTIONS     OF     THE 


381 


deposit  in  the  cartilage  of  the  edge  of  the  ear  ;  here  it  is  frequently  not  easy 
to  be  sure  if  a  white  nodule  is  urate  of  soda  or  a  projection  of  cartilage  with 
the  skin  stretched  tightly  over  it.  If  it  is  possible  to  remove  a  minute  frag- 
ment with  a  needle,  crystals  of  urate  of  sodium  may  be  seen  under  the  micro- 
scope. Secondly,  there  may  be  a  history  of  repeated  characteristic  attacks. 
The  gouty  arthritis  that  we  see  now-a-days  is  generally  strongly  inherited,  but 


Fig.  no. — Rheumatoid  arthritis:  skiagram  showing  the  transparency  of  the  ends   of  bones. 


not  often  by  women,  and  therefore  the  family  history  is  of  importance  ;  it 
rarely  shows  itself  before  the  age  of  twenty,  but  I  have  seen  it  in  a  boy  fifteen 
years  old.  Most  of  the  sufferers  from  gout  now  alive  get  their  attacks  quite 
independently  of  any  errors  in  diet  ;    many  of  them  are  most  abstemious. 

The  diagnosis  is  not  difficult  when  the  patient  has  one  or  more  attacks  of 
arthritis  in  the  characteristic  joint — that  of  the  ball  of  the  great  toe,  more  often 


382 


JOINTS,     AFFECTIONS     OF     THE 


III.— Henoch's  purpura. 


the  right  than  the  left  ;    the  attack  usually  begins  at  night  with  excruciating 

pain,  which  subsides  towards  the 
early  morning  ;  the  patient,  ex- 
hausted with  pain,  drops  asleep, 
to  wake  later  and  find  his  joint 
swollen  and  tense.  There  is  some 
fever.  Probably  during  the  day 
his  toe  does  not  cause  pain  unless 
he  walks  on  it  ;  but  he  has  another 
attack  the  next  night,  not  so 
severe  as  that  on  the  first,  and  on 
each  successive  night  the  attacks 
are  less.  He  may  have  another 
bout  at  any  period  of  his  life,  and 
he  may  have  many  bouts,  and 
other  joints  may  become  affected 
subsequently.  The  real  difficulty 
in  the  acute  cases  comes  when  it 
is  suggested  that  an  acute  arthritis 
with  pyrexia,  and  swelling  and  red- 
ness of  a  joint  other  than  that  of 
the  great  toe,  is  caused  by  gout. 
I  have  recently  seen  the  difficulty 
in  one  patient  in  the  wrist,  in 
another  in  the  knee.  Such  cases, 
if  they  are  not  gout,  are  some 
bacterial  arthritis.  If  more  than 
one    joint   is    affected    with   acute 

arthritis  at  the  same  time,  the  probability  is  against  gout,  and  the  greater  the 

number  of  joints  affected,  the  less  likely  is  the  case  to  be  one  of  gout.     The 

history  and   presence 

of    urate    of    sodium 

are    often    conclusive 

in  favour  of  gout.      If 

pus  forms,  the  case  is 

almost   certainly    not 

gout,  for  gouty  joints 

very  rarely  suppurate 

except     late     in     the 

chronic    disease.     On 

the    other    hand,    the 

implication  of  tendon 

sheaths    and    pain    in 

the  back  of  the  soles 

of    the    feet    are    in 

favour  of  gout,  but  it 

must  be  remembered 

that  both  these  occur 

in   gonorrhoeal    cases. 

The     presence     of     a 

source  of  infection  is 

of  course  against  gout. 

The  diificulty  is  made 

especially     great      in 


/'>>.  112. — Chronic   gout  :     deposition  of  urate  cf  sodium  in  and 
near  the  joints. 


JOINTS,     AFFECTIONS     OF     THE 


383 


these  cases  by  the  fact  that  the  general  sj'mptoms  and  arthritis  may,  although 
gouty,  be  continuous  rather  than  paroxj'smal  ;  but  on  the  whole,  continuously 
increasing  severity  of  general  symptoms  is  against  gout.  The  goutily-inflamed 
joint  looks  especially  shiny,  is  exquisitely  tender  on  the  surface,  and  is  more 
painful  at  night  than  during  the  day.  Cases  of  extreme  difhculty  have  been 
recorded,  in  which  the  first  joint  affected  by  pyaemia  chanced  to  be  that  of 
the  great  toe. 

Probably  most  examples  of  acute  arthritis  said  to  be  gouty  are  so,  but  mistakes 
are  common  about  chronic  gout.  Many  patients  with  chronic  arthritis  are 
quite  wrongly  said  to  have  gout ;  usually  they  have  osteo-arthritis.  The  presence 
of  visible  urate  of  sodium  in  places  already  mentioned  {Fig.  112),  the  history  of 
previous  acute  attacks,  the  history  of  gout  in  ancestors,  the  age  and  sex,  will  all 
help.     The  presence  of  bony  outgrowths  is  strongly  against  gout,  but  it  is  not 


/^^^.  113. —  Chronic  gout  :     skiagram   of  the  hands,  showing  sodium  urate  deposits  about  the  ends 
of  many  of  the  phalanges. 


conclusive,  for  such  may  occur  in  true  gout,  either  more  or  less  all  round  the 
joint^  or  in  the  form  of  little  nodules  ;  but  thej^  never  attain  the  considerable 
size  common  in  osteo-arthritis.  If  no  urate  of  soda  is  anywhere  visible,  the 
diagnosis  may  be  very  difficult  ;  the  reader  should  consult  the  principal  points 
mentioned  under  the  heading  of  osteo-arthritis.  Any  joints  in  the  body  may 
be  affected  by  gout,  but  it  is  very  rare  in  the  joints  of  the  trunk,  the  shoulder, 
or  the  hip.  The  spine,  shoulder,  and  hip  are  commonly  affected  in  osteo- 
arthritis. Urate  of  sodium  may  be  seen  in  and  near  the  joints  as  light  spots 
in  ;i;-rays  prints  {Fig.  113). 

2.  Chronic  Affections  of  Joints. — We  will  now  pass  on  to  consider  the  diagnosis 
of  varieties  of  arthritis  which  are  for  the  most  part  chronic,  but  it  must  be 
remembered  that  many  of  those  mentioned  as  acute  become  chronic,  and  their 
diagnosis  has  been  described. 


384  JOINTS,     AFFECTIONS     OF     THE 

Osteo-arthritis  is  a  chronic  disease  frequently  confused  with  rheumatoid 
arthritis,  from  which  it  is  completely  distinct,  both  clinically,  and  from  the 
point  of  view  of  morbid  anatomy.  Rheumatoid  arthritis  (p.  378)  is  primarily 
a  disease  of  the  synovial  membrane  and  soft  tissues  of  the  joints.  Osteo- 
arthritis is  primarily  a  disease  of  the  cartilage  and  bones  leading  to  the 
destruction  of  the  cartilage,  eburnation  of  bony  surfaces,  and  the  production 
of  much  new  bone  at  the  edges  of  the  joint  ;  hence  bony  outgrowths,  grating 
of  the  joint,  and  locking  of  it  so  that  movement  is  difficult,  are  common. 
Thickening  of  the  synovial  membrane  occurs,  but  is  less  important ;  the 
ligaments  become  implicated  and  may  soften  ;  if  so,  the  joint  becomes  flaU- 
like  ;  there  may  be  some  thickening  of  the  tissues  around  the  joint  and  some 
increase  of  synovial  fluid,  and  then  the  joint  becomes  enlarged..  It  is  easy 
to  distinguish  in  most  cases  between  osteo-arthritis  and  rheumatoid  arthritis, 
by  the  appearance  of  the  affected  joint.  In  the  former  we  have  an  irregularly 
enlarged  joint,  with  palpable  bone  excrescences  and  much  grating  ;  often 
the  joint  is  fixed  by  these  bony  excrescences,  rarely  it  is  flail-like  from 
destruction  of  ligaments  ;  often  all  the  causes  just  mentioned  combine  to 
make  it  very  large.  This  is  altogether  different  from  the  spindle-shaped 
swelling  of  rheumatoid  arthritis  (p.  378).  Then  osteo-arthritis  is  often  confined 
to  one  joint,  and  that  a  large  one,  e.g.,  the  knee  ;  rheumatoid  arthritis  affects 
many  joints,  and  is  raost  characteristically  seen  in  small  joints,  e.g.,  those 
between  the  first  and  second  phalanges  ;  but  when  osteo-arthritis  does  show 
itself  in  small  joints,  those  most  often  affected  are  the  terminal  joints  of  the 
phalanges,  where  the  bony  excrescences  form  Heberden's  nodes.  These  are 
characteristic  of  osteo-arthritis.  Rheumatoid  arthritis  is  far  more  commonly 
seen  in  young  women ;  osteo-arthritis  in  women  at  the  menopause.  Rheuma- 
toid arthritis  nearly  always  begins  with  fever,  although  often  slight  ;  osteo- 
arthritis is  almost  always  afebrile.  The  pulse  is  often  rapid  in  those  who 
have  rheumatoid  arthritis  ;  it  is  not  particularly  affected  in  those  who  have 
osteo-arthritis.  The  spine  is  more  often  affected  by  osteo-arthritis  than 
rheumatoid  arthritis,  and  it  is  quite  common  in  the  dissecting-room  to  find  that 
a  large  number  of  elderly  subjects  have  osteo-arthritis  of  the  spine.  Muscular 
atrophy  is  far  greater  with  rheumatoid  arthritis  than  with  osteo-arthritis.  Osteo- 
arthritis is  especially  liable  to  attack  the  hip — usuallj'  only  one — and  this  form  of 
it  is  commonest  in  elderly  men.  It  was  formerly  called  morbus  coxcb  senilis. 
Great  care  must  be  taken  to  distinguish  the  pain  due  to  this  from  that  of 
sciatica.  The  chief  point  of  distinction  is,  that  in  the  latter  the  nerve  itself  is 
tender  to  pressure  ;  but  it  must  not  be  forgotten  that  in  very  rare  cases  osteo- 
arthritic  outgrowths  from  the  hip  may  implicate  the  sciatic  nerve  and  so  cause 
genuine  sciatica.  Although  osteo-arthritis  of  the  hip  usually  causes  lameness, 
so  many  other  conditions  do  this,  e.g.,  sacro-iliac  disease,  that  the  symptom  is 
of  little  value.  The  knee  is  the  joint  most  often  affected  by  osteo-arthritis — 
usually  both,  but  sometimes  only  one  is  implicated.  This  disease  of  the  knee  is 
very  common  in  women  of  ages  between  forty-five  and  fifty-five.  Thej'  com- 
plain of  pain  and  stiffness.  Often  the  pain  and  tenderness,  if  present,  are  confined 
to  one  spot.  There  is  usually  considerable  enlargement  of  the  joint,  bony 
irregularities  may  be  felt,  and  grating  and  crackling  on  movement  are  very 
common  ;  these  are  due  to  bony  out-growths,  erosion  of  cartilage,  and  thickening 
of  synovial  membrane,  which  also  gives  a  feeling  to  the  observer's  hand  placed 
over  the  joint  when  it  is  moved,  as  though  he  were  feeling  the  movement  of  wet 
sand  in  a  bag.  The  grating  may  be  heard  very  loudly  through  the  stethoscope. 
Other  joints  often  implicated  in  osteo-arthritis  are  the  shoulder,  elbow,  ankle, 
wrist,  and  temporo-maxillary  joint ;  but  what  has  been  said  about  the  disease  in 
general,  and  that  of  the  knee  in  particular,  applies  to  them.     The  disease  may 


JOINTS,     AFFECTIONS     OF     THE 


385 


be  considerably  advanced  and  yet  confined  to  one  joint,  or  any  number  may 
be  affected.  The  points  which  have  been  especially  mentioned  as  helping  to 
distinguish  osteo-arthritis  from  rheumatoid  arthritis  will  aid  in  the  distinction 
of  it  from  other  forms  of  arthritis. 
Pads  {Figs.  114,  115)  on  the 
dorsal  aspect  of  the  joints  between 
the  first  and  second  phalanges  are 
not  rare.  They  vary  in  size  from 
a  split  pea  to  a  hazel-nut.  The 
joints  are  not  diseased,  but  these 
pads,  which  are  due  to  a  great 
growth  of  fibrous  tissue  under- 
neath the  corium,  have  been  con- 
fused with  osteo-arthritis.  They 
are  often  associated  with  Dupuy- 
tren's  contracture  [Fig.  44,  p.  167). 
Ulnar  deflection  (see  Fig.  108)  is 
seen  in  osteo-arthritis,  but  is  also 
present  in  so  many  other  affec- 
tions of  the  fingers  and  wrist  that 
by  itself  it  is  of  no  value  in 
diagnosis. 

Tuberculous  Disease  of  Joints. — 
This  is  most  common  in  children 
of  between  three  and  five  years, 
and  becomes  rarer  as  age  advances. 
About  40  per  cent  of  the  cases  are 
in  the  spine,  40  per  cent  in  the 
hip,  10  per  cent  in  the  knee,  and 
the  other  joints  which  are  affected 

not  uncommonly  are  the  ankle,  shoulder,  elbow,  and  wrist.  The  disease  is 
essentially  slow,  so  that  the  early  stages  are  often  overlooked.  It  is  stated 
that  tuberculous   arthritis   is   so   insidious   in    its    onset    that    for    one    case    in 

which  the  affection  is  detected  and 
adequately  treated  in  the  first  month 
of  its  existence,  there  are  twenty  in 
which  it  is  allowed  to  drift  on  for 
three  or  four  months,  or  even  longer, 
before  it  is  recognized.  For  some 
time  there  may  be  only  slight  transient 
impairment  of  movement,  or  an 
occasional  twinge  of  pain  ;  gradually 
impaired  movement,  showing  itself  as 
slight  lameness  in  the  lower  extremity, 
becomes  evident,  but  it  must  not  be 
concluded  that  necessarily  there  is  no 
tuberculous  disease  of  a  joint  because 
there  is  no  impairment  of  movement. 
In  the  same  way,  although  pain,  often 
worse  at  night,  and  causing  screaming, 
is  an  important  sign,  yet  pain  may 
be  absent  for  a  long  while,  or  altogether.  In  all  the  joints  except  the  shoulder 
and  the  hip — which  are  so  deeply  covered  by  soft  parts  that  unless  it  is 
considerable  it  cannot  be  detected — swelling  is  a  very  important  symptom, 
D  25 


-F/^.  114. — Pads  on  the  dorsal  aspect  of  joints  : 
not  to  be  confused  with  osteo-arthritic  changes.  ^  (By 
permission  from  Quarterly  Journal  of  Medicine, 
vol.  i.) 


Fig.  1 15. — Skiagram  showing  that  the  pads 
depicted  in  Fig-.  114  affect  the  soft  parts  and  not 
the  underlying  joints.  (By  permission  from 
Quarterly  Journal  of  Medicine,  vol.  i.) 


386  JOINTS,     AFFECTIONS     OF     THE 

for  it  is  almost  invariably  present,  even  in  the  earliest  stage.  It  may  be 
verj'  slight.  Although,  as  just  mentioned,  there  may  be  no  defect  of 
movement  in  the  early  stages,  sooner  or  later,  and  often  quite  early,  there 
is  impairment  of  movement,  and  this  symptom  is  very  common  and  of  great 
value.  Tuberculous  arthritis  is  usually  accompanied  by  wasting  of  rauscles 
moving  the  joint.  It  must  never  be  forgotten  that  a  tuberculous  arthritis  is 
so  slow  in  its  development  that  often  it  is  not  ascribed  to  its  correct  cause. 
Also  that  for  a  time  the  symptoms  are  so  slight  that  no  attention  may  be  paid  to 
them.  Mistakes  are  ver}^  serious,  and  tuberculous  arthritis  ought  always  to  be 
present  in  our  minds  when  examining  a  diseased  joint.  It  is  very  rare  for  more 
than  one,  or  perhaps  two  joints  to  be  affected  in  the  same  person  ;  tuberculous 
disease  elsewhere,  e.g.,  phthisis,  is  not  common  ;  lardaceous  disease,  formerly 
so  frequent  a  complication,  is  now  seldom  seen;  and  general  symptoms,  e.g., 
p5'Texia,  are  often  absent  and  rarely  extreme  ;  on  the  other  hand,  those  affected 
are  often  pale.  Bon3''  outgrowths  are  not  to  be  detected  ;  the  joint  affected  is 
swollen  and  feels  thick  :  hence' the  phrase  "  pulpy  knee."  There  is  often  a 
history  of  injury  to  a  joint,  which  later  becomes  tuberculous,  and  then  the 
transition  from  a  traumatic  to  a  tuberculous  arthritis  is  often  overlooked. 
Tuberculous  disease  of  the  sacro-Uiac  joint  is  particularly  difficult  to  diagnose. 
Tuberculosis  of  the  hip  is  often  overlooked,  because  the  pain  is  referred  to  the 
knee,  and  the  slight  wasting  of  the  hip  muscles  is  not  detected. 

Acquired  Syphilitic  Arthritis. — This  is  most  easily  recognized  by  those  who 
constantly  bear  in  mind  the  possibility  of  its  existence.  If  the  characteristic 
pains  of  syphilis,  which  are  usually  worse  at  night,  happen  to  occur  near  a  joint, 
thejr  nia}^  be  carelesslj^  ascribed  to  gout  or  osteo-arthritis.  In  the  secondary 
stage  of  s^'philis,  and  more  particularly  earl}^  in  it,  a  sj^hilitic  s\Tiovitis  of  any 
joint  may  occur.  It  is  subacute,  slow,  is  attended  with  stiffness,  swelling,  and 
occasionally  tenderness,  and  usuallj^  is  confined  to  one  joint.  Pain,  too,  may 
be  present,  but  commonly  neither  pain  nor  tenderness  are  prominent  symptoms. 
There  is  some,  but  not  much,  enlargement  of  the  joint  from  distention  with 
synovial  fluid  ;  in  a  few  cases  the  size  of  the  joint  varies  considerably  in  a  short 
time.  These  cases  are  often  mistaken  for  tuberculous  arthritis,  but  the  error 
can  usually  be  avoided  if  the  patient  is  examined  carefully  and  questioned  for 
other  evidence  of  S}'philis  ;  and  in  this,  and  all  other  forms  of  arthritis  in  which 
there  is  anj^  possibility  of  S5''philis,  a  Wassermann  test  should  be  done.  Syphilitic 
arthritis  in  the  tertiary'  stage  is  very  rare  :  there  are  two  varieties  of  it,  both  of 
which  produce  considerable  swelling  and  disorganization  of  the  joint ;  in  one  there 
is  a  deposit  of  gummatous  material  in  the  subsynovial  tissue,  in  the  other  in 
the  ends  of  the  bone.  Both  varieties  are  usually  confined  to  a  single  joint,  neither 
is  painful,  and  both  are  liable  to  recur.  Great  effusion  of  synovial  fluid  is  not 
common,  but  when  the  disease  is  in  the  subsynovial  tissues  the  joint  is  enlarged 
and  the  thickening  of  the  S3movial  membrane  can  be  felt. 

Congenital  Syphilitic  Arthritis. — In  children  and  young  adults  congenital  sj^ph- 
ilis  may  cause  an  arthritis  which  is  very  like  that  caused  b}''  tubercle.  The  knees 
are  affected  most  often,  and  the  disease  is  often  symmetrical.  If  there  is  much 
sj'novial  exudation,  fluctuation  is  easily  detected  ;  if  there  is  much  gummatous 
deposit  in  the  subsjmovial  tissue,  the  synovial  membrane  feels  thickened  and  ir- 
regular. There  is  no  pain,  and  verj?- little  impairment  of  movement.  The  existence 
of  this  disease  must  always  be  remembered  ;  the  history  and  examination  for 
other  signs  of  syphilis  must  be  thorough,  and  a  Wassermann  reaction  must  be  done. 

In  infants  a  remarkable  result  of  congenital  sj'-philis  occurs.  Osteochondritis 
occurs  in  the  sub-epiphyseal  plate  of  cartflage  and  adjacent  bone  ;  the  epiphysis 
becomes  separated  from  the  shaft,  so  that  there  is  motility  and  dull  grating  as  if 
a  fracture  had  occurred.     At  the   same  time  there   is  considerable  swelling  of 


JOINTS,     AFFECTIONS     OF     THE 


387 


the  soft  parts  around,  from  the  inflammation  having  spread  to  them,  so  that 
there  is  much  swelling  about  the  joint,  although  the  joint  itself  is  usually 
not  implicated.  Separation  of  the  epiphysis  from  the  shaft  makes  the  limb 
paralyzed  :  hence  the  phrase  syphilitic  pseudo-paralysis  applies  to  this  condition. 
Suppuration  is  very  rare,  and  the  improvement  with  mercury  is  rapid.  This 
condition  may  be  noticed  at  any  period  from  one  month  after  birth  till  the  age 
of  two  or  three  years,  but  it  is  most  often  seen  when  the  child  is  two  or  three 
months  old.  It  is  usually  multiple,  and  there  is  some  tenderness  and  slight  pain. 
Other  signs  of  congenital  syphilis  are  generally  present,  but  if  not,  the  condition 
is  so  characteristic  that  the  child  must  at  once  be  given  mercury. 

Intermittent  Hydrarthrosis. — 
This  rare  disease  should  be 
diagnosed  easily.  It  is  com- 
monest in  women.  Cases  have 
been  recorded  between  the 
ages  of  eight  and  fifty,  but  the 
patients  are  most  often  be- 
tween twenty  and  thirty  years 
old.  Fluid  is  rapidly  poured 
out  in  the  joint,  so  that  it  is 
distinctly  swollen  in  a  few 
hours  ;  the  distention  attains 
its  maximum  in  one  or  two 
days ;  it  then  recedes,  and  has 
disappeared  by  the  fourth  or 
fifth  day.  The  effusion  leads  to 
stiffness  of  the  joint,  and  gener- 
ally there  is  some  pain,  but 
usually  very  little  tenderness, 
and  the  joint  is  neither  red 
nor  hot.  The  knee  is  affected 
most  often  ;  it  may  be  one  or 
both  knees  ;  if  not  the  knee  it 
is  almost  always  a  large  joint 
that  is  the  seat  of  the  effusion. 
It  is  rare  for  more  than  two 
joints  to  be  affected  at  once. 
The  remarkable  part  of  the 
affection  is  that  the  effusion 
is  periodic,  and  often  the  in- 
terval of  time  between  the 
attacks  in  the  same  patient  is 
on  each  occasion  exactly  the 
same  :  thus  in  one  patient  the 

effusion  always  began  on  the  ninth  day  from  the  beginning  of  the  previous 
effusion  ;  the  interval  has  been  known  to  be  less  than  this,  and  it  is  often  more. 
It  may  be  that  for  a  period  the  intervals  are  of  a  certain  length,  and  then  for  a 
period  they  are  of  a  different  but  uniform  length.  In  other  cases  there  is  no 
periodicity.  In  each  attack  the  same  joint  or  joints  are  affected  in  the  same 
patient.  After  three  or  four  years  the  attacks  cease  in  most  cases,  but 
occasionally  there  are  recurrences. 

Charcot's  Disease  {Fig.  1 16). — This  is  the  arthritis  met  with  in  tabes  dorsalis,  and 
if  any  patient,  of  such  an  age  that  he  could  be  suffering  from  tabes,  has  chronic 
arthritis  of  a  single  joint,  we  ought  always  to  examine  him  for  signs  of  tabes. 


y'ijr.  no.  Charcot's  di<;ease  of  the  riglit  knee  joint  in 
association  with  tabes  dorsalis  :  showing  distention,  and 
also  displacement  of  tibia  to  the  right. 


JOINTS,     AFFECTIONS     OF     THE 


Because  this  is  not  done  many  cases  are  overlooked,  for  the  arthritis  may  exist 
even  when  the  patient  is  unaware  that  he  has  any  signs  of  tabes.  There  is 
nothing  cliaracteristic  of  tabetic  arthritis,  and  many  joints  affected  with  it  might, 
for  all  the  clinical  symptoms  of  the  arthritis,  or  from  the  appearances  after  death, 
be  equally  well  affected  by  osteo-arthritis  ;  but  the  following  points  will  often 
make  one  suspicious.  The  effusion  is  frequently  very  great ;  some  of  the  biggest 
joints  seen  are  those  the  seat  of  tabetic  arthritis  ;  the  ligaments  may  be  much 
softened,  so  that  the  joint  becomes  fiail-like,  but  the  growth  of  new  bone  at  the 
edges  of  the  joint  is  often  quite  slight,  and  there  is  considerable  atrophy  of  bone  ; 
thus  I  have  seen  the  floor  of  the  acetabulum  as  thin  as  paper,  and  because  it 
was  so  thin,  the  pressure  from  the  neck  of  the  femur  had  expanded  the  floor  of 
the  acetabulum  so  far  into  the  pelvis  that  it  formed  a  large  projection  into  the 
pelvic  cavity.  Tabetic  arthritis  is  usually  chronic  and  never  acute,  but  it  may 
be  rapid  ;  thus  there  may  be  advanced  destruction  of  the  joints  in  a  few  weeks  ; 
it  is  almost  always  painless  ;  generally  large  joints,  e.g.,  knee,  hip,  are  affected  ; 
generally  only  one  joint,  but  I  have  seen  two.  The  rarefaction  of  the  bones 
makes  them  liable  to  fracture.  When  tabetic  arthritis  occurs  in  the  bones  of  the 
hand  or  foot,  the  considerable  swelling  may  cause  it  to  be  mistaken  for  tuber- 
culous disease.  In  75  per  cent  of  cases  of  tabetic  arthritis,  the  joints  affected 
are  those  of  the  lower  extremity. 

Arthritis  in  Syringoinyelia. — In  75  per  cent  of  the  patients  affected  Math  this 
form  of  arthritis,  the  joints  affected  are  those  of  the  upper  extremity.  There 
is  nothing  absolutely  distinctive  of  this  variety  of  arthritis  ;  it  resembles  closely 
that  due  to  tabes  ;  perhaps,  on  the  whole,  some  of  the  cases  more  nearly  resemble 
osteo-arthritis.  Owing  to  the  loss  of  sensation  in  syringomyelia,  wounds  are 
common  ;  hence  the  joints  may  become  septic.  Mistakes  in  diagnosis  can  only 
be  avoided  by  always  having  in  mind  the  possibility  of  the  occurrence  of  syringo- 
myelia, and  examining  the  patient  for  it.  Happily  it  is  rare,  and  often  the 
symptoms  of  syringomyelia  are  evident  before  the  arthritis  shows  itself.  In  about 
half  the  cases  of  syringomyelia  there  is  scoliosis  of  the  spine. 

Arthritis  in  H cBmophilia. — In  this  disease,  blood  may  be  poured  out  into  either 
the  synovial  membrane  or  the  cavity  of  the  joint.  This  is  probably  always  the 
result  of  a  blow,  often  so  slight  as  to  pass  unnoticed.  It  is  most  common  in  the 
knee  and  ankle.  If  the  bleeding  is  at  all  considerable,  the  joint  swells,  the  rate 
of  swelling  depending  upon  the  rate  of  effusion  of  blood.  The  joint  is  puffy  ;  there 
may  be  fluctuation,  pain  on  movement,  and  tenderness.  The  whole  trouble 
often  subsides,  but  sometimes  more  or  less  swelling  persists  for  a  time,  and 
even  if  a  joint  gets  well,  relapse  is  likely.  In  other  cases,  either  the  impaired 
blood-supply  resulting  from  damaged  vessels  or  the  friction  of  the  clots, 
leads  to  erosion  of  the  cartilage,  and  permanent  disease  of  the  joint  results. 
Forgetfulness  of  the  fact  that  disease  of  the  joints  occurs  in  haemophilia 
has  led  to  the  serious  mistake  of  incising  a  joint  into  which  bleeding  has 
occurred.  The  condition  is  to  be  diagnosed  by  observing  the  other  signs  of 
hcemophilia. 

Malignant  and  Hydatid  Disease  of  Joints. — Eoth  these  are  very  rare,  and  in 
each  case  the  disease  almost  always  begins  in  the  adjacent  bone,  and  therefore 
properly  belongs  to  diseases  of  bones.  Both  are  very  serious  ;  hydatid  disease 
of  a  joint  is  very  liable  to  lead  to  suppuration  in  it. 

Displacement  of  Semilunar  Cartilages. — The  diagnosis  properly  belongs  to 
surgery.  If  it  causes  much  synovitis,  the  cause  of  the  synovitis  is  very  apt  to  be 
overlooked.  There  is  often  a  history  of  a  wrench,  or  the  patient  complains  that 
he  feels  something  in  the  joint  slip  or  catch  ;  this  may  cause  considerable 
pain,  and  there  is  often  tenderness  over  the  internal  semilunar  cartilage.  Some- 
times similar  symptoms  are  produced  by  a  thickened  fringe  of  synovial  membrane 


JOINTS,     AFFECTIONS     OF     THE 


389 


becoming  nipped.    This  may  occur  in  osteo-arthritis.    The  thickened  fringe  may 
become  detached,  and  then  it  forms  a  loose  body. 

Nervous  Mimicry,  Neuromimesis,  or  Hysterical  Joints. — In  these  cases  some  of 
the  symptoms  of  arthritis  are  imitated  without  there  being  any  actual  disease 
of  the  joint.  It  is  important  to  remember  that  hysteria  is  a  disease  and  is  not 
mere  malingering.  The  malingerer  can  voluntarily  get  rid  of  his  supposed 
disease  if  he  wishes ;  the  hysterical  girl  cannot,  as  she  has  not  sufficient  power  of 
will.  There  are  three  main  varieties  :  (i)  The  joint  is  kept  constantly  in  an 
abnormal  position,  e.g.,  the  knee  may  be  considerably  flexed  ;  (2)  The  joint 
cannot  be  moved,  e.g.,  the  hand  may  hang  down  from  the  wrist,  as  in  extensor 
paralysis,  and  it  cannot  be  raised  ;  (3)  There  may  be  acute  pain  in  the  joint.  In 
all  these  cases,  careful  examination  will  usually  show  that  there  are  no  real 
symptoms  of  arthritis  :  there  is  no  swelling,  no  heat,  no  grating,  no  bony  out- 
growth, the  immovably  fixed  joint  can  be  moved  freely  under  an  anaesthetic  ; 
on  the  other  hand,  the  pain,  if  present,  is  far  in  excess  of  any  pain  due  to  arthritis, 


I^ig:  117. — Pulmonary  osteo-arthropathy  :  the  patient  had  chronic  fibroid  phthisis.      The  bony 
parts  of  the  fingers  were  becoming  progressively  thicker,   especially  in  the  right  hand. 


and  the  tenderness  may  be  so  great  that  the  patient  will  not  let  the  joint  be 
touched.  Both  pain  and  tenderness  disappear  if  the  patient's  attention  is 
diverted,  and  neither  keeps  the  patient  awake  nor  affects  the  general  health. 
The  pain  may  radiate  far  beyond  the  joint  ;  very  rarely  in  hysteria  there  is  a 
trivial  swelling,  but  it  is  not  such  as  would  be  produced  by  distention  of  the 
synovial  cavity  ;  it  is  often  more  in  the  neighbourhood  of  the  joint  than  over 
it.  But  nearly  always  there  is  no  swelling  about  a  hysterical  joint.  Usually  the 
joint  supposed  to  be  diseased  is  cold ;  very  rarely  it  is  hot  and  perhaps  a  little 
red  ;  but  this  phenomenon,  when  present,  is  only  a  local  blush  due  to  the  fact 
that  the  patient's  attention  is  directed  to  the  joint,  and  it  quickly  passes  away. 
The  stiffness  of  a  hysterical  joint  can  be  made  out  to  be  due  to  contraction  of 
muscles  and  not  to  alteration  of  the  joint  itself  ;  occasionally  it  is  variable,  and 
it  is  often  extreme,  out  of  all  proportion  to  any  possible  joint  disease  ;  and  often, 
too,  the  attitude  of  the  joint  is  not  that  usually  seen  in  arthritis.  It  has  been 
pointed  out  repeatedly  that  muscles  which  move  a  joint  usually  atrophy,  often 


390 


JOINTS,     AFFECTIONS     OF     THE 


rapidly,  when  that  joint  is  diseased,  quite  apart  from  disuse.  In  hysterical 
affections  of  joints  the  muscles  waste  onlv  slowlv  in  proportion  to  the  disuse  of 
the  joint. 

Muscular  Paralysis. — Often,  e.g.,  in  peripheral  neuritis,  the  muscles  which 
undergo  rapid  Avasting  as  a  result  of  disease  of  the  lower  motor  neuron  soon 
begia  to  contract,  and  this  leads  to  considerable  alteration  in  the  usual  position 

of  joints.  Thus,  the  knee 
and  elbow  become  strongly 
flexed,  and  at  first  it  may 
be  thought  that  these  un- 
usual positions  are  the 
result  of  disease  of  the 
joint,  for  long-contiaued 
chronic  disease  of  a  joint 
will  lead  to  unusual  per- 
manent positions  from  con- 
tracture of  ligaments,  from 
the  pull  of  muscles  on  a 
Aveakened  joint,  and  from 
contracture  of  muscles 
wasted  from  arthritic 
atrophy  ;  but  a  little 
estimation  of  the  history, 
the  condition  of  the  joints, 
and  the  sj-mptoms  of  nerve 
disease  Avill  soon  lead  to  a 
correct  diagnosis. 

Hypertrophic  Pulmonary 
Osteo  -  arthropathy.  —  This 
rare  condition  is  not  really 
a  disease  of  joints  at  all, 
for  the  change  consists  in 
2JD.  enlargement  of  the  ends 
of  the  bones,  and  hence  the 
joints  appear  large  and  the 
patient  cannot  bend  them 
properly?.  Often  this  is  all 
that  is  the  matter  with  the 
joints,  but  in  advanced 
cases  there  is  some  thick- 
ening of  the  s\Tiovial  mem- 
brane and  some  erosion  of 
cartilage.  The  upper  ex- 
tremit}^  is  affected  more 
often  than  the  lower,  and 
the  joints  usually  deformed 
are  the  wrist,  and  the  car- 
pal and  interphalangeal 
joints  {Figs.  117  and  118)  ;  when  the  condition  exists  in  the  lower  extremitv  the 
corresponding  joints  are  implicated.  In  extreme  cases,  the  enlargement  extends 
up  the  shafts  of  the  affected  bones.  The  condition  is  easih^  distinguished,  for 
it  is  almost  always  accompanied  b}'  clubbing  of  the  fingers,  and  almost  always 
(80  per  cent  of  the  cases)  it  is  associated  with  chronic  pulmonary  disease, 
especially  fibrosis,  bronchiectasis,  or  chronic  empyema,  and  less  often  with  other 


,^'i-'-  Il3.  —  Pulmonnry  osteo-arthropathy  :  .showing  affec- 
tion of  hands  and  feet,  and  the  wasting  due  to  chronic 
phthisis. 


KIDNEY,     ENLARGEMENT    OF  391 

pulmonary  diseases.  The  remaining  20  per  cent  of  the  cases  are  associated 
with  such  diverse  conditions  that  text -books  must  be  consulted  ;  the  most 
interesting  is  aneurysm  of  the  subclavian  artery.  Hypertrophic  osteo-arthro- 
pathy  used  to  be  confused  with  acromegaly,  but  not  only  ought  the  clubbing  of 
the  fingers  and  the  associated  conditions  to  prevent  such  a  mistake,  but  in 
acromegaly  there  is  considerable  enlargement  of  the  hand  and  characteristic 
changes  in  the  face   (see  Fig.  88,  p.  263).  w.  Hale  White. 

KIDNEY,  ENLARGEMENT  OF.— A  renal  sweUing  may  be  so  slight  that  it 
is  only  found  upon  clinical  examination,  may  be  large  enough  to  attract 
the  patient's  attention  to  it,  or  may  even  occupy  a  large  portion  of  the 
abdominal  cavity.  A  number  of  pathological  changes  in  the  kidney  may  give 
rise  to  a  tumour  of  that  organ,  such  as  hydronephrosis,  pyonephrosis,  renal 
tuberculosis  or  abscess,  new  growths  and  various  forms  of  cysts  in  the  kidney  ; 
it  is  necessary  to  be  able  to  diagnose  any  one,  not  only  from  another,  but 
also  from  other  tumours  simulating  a  renal  swelling. 

The  chief  characteristic  points  of  a  renal  tumour  are  : — 

1.  The  large  intestine  is  in  front  of  the  tumour.  When  either  kidney  is  merely 
slightly  enlarged,  both  large  and  small  intestine  will  be  placed  in  front  of  it; 
but  when  the  organ  is  so  enlarged  as  to  reach  the  anterior  abdominal 
wall  the  coils  of  small  intestine  are  pushed  aside.  The  anatomical  relation  of  the 
large  intestine  to  the  kidney,  and  the  absence  of  a  mesentery,  do  not  allow  of 
the  same  mobility  of  the  colon,  which  retains  its  position  in  front  of  the  kidney. 
Hence  an  area  of  resonance  can  usually  be  obtained  in  front  of  a  renal  swelling  ; 
if  the  colon  be  empty,  it  can  sometimes  be  felt  in  a  thin  subject  and  rolled  by 
the  fingers  on  the  surface  of  the  tumour.  Bowel  is  never  placed  in  front  of  a 
splenic  tumour,  and  only  rarely  in  front  of  a  hepatic  tumour. 

2.  The  area  of  dullness  to  percussion  is  continuous  from  the  lateral  aspect  of 
the  swelling  to  the  mid-line  posteriorly — that  is,  there  is  no  area  of  resonance 
between  the  mass  and  the  vertebral  spines,  as  in  a  splenic  or  ovarian  tumour. 

3.  A  renal  tumour  usually  retains  the  shape  of  the  kidney  ;  it  is  rounded  at  its 
borders  and  poles,  and  does  not  possess  any  edge  or  sharp  margin,  as  in  splenic 
or  hepatic  swellings. 

4.  A  renal  tumour  in  the  process  of  enlargement  projects  forwards  and  down- 
wards. It  may  fill  up  the  natural  hollow  of  the  loin,  but  very  seldom  causes 
any  prominence  posteriorly.  A  perinephric  abscess,  which  often  simulates  a 
renal  swelling,  may  cause  a  distinct  prominence  in  the  loin. 

5.  A  renal  tumour  does  not  descend  so  freely  upon  deep  inspiration  as  a  splenic 
or  hepatic  tumour.  A  renal  tumour  may  be  movable  downwards  or  inwards, 
or  may  be  fixed  in  the  loin  by  preceding  inflammation.  An  enlarged  kidney 
can  be  easily  felt  bimanually,  and  if  grasped  between  the  two  hands  can  be 
pushed  into  the  loin. 

6.  When  a  renal  tumour  is  large  enough  to  reach  the  anterior  abdominal  wall, 
it  commonly  comes  in  contact  with  the  latter  at  the  level  of  the  umbilicus,  at 
the  same  time  bulging  out  the  ilio-costal  space.  There  is  usually  a  line  of 
resonance  between  the  upper  margin  of  the  tumour  and  the  hepatic  dullness. 

7.  In  renal  tumour  a  varicocele  may  be  developed  on  the  same  side  as  the 
tumour. 

8.  With  a  renal  tumour  there  may  be  changes  in  the  urine  which  will  point  to 
renal  disease :  but  on  the  other  hand,  the  urine  at  any  one  time  may  be  normal, 
free  from  blood  or  pus,  from  the  fact  that  the  ureter  of  the  diseased  side  is 
blocked,  or  that  the  disease  does  not  involve  the  renal  pelvis. 

9.  In  exceptional  cases,  a  tumour  of  the  right  kidney  may  extend  upwards 
into  the  dome  of  the  diaphragm,  rotating  the  liver  so  that  the  anterior  margin 


392  KIDNEY,     ENLARGEMENT     OF 

descends  below  the  costal  margin,  and  prevents  a  satisfactorj-  palpation  in  the 
renal  area. 

Although,  from  the  above  physical  characters,  it  would  seem  that  a  renal 
tumour  should  present  little  difficulty  in  diagnosis,  yet  it  is  by  no  means  infrequent 
to  find  that  a  tumour  possessing  several  of  these  characters  may  give  rise  to 
considerable  doubt  in  the  determination  of  the  organ  from  which  it  arises.  The 
following  points  will  assist  in  the  diagnosis  of  renal  swellings  from  other  tumours 
\vith  which  they  are  likely  to  be  confused  : — 

1.  Tumours  of  the  gall-bladder  are  placed  immediately  below  the  costal  margin, 
so  that  no  interval  exists  between  the  tumour  and  the  lower  margin  of  the  liver. 
They  are  usually  oval  in  outline,  with  the  long  axis  in  the  line  between  the  ninth 
costal  cartilage  of  the  right  side  and  the  umbilicus  ;  are  freely  movable  with 
the  respiratory  movements,  and  movable  from  side  to  side  about  a  point  at  the 
costal  margin.  There  is  dullness  on  percussion  over  them,  and  the}'  cannot  be 
felt  in  the  loin  or  be  grasped  bimanually.  With  a  tumour  of  the  gall-bladder 
there  may  be  attacks  of  colic  with  or  without  jaundice. 

2.  Enlargements  of  the  liver  pass  downwards  from  beneath  the  costal  margin, 
so  that  there  is  no  line  of  resonance,  or  area  in  which  the  hand  can  be  depressed 
between  the  tumour  and  the  costal  margin.  Hepatic  tumours  do  not  impair 
the  normal  resonance  in  the  loin  in  the  same  manner  as  a  renal  tumour.  A 
tongue-shaped  lobe  of  the  liver  (Riedel's  lobe)  may  cause  difficult],'  in  diagnosis  ; 
but  here  the  lower  margin  will  not  feel  rounded  as  in  a  renal  inimour,  nor  will 
it  be  felt  in  the  loin  on  bimanual  examination.  A  tumour  or  cyst  in  the  concave 
aspect,  or  of  the  left  lobe  of  the  liver,  is  especiallj'  liable  to  cause  error  in 
diagnosis,  whereas,  on  the  other  hand,  a  tumour  of  the  right  kidnej^  which  pro- 
jects upwards  behind  the  liver  may  so  rotate  the  latter  that  the  anterior  margin 
of  the  liver  descends  below  the  costal  margin  and  completely  obscures  the  kidney. 
In  a  case  of  a  large  carcinoma  of  the  right  kidney,  the  liver  was  in  this  waj'  so 
depressed  as  to  render  palpation  of  the  kidney  impossible. 

3.  Enlargements  of  the  spleen  descend  from  beneath  the  left  costal  margin, 
and  have  no  bowel  in  front  of  them.  The  edge  of  a  splenic  tumomr  is  usualh^ 
well-defined  and  often  notched,  and  there  is  resonance  between  the  posterior 
aspect  of  the  tumour  and  the  spinal  column.  A  splenic  tumour  is  more  movable 
than  a  renal  tumour. 

4.  Perinephric  effusions,  whether  of  blood,  pus,  or  urine,  may  form  a  tumour  in 
the  loin  which  upon  phvsical  examination  may  be  mistaken  for  a  renal  swelling. 
A  perinephric  effusion  may  arise  from  some  suppurative  condition  of  the  kidney, 
so  that  the  previous  history  and  the  examination  of  the  urine  will  not  prove  of 
assistance  in  differentiation  ;  or  it  may  be  due  to  conditions  entirely  distinct 
from  renal  disease.  An  effusion  of  blood  around  the  kidnej^  is,  in  nearly  all 
cases,  caused  by  an  injury  to  the  loin,  and  will  be  accompanied  by  other  signs 
of  injury.  A  perinephric  abscess  forms  a  much  more  ill-defined  tumour  than 
that  caused  by  a  renal  swelling,  is  more  acute  in  its  general  symptoms,  such  as 
pain  and  temperature,  and  fills  up  the  ilio-costal  space.  The  skin  over  it  may 
be  thickened  or  oedematous,  and  fluctuation  may  be  felt  to  be  more  superficial 
than  in  a  renal  swelling. 

5.  Tumours  arising  from  the  pelvic  organs,  from  the  ovary  or  uterus,  may  in 
some  cases  simulate  renal  tumours.  An  ovarian  cyst  with  a  long  pedicle  occupy- 
ing the  loin,  has  frequently  been  mistaken  for  an  enlarged  or  movable  kidney, 
and  any  sudden  attacks  of  pain  occurring  from  torsion  of  the  pedicle  may  be 
looked  upon  as  due  to  renal  colic.  The  usual  ovarian  cyst  or  uterine  fibroid 
will  seldom  be  confused  with  a  renal  swelling,  for  they  are  placed  in  the  middle 

ine  of  the  body,  can  be  felt  to  come  up  from  the  pelvis,  and  can  be  readily 
felt  upon  bimanual  vaginal  examination  to  be  attached  to  the  uterus  or  its 


KIDNEY,     ENLARGEMENT     OF  393 

appendages.  These  tumours  also  give  rise  to  dullness  anteriorly,  and  do  not 
alter  the  normal  resonance  in  the  loin.  In  cases  of  malignant  ovarian  tumours 
associated  with  ascites,  the  lumbar  resonance  may  be  lost,  but  on  turning  the 
patient  over  upon  one  side,  the  previously  dull  note  becomes  replaced  by 
resonance  in  the  uppermost  loin.  In  the  case  of  an  ovarian  cy§t  with  a  long 
pedicle,  or  of  a  uterine  fibroid  of  pedunculated,  subserous  form,  the  position 
in  the  loin  may  sometimes  suggest  a  renal  tumour  ;  it  will  be  found,  however, 
to  occupy  a  more  anterior  position  in  the  abdomen  than  a  renal  tumour,  and 
to  possess  a  much  greater  range  of  movement,  but  it  does  not  slip  back  into 
the  loin  near  the  costal  margin  in  the  same  manner  as  an  enlarged  kidney 
does  ;  there  is  resonance  posteriorly,  and  the  kidney  may  be  actually  palpated 
as  well  as  the  abdominal  tumour,  whilst  a  distinct  connection  with  the 
pelvic  organs  can  sometimes  be  traced  from  the  tumour  when  the  latter  is 
drawn  up. 

In  contradistinction  to  the  above,  a  very  large  cystic  renal  swelling  may  be 
mistaken  for  an  ovarian  cyst.  It  may  occupy  the  greater  part  of  the  abdomen, 
and  even  be  felt,  per  vaginam,  to  be  encroaching  upon  the  pelvis ;  but  on  careful 
examination  in  a  renal  tumour  of  this  form  there  will  be  no  line  of  resonance 
between  the  mass  and  the  vertebral  column  posteriorly,  the  natural  hollow  of 
the  loin  will  be  filled  up,  and  there  is  frequently  a  distinct  bulging  in  the  lower 
thoracic  wall,  together  with  an  increased  length  of  the  ilio-costal  space  on  the 
affected  side.  Some  assistance  may  be  obtained  from  the  history,  when  a  hydro- 
nephrosis may  have  been  first  noticed  as  a  tumour  commencing  under  the  costal 
margin,  and  gradually  increasing  downwards  towards  the  iliac  fossa  and  inwards 
across  the  median  line,  whereas  an  ovarian  tumour  may  have  been  noticed  to 
increase  upwards  from  the  pelvis. 

6.  Suprarenal  tumours  may  occasionally  be  of  sufficient  size  to  form  an 
abdominal  tumour,  presenting  a  rounded,  movable  swelling  in  the  hypochon- 
drium.  It  is  practically  impossible  to  distinguish  them  from  renal  tumours, 
without  laparotomy. 

7.  Faecal  accumulations  in  the  colon,  caecum,  or  sigmoid  flexure  may  give  rise 
to  a  tumour  and  pain  of  a  colicky  nature  in  the  loin.  They  will  be  distinguished 
from  renal  swellings  by  the  general  intestinal  symptoms,  flatulence,  and  the 
changes  in  form  consequent  on  the  administration  of  large  enemata.  It  must 
be  remembered  that  a  patient  with  a  collection  of  fasces  in  the  colon  may  not 
complain  of  constipation,  but  may  in  fact  have  a  small  daily  evacuation  from 
the  overloaded  bowel. 

8.  Inflammatory  thickenings  about  the  appendix  will  be  diagnosed  from  renal 
tumours  by  the  situation  of  the  pain  and  the  swelling  in  the  iliac  fossa  rather 
than  in  the  loin.  In  some  cases,  however,  the  pain  may  be  referred  to  the 
lumbar  region,  or  an  appendical  inflammatory  thickening  may  spread  upwards. 
The  onset  of  the  trouble,  the  acute  symptoms  and  the  febrile  disturbance,  will 
usually  distinguish  these  cases  from  renal  lesions. 

9.  Malignant  growths  of  the  large  intestine,  especially  of  the  ascending  or 
descending  colon,  may  form  a  tumour  in  the  loin  which  closely  resembles  a  renal 
swelling.  The  mass  formed  by  the  growth  may  be  grasped  bimanually,  is 
movable  in  the  same  directions  as  a  renal  tumour,  and  comes  forward  under  the 
costal  margin.  The  percussion  note  over  the  front  of  the  lump  is  resonant,  and 
there  is  usually  an  aching  pain  in  the  loin.  If  the  growth  has  infiltrated  through 
the  wall  of  the  bowel  uncovered  by  peritoneum,  the  perirenal  tissues  may  be 
thickened,  or  albuminuria  may  be  produced  by  direct  invasion  of  the  kidney, 
when  the  case  will  even  more  resemble  a  renal  lesion. 

Cancer  of  the  large  intestine  should  be  suspected  if  there  is  diarrhoea,  mucus 
or  blood  in  the  motions,  or  any  symptom  of  commencing  obstruction  in  the 


394  KIDNEY,     ENLARGEMENT     OF 

intestine.  The  tumour  may  be  irregular  and  nodular,  whereas  a  renal  tumour 
presents  rounded  margins.  The  occurrence  of  a  tumour  in  either  side,  associated 
with  discomfort  or  palpable  distention  of  the  Ccecum  from  the  accumulation  of 
faeces,  would  render  a  growth  in  the  colon  the  more  suspicious. 

lo.  Tumours  of  the  omentum,  mesentery,  or  pancreas,  either  cystic  or 
malignant,  are  more  median  in  position,  do  not  project  into  the  loin,  and 
seldom  resemble  a  renal  tumour. 

A  kidnej'  may  be  enlarged  but  j'et  not  palpable,  from  the  fact  that  it  is  either 
whoUv  above  the  costal  margin  or  obscured  by  the  liver  or  the  thick  abdominal 
walls  of  the  patient.  On  the  other  hand,  a  kidney  may  be  so  diseased  as  to  be 
functionless  and  shrunken,  when  it  cannot  be  felt ;  but  the  remaining  organ 
may  be  enlarged  in  a  compensatory  degree  and  ma}^  be  distinctly  palpable.  One 
must  remember  the  danger  of  regarding  an  enlarged  kidney  as  the  diseased 
organ,  when  it  is  in  reality  the  only  functionating  one.  Aching  pain  may  be 
present  on  the  functional  side,  as  a  reno-refiex  pain  from  the  disease  on  the  other 
side.  The  kidney  of  normal  size  and  position  is  not  palpable  from  the  abdomen,  or 
on  bimanual  examination  with  one  hand  on  the  loin ;  but,  in  a  thin  subject,  the 
lower  pole  may  be  felt  to  descend  between  the  hands,  on  the  patient  taking  a 
full  inspiration  ;  if,  therefore,  a  kidney  can  be  felt  easily  on  bimanual  examina- 
tion, it  is  either  unduly  mobile  or  enlarged.  It  is  often  difficult  to  say  if  a 
kidney  that  is  movable  is  also  enlarged  to  a  slight  degree ;  and  a  kidney  which 
was  thought  clinically  to  be  enlarged  has  often  been  found  to  be  of  normal  size 
when  exposed  ;  this  is  in  part  due  to  the  thick  coverings  of  the  abdominal  wall, 
or  to  the  amount  of  fatt\^  tissue  surrounding  the  organ. 

If  the  kidney  is  definitelj^  enlarged,  it  remains  to  determine  the  nature  of  the 
enlargement ;  in  this  one  is  guided,  not  only  by  the  physical  characters  of  the 
tumour  present,  but  also  by  other  symptoms  that  are  associated  with  it,  more 
especiall}',  perhaps,  by  the  altered  characters  of  the  urine.  The  kidney  may  be 
enlarged  only  slightly,  as  in  tuberculosis,  pj'elonephritis,  commencing  hydro- 
nephrosis, or  carcinoma;  or  may  be  enlarged  to  a  considerable  degree  in  poh'cystic 
disease,  hj^dro-  or  p^'onephrosis,  and  in  some  forms  of  malignant  growth.  From 
the  phj^sical  examination  of  the  enlarged  organ  it  is  often  possible  to  say  that 
the  swelling  is  fluid  or  solid  in  nature,  but  it  is  seldom  that  a  true  diagnosis  of 
the  lesion  can  be  made  from  palpation  of  the  kidney  alone.  In  the  following 
diseases  in  which  renal  enlargement  is  usually  present,  the  diagnosis  must  be 
arrived  at  b}^  the  consideration  of  associated  symptoms. 

In  renal  tuberculosis  the  disease  occurs  in  a  miliary  or  in  a  caseous  form. 
Miliary  tuberculosis  occurs  as  a  part  of  a  general  tuberculosis,  usually  in  children, 
is  bilateral  and  causes  no  tumour.  The  caseous  variety  occurs  as  a  primary 
disease  in  one  kidney  in  which  one  or  several  foci  may  be  present.  These 
enlarge  and  soften  to  form  a  tuberculous  abscess,  Avhich  invades  the  medullary 
tissues,  to  open  eventually  and  discharge  its  contents  into  the  renal  pelvis.  The 
kidney  is  enlarged  and  tender,  and  there  are  persistent  pyuria  and  heematuria 
in  small  amount.  The  lining  membrane  of  the  ureter  is  quickly  invaded  by  the 
tuberculous  process,  becoming  thickened  and  infiltrated,  and  at  the  same  time 
shortened  in  length.  An  early  symptom  of  renal  tuberculosis  is  increased  fre- 
quency of  micturition,  even  before  the  bladder  has  become  infected  in  the 
downward  progress  of  the  disease.  The  ureter  may  be  felt  to  be  thickened  per 
rectum  or  per  vaginam,  or  other  tuberculous  foci  may  be  found  in  the  prostate, 
vesiculae  seminales  or  testes  in  the  male.  A  thorough  search  should  be  made 
for  tubercle  bacilli  in  the  urine. 

In  pyelonephritis  the  kidney  may  be  slightly  enlarged,  together  with  renal 
pain,  pjmria,  and  general  malaise.     Pj^elonephritis  is  usually  bilateral,  and  due 


KIDNEY,     ENLARGEMENT     OF  395 

to  some  infective  or  obstructive  lesion  in  the  lower  urinary  tract,  symptoms  of 
which  are  usually  obvious  (see  Pyuria). 

Malignant  tumours  of  the  kidney  give  rise  either  to  an  irregular  nodular 
enlargement  of  the  kidney,  or  to  a  general,  uniform,  solid  tumour.  There  is 
usually  aching  pain  in  the  loin,  with  intermittent  attacks  of  profuse  hsematuria, 
the  latter  occurring  as  soon  as  the  growth  has  infiltrated  the  renal  pelvis.  The 
bleeding  may  be  so  profuse  that  clots  are  formed  in  the  renal  calyces,  pyramidal 
in  shape,  which  in  their  passage  down  the  ureter  give  rise  to  typical  renal  colic. 
The  malignant  tumours  found  in  the  kidney  are  of  several  varieties,  and  their 
origin  and  exact  pathological  nature  have  given  rise  to  much  discussion  in 
recent  years.  The  true  carcinoma  and  sarcoma  exist,  but  are  very  rare,  forming 
but  a  small  percentage  of  the  malignant  renal  tumours.  They  give  rise  to  renal 
enlargement  and  intermittent  hsematuria,  are  usually  extremely  malignant  and 
are  accompanied  by  early  metastases.  Much  more  commonly  a  malignant 
tumour  of  the  kidney  arises  from  an  "  adrenal  rest,"  or  the  small  collection  of 
aberrant  suprarenal  tissue  which  is  frequently  found  in  the  kidney.  These 
tumours  commonly  arise  in  the  upper  pole  of  the  kidney,  are  of  yellow  or  brown 
colour,  and  are  usually  fairly  well  defined  from  the  renal  tissues.  Micro- 
scopically, their  structure  is  similar  to  that  of  the  suprarenal  gland,  and  their 
metastases  are  of  the  same  nature.  These  tumours  have  formerly  been  classified 
as  angiosarcoma,  alveolar  sarcoma,  endothelioma,  or  carcinoma,  but  are  now 
classified  under  the  term  hypernephroma.  They  form  a  comparatively  slowly- 
growing  tumour  of  the  kidney,  and  give  rise  to  less  severe  symptoms  than  the 
true  sarcoma  or  carcinoma.  There  is  aching  in  the  loin,  and  enlargement  of 
the  kidney  may  be  found  on  examination,  but  at  first  the  symptoms  are  slight. 
Hcematuria  occurs  without  any  apparent  exciting  cause,  and  there  may  be 
renal  colic  from  the  passage  of  clots  down  the  ureter  ;  the  tumour  may  be  of 
fair  size  before  any  hsematuria  is  noticed. 

Another  form  of  malignant  tumour  that  occurs  in  the  kidney  is  that  which 
is  supposed  to  arise  from  embryonic  tissues,  and  to  which  the  name  of  embryoma 
has  been  applied.  These  tumours  are  formed  of  striated  muscle  (rhabdomyoma) 
or  of  mixed  tissues  such  as  striated  and  non-striated  muscle,  cartilage  or  bone, 
and  epithelial  stiuctures  in  tubular  or  glandular  form.  They  grow  in  the  renal 
tissues,  expanding  the  latter  to  form  a  spurious  capsule.  They  occur  most 
frequently  in  children,  and  hsematuria  is  comparatively  infrequent. 

Thus,  the  occurrence  of  a  renal  tumour,  accompanied  by  intermittent  attacks 
of  hasmaturia,  especially  if  profuse,  should  always  give  suspicion  of  renal  growth 
in  an  adult.  Renal  tuberculosis  and  calculus  both  may  give  rise  to  renal 
enlargement,  but  the  hasmaturia  is  seldom  profuse  ;  with  calculus,  the  hsematuria 
is  often  brought  on  or  increased  by  exertion,  whereas  with  growth  it  may  come 
on  at  any  time,  even  during  rest.  At  the  same  time,  it  should  be  remembered 
that  both  profuse  hsematuria  and  renal  enlargement  may  arise  from  a  vesical 
tumour  which  obstructs  the  normal  flow  of  urine  from  the  ureteric  orifice  ; 
in  all  cases  therefore  a  cystoscopic  examination  should  be  made  before  any 
operative  measure  is  carried  out.  The  rapid  development  of  a  varicocele, 
especially  on  the  right  side,  is  a  point  significant  of  renal  growth,  it  being  due  to 
blockage  of  the  renal  vein  by  direct  extension  of  the  growth. 

Hydronephrosis  and  pyonephrosis  form  definite  enlargements  of  the  kidnej'' 
which  may  attain  a  large  size.  The  tumour  is  oval  or  rounded,  smooth,  and 
gives  a  sense  of  tenseness  or  elasticity,  whilst  occasionally  distinct  fluctuation 
may  be  obtained.  A  hydronephrosis  occurs  when  there  is  a  partial  obstiuction 
to  the  ureter,  or  in  cases  of  repeated  attacks  of  complete  ureteric  obstiuction. 
Bilateral  hydronephrosis  may  also  exist,  from  the  back- pressure  due  to  any 
obstiuction  of  the  normal  passage  of  urine  from  the  bladder.      Hydronephrosis  is 


396  KIDNEY,     ENLARGEMENT     OF 

usually  unaccompanied  by  pain  or  haematuria  ;  but  the  tumour  may  show 
marked  changes  in  size,  from  the  varying  character  of  the  lesion  producing  the 
obstruction  ;  thus,  if  the  ureter  be  wholly  blocked,  the  tumour  will  increase  in 
size  and  become  more  tense  ;  whilst  if  the  obstruction  be  partially  relieved,  the 
tumour  will  diminish,  synchronously  with  the  passage  of  a  larger  quantity  of 
urine  of  low  specific  gravity.  The  presence  of  any  obstruction  to  the  normal  flow 
of  urine  from  the  kidney  predisposes  to  the  onset  of  infection  of  the  kidney  by 
micro-organisms,  so  that  a  hydronephrosis  may  become  converted  into  a  pyo- 
nephrosis, or  the  latter  may  arise  from  the  obstruction  to  the  ureter  of  a  kidney 
already  the  seat  of  pyelitis.  The  physical  examination  of  a  kidney  distended 
with  urine  or  with  pus  shows  practically  no  difference  between  them,  but  with 
pyonephrosis  there  are  other  indications  usually  present  to  assist  the  diagnosis. 
The  examination  of  the  urine  will  reveal  the  presence  of  pus  at  some  time, 
although,  if  the  ureter  is  wholly  obstructed  at  the  time  of  examination,  pus  may 
be  absent  if  the  other  kidney  and  the  bladder  are  normal.  If,  however,  the 
ureter  is  blocked  only  partially,  pus  will  be  found  in  the  urine  ;  in  the  inter- 
mittent form,  pus  may  be  present  in  large  quantities,  coinciding  with  the  decrease 
in  the  size  of  the  renal  tumour.  With  pyonephrosis,  also,  there  will  be  the 
general  evidence  of  suppuration,  namelj^,  raised  temperature,  sweating,  pallor, 
and  often  diarrhoea.  The  most  frequent  causation  of  pyonephrosis  is  renal 
calculus,  so  that  a  careful  enquiry  into  the  history  of  the  case  for  symptoms  of 
calculus  may  give  important  indications  and  ;t;-ray  examination  may  be  of 
service  {Fig.  97,  p.  309)  unless  the  stone  has  been  passed. 

A  serous  or  hydatid  cyst  of  the  kidney  may  give  rise  to  a  tumour  in  the  loin 
exactly  resembling  a  hydronephrosis,  and  would  usually  be  diagnosed  as  such. 
The  discovery  of  booklets  {Fig.  6,  p.  57)  or  hydatid  elements  in  the  urine  or  in  the 
fluid  aspirated  from  a  renal  cyst  will  point  to  the  nature  of  the  disease. 

Polycystic  disease  of  the  kidney  may  occur  in  children  or  in  adults,  and  forms 
a  tumour  which  is  commonly  bilateral,  though  that  of  one  side  may  be  larger 
than  the  other.  In  adults,  the  disease  causes  practically  no  trouble,  except  the 
presence  of  the  tumour,  in  the  early  stages  ;  but  later,  symptoms  of  renal  in- 
efficiency develop.  The  turaour  gives  the  usual  physical  signs  of  a  renal  enlarge- 
ment, and  may  attain  a  great  size  on  both  sides.  There  may  be  aching  pain  in 
the  loins  and,  occasionally,  marked  hasmaturia.  The  urine  is  of  low  specific 
gravity,  is  increased  in  amount,  and  in  the  absence  of  blood  often  contains  a 
small  amount  of  albumin.  The  disease  is  usually  accompanied  by.  arterio- 
sclerosis. The  character  of  the  urine  and  the  bilateral  renal  tumour  are  usually 
sufficient  data  upon  which  to  form  a  diagnosis  ;  but  with  unilateral  tumour,  as 
occasionally  occurs,  the  diagnosis  is  very  difficult.  A  hydronephrotic  or  pyo- 
nephrotic  kidney  may  give  evidence  of  fluctuation  which  will  not  be  obtained 
with  a  polycystic  kidney.  R.  h.  Jocelyn  Swan. 

KNEE-JERK,  ABNORMALITIES  OF  THE.— Before  discussing  the  abnor- 
malities of  the  knee-jerk,  it  is  desirable  to  say  a  few  words  about  the  methods 
used  for  eliciting  this  valuable  physical  sign,  and  what  may  be  considered  to  be 
its  normal  variations. 

In  the  first  place,  it  is  essential,  if  mistakes  are  to  be  avoided,  to  test  the  knee- 
jerk  with  a  suitable  instrument.  The  fingers,  or  the  edge  of  a  hand  or  of  a  book 
are  unsatisfactory,  and  useless  for  accurate  examination.  Several  percussors 
are  made  for  the  purpose,  the  best  being  a  wooden  stethoscope  with  a  moderately 
heavy  ear-piece  surrounded  by  a  thick  indiarubber  ring.  In  the  second  place, 
the  patient  should  be  either  sitting  or  lying  down.  If  seated  in  a  chair,  he  may 
be  directed  to  cross  one  knee  over  the  other,  or,  better  still,  place  both  feet  on 
the  floor  as  far  away  from  him  as  is  possible  so  long  as  the  whole  sole  of  each  is 


KNEE-JERK,     ABNORMALITIES     OF     THE  397 

in  contact  with  the  ground.  In  either  position  a  tap  on  the  patellar  tendon 
will  provoke  a  contraction  of  the  quadriceps  extensor  muscle,  which  will  extend 
the  leg  on  the  thigh,  and  even  if  it  fails  to  actually  move  the  leg,  may  be  seen  or 
felt.  If  the  patient  is  in  bed,  he  should  lie  flat  on  his  back,  and  be  told  to  allow 
the  observer  to  move  his  legs  without  resistance.  The  latter  then  flexes  the 
knee  by  grasping  the  thigh  above  the  joint  and  raising  it  until  an  obtuse  angle 
is  formed  by  the  popliteal  space,  the  foot  resting  on  the  bed.  The  position  of  the 
manipulator's  hand  will  enable  him  to  detect  whether  the  quadriceps  and  ham- 
string muscles  are  sufficiently  relaxed  for  the  purpose  of  carrying  out  the  test. 
In  the  case  of  small  children  or  infants  it  is  advisable  to  stand  at  the  end  of  the 
bed  and  to  grasp  the  ankle  with  the  left  hand.  The  knee  can  then  be  flexed 
easily  by  pushing  the  foot  towards  the  patient,  and,  at  the  moment  when  the 
limb  feels  relaxed,  a  tap  on  the  patellar  tendon  be  given  with  the  instrument  in 
the  right  hand.  If  difficulty  is  found  in  making  the  patient  relax  his  limb  in 
any  of  these  positions,  his  attention  should  be  directed  to  carrying  out  some 
other  voluntary  movement,  such  as  pulling  apart  his  grasped  hands  while  he 
looks  at  the  ceiling.     This  is  known  as  "  reinforcement." 

The  Normal  Knee-jerk. — It  is  impossible  to  define  a  normal  knee-jerk,  because 
the  extent  of  the  reaction  varies  much  in  individuals  and  much  in  the  same 
person  at  different  times.  Absence  of  the  knee-jerk  indicates  an  abnormality, 
and  must  be  regarded  as  pathological.  Inequality  of  the  jerk  on  the  two  sides 
must  also  be  regarded  as  very  strong  evidence  of  some  organic  morbid  condition. 

Abnormalities. — The  knee-jerk  may  be  exaggerated,  diminished,  or  lost. 

The  knee-jerk  is  exaggerated  when  the  reflex  arc  which  governs  the  tone  of  the 
quadriceps  muscle  is  insufficiently  inhibited  or  controlled  by  the  higher  nervous 
centres.  This  occurs  under  two  chief  conditions,  one  of  which  constitutes  a 
functional,  the  other  an  organic,  loss  of  control. 

Functional  loss  of  control  occurs  whenever  the  general  health  or  nervous  tone 
of  the  patient  is  below  par.  Exaggeration  of  the  knee-jerk  may  therefore  be 
met  with  in  almost  any  constitutional  ailment,  and  is  nearly  always  to  be  observed 
when  a  person  is  seriously  out  of  health.  For  instance,  a  phthisical  patient,  a 
case  of  chronic  renal  disease,  a  convalescent  from  enteric  fever,  or  a  neurasthenic 
may  present  very  brisk  jerks,  and  their  presence  may  only  be  looked  upon  as 
an  indication  of  a  general  loss  of  nervous  tone.  This  fact  emphasizes  the 
necessity  for  never  being  satisfied  with  an  examination  of  the  knee-jerk  alone 
in  attempting  to  diagnose  the  condition  of  the  nervous  system.  The  exami- 
nation of  the  knee-jerk  must  at  least  be  supplemented  by  that  of  certain  other 
reflexes,  the  most  important  of  which  are  the  abdominal  and  plantar.  If 
exaggerated  knee-jerks  are  associated  with  normal  abdominal  reflexes  and  with 
the  flexor  type  of  plantar  response,  and  if  the  knee-jerks  are  approximately 
equal  on  the  two  sides,  it  may  be  assumed  with  some  exceptions  that  the 
exaggeration  is  due  to  a  functional  loss  of  control  over  the  reflex  arc.  If,  on 
the  other  hand,  the  abdominal  reflex  is  absent  and  the  plantar  response  is  of  the 
extensor  type,  the  exaggeration  of  the  knee-jerk  is  due  to  some  organic  change 
in  the  cells  of  the  motor  area  of  the  brain  or  in  the  pyramidal  tracts  which  are 
made  up  of  the  axonal  processes  of  those  cells. 

From  what  has  just  been  said  it  is  clear  that  exaggeration  of  the  knee-jerk 
due  to  organic  disease  is  always,  or  nearl}^  always,  associated  with  other  reflex 
changes,  and  particularly  with  the  extensor  type  of  plantar  response.  Fre- 
quently, but  not  invariably,  these  two  signs  are  supplemented  by  the  presence 
of  ankle-clonus,  by  a  spastic  condition  of  the  lower  extremities,  and  by  a  loss  of 
voluntary  control  over  the  vesical  and  rectal  sphincters. 

When  the  pyramidal  tract  is  equally  affected  on  both  sides,  the  jerks  will  also 
be  exaggerated  equally  ;  but  if,  as  ir  hemiplegia,  one  pyramidal  tract  is  mor 


KNEE-JERK,     ABNORMALITIES     OF     THE 


diseased  than  the  other,  there  is  a  corresponding  difference  in  the  exaggeration 
of  the  knee-jerk  on  the  two  sides,  that  of  the  paralyzed  leg  being  more  brisk 
than  that  of  the  sound  limb.  Inequality  of  the  knee-jerk  is  also  observed  in 
certain  cases  of  general  paralysis  of  the  insane  for  the  same  reason. 

A  very  brisk  knee-jerk  is  sometimes  associated  with  a  phenomenon  which 
goes  by  the  name  of  patellar  clonus.  With  the  limb  resting  relaxed  and  fully 
extended  on  the  bed,  the  patella  is  sharply  pressed  towards  the  foot,  with  the 
result  that  clonic  contractions  of  the  quadriceps  are  provoked  and  continue 
as  long  as  the  pressure  is  sustained.  Thus  a  very  exaggerated  knee-jerk  is 
associated  with  patellar  clonus,  just  as  a  very  brisk  ankle- jerk  is  associated 
with  ankle-clonus.  The  presence  of  well-sustained  patellar  clonus  is  generally 
indicative  of  organic  disease. 

In  order  to  summarize  in  a  few  words  the  significance  of  brisk  knee-jerks,  it 
may  be  stated  that  they  only  indicate  organic  disease  when  they  are  accompanied 
by  other  abnormal  reflex  phenomena,  such  as  extensor  plantar  response,  ankle 
or  patellar  clonus,  absence  of  abdominal  reflexes,  or  imperfect  control  of  the 
sphincters,  or  when  they  are  markedly  unequal  in  the  two  lower  extremities. 
It  might  be  added  that  the  presence  of  spasticity  is  of  equal  importance  ;  but 
there  are  cases  with  rigid  limbs  in  which  it  is  often  difficult  to  say  whether  the 
rigidity  is  of  hysterical  or  organic  origin. 

The  knee-jerk  may  be  diminished  as  the  result  of  some  pathological  processes 
similar  to  those  which  abolish  the  jerk.  On  the  other  hand,  owing  to  the  natural 
variations  in  the  activity  of  the  reflex,  it  is  often  difficult  to  be  sure  that  the 
sluggish  character  of  a  knee-jerk  is  of  pathological  origin  unless  there  is  evidence 
to  show  that  it  had  been  obtained  previously  with  greater  facility.  Most  infants 
suffering  from  acute  febrile  or  debilitating  disorders  present  very  diminished 
knee-jerks;  often  the  latter  cannot  be  obtained  at  all,  at  the  height  of  broncho- 
pneumonia or  epidemic  diarrhoea  for  instance,  though  they  return  to  normal 
as  convalescence  progresses. 

The  knee-jerk  is  lost  only  in  organic  disease,  and  the  absence  of  that  reflex, 
therefore,  is  evidence  of  some  pathological  process. 

The  conditions  under  which  the  knee-jerk  is  lost  may  be  classified  in  the 
following  manner  : — 

1.  Affections  of  the  quadriceps  extensor  muscle,  as  in  the  myopathies. 

2.  Affections  of  the  afferent  path  of  the  reflex  arc,  as  in  cases  of  tabes  in  which 
the  lumbar  region  of  the  spinal  cord  is  involved. 

3.  Affections  of  the  anterior  horn  cells,  such  as  occur  when  myelitis  involves 
the  third  and  fourth  lumbar  segments  of  the  cord. 

4.  Affections  of  the  efferent  fibres  in  the  anterior  crural  nerve  innervating 
the  quadriceps  muscle,  as  in  some  forms  of  peripheral  neuritis. 

5.  In  complete  transverse  lesions  of  the  spinal  cord  above  the  lumbar  enlarge- 
ment. This  is  usually  the  result  of  a  dorsal  myelitis,  or  of  a  fracture-dislocation 
of  the  vertebral  column  with  severe  injury  to  the  cord. 

6.  When  the  intracranial  pressure  is  greatly  increased,  particularly  in  cases 
of  intracranial  tumour,  and  more  especially  when  the  tumour  occupies  the 
posterior  fossa  of  the  skull. 

It  should  be  noted  carefully  that  the  absence  of  the  knee-jerk  in  most  cases 
affords  evidence  of  some  lesion  of  the  structures  which  constitute  the  reflex  arc, 
on  the  integrity  of  which  it  depends.  It  is  a  localizing  sign,  not  necessarily 
a  sign  of  some  particular  disease.  For  instance,  it  is  quite  possible  for  patients 
suffering  from  tabes  to  retain  their  knee-jerks  so  long  as  the  morbid  process  has 
not  involved  the  lumbar  region  of  the  spinal  cord,  or  one  knee-jerk  may  dis- 
appear before  the  other.  For  the  same  reason  the  jerk  may  be  present  in  certain 
cases  of  acute  poliomyelitis,  or  one  may  remain  when  the  other  has  been  lost. 


LEUCOCYTOSIS  399 


It  is  also  desirable  to  point  out  that  the  abolition  of  the  knee-jerk  may  be  the 
only  indication  of  any  affection  of  the  nervous  mechanism.  For  example,  the 
knee-jerk  is  often  lost  after  an  attack  of  diphtheria,  even  when  there  is  no  evidence 
of  paralysis  of  the  leg  muscles  or  of  any  sensory  loss  in  the  lower  extremities. 
Another  instance  of  the  same  kind  is  afforded  by  many  cases  of  lobar  pneumonia, 
especially  in  children,  in  which  the  pneumo-toxin  is  sufficiently  poisonous  to 
interfere  with  the  sensitive  patellar  reflex  without  producing  other  signs  of 
disturbance  of  the  nervous  system.  In  diabetes  mellitus  the  knee-jerks  may  be 
absent  without  any  further  signs  of  peripheral  neuritis  developing. 

Attention  has  been  drawn  to  the  occasional  absence  of  knee-jerk  in  cases  of 
intracranial  tumour.  The  explanation  of  this  is  not  very  clear  and  need  not  be 
discussed  here,  but  reference  may  be  made  to  the  great  variability  of  this  pheno- 
menon from  time  to  time.  At  one  examination  the  knee-jerk  is  obtained  ; 
at  another,  a  few  hours  later,  it  is  lost,  perhaps  to  return  on  the  following 
day.  This  ebb  and  flow  of  the  knee-jerk  is  highly  characteristic  of  increased 
intracranial  pressure,  and  is  rarely  found  under  other  conditions. 

Two  other  forms  of  abnormal  knee-jerk  deserve  brief  reference.  One  of  them 
is  what  is  sometimes  called  the  choreic  knee-jerk.  In  many  cases  of  chorea,  when 
the  leg  is  extended  on  the  thigh  as  the  result  of  tapping  the  patellar  tendon, 
it  is  held  in  that  position  for  an  appreciable  length  of  time  before  relaxation 
takes  place  and  the  foot  falls  to  its  former  position.  In  myasthenia  gravis  it  is 
sometimes,  but  only  rarely,  possible  to  tire  out  the  knee-jerk.  A  ready  response 
is  obtained  at  first,  but  rapid  repetition  of  the  test  leads  to  abolition  of  the  reflex 
excitability,  which  quickly  recovers  itself  after  a  short  rest. 

E.  Farquhar  Buzzard. 
KRAUROSIS  VULVAE.— (See  Pruritus.) 

LEUCOCYTOSIS  is  a  word  which  has  been  used  to  denote  two  different 
conditions,  namely :  first,  an  absolute  increase  above  the  normal  of  the  number 
of  leucocytes  per  c.mm.  of  blood,  without  distinction  as  to  which  particular 
variety  of  leucocyte  is  mainly  increased  ;  and  secondly,  an  absolute  increase  in 
the  total  numbers  of  polymorphonuclear  cells  per  c.mm.  of  blood.  If  the  word 
leucocytosis  is  used  in  the  latter  restricted  sense,  then  there  is  no  clinical  term 
to  express  an  absolute  increase  of  all  the  leucocytes  in  the  blood,  whatever  their 
kind,  and  it  seems  preferable  to  use  the  term  leucocj^tosis  in  the  broader  sense, 
as  being  an  absolute  increase  in  the  total  number  of  white  corpuscles  per  c.mm. 
of  blood,  indicating  the  kind  of  leucocytosis  by  means  of  a  dift'erential  leucocyte 
count.     It  is  in  this  sense  that  the  term  is  used  here. 

The  point  at  which  an  increase  in  the  total  number  of  leucocj'tes  per  c.mm.  of 
blood  can  be  called  leucocytosis  is  an  arbitrary  one,  for  whereas  5,000  per  c.mm. 
is  regarded  as  the  average  in  health,  there  are  considerable  variations  during 
the  day,  either  in  relation  to  digestion,  exercise  or  what  not,  and  the  same 
person  who  at  one  time  of  the  day  may  have  5,000  may  at  another  have  even  as 
many  as  14,000  per  c.mm.  If  the  differential  leucocyte  count  remains  normal, 
no  total  leucocyte  count  less  than  15,000  per  c.mm.  can  be  regarded  as  abnormal, 
and  it  is  not  until  the  figure  reaches  20,000  or  more  that  much  stress  can  be 
laid  upon  it.  The  numbers  tend  to  be  higher  in  children  and  in  pregnant  women 
than  in  other  healthy  individuals. 

From  a  cUnical  point  of  view  there  are  only  two  main  groups  of  conditions 
in  which  the  existence  of  leucocytosis  is  really  of  diagnostic  importance, 
namely :  first,  in  cases  of  splenomedullary,  lymphatic,  or  mixed  leukaemia,  the 
differential  diagnosis  of  which  is  discussed  under  An^^mia  ;  and  secondly, 
in  connection  with  infective  processes,  particularly  those  associated  with 
suppuration. 


400  LEUCOCYTOSIS 


There  are  a  large  number  of  maladies  in  which  a  moderate  degree  of  leuco- 
cytosis  may  occur,  but  in  which  the  behaviour  of  the  leucocytes  themselves 
is  of  little  diagnostic  significance.  Thus,  whether  there  is  or  is  not  any 
leucocytosis  makes  little  or  no  difference  in  the  diagnosis  of  the  following 
conditions,  in  all  of  which  the  number  may  be  anything  from  5,000  to  20,000 
per  c.mm.  :  acute  rheumatism,  scarlet  fever,  myxoedema,  intestinal  obstruction, 
diphtheria,  cholera,  foetid  bronchitis,  bronchiectasis,  urethritis,  acute  follicular 
tonsillitis,  whooping-cough,  carcinoma,  sarcoma,  and  rabies.  In  all  of  these  con- 
ditions, and  probably  in  many  others,  whereas  many  cases  show  no  leucocytic 
change  at  all,  a  certain  proportion  may  exhibit  leucocytosis.  If  there  was  a 
universal  rule,  either  that  there  was  or  was  not  leucocytosis,  the  fact  might  be 
used  in  differential  diagnosis  ;  for  instance,  the  occurrence  of  leucocytosis  in 
scarlet  fever  might  be  used  as  a  point  in  distinguishing  it  from  measles,  in  which 
such  leucocj'tosis  is  rare  ;  but  it  is  just  possible  that  there  may  be  a  leucocytosis 
in  a  case  of  measles,  and  it  is  more  than  possible  that  scarlet  fever  may  present 
no  leucocytosis,  so  that  whereas  the  general  rule  is  to  the  contrary,  it  is  not  so 
constant  as  to  be  a  safe  ground  upon  which  to  make  a  differential  diagnosis. 
It  can  only  be  said,  broadly  speaking,  that  whereas  leucocytosis  is  not  uncommon 
in  the  conditions  already  enumerated,  it  is  upon  the  whole  not  common  in 
measles,  malaria,  tj'-phoid  fever,  typhus  fever,  influenza,  small-pox,  mumps,  and 
tuberculosis  other  than  caseous  bronchopneumonia,  secondary  infected  phthisical 
cavities,  or  tuberculous  meningitis. 

It  is  stated  that  certain  drugs  may  produce  leucocytosis,  though  careful 
experiments  with  some  of  them  have  by  no  means  always  confirmed  this. 
Succinic  acid,  protargol,  and  essential  oils  such  as  turpentine,  peppermint,  or 
cinnamon,  are  examples  of  those  said  to  produce  shght  leucocytosis.  After 
severe  loss  of  blood,  such  as  may  result  from  excessive  hsematemesis,  venesection, 
post-partum  haemorrhage,  and  the  hke,  the  leucocytes  may  rise  in  a  compara- 
tively short  time  to  over  15,000,  and  perhaps  to  over  20,000  per  c.mm. 

It  is  clear,  therefore,  that  when  so  many  conditions  may  lead  to  leuco- 
cytosis, its  importance  is  much  diminished  as  a  means  of  differential  diagnosis. 
One  may  say,  however,  that  unless  there  are  other  chnical  indications  to  the 
contrary,  a  definite  leucocytosis  of  20,000  or  more,  the  figure  sometimes  reach- 
ing even  50,000  or  60,000,  together  with  a  relative  increase  in  the  polymorpho- 
nuclear cells  from  their  normal  65  per  cent  to  80,  85,  or  even  90  per  cent 
of  all  the  leucocytes  present  in  the  blood,  is  considerable  evidence  of  there 
being  suppuration  somewhere.  It  is  worthy  of  notice,  that  in  a  suppuration 
which  produces  leucocytosis  with  a  relative  increase  in  the  polymorphonuclear 
cells,  the  pus  requires  to  be  confined  under  pressure,  for  instance,  in  an  appen- 
dicular abscess,  an  abscess  of  the  hver,  empyema  of  the  gall-bladder,  suppurative 
pylephlebitis,  infective  cholangitis,  perineal  abscess,  pyosalpinx,  suppurating 
ovarian  cyst,  thoracic  empyema,  abscess  of  the  lung,  cerebral  abscess,  sub- 
cutaneous or  pyaemic  abscess,  an  unopened  whitlow,  an  infected  thrombosed 
vein,  or  suppurating  lymphatic  glands.  "When  an  abscess  which  has  hitherto 
been  associated  with  leucocytosis  is  opened,  the  number  of  leucocytes  in  the 
blood  quickly  falls  to  normal ;  there  is  little  or  no  leucocytosis  in  conditions  in 
which  pus  is  not  under  pressure,  for  instance  in  cases  of  impetigo  and  other 
forms  of  pyodermia,  superficial  gangrene  of  the  skin,  suppuration  connected 
with  opened  hip-joint  disease  or  psoas  abscess,  and  so  forth.  It  is  probably 
on  this  account  that  fungating  endocarditis  often  produces  a  slight,  but  hardly 
ever  any  considerable,  leucocytosis;  the  same  applying  to  pyelitis,  pyonephrosis, 
and  pyelonephritis,  in  all  of  which,  if  there  is  free  drainage  through  the  ureter, 
leucocytosis  is  absent,  whilst  if  there  are  abscesses  in  the  kidney  substance  the 
leucocytosis  may  be  considerable.     Gangrene  of  the  lung  is  another  instance  of 


LEUCOPENIA  4or 


the  same  kind,  for  there  may  be  extensive  gangrene  without  leucocytosis  if 
there  is  free  expectoration ;  whilst  if  the  gangrenous  tissue  is  prevented  from 
escaping,  leucocytosis  may  result.  Erysipelas  is  an  exception  to  the  rule  that 
superficial  suppuration  does  not  produce  leucocytosis,  for  here  considerable 
increase  in  the  leucocytes  is  common. 

Amongst  diseases  in  which,  though  they  are  not  in  the  ordinary  sense 
suppurative,  leucocytosis  is  the  rule,  may  be  mentioned  in  particular  acute 
meningitis  and  pneumonia.  Unfortunately,  all  forms  of  acute  meningitis, 
whether  tuberculous,  suppurative,  or  meningococcal,  lead  to  more  or  less  leuco- 
cytosis, so  that  this  point  cannot  be  made  much  use  of  in  the  differential  diagnosis 
between  them  ;  but  upon  the  whole  the  greatest  leucocytosis,  up  to  40,000  or 
more,  is  to  be  expected  in  the  acute  cerebrospinal  form.  The  fact  that  pneu- 
monia, whether  of  the  lobar  or  lobular  tj^pe,  produces  leucocytosis  with  a  relative 
increase  in  the  polymorphonuclear  cells,  more  often  than  not  makes  it  impossible 
to  rely  upon  this  point  in  determining  whether  or  not  an  empyema  is  developing 
after  the  lung  inflammation,  unless  it  is  known  that  up  to  the  time  of  the  crisis 
there  was  only  a  moderate  leucocytosis,  and  that  after  a  continuance  of  the 
fever,  or  a  recurrence  of  it  after  the  crisis,  there  is  a  greater  leucocytosis,  with  a 
still  further  rise  in  the  relative  percentage  of  polymorphonuclear  cells.  When 
there  has  been  no  pneumonia,  and  when  the  physical  signs  are  such  as  to  suggest 
fluid  in  the  chest,  it  is  to  some  extent  helpful  to  know  that  acute  pleurisy,  with 
effusion  of  the  type  sometimes  spoken  of  as  "  simple,"  shows  little  leucocytosis, 
whereas  empyema  nearly  always  produces  a  considerable  leucocytosis  of  the 
polymorphonuclear  type. 

The  value  of  the  knowledge  that  there  is  leucocytosis,  when  a  given  case  has 
been  hitherto  regarded  as  one  of  some  disease  not  associated  with  leucocytosis, 
is  obvious  (see  Leucopenia)  ;  thus,  typhoid  fever  may  have  been  the  diagnosis 
in  a  case  of  obscure  pyrexia,  in  which  the  existence  of  polymorphonuclear  leuco- 
cytosis indicates  that  the  diagnosis  of  typhoid  fever  is  wrong,  and  that  there  is 
really  deep-seated  suppuration,  such  as  an  appendicular  abscess  or  a  pyosalpinx. 
Another  similar  example  of  the  possible  value  of  this  in  differential  diagnosis 
is  in  distinguishing  malaria,  in  which  there  should  be  no  leucocytosis,  from 
hepatic  abscess,  in  which  leucocytosis  is  the  rule.  Herbert  French. 

LEUCOPENIA  denotes  the  presence  of  a  smaller  number  of  leucocytes  per 
c.mm.  of  blood  than  normal.  When  there  are  less  than  5,000  leucocytes  per 
c.mm.  one  may  call  the  condition  leucopenia.  There  are  a  large  number  of 
affections  in  which  this  occurs,  in  most  of  which  the  fact  is  of  little,  if  any, 
diagnostic  importance.  It  may  result  from  simple  starvation,  either  voluntary, 
due  to  stenosis  of  the  oesophagus,  or  from  ulcerative  colitis.  It  is  the  rule 
in  most  chronic  intoxications,  particularly  those  which  result  from  plumbism 
or  poisoning  by  mercury,  arsenic,  ether,  alcohol,  or  morphia.  It  is  to  be  found 
in  certain  of  the  severe  ancsmias,  more  particularly  in  cases  of  pernicious  ancemia, 
aplastic  ancemia,  and  some  cases  of  Hodgkin's  disease  or  lymphadenoma, 
particularly  in  the  later  stages.  Acute  miliary  tuberculosis  is  often  associated 
with  leucopenia,  and  so  also  is  tuberculous  peritonitis  in  more  cases  than  not. 

The  chief  clinical  importance  of  leucopenia  is  in  connection  with  two  diseases 
in  particular,  namely  typhoid  fever  and  malaria.  In  the  former  it  may  some- 
times be  of  great  importance  to  know  that  there  is  leucopenia  almost  from  the 
beginning,  for  not  a  few  cases  have  been  regarded  at  first  as  examples  of  typhoid 
when,  days  before  the  Widal's  reaction  could  be  positive,  the  existence  of  leuco- 
cytosis instead  of  leucopenia  has  served  to  suggest  suppuration  rather  than 
typhoid,  the  pus  being  subsequently  discovered  in  the  pelvis  in  connection, 
perhaps,  with  a  pyosalpinx,  or  in  an  appendicular  abscess  or  the  like.  The 
D  26 


402  LEUCOPENIA 


differential  leucocyte  count  may  also  be  of  assistance  in  the  same  direction,  for 
the  leucopenia  of  typhoid  fever  is  associated  with  a  relative  increase  of  the 
smaller  Ij^mphocytes  and  diminution  of  the  polymorphonuclear  cells,  whilst 
with  suppuration  the  reverse  is  the  case.  Leucopenia  will  not  serve  to  dis- 
tinguish between  typhoid  fever  on  the  one  hand,  and  either  general  tuberculosis, 
influenza,  or  malaria  upon  the  other  ;  but  granted  that  there  is  a  pyrexial  illness 
suggestive  of  typhoid  fever,  the  occurrence  of  leucopenia  with  a  relative  increase 
in  the  small  lymphocytes,  helps  considerably  in  confirming  the  diagnosis  days 
before  the  Widal's  reaction  would  be  positive.  The  leucopenia  persists  unless 
perforation  or  other  complications  that  may  lead  to  pus  formation  supervene. 

Malaria  is  generally  associated  with  a  reduction  of  the  total  number  of  leuco- 
cytes per  c.mm.  down  to  perhaps  3000,  2000,  or  even  less.  Associated  with 
this  leucopenia  there  is  relative  increase,  not  in  the  small  lymphocytes  as  in 
typhoid  fever,  but  in  the  large  hyaline  lymphocytes  ;  the  association  of  these  two 
things  together,  in  a  patient  whose  history  points  to  the  possibility  of  malaria, 
is  of  considerable  assistance  in  clinching  the  diagnosis,  and  it  may  be  of  particular 
value  in  cases  in  which  quinine  has  been  administered,  so  that  the  most  con- 
clusive proof  of  the  nature  of  the  complaint,  namely  the  discovery  of  the  malarial 
parasites  in  blood  films  is  not  for  the  moment  possible.  One  difficulty,  which  is 
not  at  all  uncommon  in  the  tropics,  is  to  decide  between  malaria  on  the  one  hand 
and  abscess  of  the  liver  upon  the  other.  Leucopenia  and  a  relative  increase  in 
the  large  lymphocytes  strongly  favours  malaria,  whereas  an  abscess  would  cause 
leucocytosis  and  a  relative  increase  in  the  polymorphonuclear  cells. 

LEUCORRHCEA.— (See  Discharge,  Vaginal.) 

LIMPING. — (See  Gait,  Abnormalities  of.) 

LINE£  ALBIC ANTES. — These  are  sometimes,  and  with  equal  propriety, 
termed  lineae  atrophicse  ;  both  terms  precisely  describe  them  ;  the  one  their 
appearance  and  the  other  their  origin.  They  consist  of  areas  of  skin  many,  times 
longer  than  broad — hence  the  word  linea  to  describe  them  ;  somewhat  shiny, 
bluish-white  in  colour — hence  albicantes  ;  and  they  are  produced  by  atrophy  of 
portions  of  the  true  corium  (sub-epithelial)  — hence  the  term  atrophicae. 

There  is  no  disease  that  really  resembles  them,  and  indeed  no  other  condition 
of  the  skin  with  which  they  can  be  confounded  when  once  they  have  been  pointed 
out.  Morphoea  and  leucodermia  {q.v.)  are  the  only  possible  exceptions,  and 
these  only  under  the  rarest  circumstances,  for  the  patches  of  these  affections 
are  not  linear,  do  not  shine,  are  not  atrophic,  and  above  all.  do  not  show  those 
small  cross  wrinkles  of  epidermis  at  right  angles  to  the  axis  of  a  linea  so  character- 
istic of  lineae  albicantes  ;  these  wrinkles  can  be  smoothed  away  by  stretching 
the  skin  in  a  direction  parallel  to  the  linea,  but  they  return  at  once  on  relaxing 
the  tension. 

The  meaning  of  these  lineae  is  that  the  skin  has  been  unduly  stretched  over 
some  fairly  long  period  of  time ;  but  it  must  be  distinctly  understood  that  they 
give  not  the  slightest  indication  as  to  the  cause  of  the  stretching,  this  caution 
being  necessary,  because  when  these  lineae  are  found  on  a  woman's  abdomen  or 
breasts,  it  is  commonly  assumed  that  they  constitute  evidence  of  a  past 
pregnancy  ;  it  is  perfectly  true  that  this  is  the  commonest  origin  ;  but  any  other 
cause  of  swelling,  such  as  tumour,  ascites,  and  even  fat  and  oedema,  etc.,  will 
produce  them  by  stretching  the  skin. 

They  are  very  frequently  seen  on  the  shoulders  and  thighs  of  persons  of  either 
sex,  and  in  these  positions  suggest  either  present  or  past  obesity,  but  are  not 
conclusive  evidence  of  anything  but  undue  stretching.  Fred.  J.  Smith. 


LIPS,     AFFECTIONS     OF     THE     RED     PART     OF  403 

LIPS,  AFFECTIONS  OF  THE  RED  PART  OF  THE— The  simplest  affection 
to  which  the  vermihon  of  the  hps  is  liable  is  that  known  as  "  chapping,"  a 
condition  frequently  due  to  exposure  to  keen  winds,  and  sometimes  aggravated 
by  the  habit  of  "  picking."  In  some  cases  the  fissuring  is  sufficiently  deep  to 
cause  appreciable  pain  and  great  disfigurement. 

The  vermilion  of  the  lips  may  be  involved  also  in  a  number  of  cutaneous 
diseases,  among  them  lupus  vulgaris,  lupus  erythematosus,  lichen  planus,  herpes 
febrilis  and  zoster,  tinea  circinata,  urticaria,  psoriasis,  and  some  forms  of  syphilis. 
The  lesions  of  the  epithelium  of  the  lips,  as  of  mucous  membranes  in  general, 
are  seldom  characteristic  enough  to  warrant  a  confident  diagnosis  ;  in  none 
of  the  affections  enumerated  in  this  paragraph  is  the  red  of  the  lips  alone 
aft'ected,  and  guidance  as  to  the  nature  of  the  affection  will  be  found  in  the  more 
distinctive  lesions  of  the  cutaneous  surface. 

Ordinary  eczema  is  sometimes  limited  to  the  lips  and  immediately  adjacent 
parts.  Associated  with  a  slightly  seborrhoeic  condition  of  the  scalp,  there  is 
sometimes  a  persistent  and  repeated  exfoliation  of  the  vermilion  of  the  lips 
{cheilitis  exfoliativa).  In  a  somewhat  similar  yet  not  identical  case  of  mine, 
the  lips  as  a  whole  were  covered  with  a  thick  accumulation  of  scales,  which 
caused  them  to  protrude.  When  the  scales  were  removed  the  lips  were  blue 
instead  of  red.  The  patient  complained  of  some  burning  pain,  but  chiefly 
of  a  feeling  of  deadness  in  the  lips.  The  condition  had  persisted  for  eleven 
years,  and  appeared  to  have  been  set  up  by  a  habit  of  biting  the  lips  and  tearing 
off  the  skin.  The  subjects  of  cheilitis  exfoliativa  are  usually  neurotic,  and 
in  this  case  there  was  some  tendency  to  that  condition,  but  there  was  no 
associated  seborrhoea.  In  cheilitis  glandularis  there  may  be  neither  seborrhoea 
nor  neurosis  :  the  chronic  inflammation  of  the  lower  lip,  with  swelling  of  the 
mucous  glands,  appears  to  originate  in  catarrh  of  the  mouth  and  pharynx. 
It  is  chiefly  the  vermilion  that  is  affected,  but  the  inflammation  spreads  to  the 
inside  of  the  lip,  and  sometimes  also  to  the  neighbouring  skin,  which  presents 
an  erythematous  aspect.  The  conditions  here  described  are  all  rare,  and  are 
not  likely  to  be  confused  with  more  ordinary  affections  of  the  labial  epithelium. 

In  syphilis  the  red  of  the  lips  is  sometimes  the  seat  of  the  primary  sore 
(see  Fig.  10,  p.  86),  and  in  the  secondary  stage  condylomata  may  occur  in  this 
situation.  The  chancre  may  be  flattish  and  covered  with  a  false  membrane,  or 
it  may  present  itself  as  a  crateriform  infiltrated  ulcer. 

In  epithelioma  the  lip-— usually  the  lower  one — is  frequently  the  point  of 
attack,  the  growth  beginning  as  a  slight  abrasion,  crack,  or  papule,  and  running 
the  usual  course.     (See  under  Tumours  of  the  Skin.) 

Fordyce's  disease  specially  attacks  the  red  of  the  lips  and  the  oral  mucous 
membrane,  the  lesions  consisting  of  small  whitish  or  yellowish  milium-like 
bodies,  which  may  be  discrete  or  coalescent,  profuse  or  scanty.  Inside  the  mouth 
the  milium-like  bodies  are  whiter  than  those  on  the  lip,  and  are  also  more 
projecting.  If  subjective  symptoms  are  present,  they  take  the  form  of  slight 
burning  and  itching,  with  a  feeling  of  stiffness.  The  signs  can  hardly  be 
confounded  with  those  of  any  other  affection.  When  the  lesions  are  very 
abundant  they  may  simulate  a  solid  patch ;  but  if  the  tissues  are  stretched, 
the  milium-like  bodies  can  be  distinguished. 

Perleche  is  a  contagious  affection  almost  peculiar  to  children,  and  due  pro- 
bably to  streptococci.  It  usually  starts  at  both  angles  of  the  lips,  as  a  whiten- 
ing and  maceration  of  the  epithelium,  which  is  easily  detached  ;  it  extends  along 
the  epithelium  towards  the  middle  line,  involving  also  the  surrounding  skin 
and  the  mucosa  of  the  inside  of  the  lips.  There  are  usually  some  hyperaemia 
and  inflammation,  and  the  feeling  of  heat  and  discomfort  prompts  the  child 
constantly    to    lick    its    lips — hence    perleche.     The    affection  often    appears    in 


404  LIVER     DULLNESS,     DEFICIENT 

association  with  impetigo  contagiosa,  or  impetiginous  stomatitis,  or  vesicular 
erythema.  In  some  cases  it  can  only  be  discriminated  from  the  mucous  patches 
of  syphilis  by  the  absence  of  other  secondary  signs.  From  herpes  it  can  be 
diagnosed  by  its  bilaterality  and  its  not  beginning  as  a  vesicular  eruption. 

Malcolm  Morris. 
LIPURIA (See  Chyluria.) 

LIVER  DULLNESS,  DEFICIENT.— The  most  common  cause  for  diminution 
of  the  hepatic  dullness  is  emphysema.  The  chest  is  barrel-shaped,  the  lower 
ribs  are  everted,  and  the  diminution  of  the  dullness  is  at  its  upper  part.  The 
dullness  is  diminished  from  above  downwards  in  cases  of  tight  lacing,  which  forces 
the  liver  down,  and  in  cases  of  hepatoptosis  [q.v.,  p.  406).  But  in  these  two 
instances  the  hepatic  dullness  descends  lower  than  is  normal,  so  that  the  total 
liver  dullness  is  often  natural.  The  hepatic  dullness  is  diminished  very  con- 
siderably and  rapidly  in  acute  yellow  atrophy  :  the  signs  of  this  disease  are  so 
numerous  and  striking  that  the  diagnosis  is  not  as  a  rule  difficult.  It  slowly 
diminishes  when  the  liver  shrinks  in  the  terminal  stage  of  cirrhosis.  It  is  often 
said  that  in  perforative  peritonitis  the  presence  of  free  gas  in  the  peritoneal 
cavity  leads  to  a  diminution  of  the  hepatic  dullness.  This  is  undoubtedly  true 
sometimes,  but  the  sign  is  so  often  absent,  that  considering  there  are  other 
causes  of  diminution  of  hepatic  dullness,  it  is  unwise  to  lay  much  stress  on  its 
presence  or  absence  in  coming  to  a  diagnosis  of  perforative  peritonitis.  Con- 
siderable gaseous  distention  of  the  bowels  will  also  cause  diminution  of  the 
hepatic  dullness.  w.  Hale  White. 

LIVER,  ENLARGEMENTS  OF  THE.— In  adults,  the  liver  is  about  ^, 
but  at  birth  it  is  ttj  to  yV  ^^  ^^^  weight  of  the  whole  body ;  therefore  in  infants 
and  young  children  it  is  relatively  larger  than  in  adults.  Unless  this  is  remem- 
bered, the  liver  may  in  such  patients  be  thought  enlarged  when  really  it  is  of 
normal  size. 

On  deep  inspiration,  in  thin  people  whose  abdominal  muscles  are  lax,  the 
lower  edge  of  the  normal  liver  can,  in  the  supine  position,  be  felt  by  the  fingers 
to  descend,  if  they  are  thrust  up  under  the  ribs  outside  the  right  rectus.  In  the 
upright  position  it  may  descend  half  an  inch  lower  than  this.  In  the  epigastric 
angle,  a  small  portion  of  the  anterior  surface  of  the  left  lobe  is  in  contact  with  the 
anterior  abdominal  wall.  Often  this  cannot  be  felt  owing  to  rigidity  of  the  recti 
abdominales  muscles,  but  it  may  be  the  only  part  that  can  be  felt  unless  the 
ribs  are  raised  as  in  emphysema. 

The  hepatic  dullness  to  the  left  of  the  sternum  cannot  be  distinguished  from 
that  due  to  the  heart ;  on  the  right,  it  begins  at  the  middle  of  the  ensiform 
process  of  the  sternum,  in  the  nipple  line  it  reaches  the  upper  part  of  the  fifth 
intercostal  space,  in  the  mid-axillary  line  the  seventh,  in  the  line  of  the  angle 
of  the  scapula  the  ninth.  In  health  the  edge  of  the  liver  is  firm  and  uniform, 
and  the  surface  feels  smooth.  In  excessively  rare  instances  the  whole  organ 
is  lobulated.  This  is  probably  not,  as  has  been  supposed,  a  developmental 
abnormality,  but  represents  past  disease,  possibly  intra-uterine.  If  the  liver 
is  transposed,  the  right  lobe  is  small  and  the  left  large.  Occasionally  either  lobe 
is  dwarfed  by  disease,  e.g.,  alcohol  or  syphilis.  A  tongue-like  projection  of 
the  right  lobe  may  protrude  from  its  lower  right-hand  part.  This  projection, 
known  as  Riedel's  lobe,  is  often  associated  with  disease  of  the  gall-bladder  such 
as  gall-stones,  or  with  tight  lacing,  and  is  commoner  in  women  than  in  men,  but 
as  it  may  be  found  in  quite  young  children,  it  must  be  regarded  as  sometimes 
an  anatomical  abnormality.  A  Riedel's  lobe  may  give  rise  to  great  difficulties 
of  diagnosis  ;   the  connection  between  it  and  the  liver  may  be  only  peritoneum, 


LIVER,     ENLARGEMENTS     OF     THE  405 

it  may  then  easily  be  mistaken  for  a  floating  kidney,  especiall}^  as  in  such  a  case 
there  may  be  a  band  of  resonance  between  it  and  the  Uver ;  or  such  a  lobe  may 
be  confused  with  any  tumour  that  may  be  found  on  the  right  side  of  the  abdomen. 
When  palpating  the  abdomen  it  is  often  very  difficult  to  tell  the  right-hand  lower 
part  of  the  liver  from  the  kidney,  even  when  there  is  no  projection  which  can 
be  called  a  Riedel's  lobe. 

Many  conditions  quite  unconnected  with  the  liver  cause  an  apparent  alteration 
in  its  size.  Thus,  a  general  weakness  of  the  tissues  may  lead  to  its  dropping 
downwards  in  the  erect  posture  from  laxness  of  its  supports,  which  are  chiefly 
its  ligaments,  and  to  a  less  extent  the  abdominal  walls.  I  have  known  this 
occur  in  wasting  diseases,  the  fact  that  the  liver  was  not  enlarged  having 
been  evident  on  post-mortem  examination  ;  indeed,  in  such  a  case  I  have  known 
the  dropped  liver  to  be  regarded  as  enlarged  from  cancer,  which  was  believed 
to  be  the  cause  of  the  wasting,  when  in  reality  the  patient  was  wasted  because 
he  had  diabetes.  Again,  if  the  liver  is  somewhat  enlarged  from  disease,  its  extra 
weight  may  cause  it  to  drop,  and  hence  it  appears  larger  than  it  really  is. 
Thus  it  is  not  uncommon  for  a  nutmeg  liver  to  appear  during  life  larger  than 
it  is  ;  but  that  it  is  not,  may  be  proved  by  noticing  that  percussion  shows  the 
upper  line  of  hepatic  dullness  to  have  descended. 

Alterations  in  the  chest  may  lead  to  depression  of  the  liver,  which  may  there- 
fore erroneously  be  thought  to  be  enlarged.  Thus,  in  an  extreme  case  of  fibrosis 
of  the  lungs  with  adherent  pleura,  I  have  seen  the  sucking  in  of  the  ribs  on 
inspiration  lead  to  depression  of  the  liver  down  to  the  umbilicus  :  and  the  right 
lobe  may  be  depressed  into  the  right  loin  by  compression  of  the  chest  due  to 
tight  lacing,  this  being  often  associated  with  a  movable  right  kidney.  Deform- 
ities of  the  chest  due  to  rickets  or  curvature  of  the  spine  may  lead  to  great 
depression  of  the  hver.  It  may  be  depressed  by  large  collections  of  fluid  in 
the  right  side  of  the  chest,  but  they  must  be  quite  large,  for  the  fluid  will 
more  easily  compress  the  lungs  and  push  the  heart  to  the  left  than  depress  the 
diaphragm.  It  may  also  be  depressed  by  a  right-sided  pneumothorax.  If  in 
diaphragmatic  pleurisy  the  diaphragm  is  not  working,  and  is  in  a  more  or  less 
constant  position  of  inspiration,  the  liver  is  also  constantly  in  this  position, 
and  hence  seems  to  be  a  little  depressed.  Extreme  pericardial  eflusion  is  said 
to  depress  the  liver,  but  this  must  be  very  rare,  for  the  pressure  would  have 
to  act  through  the  fibrous  part  of  the  pericardium,  which  is  very  firm.  It  is 
often  stated  that  a  subdiaphragmatic  abscess  will  depress  the  liver  considerably ; 
but  this  is  incorrect,  for  the  numerous  adhesions  in  connection  with  such  an 
abscess  generally  prevent  depression  of  the  liver. 

Tight  lacing  may  cause  a  deep  furrow  on  the  liver  palpable  during  life.  I 
have  known  so  deep  a  furrow  caused  by  a  man's  belt  that  the  part  of  the  Uver 
below  the  furrow  felt  almost  separated  from  the  rest  of  the  organ  ;  in  such  a 
case  there  may  be  a  false  impression  of  enlargement.  The  effect  of  corsets  or 
other  artificial  pressure  is  often  such  as  to  give  an  incorrect  impression  of 
enlargement,  because  the  organ  is  pressed  down  ;  most  commonly  the  liver  is 
forced  down,  flattened,  and  elongated  from  above  downwards.  It  thus  forms 
an  apron,  covering  much  more  of  the  intestines  than  is  natural,  but  sometimes 
some  of  them  may  get  in  front  of  it.  Such  a  pressure  often  leads  to  a  transverse 
depression  across  the  right-hand  lower  part  of  the  right  lobe,  so  that  a  more  or 
less  detached  portion  of  it  lies  in  the  position  of  a  Riedel's  lobe. 

It  is  quite  rare  for  enlargement  of  the  liver  to  lead  to  any  upward  extension 
of  the  hepatic  dullness.  This  is  what  might  be  expected,  for  the  mere  weight 
of  the  enlarged  liver  will  lead  to  its  falling,  and  the  resistance  of  the  intestines 
and  abdominal  walls  being  much  less  than  that  of  the  diaphragm,  it  will  there- 
fore grow  in  the  direction  of  least  resistance,  that  is,  downwards.     Raising  of 


4o6  LIVER,     ENLARGEMENTS     OF     THE 

the  upper  limit  of  hepatic  duUness  is  best  observed  when  some  local  disease  of 
the  Uver  directly  imphcates  the  diaphragm  ;  thus,  a  tropical  abscess  of  the  liver 
growing  from  its  upper  surface  wiU  soften  the  diaphragm  and  extend  upwards  ; 
a  hydatid  will  do  the  same.  So,  when  there  is  an  extension  upwards  of  the 
upper  hepatic  dullness,  it  is  a  local  extension  forming  a  dome-shaped  addition 
to  the  hepatic  dullness.  Very  large  collections  of  ascitic  fluid  or  very  large 
abdominal  tumours  may  push  the  liver  up,  but  this  is  excessively  rare,  for  such 
conditions  will  more  readilj^  compress  the  iatestiaes  and  bulge  the  abdominal 
walls.  A  subdiaphragmatic  abscess,  by  its  extension  of  dullness  up  into  the 
chest,  mav  appear  to  extend  the  liver  dullness  upwards. 

There  are  three  moderately  common  tumours  in  the  abdomen  which  may  give 
a  false  impression  of  increase  in  the  size  of  the  liver.  The^'  are  :  A  stomach 
affected  with  malignant  disease,  especially  when  the  growth  infiltrates  much  of 
the  greater  curvature  ;  malignant  disease  of  or  impaction  of  fcBces  in  the  transverse 
colon  ;  and  the  great  omentum  thickened  and  puckered  up  towards  the  transverse 
colon  by  some  form  of  chronic  peritonitis.  Any  of  these  tumours  may  move  up 
and  down  with  respiration,  for  they  are  all  directlj'-  or  indirectly  attached  to 
the  liver  ;  but  the  movement  is  not  usually  so  extensive  as  that  of  the  liver 
should  be,  and  a  band  of  resonance  maj^  sometimes  be  detected  betAveen  the 
liver  and  the  tumour,  or  the  edge  of  the  liver  may  be  felt  above  it.  Enlarge- 
ments of  the  p3dorus,  and  thickening  in  connection  with  a  gastric  or  duodenal 
ulcer  may  aU  be  difficult  to  distinguish  from  an  enlarged  gall-bladder.  The  hepatic 
dullness  may  be  altered  by  gas,  and  it  ma^^  be  almost  obliterated  by  the  descent 
of  an  emphysematous  lung  ;  slight  lowering  of  the  upper  margin  of  the  hepatic 
duUness  from  this  cause  is  quite  common.  In  emphysema,  too,  the  lower  ribs 
stand  so  far  forward  that  it  maj^  be  impossible  to  feel  the  lower  edge  of  the 
liver.  When,  as  in  perforative  peritonitis,  there  is  free  gas  in  the  peritoneal 
cavity,  the  gas  getting  in  front  of  the  liver  may  diminish  the  hepatic  dullness, 
but  this  sign  is  so  often  absent  that  its  absence  must  not  be  used  as  an  argument 
against  the  existence  of  perforative  peritonitis.  On  the  other  hand,  partial 
obliteration  of  the  hepatic  dullness  may  be  due  to  the  fact  that  some  of  the 
intestine  is  between  the  liver  and  the  anterior  abdominal  wall.  A  large 
collection  of  ascitic  fluid  often  renders  it  difi&cult  to  estimate  the  size  of  the  liver. 

Hepatoptosis,  and  wandering  liver,  are  terms  applied  to  a  liver  which,  being 
unduly  displaceable,  leaves  its  normal  position.  It  is  a  rare  condition,  but  must 
be  borne  in  mind,  for,  if  not,  a  liver  which  is  only  displaced  may  erroneously  be 
thought  to  be  enlarged.  Extreme  degrees  are  met  with  in  cases  of  general  viscero- 
ptosis. It  is  commoner  in  women  than  men,  and  is  most  often  seen  after  the  age 
of  fort}^  The  abdominal  walls  are  usually  pendulous,  and,  as  the  abdominal 
muscles  are  powerful  agents  for  keeping  the  abdominal  viscera  in  place,  this 
weakness,  combined  with  a  laxit}-  of  the  hepatic  ligaments,  is  probably  the  cause 
of  the  hepatoptosis.  Tight  lacing  leads  to  weakness  of  the  abdominal  muscles, 
as  well  as  pressing  the  liver  down.  "When  the  liver  in  this  condition  is  examined, 
it  is  found  to  have  fallen,  and  to  be  flattened,  extending  often  to  the  umbilicus, 
with  its  greatest  prominence  near  its  lower  part  and  on  the  right.  It  ma}'  form 
a  protrusion  of  the  abdominal  walls  ;  it  is  easily  palpable,  moves  up  and  down 
with  respiration,  and  can  usuallj'  be  pushed  back  into  its  normal  position  when 
the  patient  lies  down  ;  indeed,  when  the  patient  is  in  the  supine  position,  it 
sometimes  goes  back  of  its  own  accord,  only  to  fall  again  when  she  stands  up. 
It  is  movable  laterally,  and  can  be  rotated  with  the  hands  about  a  horizontal 
axis  passing  through  the  attachment  of  the  organ  to  the  inferior  vena  cava. 
There  is  considerable  diminution  in,  or  even  absence  of,  the  hepatic  dullness  in 
the  chest  ;  in  an  extreme  case  the  hand  may  be  passed  up  between  the  liver 
and  the  ribs,  and    at   the   upper  right-hand   part   of   the   abdomen  there  is  a 


LIVER,     ENLARGEMENTS     OF     THE  407 

depression  between  the  liver  and  the  ribs.  There  may  be  no  symptoms,  but 
the  patient  usually  complains  of  a  dragging  pain  and  a  heaviness  in  the  hepatic 
region.  These  are  much  worse  in  the  erect  posture,  so  that  she  may  have  always 
to  lie  down.  Often,  sudden  attacks  of  pain  occur  in  the  right  of  the  abdomen ; 
these  may  be  due  to  gall-stones  or  to  a  floating  kidney  (both  often  present  with 
hepatoptosis),  or  to  kinking  of  the  bile  duct,  which  may  lead  to  jaundice. 
The  patients  are  usually  neurotic,  dyspeptic  valetudinarians.  As  the  abdon:iinal 
muscles  are  weak,  the  blood  stagnates  in  the  abdominal  vessels  in  the  erect 
posture  ;  hence  faintness,  palpitation,  exhaustion,  and  dyspnoea  on  exertion 
are  common,  these  symptoms  passing  away  when  the  patient  lies  down. 

We  shall  now  consider  each  of  the  pathological  enlargements  of  the  liver, 
and  indicate  the  chief  points  to  be  utilized  in  the  diagnosis  of  each. 

Venous  Congestion  of  the  Liver,  or  Nutmeg  Liver. — There  must  be  heart 
disease,  usually  of  the  mitral  valve,  or  perhaps  incompetence  of  it  secondary 
to  severe  aortic  disease,  or  disease  of  the  valves  on  the  right  side,  or  severe 
disease  of  the  myocardium,  or  chronic  pulmonary  disease,  usually  bronchitis. 
The  enlargement  of  the  liver  is  firm  and  uniform,  its  edge  is  hard  and  uniform, 
its  surface  smooth.  The  enlarged  organ  may  reach  to  the  umbilicus,  and 
as  the  abdominal  muscles  are  often  weak  in  these  cases,  especially  in  women, 
and  the  liver  is  very  heavy  from  the  extra  amount  of  blood  in  it,  the  organ  is 
often  a  little  dropped.  Pain  and  tenderness  over  the  liver  are  very  common  ; 
they  are  due  in  some  cases  to  stretching  of  the  hepatic  capsule,  in  others  to  local 
patches  of  perihepatitis.  The  skin  over  the  liver  may  be  tender.  In  severe  cases 
there  is  often  slight  jaundice.  Dyspeptic  symptoms  are  frequent.  Ascites  may 
be  present ;    if  so,  it  is  associated  with  the  oedema  due  to  the  heart  disease. 

In  a  severe  degree  of  nutmeg  liver  the  organ  may  pulsate.  If  so,  the  tricuspid 
orifice  must  be  incompetent  and  the  right  ventricle  must  be  beating  strongly ; 
then  a  pulse-wave  travels  back  in  the  inferior  vena  cava  and  hepatic  veins  to 
reach  the  liver,  and  makes  the  whole  organ  expand  synchronously  with  each 
contraction  of  the  right  ventricle.  Such  incompetence  of  the  tricuspid  orifice 
is  nearly  always  secondary  to  mitral  disease.  Great  care  must  be  taken  not 
to  mistake  a  thrust  downwards  of  the  liver  by  the  contraction  of  a  hypertrophied 
heart,  or  the  thrust  forwards  by  a  pulsating  aorta,  for  hepatic  pulsation.  The 
distinguishing  feature  of  this  is,  that  when  one  hand  is  placed  on  the  front 
and  the  other  on  the  back  of  the  abdomen  over  the  enlarged,  congested  liver, 
the  two  hands  can  be  felt  to  be  separated  by  the  expansile  pulsation  of  the 
liver.  This  is  not  the  case  when  the  pulsation  is  transmitted.  Naturally, 
pulsation  of  the  veins  of  the  neck  is  often  seen  in  cases  in  which  the  liver  can 
be  felt  to  pulsate. 

General  Congestion  of  the  Liver. — This  is  frequently  said  to  be  present  in 
those  who  suffer  from  dj'spepsia,  but  if  this  be  so  it  does  not  give  rise  to  a 
demonstrable  enlargement.  When,  however,  a  European  lives  for  many  years  in 
a  tropical  country,  he  is  liable  to  suffer  from  attacks  of  congestion  of  the  liver, 
and  these,  when  frequently  repeated,  lead  to  an  enlargement  called  tropical 
liver.  The  organ  is  uniformly  enlarged,  smooth,  somewhat  hard,  and  has  a 
uniform  edge.  Pain  and  tenderness  are  not  such  prominent  features  as  the}^  are 
in  a  nutmeg  liver.  The  condition  is  often  associated  with  indigestion,  errors 
of  diet — especially  the  taking  of  too  much  alcohol — and  attacks  of  p^aexia. 
When  these  are  present  the  liver  becomes  tender,  painful,  and  more  enlarged, 
and  I  have  known  such  a  condition  mistaken  for  hepatic  abscess.  The  sufferer 
complains  of  a  sensation  of  weight  in  the  hepatic  region  ;  he  is  constipated,  and 
the  urine  is  full  of  lithates.  In  an  extreme  and  chronic  case  the  organ  may 
extend  four  inches  below  the  ribs ;  the  patient  is  depressed,  irritable,  and  of  a 
sallow  complexion.     The  spleen  may  be  enlarged. 


4o8  LIVER,     ENLARGEMENTS     OF     THE 

Suppuration  within  the  Liver. — Multiple  pysemic  abscesses  within  the  liver, 
which  constitute  part  of  the  condition  known  as  portal  pyaemia,  generally  do 
not  cause  enlargement  of  the  liver,  but  this  is  often  present  with  a  large  single 
abscess.  There  is  usually  a  history  of  dysentery,  for  amoebic  dysentery  is  by 
far  the  commonest  cause  of  a  large  single  abscess;  therefore  it  usually  occurs 
in  the  tropics,  and  is  then  commonly  called  a  tropical  abscess.  Very  rarely  it 
is  secondary  to  other  specific  fevers,  it  may  be  due  to  suppuration  round  a 
gall-stone,  or  may  spread  from  some  neighbouring  suppuration,  e.g.,  a  peri- 
nephritic  abscess.  Or  again,  it  may  be  caused  by  suppuration  of  a  hydatid 
or  by  injury.  The  presence  of  any  of  these  causes  may  help  the  diagnosis  ; 
but  sometimes,  even  when  the  abscess  is  due  to  the  dysenteric  amoeba,  it 
may  be  difficult  to  obtain  a  history  of  dysentery  ;  and  indeed  the  dysenteric 
ulcers  of  the  intestine  may  have  healed  years  before  the  symptoms  of  hepatic 
abscess  show  themselves.  Very  rarely  it  appears  to  follow  intestinal  ulcera- 
tion which,  as  far  as  we  know,  is  not  dysenteric  ;  this  is  so  in  some  of  the 
examples  of  single  large  abscess  in  which  the  patient  has  never  left  this 
country.  Indeed,  sometimes  a  single  large  hepatic  abscess  is  found  in  the 
tropics,  when  the  most  careful  search  fails  to  find  any  amoebae  in  the  pus 
of  the  abscess,  or  to  obtain  any  history  of  dysentery,  or  only  a  history  of 
bacillary  dysentery.  Probably  the  true  cause  of  a  single  large  abscess  is  not 
known,  and  the  amoeba  is  only  a  contributory,  although  a  powerfully  con- 
tributory, cause.  These  abscesses  are  most  common  in  men  between  the  ages 
of  twenty-five  and  forty-five.  They  are  much  commoner  in  Europeans  than 
natives.  Eighty  per  cent  are  in  the  right  lobe,  usually  in  its  upper  part.  The 
colour  of  the  pus  depends  upon  the  amount  of  broken-down  hepatic  tissue 
present ;  if  there  is  much,  it  is  the  colour  of  anchovy  paste ;  if  there  is  none,  it 
is  yellow,  but  the  anchovy-paste-like  pus  is  of  the  characteristic  colour.  Amoebae 
may  be  found  in  it  (see  Fig.  12,  p.  91),  or  more  often  in  the  granulation  tissue 
forming  the  wall  of  the  abscess.  Bacteria  may  be  present,  but  if  the  abscess 
has  existed  some  time  the  pus  is  often  sterile.  The  symptoms  and  physical 
signs  to  which  attention  must  be  directed  are  as  follow  : — 

General. — The  most  important  is  pyrexia  ;  often  this  is  the  initial  symptom. 
At  first  the  rise  of  temperature  is  slight  and  irregular;  gradually  it  becomes 
hectic,  with  a  wide  daily  excursion,  say  from  99°  F.  in  the  morning  to  103°  F.  or 
104°  F.  in  the  evening.  Often  the  patient  is  thought  to  have  malaria,  but  an 
examination  of  the  blood  will  show  that  no  malarial  organisms  are  present. 
There  are  sometimes  considerable  intermissions  during  which  the  temperature 
is  normal  for  weeks  or  months,  and  then  there  is  a  week  or  so  of  pyrexia.  When 
such  a  case  occurs  in  this  country,  mistakes  in  diagnosis  are  very  likely.  I  know 
of  a  man  afflicted  with  tropical  abscess  whose  attacks  of  pyrexia  were 
separated  by  such  long  intervals  of  normal  temperature  that  he  was  thought 
by  many  physicians  to  have  recurrent  attacks  of  influenza,  and  this  although 
it  was  well  known  that  he  had  been  in  the  tropics.  Rigors  are  striking  and 
severe,  and  in  cases  of  doubtful  diagnosis  are  very  suggestive  of  hepatic 
abscess,  but  they  also  make  this  disease  resemble  malaria.  In  mild  cases 
the  rigor  is  reduced  to  a  mere  feeling  of  chilliness.  Often  there  are  profuse 
sweats.  The  pulse  is  rapid  in  proportion  to  the  temperature.  Jaundice 
may  be  present.  In  bad  cases  the  patient  is  excessively  ill  and  weak,  anemic, 
and  wasted  to  a  mere  skeleton.  In  this  country  we  see  such  cases  on  their 
arrival  from  India,  the  disease  having  made  rapid  progress  on  board  ship. 
On  the  other  hand,  if  there  are  long  intervals  of  apyrexia,  the  patient  hardly 
suffers  in  his  general  health;  in  such  cases  the  abscess  usually  has  thick  walls. 
The  blood  may  show  a  great  increase  of  polymorphonuclear  cells,  but  this 
leucocytosis  is  often  absent,  especially  if  the  pus  is  sterile  or  the  abscess  has 


LIVER,     ENLARGEMENTS     OF     THE  409 

thick  walls.  During  the  fever  the  patient  has  a  dry  tongue,  is  thirsty,  and 
has  anorexia  ;  the  urine  is  scanty  and  high-coloured,  and  may  contain 
albumin. 

Local. — The  abscess  is  most  often  at  the  upper  part  of  the  right  lobe,  it  grows 
upwards  between  the  layers  of  the  coronary  ligament,  and  thus  forms  an  extra- 
peritoneal subphrenic  abscess  which  softens  the  diaphragm  and  pushes  it  up, 
giving  a  dome-shaped  area  of  dullness  varying  in  size  from  one  to  several  inches 
across,  added  to  the  top  of  the  normal  line  of  the  hepatic  dullness,  and  best 
seen  by  mapping  out  the  dullness  with  a  blue  pencil.  It  is  usually  posterior 
to  the  mid-axillary  line.  Sometimes  the  abscess  is  in  such  a  place  that  a 
rounded  swelling  may  be  felt  on  the  liver  when  the  patient  draws  a  deep 
breath ;  it  may  be  palpable  without  this,  or  it  may  be  visible.  The  measure- 
ment round  the  lower  part  of  the  chest  may  be  longer  on  the  affected  side,  the 
intercostal  spaces  may  be  obliterated,  and,  if  the  abscess  be  very  large,  the 
lower  ribs  may  bulge.  Not  uncommonly  the  abscess  is  of  such  a  size  and  in  such 
a  position  that  the  greatest  care  is  necessary  before  it  can  be  detected.  The 
whole  of  the  hepatic  area  should  be  pressed  carefully  by  one  finger,  for  local 
tenderness  is  often  a  great  aid  in  the  diagnosis.  If  the  abscess  presents  in  the 
abdomen,  the  rectus  muscle  over  it  may  be  rigid.  Pain  is  very  variable  ;  it  may 
be  absent,  it  may  be  severe  ;  often  coughing,  drawing  a  deep  breath,  or  shaking 
the  patient,  will  cause  pain.  In  about  one-sixth  of  the  cases  there  is  pain  in  the 
right  shoulder  ;  if  the  abscess  is  in  the  left  lobe,  there  may  be  pain  in  the  left 
shoulder.  If  the  abscess  comes  close  to  the  skin,  there  may  be  oedema  and 
redness  of  it,  and  in  excessively  rare  cases,  fluctuation.  Often  the  liver  is  enlarged 
generally  as  well  as  locally.  If  the  abscess  is  large,  it  may  be  seen  with  the 
;v-rays,  for  pus  casts  a  very  dark  shadow.  Lastly,  I  would  again  remind  the 
reader,  that  in  some  of  the  chronic  cases  seen  in  this  country,  both  the  local 
and  general  signs  may  be  so  slight  that  great  skill  is  necessary  to  detect  the 
abscess.  If  the  abscess  implicates  the  diaphragm,  infection  may  spread  through 
it  and  cause  bronchitis,  pleurisy,  empyema,  pneumonia,  or  gangrene  of  the 
lung,  but  this  is  not  nearly  so  common  as  with  other  subphrenic  abscesses  ; 
hepatic  pus  may  be  coughed  up  from  the  lung  when  the  abscess  has  ruptured 
into  it,  may  be  vomited  when  it  has  ruptured  into  the  stomach,  or  may  be 
passed  by  the  bowel  when  it  has  ruptured  into  the  intestine. 

Cirrhosis  of  the  Liver. — Nearly  always  the  patient  has  taken  more  alcohol 
than  he  should,  but  in  rare  cases  cirrhosis  of  the  liver,  indistinguishable  from 
alcoholic  cirrhosis,  occurs  in  children  and  others  who  have  not  taken  alcohol. 
Here  we  have  to  consider  only  the  stage  of  cirrhosis  of  the  liver  in  which  the 
organ  is  enlarged.  It  has  been  known  to  weigh  200  oz.,  but  anything  over 
100  oz.  is  exceptional.  In  the  early  stages  the  liver  is  not  altered  in  shape, 
and  the  surface  is  smooth ;  later  on,  as  the  fibrous  tissue  contracts  and  the 
fat  is  absorbed  from  the  cells  which  have  undergone  degeneration,  the  surface 
becomes  finely  uneven  ;  this  unevenness  increases,  the  liver  becomes  hard  and 
more  uneven  until  the  irregularities  on  it  are  like  hobnails,  and  can  be  felt  with 
the  hand  through  the  abdominal  wall.  At  this  stage  the  edge  of  the  liver  is 
very  firm  and  irregular.  As  the  irregularity  increases,  the  diagnosis  from  cancer 
becomes  more  difficult,  but  no  irregularity  from  cirrhosis  ever  exceeds  the  size 
of  a  small  cherry,  nor  is  it  ever  umbilicated,  nor  does  it  ever  suddenly  enlarge  ; 
whereas  a  cancerous  nodule  may  be  umbilicated  and  may  suddenly  enlarge  from 
haemorrhage  into  it.  Usually  a  cirrhotic  liver  is  not  painful ;  if  it  be,  the  pain 
is  due  to  some  local  perihepatitis.  Other  symptoms  to  be  looked  for  in  cirrhosis, 
and  to  be  borne  in  mind  when  making  a  diagnosis,  are  that  in  cirrhosis  the 
spleen  is  often  much  enlarged,  and  the  increased  fibrous  tissue  in  the  liver  con- 
stricting its  small  portal  veins  leads  to  engorgement  of  the  veins  of  the  stomach  ; 


41  o  LIVER,     ENLARGEMENTS     OF     THE 

and  hence  haematemesis,  which  may  be  accompanied  by  melsena,  is  common ; 
and  occasionally  we  see  dilatation  of  the  veins  round  the  umbilicus.  There 
are  often  symptoms  of  chronic  gastritis  and  enteritis.  Cirrhosis  is  commoner 
in  men  than  women  in  the  proportion  of  three  to  one  ;  the  patients  are  usually 
over  thirty  ;  there  is  a  more  frequent  association  of  alcoholic  excess  in  the  lower 
classes  than  among  those  who  are  socially  above  them.  Dyspepsia  and  morning 
sickness  are  common  ;  there  are  much  impairment  of  strength,  wasting,  a  sallow 
look,  dilated  venules  on  the  cheek,  red  nose,  a  furred  tongue  which  is  often  tremu- 
lous, and  a  dry,  harsh  skin.  The  pulse  becomes  weaker,  and  when  the  disease 
is  fatal,  its  end  is  usually  by  cardiac  failure.  In  about  one-third  of  the  cases 
that  are  ill  enough  to  come  into  the  hospital,  the  temperature  is  raised  a  little 
every  evening.  Jaundice  is  present  in  about  one-third  of  the  cases  ;  it  is  usually 
persistent,  and  rarely  if  ever  becomes  as  deep  as  that  seen  in  cancer  of  the  liver. 
Ascites  occurs  in  50  per  cent  of  all  cases  of  cirrhosis  ;  if  it  is  abundant,  the  enlarged 
liver  can  be  felt  only  by  dipping,  which  means  pressing  the  hand  down  suddenly 
on  the  liver,  and  so,  by  dispersing  the  fluid  which  is  over  it,  coming  down  on  it. 
Tympanites  is  not  uncommon  in  severe  cases  of  cirrhosis,  and  it  too  may  make 
it  difficult  to  feel  the  liver.  The  urine  is  usually  scanty,  of  high  specific  gravity, 
very  acid,  high-coloured,  and  full  of  urates  ;  it  may  contain  bile.  Naturally 
sufferers  from  cirrhosis  may  have  delirium  tremens,  but  apart  from  this,  cirrhosis 
towards  the  end  is  often  accompanied  by  nervous  symptoms,  especially  coma, 
and  this  may  be  so  in  those  who  have  not  recently  taken  alcohol  and  who  are 
not  jaundiced.  In  severe  cases  the  ankles  swell,  even  when  there  is  no  disease 
of  the  heart,  lungs,  or  kidneys,  or  pressure  on  the  vena  cava,  to  account  for  it. 
Lastly,  it  should  be  remembered  that  cirrhosis  may  exist  Avithout  any  symptoms  ; 
in  between  a  third  and  a  half  of  all  cases  of  cirrhpsis  found  in  the  post-mortem 
room  the  patient  has  died  of  something  else,  and  in  many  of  these  cases, 
although  he  has  been  under  observation  in  the  wards,  no  symptoms  of  cirrhosis 
have  been  observed. 

The  difficulties  of  diagnosis  fall  into  one  of  two  classes  :  the  cause  of  Ascites 
{q.v.),  and  the  cause  of  enlargement  of  the  liver.  If  we  have  made  out  that  the 
liver  is  undoubtedly  enlarged,  it  is  often  a  matter  of  great  difficulty  to  tell  whether 
the  enlargement  is  due  to  cancer  or  cirrhosis  :  this  will  be  referred  to  in  speaking 
of  cancer.  Sometimes  cancer  and  cirrhosis  are  present  in  the  same  liver, 
but  this  is  rare.  Syphilis  of  the  liver  does  not  cause  much  difficulty,  for  it  is 
extremely  uncommon  at  the  bedside  ;  the  irregularities  of  the  liver  are  much 
larger  than  the  hobnails  of  cirrhosis  ;  the  patient  who  has  a  syphilitic  liver  is 
rarely  if  ever  jaundiced,  and  hardly  ever  has  ascites.  The  symptoms  of  a 
syphilitic  liver  are  entirely  local  ;  syphilitic  disease  of  the  liver  produces  no 
general  symptoms.  Obstruction  of  the  common  bile-duct  leads  to  a  large  smooth 
liver  ;  when  this  is  due  to  a  gall-stone  there  is  usualh^  deeper  jaundice  than  in 
cirrhosis,  but  no  ascites  ;  the  stools  are  quite  white,  which  is  very  unusual  in 
cirrhosis,  and  there  is  commonly  a  history  of  gall-stones.  There  is  no  real 
difficulty  of  diagnosis  between  the  enlargement  of  malaria  and  ordinary  cirrhosis, 
for  so-called  malarial  cirrhosis  occurs  only  in  those  who  have  drunk  to  excess, 
and  is  then  to  be  ascribed  to  alcohol. 

Hanot's  Cirrhosis — often  called  hypertrophic  biliary  cirrhosis,  an  extremely 
bad  name — is  a  very  rare  disease,  of  which  the  distinguishing  features  are  : 
Most  of  the  sufferers  are  children  ;  few  reach  the  age  of  thirty  ;  it  is  commoner 
in  males  than  females  ;  it  lasts  many  years  ;  the  liver  is  firm,  enlarged,  and 
smooth  ;  long-standing  jaundice  is  present  ;  the  spleen  is  very  much  enlarged. 
The  patients  are  usually  children  of  stunted  growth,  and  therefore  the  liver 
appears  very  large,  but  the  spleen  is  proportionately  more  enlarged.  The  liver 
usually  remains  smooth  throughout,  and  even  when  towards  the  end  of  a  long 


LIVER,     ENLARGEMENTS     OF     THE  411 

case  it  becomes  a  little  granular,  it  never  proceeds  to  anything  like  the  irregularity 
of  ordinary  cirrhosis.  Jaundice  is  an  early  symptom  and  lasts  till  the  end,  so 
it  may  be  present  many  years;  very,  very  slowly  it  becomes  darker.  From 
time  to  time  the  patient  has  periods  during  which  he  feels  ill  and  his  temperature 
is  raised.  It  is  strange  that  in  spite  of  their  jaundice,  the  children  afflicted 
with  this  disease  do  not  for  years  appear  ill  ;  such  children  may  be  seen 
running  about  enjoying  life,  with  a  clean  tongue  and  a  good  appetite.  Ascites 
is  rare,  and  if  present  means  that  the  end  is  near.  In  many  cases  the  fingers 
have  become  clubbed,  especially  in  children.  The  clubbing  is  exactly  like  that 
seen  in  chronic  fibrosis  of  the  lung.  As  growth  is  stunted — for  example,  the 
average  height  at  13  years  is  4  ft.  9  in.,  but  a  patient  with  this  disease  was 
only  4  ft.  I  in. — the  size  of  the  liver  and  spleen  makes  the  abdomen  very 
prominent.     At  the  later  stages  there  may  be  htemorrhages. 

Splenic  Anaemia. — This  is  a  disease  in  which  there  are  progressive  enlargement 
of  the  spleen,  secondary  anaemia,  leucopenia,  a  marked  tendency  to  haemorrhage, 
especially  from  the  stomach,  and  in  many  cases,  a  terminal  stage  of  cirrhosis  of 
the  liver,  jaundice,  and  ascites.  The  disease  is  often  called  splenomegalic  cirrhosis, 
and  its  terminal  stage  of  cirrhosis  of  the  liver  is  frequently  designated  Band's 
disease.  When  in  this  terminal  stage  the  liver  is  enlarged  from  cirrhosis,  it  maybe 
almost  impossible  to  distinguish  the  condition  from  ordinary  cirrhosis  of  the  liver, 
unless  we  know  from  the  medical  history  of  the  case  that  the  spleen  has  been 
enlarged  for  some  time.  Other  points  that  may  help  are  :  on  the  average 
the  spleen  is  much  larger  in  splenic  anaemia  than  in  ordinary  cirrhosis,  so  that 
an  excessively  large  spleen  is  somewhat  in  favour  of  splenic  anaemia  ;  hjemat- 
emesis  is  an  early  symptom,  usually  present  long  before  the  stage  of  cirrhosis 
of  the  liver.  The  disease  is  very  slow,  but  the  patient  may  die  before  the  super- 
vention of  either  ascites  or  jaundice  ;  he  does  not  often  do  this  in  ordinary 
cirrhosis.  Anaemia  is  present  in  both  conditions,  but  is  probably,  on  the  whole, 
severer  in  splenic  anaemia. 

Bronzed  Diabetes. — In  this  disorder,  which  is  very  seldom  seen,  the  liver  is 
enlarged,  hard,  and  cirrhotic,  exactly  like  that  of  an  ordinary  cirrhosis  :  the 
pigmentation  of  the  skin,  which  is  like  the  discoloration  due  to  arsenic,  the 
absence  of  jaundice,  and  the  presence  of  sugar  in  the  urine,  sufficiently  distin- 
guish the  disease. 

Syphilis  of  the  Liver. — Syphilis  when  it  affects  the  liver  produces  gummata 
in  it,  and  leads  to  increased  growth  of  fibrous  tissue.  Much  of  this  is  in  the 
form  of  hard  bands  traversing  the  liver  irregularly  and  leaving  large  areas 
of  healthy  liver  substance.  It  will  be  easily  understood  that  what  with  the 
presence  of  recent  gummata,  gummata  that  have  begun  to  shrink,  bands  of 
fibrous  tissue  that  have  begun  to  contract,  and  pieces  of  normal  liver,  a 
syphilitic  liver  is  very  lumpy  and  irregular  in  shape.  It  may  be  enlarged,  and 
even  during  life  this  lumpiness  may  be  felt,  but  the  syphilitic  liver  does  not 
become  so  large  as  a  large  cirrhotic  liver,  unless  lardaceous  disease  be  present  ; 
it  is  much  more  irregular,  and  indeed  usually  resembles  a  cancerous  more  than 
a  cirrhotic  liver,  but  it  seldom  produces  any  clinical  symptoms ;  if  detected 
during  life  the  discovery  is  generally  accidental  ;  it  occurs  at  a  younger  age 
than  cancer  ;  there  are  none  of  the  other  signs  of  cancer,  but  there  may  be 
some  of  syphilis  ;  ascites  and  jaundice  do  not  occur  as  signs  of  this  disease 
unless  an  enlarged  gland  presses  on  the  portal  fissure,  which  is  so  rarely  the 
case  as  to  be  negligible  ;  and  the  liver  is  at  most  a  little  enlarged,  never  huge 
as  in  cancer. 

In  children,  congenital  syphilis  may  produce  in  the  liver  precisely  the  same 
effects  as  the  acquired  disease  does  in  adults.  Lardaceous  disease  may  be  due 
to  syphilis  ;   it  will  be  discussed  presently. 


412  LIVER,     ENLARGEMENTS     OF     THE 

Universal  Chronic  Perihepatitis  may  make  the  liver  appear  large,  for  in  this 
condition  the  peritoneal  coating  of  the  whole  organ  is  much  thickened  ;  but  as 
the  liver  itself  is  of  normal  size  the  apparent  increase  is  not  great,  rarely  exceeding 
an  extra  finger's  breadth  below  the  ribs.  Such  of  the  liver  as  can  be  felt  is 
smooth ;  the  edge  is  uniform  and  thick.  Usually,  however,  no  apparent  enlarge- 
ment can  be  detected  in  universal  chronic  perihepatitis,  and  often  the  organ 
and  its  thickened  capsule  weigh  the  same  as  a  normal  liver,  from  which 
we  may  conclude  that  the  liver  itself  is  a  little  atrophied  :  in  a  few  cases  it 
appears  actually  smaller  than  natural,  for  the  thin  anterior  edge  is  folded 
upwards  under  the  thick  peritoneal  coat.  There  are  no  hepatic  symptoms,  e.g., 
jaundice,  and  the  universal  perihepatitis  is  only  part  of  a  general  chronic  peri- 
tonitis, symptoms  of  which,  e.g.,  ascites  and  thickening  of  other  parts  of  the 
peritoneum,  may  be  detected  on  palpation. 

Secondary  Cancer  of  the  Liver. — This  is  the  commonest  tumour  of  the  liver. 
Generally  there  will  be  symptoms  of  the  primary  malignant  disease,  which 
in  about  90  per  cent  of  the  cases  is  in  the  periphery  of  the  portal  area,  but 
not  infrequently  none  are  present,  and  the  patient  does  not  know  that  he 
has  anything  serious  the  matter  with  him  until  he  has  symptoms  of  hepatic 
carcinoma.  In  about  half  the  cases  of  hepatic  carcinoma  no  symptoms  of  it 
are  present,  and  it  is  not  known  to  exist  until  a  post-mortem  examination  is 
performed,  for  the  primary  disease  kills  while  the  hepatic  disease  is  still  in  its 
early  stages.  Seventy-five  per  cent  of  all  the  patients  are  between  40  and  70 
years  old,  and  hepatic  carcinoma  is  all  but  unknown  under  the  age  of  twenty. 
If  the  disease  gives  rise  to  clinical  symptoms  the  liver  can  usually  be  made  out 
to  be  enlarged  both  by  percussion  and  palpation.  There  is  no  other  disease  in 
which  such  a  huge  liver  may  be  found.  I  have  known  a  cancerous  liver  to  weigh 
19  lb.,  and  I  have  read  of  one  which  weighed  33-J-  lb.  ;  weights  of  6  or  7  lb. 
are  quite  common.  In  rare  cases,  the  increase  in  the  weight  of  the  liver  may 
be  so  great  that  the  patient  actually  gains  a  little  weight  in  spite  of  the  general 
wasting  caused  by  the  cancer.  The  organ  may  be  felt  well  below  the  ribs, 
even  far  below  the  umbilicus.  Upward  increase  of  the  hepatic  dullness  is  rare, 
and  when  present,  slight.  The  edge  of  the  enlarged  organ  can  be  felt  to  move 
up  and  down  with  respiration,  unless  it  is  fixed  by  adhesions,  which  is  unusual. 
Often  it  is  so  big  that  it  can  be  seen  to  go  up  and  down  with  each  breath.  The 
edge  is  hard,  and,  owing  to  the  presence  of  carcinomatous  nodules,  often  irregular  ; 
those  nodules  on  such  parts  of  the  upper  and  anterior  surfaces  as  come 
below  the  ribs  can  be  felt,  so  that  the  whole  organ  feels  irregular,  knobby, 
and  hard,  and  sometimes  the  lumps  on  it  feel  umbilicated  ;  this  is  absolutely 
diagnostic  of  cancer.  Occasionally,  if  much  softening  has  occurred,  a  faint 
sensation  of  fluctuation  may  be  detected,  and  in  a  few  instances  local  peritonitis 
causes  a  rub.  Sometimes  the  nodules  can  be  appreciated  by  the  hand  only  when 
the  patient  takes  a  deep  breath,  for  then  those  under  the  ribs  come  far  enough 
down  to  be  felt.  Sometimes  the  cancer  grows  so  fast  that  the  liver  obviously 
increases  in  size  in  a  week  ;  very  rarely  a  nodule  may  enlarge  suddenly  from 
haemorrhage  into  it.  Either  or  both  these  points  are  almost  proof  that  the 
enlargement  of  the  liver  is  due  to  carcinoma.  It  must  not  be  forgotten  that 
not  all  livers  enlarged  from  malignant  disease  have  palpable  nodules,  for  they 
may  be  in  such  a  situation  that  they  cannot  be  felt,  they  may  be  too  small  to  be 
felt,  or  the  growth  may  be  diffused  through  the  whole  liver.  About  half  the 
patients  have  pain  in  the  hepatic  region,  and  may  have  it  near  the  right  shoulder 
and  down  the  right  arm.  If  the  liver  is  very  large,  there  is  a  sense  of  dragging 
and  fullness  in  the  right  hypochondrium.  About  half  the  patients  are  jaundiced. 
It  is  extremely  important  to  remember  that  by  far  the  most  frequent  cause  of 
long-standing  jaundice  is  cancer  of  the  liver,  which  produces  a  deeper  yellow 


LIVER,     ENLARGEMENTS     OF     THE  413 

of  the  skin  than  any  other  disease  ;  as  time  goes  on,  this  yellow  changes  to 
deep  olive-green.  The  wasting  becomes  extreme,  the  skin  dry  and  shrivelled, 
the  patient  becomes  weaker  and  weaker,  his  pulse  feebler,  his  respiration  shallow, 
and  finally  he  dies  comatose.  The  usual  symptoms  of  Jaundice  [q.v.)  are  present. 
Ascites  {q.v.)  is  rather  less  frequent  than  jaundice,  and  the  patient  generally  dies 
before  tapping  is  necessary,  for  ascites  is  a  late  symptom.  The  urine  usually 
contains  much  bile  and  lithates.  Rapidly  growing  carcinoma  of  the  liver  is 
often  associated  with  an  evening  rise  of  temperature  to  99°  F.  or  101°  F.  I 
have  known  it  to  be  102°  F.  every  evening  for  weeks. 

The  chief  difficulty  of  diagnosis  is  from  cirrhosis.  The  large  cirrhotic 
liver  is  uniformly  large,  and  the  palpable  nodules  are  small  ;  if  they  feel 
bigger  than  small  cherries  the  case  cannot  be  one  of  cirrhosis,  for  hobnails 
are  never  bigger  than  this  ;  hobnails  are  never  umbilicated,  and  never  increase 
rapidly  in  size  ;  if  jaundice  is  present  and  the  patient  has  a  large  cirrhotic 
liver,  the  jaundice  is  never  very  deep,  and  remains  yellow  ;  we  never  see 
the  dark  olive-green  seen  in  cancer.  The  patient  with  cirrhosis  is  more 
likely  to  die  rapidly  after  the  onset  of  ascites  than  the  sufferer  from 
cancer  ;  in  cirrhosis  we  do  not  get  clay-coloured  motions  nor  dilatation  of 
the  gall-bladder,  but  we  often  find  a  large  spleen.  Extreme  wasting  and 
dryness  of  the  skin  are  more  common  in  cancer.  A  moderate  leucocytosis 
is  often  found  in  cancer,  but  not  in  cirrhosis.  The  discovery  of  cancer 
elsewhere  is  of  course  conclusive,  and  the  history  is  of  great  help.  Syphilis 
of  the  liver,  has  already  been  described  sufficiently  to  indicate  the  points  of 
difference.  Cases  in  which,  owing  to  non-malignant  obstruction  of  the  bile- 
duct,  usually  by  a  gall-stone,  there  are  enlargement  of  the  liver  and  jaundice, 
may  give  rise  to  difficulty  of  diagnosis  ;  but  these  patients  rarely  have  the 
extreme  wasted  look,  with  dry  shrivelled  skin,  so  frequently  seen  in  cancer ;  the 
hepatic  enlargement  is  uniform  and  never  so  great  as  it  may  be  in  cancer ;  and 
the  jaundice  does  not  become  green  ;  if  it  disappears  for  a  time,  it  means  that 
the  gall-stone  has  shifted  ;  that  the  jaundice  due  to  cancer  should  disappear  is 
almost  unknown.  Rigors  are  common  in  cases  of  gall-stones.  The  age,  history, 
and  detection  of  growths  elsewhere  will  be  of  help.  As  far  as  my  experience 
goes,  when  we  are  in  considerable  doubt  as  to  whether  a  patient  has  an  impacted 
gall-stone  or  a  malignant  growth,  exploration,  if  done,  almost  always  reveals  a 
growth.  Hydatid  tumours  of  the  liver  are  seldom  confused  with  cancer,  for 
almost  always  these  are  only  one  or  two  in  number,  the  liver  is  smooth  and 
regular,  and  is  not  tender;  the  hydatid  tumour  causes  neither  pain,  jaundice, 
ascites,  nor  general  emaciation,  and  it  may  give  a  thrill.  There  is  no  ordinary 
leucocytosis,  but  the  patient  may  have  eosinophilia. 

Primary  Carcinoma  of  the  Liver. — This  is  very  rare  ;  the  liver  has  the  same 
character  as  in  the  secondary  form,  but  there  are  no  symptoms  of  a  primary 
growth  elsewhere.  It  is  almost  always  a  disease  of  adult  life.  It  is  usually 
more  rapid  than  secondary  cancer  ;  most  of  the  patients  are  dead  within 
three  months  from  the  onset  of  symptoms,  and  therefore  the  jaundice  has  not 
time  to  become  dark  green.  Wasting,  and  other  general  signs  including  slight 
pyrexia,  are  present.  During  life,  primary  can  hardly  ever  be  diagnosed  from 
secondary  cancer  of  the  liver,  for,  in  this  condition,  the  primary  disease  often 
gives  no  symptoms,  and  is  not  detected  till  after  death. 

Secondary  Sarcoma  and  Embryomata  of  tlie  Liver. — These  do  not  produce 
enlargement  enough  to  be  detected  during  life — except  perhaps  in  the  case  of 
melanotic  sarcoma, — for  the  primary  disease  and  the  numerous  secondary 
deposits  elsewhere  than  in  the  liver  soon  kill  the  patient. 

Primary  Sarcoma  of  the  Liver  is  very  rare,  and  cannot  during  life  be 
distinguished  from  primary  carcinoma. 


414  LIVER,     ENLARGEMENTS     OF     THE 

Adenomata  of  the  Liver  are  also  very  rare  ;  they  are  hardly  ever  of 
sufficient  size  to  be  detected  during  life.  They  are  single,  and  I  know  of 
an  instance  in  which  a  large  one  was  operated  on  under  the  impression  that 
it  was  a  hydatid. 

Lymphadenomata  of  the  Liver. — New  formations  consisting  of  lymphoid 
tissue,  generally  diffused  through  the  whole  liver  but  sometimes  occurring 
in  nodules,  may  be  seen  in  those  dying  from  Hodgkin's  disease  or  from 
lymphatic  leukaemia.  The  nodules  cannot  be  detected  during  life,  but  in 
a  few  cases  the  diffuse  variety  makes  the  liver  uniforinly  enlarged  ;  it  is 
smooth,  its  surface  and  edge  are  firm,  it  is  painless,  not  tender,  never  of  great 
size,  and  there  is  no  jaundice.  Leuksemic  cases  will  be  detected  by  the  blood- 
count  (see  Anjemia). 

Angiomata. — It  is  not  uncommon  to  find  small  angiomata  in  the  liver  in  the 
post-mortem  room,  but  they  cannot  be  detected  during  life  unless  they  are 
large  enough  to  give  symptoms  which  result  from  their  size,  and  this  is  very 
rare.  In  nearly  all  the  cases  in  which  a  large  tumour  of  the  liver  has  been 
thought  to  be  a  carcinoma,  and  yet  the  patient  has  seemed  well  enough  to  be 
suitable  for  operation,  the  growth  has  turned  out  to  be  a  cavernous  angioma, 
and  these  tumours  have  been  excised.  About  fifteen  of  such  cases  are  on  record, 
and  the  patient  was  usually  under  fifty  years  of  age. 

Fatty  Liver. — This  is  very  common,  but  the  enlargement  of  a  fatty  liver  is 
usually  not  sufficient  to  be  detected  during  life,  sometimes  because  the 
patients  are  so  obese  that  palpation  of  the  liver  is  difficult.  A  fatty  liver,  if 
increased  in  size,  is  uniformly  enlarged,  has  a  rounded  edge,  feels  a  little 
softer  than  natural,  with  a  smooth  surface  ;  there  is  neither  pain  nor 
tenderness.  The  causes  are  so  numerous  that  often  they  hardly  help  the 
diagnosis.  The  largest  fatty  livers  are  met  with  in  phosphorus  poisoning  ; 
they  then  may  weigh  lo  or  12  lbs.  Severe  anaemia,  wasting  disease,  especi- 
ally tubercle,  and  alcoholic  excess,  are  perhaps  the  commonest  causes.  There 
is  neither  jaundice  nor  other  symptom  that  can  be  attributed  to  the  disease 
of  the  liver. 

Lardaceous  Liver. — The  liver  is  uniformly  enlarged  ;  the  increase  in  size 
may  be  considerable  ;  indeed,  next  to  cancer,  lardaceous  disease  causes  the 
largest  livers  with  which  we  meet.  A  lardaceous  liver  has  been  known  to  weigh 
14  lbs.  It  is  so  smooth  that  even  through  the  skin  it  feels  smooth;  it  is  firm, 
and  the  edge  is  sharp  and  hard  ;  it  causes  no  pain,  and  is  not  tender.  The 
diagnosis  of  this  disease  is  much  facilitated  by  finding  lardaceous  disease  of 
other  organs  ;  thus  the  spleen  may  be  enlarged  considerably  and  uniformly, 
there  may  be  albuminuria  from  lardaceous  disease  of  the  kidneys,  or  diarrhoea 
from  lardaceous  disease  of  the  intestine.  Only  two  causes  for  lardaceous  disease 
are  known,  viz.,  long-continued  suppuration,  e.g.,  psoas  abscess,  and  long-standing 
syphilis,  even  if  this  has  not  caused  any  suppuration.  I  have  known  it  occur 
in  a  small  child  as  a  result  of  congenital  syphilis.  In  a  very  few  instances  no 
cause  for  lardaceous  disease  can  be  discovered,  but  this  is  so  exceptional  that 
we  should  be  very  cautious  of  diagnosing  lardaceous  disease  in  the  absence  of 
syphilis  or  suppuration. 

Tuberculosis  of  the  Liver. — It  is  excessively  rare  for  a  tuberculous  deposit  in 
the  liver  to  form  a  mass  sufficiently  large  to  be  detected  clinically :  indeed,  so 
rare  is  it  that  the  diagnosis  could  not  be  made  before  exploration  unless  it  were 
known  that  the  patient  had  tuberculous  disease  at  the  periphery  of  the  portal 
vein.  Judging  by  morbid  anatomy,  a  tuberculous  tumour  of  the  liver  would, 
if  discovered  during  life,  be  a  solitary  tumour  of  the  liver.  At  an  exploratory 
operation  an  irregular  shaggy  abscess  cavity  would  be  found,  the  pus  of  which 
would  contain  tubercle  bacilli. 


LIVER,     ENLARGEMENTS     OF     THE  415 


Actinomycosis,  or,  as  it  is  sometimes  called,  stveptotrichosis  of  the  liver.  This 
could  hardly  be  diagnosed  without  laparotomy  unless  the  patient  were  known 
to  have  actinomycosis  elsewhere.  It  is  very  rare,  and  has  seldom  been 
recognized  in  the  liver  until  after  the  patient's  death.  If  detected  during  life, 
there  would  be  a  local  enlargement  of  the  liver.  The  pus  in  it  would  be  in  an 
irregular  cavity  with  shaggy  walls  and  trabeculae,  and  the  characteristic  little 
sulphur-coloured  granules  would  be  seen  in  it  with  the  naked  eye,  and  the  ray 
fungus  on  examination  with  the  microscope  [Plate  XII,  Fig.  S). 

Hydatid  Disease  of  the  Liver. — This  can  hardly  be  recognized  unless  the 
cyst  causes  a  discoverable  tumour  of  the  liver.  This  may  be  huge.  Hydatid 
cysts  of  the  liver  may  contain  thirty  pints  or  more.  If  the  tumour  can 
be  felt,  it  is  rounded,  smooth,  localized,  and  regular,  and  thus  is  distinguished 
by  its  feel  from  cancerous  or  syphilitic  livers,  for  in  these  the  tumours  are 
irregular  and  rough,  and  often  there  are  one  or  more  in  different  parts  of  the 
liver.  A  hydatid  tumour  is  neither  tender  nor  painful,  and  thus  differs  from 
an  abscess.  If  the  tumour  projects  from  the  lower  part  of  the  liver,  it  may 
resemble  a  gall-bladder  ;  if  it  is  more  on  the  surface  of  the  liver,  it  may  be  felt 
there,  especially  when  the  patient  takes  a  deep  inspiration,  for  then  it  descends 
from  under  the  ribs.  A  large  hydatid  cyst  of  the  lower  part  of  the  right  lobe 
of  the  liver  causes  considerable  intra-abdominal  enlargement  of  that  lobe  ; 
on  the  other  hand,  if,  as  is  frequently  the  case,  it  grows  upwards  between  the 
layers  of  the  coronary  ligament,  it  pushes  up  the  diaphragm,  forming  a  rounded 
projection  which  may  be  percussed  out  in  the  chest  as  an  addition  to  the  top 
of  the  normal  hepatic  dullness  :  in  exceptional  cases  the  tumour  may  be  so 
huge  that  the  dome  shape  of  the  dullness  is  lost,  and  the  case  is  regarded  as 
one  of  pleuritic  effusion.  When  the  tumour  attains  considerable  size  there  is 
impaired  vesicular  murmur  over  the  right  chest,  which  is  bulged  so  that  it 
measures  more  than  the  left.  If  a  hydatid  tumour  is  deep  in  the  liver,  the 
swelling  feels  hard  ;  if  it  comes  to  the  surface,  the  tumour  feels  tense — so  tense 
that  fluctuation  is  very  rare.  The  so-called  hydatid  thrill,  being  the  thrill  felt 
in  the  finger  lying  on  the  tumour  when  it  is  struck  by  a  finger  of  the  other  hand, 
is  not  often  felt,  though  it  may  be  obtained  over  any  tense  collection  of  fluid  ; 
but  if  it  be  present  it  is  of  considerable  diagnostic  value,  for  other  tense  cysts  are 
very  unusual  in  the  liver.  Occasionally  two  or  even  three  hydatid  cysts  are 
present  in  .the  same  liver ;  each  then  has  the  characteristics  of  a  single  cyst,  but 
the  diagnosis  of  these  cases  may  give  much  difficulty.  It  is  excessively  rare  for 
hydatids  to  cause  pressure  symptoms  ;  jaundice  is  hardly  ever  seen  ;  if  present, 
it  is  probably  caused  by  rupture  of  the  cyst  into  the  bile-passages.  A  huge 
cyst  may  displace  the  heart.  Eosinophilia  [q-v.),  even  to  a  considerable  degree, 
is  sometimes  found.  I  have  seen  10  per  cent  of  eosinophiles,  and  even  50  per 
cent  have  been  recorded.  A  more  moderate  increase  is  sometimes  seen  in 
cancer.  Usually,  eosinophilia  is  absent  in  hydatid  disease  ;  when  present  it 
is  a  considerable  help  in  diagnosis.  It  decreases  greatly  after  the  cyst  is  drained. 
If  the  hydatid  fluid  become  absorbed  the  patient  may  have  urticaria.  When 
the  blood-serum  of  a  patient  with  hydatid  disease  is  mixed  with  some  hydatid 
fluid,  a  precipitate  may  be  formed  after  about  twenty  hours  ;  this  reaction  is 
not  constant,  but  it  does  not  occur  when  hydatid  fluid  is  mixed  with  the  serum 
of  a  patient  who  has  not  got  hydatid  disease.  Hydatid  fluid  does  not  give 
an  albuminous  precipitate  when  heated,  whereas  the  fluid  of  an  ordinary 
pleuritic  effusion  does  ;  on  the  other  hand,  hydatid  fluid  gives  an  abundant 
white  precipitate  of  silver  chloride  when  silver  nitrate  is  added  to  it.  Hooklets 
(see  Fig.  6,  p.  57)  may  often  be  found  in  hydatid  fluid,  especially  after  it  is 
centrifugalized.  Hydatid  cysts  sometimes  suppurate,  and  then  they  can  hardly 
be  distinguished  from  other  forms  of  single  solitary  abscess. 


41 6  LYMPHATIC     GLAND     ENLARGEMENT 

Alveolar  Echinococcus  Disease  is  very  rare.  No  case  has  been  recorded  in 
England.  The  liver  is  enlarged,  and  jaundicej  graduallj'  deepening  during  the 
two  or  three  j^ears  the  patient  lives,  is  present.  P}Texia  and  gastro-intestinal 
symptoms  are  often  present,  and  the  patient  dies  from  exhaustion. 

Other  cj^sts  of  the  liver  are  very  rare  and  very  difficult  to  diagnose.  Special 
text-books  dealing  with  the  liver  should  be  consulted  about  them. 

W.  Hale  White. 

LIVIDITY,  EXTREME (See  Cyanosis.) 

LOCK-JAW (See  Trismus.) 

LYMPHATIC  GLAND  ENLARGEMENT. 

[A). — Generalized  Enlargement. 

There  are  certain  diseases  in  which  there  is  a  tendency  for  all  or  nearly  all  the 
IjTnphatic  glands  in  the  body  to  be  enlarged — generalized  glandular  enlargement, 
as  distinct  from  enlargement  of  local  groups  of  glands  only.  The  distinction  is 
not  an  absolute  one,  however,  for  in  a  certain  proportion  of  patients  suffering 
from  a  malady  which  usually  causes  general  lymphatic  glandular  enlargement, 
the  changes  may  be  confined  to  local  groups  instead  of  being  as  widespread  as 
usual.  It  may  be  said,  however,  that  if  there  is  generalized  enlargement  of  the 
lymphatic  glands,  the  patient  is  probabl}^  suffering  from  one  or  other  of  the 
following  diseases  : — 


Lymphatic   leukemia 
Hodgkin's  disease 
Lj^mphadenoma 
Lymphoma 
Lj-mphosarcoma 


Secondary  syphilis 
German  measles 
Still's  disease 
Plague. 


It  is  of  course  important  to  be  quite  sure  that  the  glands  are  really  enlarged, 
and  not  merely  palpable  with  greater  ease  than  usual  ;  experience  alone  will 
decide  this  question.  There  are  many  conditions  in  which  wasting  affects  the 
subcutaneous  fat  and  not  the  lymphatic  glands,  so  that  the  latter  are  felt 
with  considerable  ease,  especially  in  the  groins  in  very  thin  persons.  General 
glandular  enlargement  usually  imphes  affection  of  the  cervical,  axillarj',  and 
inguinal  glands  at  the  same  time  ;  those  in  the  popliteal  space  or  above  the 
internal  condyle  of  the  humerus,  are  less  often  affected  ;  the  various  groups 
within  the  abdomen  can  seldom  be  palpated,  unless  perhaps  in  the  iliac  region 
or  pelvis,  whilst  enlargement  of  the  mediastinal  and  bronchial  groups  can  only 
be  surmised  when  there  is  evidence  of  obstruction  to  one  or  other  bronchus. 

When  a  case  of  generahzed  Ij^mphatic  glandular  enlargement  presents  itself, 
it  is  important  to  make  a  blood-count  ;  the  blood-changes  will  either  indicate 
lymphatic  leukcemia  (see  Anemia),  or  else,  if  the  characteristic  leucocyte  counts 
of  the  latter  are  not  found,  lymphatic  leukaemia  will  be  excluded.  Xone  of  the 
other  conditions  exhibit  pathognomonic  blood-changes,  although  there  will  very 
often  be  a  considerable  degree  of  aneemia  of  the  chlorotic  type. 

Hodgkin's  disease  nearly  alwa3-s  starts  with  much  swelling  of  one  group  of 
glands  before  the  rest,  especially  those  in  the  neck  ;  there  is  usually  a  moderate 
degree  of  enlargement  of  the  spleen  at  the  same  time,  and  in  the  course  of  weeks 
or  months,  generalized  swelling  of  the  lymphatic  glands  occurs,  especially  those 
in  the  axillae  and  within  the  thorax,  the  resultant  masses  sometimes  being  of 
considerable  size  {Fig.  119)  though  the  individual  glands  remain  distinct  from 
one  another,  do  not  tend  to  break  down  and  suppurate,  and  do  not  become 
fixed  either  to  the  skin  or  to  the  deeper  parts,  as  they  would  do  if  they  were 


LYMPHATIC     GLAND     ENLARGEMENT 


417 


tuberculous  or  due  to  secondary  deposits  of  malignant  disease.  The  blood- 
changes  in  Hodgkin's  disease  are  for  the  most  part  negative  (see  An/Emia), 
though  in  blood-tilms  the  occurrence  of  an  occasional  basophile  corpuscle  or 
myelocyte  may  help  to  clinch  the  diagnosis. 

Lymphadenoma  differs  from  Hodgkin's  disease  so  little  that  some  authorities 
use  the  two  names  as  though  they  were  synonymous  ;  others  reserve  the  term 
lymphadenoma  for  those  cases  in  which  splenic  enlargement  is  not  apparent, 
whilst  the  affection  of  the  lymphatic  glands  is  very  profound  in  one  group  and 
little  marked  elsewhere.  Lymphoma  is  a  term  that  has  sometimes  been  used 
in  the  same  sense. 

Where  lymphosarcoma  ends  and  Hodgkin's  disease,  lymphadenoma,  or 
lymphoma  begin,  it  is  difficult  to  say.  If  there  is  generalized  enlargement 
of  the  lymphatic  glands  without   much   affection   of  the   spleen,  without  any 


Fig-.  119. — Hodgkin's  disease.  The  lymphatic  glands  in  the  left  side  of  the  neck  are 
very  large  ;  there  is  considerable  overgrowth  of  the  lymphatic  gland.s  in  the  right  axilla, 
particularly  along  the  outer  border  of  the  pectoralis  major  muscle  ;  the  glands  in  the  left 
axilla  are  also  enlarged,  but  to  a  less  extent ;  even  the  left  epitrochlear  gland  is  visibly 
enlarged. 


pathognomonic  blood-changes,  and  with  a  rapidly  fatal  ending,  the  condition 
is  spoken  of  as  lymphosarcoma,  but  it  might  equally  well  be  termed  acute 
lymphadenoma. 

Syphilitic  glands  seldom  reach  any  great  size,  only  swelling,  roughly  speaking, 
to  two  or  three  times  the  normal  ;  the  first  to  be  involved  are  those  in  the 
neighbourhood  of  the  chancre,  and  therefore  most  often  those  in  the  groin, 
spreading  later  to  all  the  glands  in  the  body,  including  those  in  the  occipital 
region,  which  are  not  as  a  rule  affected  except  by  sjrphiUs,  pediculosis  capitis 
with  sores,  and  German  measles.  Syphilitic  glands  are  almond-shaped  and 
firm,  painless,  or  at  most  slightly  tender,  and  they  do  not  become  adherent  to 
the  skin  or  to  the  deeper  parts.  They  may  remain  palpable  for  years  after  all 
the  signs  of  secondary  syphilis  have  disappeared.  The  difficulty  in  their 
diagnosis  does  not  arise  when  chancre  or  roseola  is  present  ;  but  later,  their 
nature  may  not  be  obvious  unless  there  is  a  clear  history  of  syphilis  or 
unless  Wassermann's  serum  test  is  positive. 

D  27 


4i8 


LYMPHATIC     GLAND     ENLARGEMENT 


Gernian  measles  causes  generalized  enlargement  of  the  lymphatic  glands 
very  similar  to  that  of  secondary  syphilis,  but  the  diagnosis  is  generally  obvious 
from  the  nature  of  the  skin  eruption.  The  occurrence  of  enlarged  occipital  and 
other  glands  associated  with  a  measles-like  rash  serves  to  distinguish  German 
measles  from  ordinary  measles,  and  also  from  scarlet  fever  and  other  erythemata. 
Still's  disease  attracts  attention  primarily  on  account  of  the  affection  of  the 
joints,  and  the  enlargement  of  the  lymphatic  glands  is  a  symptom  of  secondary 

importance.  It  is  an  affection 
of  children  [Fig.  120)  precisely 
corresponding  to  acute  rheu- 
matoid arthritis  of  adults  ; 
no  joint  in  the  body  is 
exempt,  and  it  is  probable 
that  the  Ivmphatic  glandular 
enlargement  is  secondary  to 
absorption  of  micro-organ- 
isms from  the  infected  joints. 
The  patient  becomes  anaemic, 
with  a  tendency  to  pigmen- 
tation, and  the  spleen  is  en- 
larged as  well  as  the  lymph- 
atic glands.  The  disease  is 
unmistakable.  Similar  lym- 
phatic glandular  enlargement 
occurs  in  the  acute  rheuma- 
toid arthritis  or  infective 
svnovitis  or  peri-arthritis  of 
older  persons,  especially  in 
that  form  which  is  charac- 
terized by  spindle-shaped 
swelling  of  the  first  inter- 
phalangeal  joints  of  the 
hands  {Fig.  107,  p.  378)  ;  but, 
as  a  rule,  the  enlargement  is 
confined  to  those  glands 
which  are  closest  to  the 
affected  joints — epitrochlear 
glands,  for  instance,  in  the 
case  of  the  fingers  and  hands, 
and  so  forth. 
Plague  may  be  associated  with  very  acute  glandular  enlargement  all  over  the 
body  ;  the  diagnosis  depends  largely  on  the  history,  and  particularly  upon  the 
patient  having  been  exposed  to  the  risk  of  contracting  plague  in  some  infected 
town  or  port.     The  diagnosis  may  be  confirmed  bacteriologically. 

B. — Localized  Lymphatic  Glandular  Enlargement. 

It  has  been  mentioned  already  that  in  all  those  diseases  in  which  enlargement 
of  the  lymphatic  glands  may  be  general,  it  may  sometimes  be  local,  or  may 
begin  locally  before  it  becomes  general,  so  that  in  every  case  in  which  there  is 
an  affection  of  a  local  group  of  lymphatic  glands,  it  is  important  to  remember 
the  possibility  of  the  case  being  due  to  one  of  the  diseases  already  discussed 
under  heading  A.  The  following  additional  causes,  however,  have  also  to  be 
considered,  namely  : — 


Fig.  120. — Still's  disease  :  acute  rheumatoid  arthritis  in 
childhood.  The  knees  are  swollen  and  their  ordinary  outlines 
lost  ;  there  is  typical  spindle-shaped  enlargement  of  the  first 
interphalangeal  joints. 


LYMPHATIC     GLAND     ENLARGEMENT  419 

Septic  absorption,  from  sores,  etc.,  on  the  skin  or  mucous 
membranes  from  which  the  lymphatics  drain  into  the 
particular  glands   that  are  involved 

Tuberculous  disease 

Secondary   malignant   disease. 

Whenever  there  is  any  doubt,  a  blood-count  should  be  made  in  order  either 
to  diagnose  or  exclude  lymphatic  leukasmia.  When  this  can  be  excluded,  the 
nature  of  the  local  glandular  enlargement  will  generally  be  suggested  by  the 
age  of  the  patient,  by  the  characters  of  the  glands  themselves,  and  by  their 
locality.  We  will  here  deal  with  the  subject  from  the  point  of  view  of  the 
particular  group  of  glands  involved. 

Occipital  Glands. — These  seldom,  if  ever,  become  enlarged  as  the  result  of 
leukasmia,  Hodgkin's  disease,  lymphadenoma,  German  measles,  syphilis,  or 
tuberculosis,  unless  there  is  obvious  enlargement  of  other  glands  at  the  same 
time.  When  there  is  enlargement  of  the  occipital  glands  and  no  others,  by  far 
the  most  likely  cause  is  septic  absorption  from  the  posterior  region  of  the  scalp, 
particularly  from  impetigo,  seborrhceic  dermatitis,  or  most  hkely  of  all,  pediculosis 
capitis.  Nits  should  always  be  looked  for  in  the  hair  with  care,  and  they  may 
sometimes  be  found  even  in  wealthy  ladies  in  whom  the  mode  of  infection  may 
be  quite  inexplicable.  The  patients  generally  have  much  irritation  of  the  skin 
at  the  back  of  the  neck  at  the  same  time,  and  it  may  be  attributed  to  the  rubbing 
of  a  collar  or  the  neck  of  a  dress.  There  is  generally  considerable  anaemia, 
and  the  patient  looks  unwell. 

Pre-auricular  Gland. — ^The  most  common  causes  for  enlargement  of  the  pre- 
auricular glands  are  :  Septic  infection  of  the  skin  of  the  cheek,  eyehd,  ear,  or 
temporal  region  of  the  scalp,  or  epithelioma  of  these  regions.  The  occurrence 
of  enlargement  of  this  gland  in  association  with  an  ulcer  which  may  be  rodent 
on  the  one  hand,  and  an  epithelioma  on  the  other,  does  not  necessarily  indicate 
the  latter,  for  without  there  being  secondar}-  deposits,  the  gland  may  become 
enlarged  from  absorption  of  bacteria  and  their  products  from  the  pus  of  rodent 
ulcer.  In  those  very  rare  cases  of  chancre  of  an  eyelid  or  other  neighbouring 
part,  enlargement  of  the  pre-auricular  gland  may  precede  the  generalized  en- 
largement of  the  glands  to  which  syphilis  gives  rise.  The  gland  may  also  be  the 
site  of  melanotic  sarcoma  in  very  rare  cases,  the  primary  growth  being  in  the  eye. 

Submaxillary  Glands. — The  commonest  cause  for  enlargement  of  these  is 
septic  absorption  from  the  mouth  ;  tonsilhtis  and  inflammation  of  the  fauces  are 
responsible  for  the  great  majority  of  cases  in  which  a  firm  gland  becomes  palpable 
just  beneath  and  behind  the  angle  of  the  jaw  ;  generally  the  enlargement  is 
greater  upon  one  side  than  upon  the  other,  and  it  may  persist  for  days  or  even 
weeks  after  the  causal  inflammation  in  the  tonsil  has  subsided.  The  glands 
are  painful  in  the  acute  stages,  and  in  a  few  cases  the  infection  is  so  severe  that 
the  tissues  break  down,  and  suppurative  adenitis  with  an  abscess  results.  All 
kinds  of  inflammation  of  the  throat  may  cause  this  glandular  enlargement — 
ordinary  simple  tonsillitis,  hospital  sore  throat,  rheumatic  tonsillitis,  quinsy, 
diphtheria,  scarlet  fever,  acute  phlegmonous  tonsilhtis.  The  precise  nature  of 
the  infecting  organism  is  to  be  ascertained  by  taking  swabbings  from  the  tonsils 
or  fauces  for  bacteriological  cultivation.  Vincent's  angina  less  frequently 
produces  glandular  enlargement  than  do  other  severe  forms  of  sore  throat. 

Inflammatory  changes  in  glands  further  forward  beneath  the  jaw  are  often 
secondary  to  caries  of  a  tooth  or  to  some  variety  of  stomatitis,  the  diagnosis 
being  ascertained  by  inspection  of  the  mouth.  Less  acute  enlargement,  going 
on  to  much  greater  size  than  is  the  rule  with  inflammatory  adenitis,  may  result 
from  secondary  deposits  of  malignant  disease  in  the  submaxillary  glands  when 
there  is  squamous-celled  carcinoma  (epithehoma) .  of  the  tongue,  lip,  gum,  cheek, 


LYMPHATIC     GLAND     ENLARGEMENT 


nose,  palate,  fauces,  tonsil,  pharynx,  or  larynx.  The  diagnosis  in  these  cases 
depends  upon  the  presence  of  an  obvious  primary  epithehoma  ;  if  there  is  any 
doubt  as  to  this,  a  small  portion  of  the  ulcerating  mass  may  be  excised  for 
microscopical  examination.  ^Mlen  a  gummatous  ulcer  simulates  epithehoma, 
the  effect  of  iodide  of  potassium  and  mercury"  may  point  to  the  former,  or 
Wassermann's  serum  test  ma}^  be  positive.  A  gumma  of  the  tongue  is  likeh- 
to  be  median,  an  epithelioma  not  median. 

Cervical  Glands. — Enlargement  of  the  glands  in  the  neck  generally  maj^  be 
either  unilateral  or  bilateral.  If  unilateral,  if  onty  a  few  glands  are  involved, 
and  if  the  histor}"  is  a  short  one,  the  changes  are  probably  inflammatory , 
particularly  if  there  has  been  any  sore  place  upon  the  skin  of  the  neck, 
upon  the  buccal  mucosa  or  throat,  or  if  there  is  any  evidence  that  the  patient 
has  been  recentty  exposed  to  scarlet  fever,  or  if  there  is  otitis  media. 
Pediculosis  capitis  is  a  common  cause  of  enlargement  of  the  cervical  glands 
in  the  children  of  the  poorer  classes.  It  becomes  very  difficult,  however, 
to  decide  when  such  cervical  glandular  enlargement  is  merelj^  inflammatory 
and  when  it  is  due  to  some  more  serious  lesion,  particularly  tuberculosis  on 
the  one  hand  and  Hodgkin's  disease,  lymphadenoma,  or  lymphosarcoma  upon 
the  other.  The  longer  the  glandular  swelhngs  persist,  the  less  likely  is  it 
that  thev  are  purely  inflammatory.  The  3?ounger  the  patient,  and  the  more 
unsterihzed  cow's  milk  he  has  been  drinking,  the  more  likely  are  they  to  be 
tuberculous.  If  they  are  present  on  both  sides  of  the  neck ;  if  they  show  a 
tendency  to  become  adherent  to  one  another  and  to  the  skin  ;  if  they  are  tender 
notAvithstanding  their  having  been  present  for  some  time,  they  are  probably 
tuberculous,  and  it  is  probable  that  the  diagnosis  will  be  settled  b}^  surgical 
measures,  the  affected  glands  being  excised  and  examined  microscopically. 
Spontaneous  breaking  down  of  the  glands,  with  a  discharging  fistula,  with  a  red 
indolent  condition  of  the  skin  around  the  fistula,  and  very  slow  heahng,  are  to  be 
forestalled  whenever  possible  ;  but  if  thej'  have  occurred,  then  the  condition  is 
almost  certainly  tuberculous  in  cases  in  which  there  is  no  question  of  a  late  stage 
!)f  malignant  disease.  There  may  be  confirmatory  evidence  in  the  shape  of 
tuberculous  lesions  elsewhere,  especially  in  a  joint,  the  spine,  or  the  peritoneum. 
It  is  noteworthy-  in  this  connection,  that  cases  of  tuberculosis  of  the  glands  are 
even  less  hkety  than  other  individuals  to  develop  ordinary  phthisis,  so  that  the 
absence  of  lung  signs  is  no  indication  that  the  glands  are  not  tuberculous. 
Hodgkin's  disease,  or  Ij-mphadenoma,  is  sometimes  so  restricted  in  its  earlier 
lesions  as  to  affect  the  cervical  lymphatic  glands  to  a  great  extent,  and  long 
before  anv  other  groups  are  involved  ;  in  such  cases,  previous  to  operation 
and  microscopical  examination,  the  nature  of  the  glandular  enlargement  may 
be  open  to  great  doubt ;  and  even  after  an  operation  there  may  be  differences 
of  opinion,  for  there  are  some  who  hold  that  the  large-celled  hyperplasia  exhibited 
microscopicallv  bv  Hodgkin's-disease  glands,  is  an  indication  that  they  are  only 
a  chronic  variety  of  tuberculosis.  Chnicalh-,  the  two  are  distinguished  by  the  fact 
that  tuberculous  glands  become  matted  together,  while  Hodgkin's-disease  glands 
remain  separate  from  one  another,  and  do  not  soften  or  break  down  even  when 
they  have  become  of  such  great  size  that  had  they  been  tuberculous  thej^  almost 
certainly  would  have  done  so  ;  consequenth^,  they  do  not  become  adherent 
to  the  skin,  to  one  another,  or  to  the  deeper  parts,  and  they  do  not  cause  a 
fistulous  discharge.  Enlargement  of  the  spleen  as  well  as  of  the  lymphatic 
glands  in  the  neck  would  indicate  Hodgkin's  disease  rather  than  tubercle. 

Secondary  carcinoma  of  the  glands  in  the  neck  is  easy  enough  to  diagnose 
when  a  primar}^  growth  is  ahead}'  known  to  exist ;  it  is  generally  either  a 
squamous-celled  carcinoma  of  the  buccal  cavit}',  especially  of  the  tongue,  lip,  or 
palate,  or  else  of  the  pharynx,  larynx,  or  CESophagus.     The  cases  which  give  rise 


LYMPHATIC     GLAND     ENLARGEMENT  421 

to  the  greatest  doubt  are  those  in  which  an  oesophageal  growth  has  not  caused 
stenosis,  so  that  the  occurrence  of  secondary  deposits  in  the  glands  may  be  the 
first  indication  of  anything  being  wrong.  The  patient's  age  will  generally 
suffice  to  make  tuberculosis  unlikely,  for  tuberculous  glands  are  far  commoner 
in  children  than  in  adults,  whilst  carcinoma  is  a  disease  of  the  middle  and 
later  periods  of  life  ;  if  there  is  any  doubt  to  start  with,  the  rapid  enlarge- 
ment of  the  glands,  their  extreme  hardness,  the  way  they  become  fixed  to  the 
deeper  structures  and  ultimately  to  the  skin,  through  which  they  finally  ulcerate, 
will  leave  little  or  no  doubt  as  to  their  character. 

Sarcomatous  glands  in  the  neck  are  much  rarer,  the  only  variety  to  be  met 
with  being  that  which  has  already  been  referred  to  above  as  acute  lymphadenoma 
which,  on  account  of  its  acuteness,  is  sometimes  termed  lymphosarcoma. 

Supraclavicular  Glands. — When  the  glands  immediately  above  the  clavicle, 
especially  those  on  the  left  side  in  the  region  of  the  attachment  of  the  sterno- 
mastoid  muscle,  are  enlarged,  without  affection  of  any  other  lymphatic  glands 
in  the  neck,  it  is  highly  suggestive  of  there  being  a  primary  new-growth  in  the 
abdomen,  with  secondary  deposits  ascending  along  the  course  of  the  thoracic 
duct,  and  exhibiting  themselves  in  the  glands  close  to  where  the  thoracic  duct 
enters  the  junction  of  the  left  jugular  and  left  subclavian  veins.  There  are, 
of  course,  many  cases  of  abdominal  malignant  disease  in  which  these  glands 
do  not  become  affected  at  all ;  but  the  value  of  the  sign  when  it  does  occur  can 
scarcely  be  exaggerated.  No  one  variety  of  intra-abdominal  carcinoma  is  more 
liable  than  another  to  produce  secondary  deposits  here  ;  the  primary  seat  may 
be  the  stomach,  gall-bladder,  pancreas,  duodenum,  colon,  rectum,  an  ovary, 
or  even  a  testicle  or  kidney  ;  in  not  a  few  cases,  excision  and  microscopical 
examination  of  the  left  supraclavicular  gland  has  indicated  the  exact  site  of  the 
primary  growth.  The  right  supraclavicular  gland  may  be  enlarged  in  a  similar 
way,  but  far  less  often  ;  and  generally  not  as  the  result  of  intra-abdominal  but 
of  intrathoracic  new-growth,  particularly  squamous-celled  carcinoma  of  the 
oesophagus.  When  the  supraclavicular  glands  are  affected  at  the  same  time 
as  the  axillary  glands,  in  cases  of  cancer  of  the  breast,  the  condition  is  very 
important  as  indicating  that  the  disease  has  extended  beyond  the  limits  within 
which  operative  cure  is  likely  to  be  possible. 

Axillary  Glands. — The  three  main  causes  for  enlargement  of  the  glands  in 
one  axilla  without  enlargement  of  the  glands  elsewhere  are  :  Septic  absorption 
from  sore  places  upon  the  fingers,  arm,  breast,  shoulder,  or  upper  part  of  the 
back  ;  secondary  deposits  of  carcinoma  from  the  breast  ;  and  Hodgkin's  disease 
or  lymphadenoma.  Tuberculous  axillary  glands  without  obvious  affection  of 
those  in  the  neck  have  been  recorded,  but  they  are  by  no  means  common.  It  is 
important  to  examine  carefully  for  any  possible  source  of  septic  absorption, 
for  sometimes  it  is  by  no  means  obvious  ;  it  may  be  no  more  than  inflammation 
around  a  ragnail.  Inflammatory  glands  are  generally  very  painful,  and  they 
are  associated  with  more  or  less  pyrexia. 

Lymphatic  leukaemia  will  be  excluded  by  the  absence  of  pathognomonic  blood- 
changes  ;  secondary  malignant  glands  should  be  diagnosed  when  primary 
growth  is  found  on  careful  palpation  of  the  breast  ;  Hodgkin's  disease  will  only 
suggest  itself  if  inflammatory  absorption,  secondary  growth,  tubercle,  and 
malignant  disease,  can  be  excluded  ;  and  it  is  probable  that  if  the  case  is  watched, 
if  it  is  one  of  Hodgkin's  disease,  other  lymphatic  glands  will  presently  become 
enlarged  also,  particularly  those  in  the  neck  of  the  same  or  opposite  side,  and 
those  in  the  other  axilla  (see  Fig.  119,  p.  417).  Enlargement  of  the  spleen  at 
the  same  time  would  be  an  argument  in  favour  of  Hodgkin's  disease. 

Epitrochlear  Glands. — The  only  important  cause  of  enlargement  of  the 
epitrochlear  gland  is  microbial  absorption  from  the  fingers,  hand,  or  forearm  ; 


422  LYMPHATIC     GLAND     ENLARGEMENT 

the  site  of  primary  infection  may  be  in  the  skin — a  whitlow,  for  example,  or  a 
post-mortem  wound,  or  a  dissecting-room  sore  ;  or  it  may  be  more  deep-seated, 
as  in  cases  of  infective  synovitis,  arthritis,  or  peri-arthritis.  It  is  important 
not  to  mistake  for  a  simple  whitlow  such  a  lesion  as  a  digital  chancre,  which 
may  also  cause  enlargement  of  the  epitrochlear  gland  before  infection  becomes 
general  ;  if  the  history  and  the  local  appearance  of  the  chancre  do  not  suggest 
the  diagnosis,  its  course  and  the  associated  secondary  symptoms  will  indicate 
the  nature  of  the  case.     Wassermann's  serum  reaction  should  be  tried. 

Mediastinal  and  Bronchial  Glands. — These  glands  can  never  be  palpated, 
and  their  enlargement  can  only  be  surmised  when  there  are  signs  of  something 
within  the  thorax  obstructing  one  or  other  bronchus,  or  leading  to  laryngeal 
paralysis,  or  stenosis  either  of  the  innominate  vein  or  of  the  superior  or  inferior 
vena  cava.  The  diagnosis  will  be  between  aortic  aneurysm,  chronic  mediastinitis, 
and  mediastinal  new  growth.  The  A-raj^s  may  be  of  considerable  value  in 
confirming  the  diagnosis,  and  in  distinguishing  enlarged  malignant  glands 
from  aneurysm  of  the  aorta.  It  is  noteworthy  that  infiammator}^  or  caseous 
bronchial  or  mediastinal  glands  seldom  if  ever  obstruct  a  bronchus  in  the  way 
that  malignant  glands  do,  possibly  because,  before  they  reach  a  sufficient  size 
to  stenose  a  bronchus,  they  have  softened,  and  perhaps  discharged  their 
contents  into  the  lumen  of  the  bronchial  tube.  When,  as  happens  in  rare 
cases,  a  caseous  gland  does  obstruct  a  bronchus,  it  is  important  to  remember 
that  post-mortem  evidence  shows  that  it  is  very  much  less  uncommon  for  a 
right  bronchial  gland  to  do  this  than  a  left. 

Mesenteric  Glands. — It  is  seldom  possible  to  palpate  enlarged  mesenteric 
glands,  although  the  diagnosis  that  they  are  swollen  may  often  be  made  upon 
circumstantial  evidence.  Any  inflammatory  condition  of  the  bowel  may  lead  to 
their  being  enlarged,  particularly  if  there  is  any  breach  of  the  mucous  membrane, 
as  in  cases  of  ulcerative  colitis,  dysentery,  tuberculosis  of  the  bowel,  or  typhoid 
fever.  They  are  greatly  involved  in  most  cases  of  tuberculous  peritonitis  ; 
the  masses  that  are  felt  in  the  abdomen,  however,  are  hardly  ever  the  glands 
themselves,  but  rather  extensive  inflammatory  and  caseous  foci  of  which  glands 
may  form  the  nucleus.  Malignant  new  growth,  such  as  primary  carcinoma  of  the 
stomach  or  colon,  pelvic  organs,  or  testes,  may  cause  extensive  secondary 
deposits  in  the  mesenteric  and  retroperitoneal  lymphatic  glands,  usually  most 
marked  in  the  immediate  neighbourhood  of  the  primary  new  growth,  but  ex- 
tending thence  in  the  direction  of  the  liver  until  the  portal  glands  are  invohed  ; 
however,  without  opening  the  abdomen,  it  is  almost  impossible  to  determine 
whether  the  masses  felt  in  cases  of  this  kind  are  really  enlarged  Ij-mphatic  glands. 

Iliac  and  Pelvic  Glands.  — What  has  been  said  above  in  connection  with 
mesenteric  glands  applies  here  also  ;  but  it  is  more  often  possible  to  determine 
by  palpation  whether  or  not  the  pelvic  lymphatic  glands  are  affected.  In  cases 
of  suspected  malignant  disease,  characteristic  nodules  of  secondary  deposits  in 
lymphatic  glands  may  be  felt  sometimes  on  careful  palpation  of  the  ihac  fossa 
or  upon  making  a  rectal  examination. 

Inguinal  and  Femoral  Lymphatic  Glands. — The  commonest  cause  by  far  of 
enlargement  of  the  inguinal  lymphatic  glands  and  not  of  those  elsewhere,  is 
septic  absorption  from  microbial  foci  in  the  regions  whose  lymphatic  vessels 
drain  into  these  glands  ;  sore  places  should  be  looked  for  upon  the  toes,  and 
between  them,  upon  the  feet,  legs,  thighs,  buttiocks,  lower  part  of  the  back, 
.scrotum,  penis,  perineal  and  vulval  regions  (see  Sores,  Perineal,  etc.)  ;  and  a 
urethral  discharge,  gonorrhoeal  or  otherwise,  should  also  be  sought  for.  Most  of 
those  cases  will  be  associated  with  constitutional  symptoms,  especially  p\'rexia 
and  loss  of  appetite,  and  with  local  pain  and  perhaps  reddening  of  the  skin  o\er 
the  inflamed  glands.     The  latter  may  break  down  into  abscesses — buboes. 


MACULES  423 


Another,  but  far  less  common,  cause  for  localized  enlargement  of  the  inguinal 
glands,  is  secondary  carcinoma — secondary  to  squamous-celled  carcinoma  of  the 
scrotum,  prepuce,  penis,  perineal  region,  anus,  clitoris,  labium  majus,  or  vagina. 
In  such  cases  the  diagnosis  will  become  obvious  when  the  .primary  growth  is 
found,  and  if  doubt  exists  as  to  the  nature  of  any  such  ulcerating  sore,  the 
result  of  microscopical  examination  of  a  small  portion  excised  will  clinch 
the  diagnosis. 

Melanotic  sarcoma  is  another  rare  but  very  important  cause  of  enlargement 
of  the  inguinal  lymphatic  glands  ;  sometimes,  when  the  primary  growth  is  hardly 
larger  than  a  pea,  arising  in  connection  with  the  skin  of  one  of  the  toes,  or  perhaps 
a  mole,  the  inguinal  glands  may  be  as  big  as  pigeon's  eggs,  rapidly  growing 
and  comparatively  painless.  The  nature  of  this  enlargement  may  be  quite 
obscure  unless  the  dark  tinge  of  the  growth  can  be  seen  through  the  skin,  or 
there  is  melanuria,  or  a  careful  examination  reveals  a  small  primary  new  growth 
of  the  skin,  or  unless  surgical  measures  are  adopted  for  their  removal. 

Popliteal  Glands  are  seldom  felt,  and  when  palpable  they  are  discovered,  as  a 
rule  rather  because  there  are  enlarged  lymphatic  glands  elsewhere,  than  from 
any  symptoms  which  attract  notice  to  the  popliteal  space  itself.  Almost  the 
only  cause  for  their  enlargement  is  septic  absorption  either  from  joints  or  from 
the  skin  of  the  toes,  feet,  or  legs,  comparable  to  the  conditions  which  produce 
enlargement  of  the  epitrochlear  glands  of  the  arm. 

Lymphatism  or  Status  Lymphaticus.  —  Much  attention  has  recently  been 
attracted  to  the  fact  that  in  young  persons  under  puberty  who  have  died  as  the 
result  of  poisoning  by  anaesthetics,  or  of  what  under  ordinary  circumstances 
would  be  regarded  as  inadequate  causes,  such  as  operation  for  the  removal  of 
tonsils,  circumcision,  and  so  forth,  the  internal  lymphatic  glands  and  tissues, 
particularly  the  tonsils,  thymus  gland,  bronchial  glands,  mesenteric  glands, 
the  Peyer's  patches,  and  the  solitary  follicles  of  the  intestines,  are  considerably 
larger  than  is  usually  the  case  in  ordinary  post-mortem  examinations  upon 
patients  of  similar  ages  who  have  died  of  other  diseases.  It  is  generally  stated 
that  the  condition  referred  to  is  pathological,  and  it  has  been  described  as  the 
status  lymphaticus  or  lymphatism.  It  is  doubtful,  however,  whether  this  is 
not  really  the  normal  condition  of  the  lymphatic  tissues  at  this  age,  for  very 
similar  appearances  are  to  be  found  in  the  bodies  of  children  killed,  not  slowly 
by  disease,  but  suddenly  by  accidents.  In  any  case,  it  is  almost  impossible 
to  diagnose  the  so-called  status  lymphaticus  during  life,  for  if  it  is  an  affection 
at  all,  it  is  one  of  the  internal  lymphatic  tissues  and  not  of  the  peripheral  and 
easily  palpable  lymphatic  glands.  It  is  doubtful,  however,  if  it  is  really  a 
pathological  state,  though  deaths  produced  by  anaesthetics  are  being  accredited 
to  it.  Herbert  French. 

MACULES, — The  macule  is  a  circumscribed  discoloration  or  decolorization 
of  the  skin,  without  noticeable  elevation  or  depression.     Macules  may  be  due  : 

1.  To  the  passage  of  blood,  or  of  the  colouring  matter  of  the  blood,  into  limited 
areas  of  the  skin,  as  in  purpura. 

2.  To  hyperaemia,  either  arterial  or  venous,  as  in  erythema. 

3.  To  dilatation  of  the  vessels  of  the  skin,  or  the  fopmation  of  new  vessels,  as  in 
capillary  naevus  and  telangiectases. 

4.  To  changes  in  the  pigmentation  of  the  skin,  whether  of  the  rete  or  of  the 
corium — on  the  side  of  excess  as  in  chloasma,  or  on  that  of  deficiency  as  in  leuco- 
dermia ;  and  such  changes  may  result  from  the  administration  of  drugs  such  as 
arsenic  and  chloral,  or  may  be  an  expression  of  trophoneurosis,  as  in  glossy  skin. 

Macules  of  the  second  and  third  groups  are  temporarily  effaced  by  pressure  ; 
those  of  the  first  and  fourth  remain  unaltered. 


424  MACULES 


Macules  may  be  inflammatory  as  in  the  rose  spots  of  enteric  fever,  or  non- 
inflammatory as  in  purpura  ;  congenital  as  in  moles,  or  acquired  as  in  the  exan- 
themata ;  temporary  as  in  drug  rashes,  or  permanent  as  in  leucodermia ;  scanty 
as  sometimes  in  leucodermia,  or  abundant  as  in  roseola.  They  may  be  attended 
by  subjective  symptoms  {e.g.,  itching)  as  in  drug  rashes  ;  but  generally  there  are 
no  such  accompanying  symptoms.  Usually  round  or  roundish,  they  may  be 
oval,  or  irregular  ;  they  also  vary  greatly  in  definition.  In  colour  they  may 
be  red,  brown,  or  yellow,  in  various  shades.  In  size  they  vary  from  a  mere 
speck  to,  say,  the  area  of  a  man's  hand  ;  if  very  widely  diffused,  as  in  malaria,  the 
pigmentation  is  usually  styled  a  discoloration.  Most  frequently  a  primary 
lesion,  as  in  lentigo,  the  macule  may  also  be  secondary  to  burns,  blisters,  ex- 
coriations, and  eruptions  of  various  kinds,  erythematous,  vesicular,  bullous, 
papular,  pustular,  and  eczematous.  The  brown  spots  which  follow  traumatic 
or  purpuric  ecchymoses,  haemorrhagic  urticaria,  varicose  eczema,  etc.,  form  a 
special  group  of  macules  in  which  the  pigment  is  hemosiderin.  If  a  macule 
takes  on  a  slight  degree  of  elevation  it  is  sometimes  styled  a  maculo-papule. 

The  differential  diagnosis  of  the  erythemas,  of  which  the  lesions  are  for  the 
most  part  too  diffuse  to  be  regarded  as  macules,  is  set  out  in  the  articles  on 
Erythema  and  Nodules  ;  that  of  the  purpuras  in  the  article  on  Purpur.\  ; 
that  of  leucodermia,  sclerodermia,  morphoea,  the  various  forms  of  chloasma 
(including  hsmo-chromatosis),  and  the  discolo rations  due  to  the  use  of  drugs,  in 
the  article  on  Pigmentation  of  the  Skin.  Nor  need  the  most  familiar  macule, 
that  which  occurs  in  lentigo  (freckles),  be  described  here,  for  the  only  affection 
with  which  it  can  be  confused  is  xeroderma  pigmentosum,  the  diagnosis  from 
which  is  given  under  Tumours  of  the  Skin,  where  also  will  be  found  the  differ- 
ential diagnosis  of  another  macular  affection,  xanthoma  in  its  various  forms. 
Tinea  versicolor  has  been  dealt  with  under  Fungous  Affections  of  the  Skin  ; 
pityriasis  rosea  under  Scales  ;  lichen  planus  and  herpes,  in  both  of  which 
macules  appear  as  secondary  lesions,  respectively  under  Papules  and  Vesicles. 
Of  naevi  and  of  telangiectases  the  identification  is  self-evident,  and  it  only 
remains  to  speak  of  the  macules  of  leprosy  and  syphilis. 

In  leprosy,  following  the  prodromal  symptoms  and  the  period  of  invasion, 
erythematous  spots  appear  on  the  face,  limbs,  or  trunk,  varying  in  colour  accord- 
ing to  the  natural  pigmentation  of  the  skin,  but  usually  in  white  races  of  a  light 
red.  The  colour  is  brightest  at  the  edge  ;  the  centre  may  become  white  and 
atrophic.  In  size  the  macules  vary  from  a  pin's  head  to  the  palm  of  the  hand, 
or  larger  ;  they  are  smooth  and  shining,  with  a  well-defined  outline.  Some 
infiltration  is  usually  present.  Fresh  crops  continue  to  come  out  at  irregular 
intervals,  and  each  outburst  is  accompanied  by  an  exacerbation  of  the  con- 
stitutional symptoms.  After  a  time  the  macules  and  the  neighbouring  areas  of 
apparently  normal  skin  become  more  or  less  anaesthetic,  owing  to  pressure  of 
the  infiltration  on  the  peripheral  nerves.  The  macular  stage  of  leprosy  may 
possibly  be  confused  with  erythema  simplex,  but  the  macular  areas  are  usually 
larger  than  in  erythema,  in  which  also  there  is  little  or  no  constitutional  dis- 
turbance. As  soon  as  anaesthesia  arises  the  diagnosis  is  settled.  This  is  indeed 
the  crucial  test  in  all  cases  of  doubt  as  between  leprosy  and  any  other  affection, 
for  in  leprosy  it  is  almost  invariably  present,  if  not  in  the  lesions  themselves, 
then  in  some  neighbouring  area  of  the  skin.  Its  commonest  sites  are  towards 
the  centre  of  the  macule,  in  the  pale  patches  left  by  macules  that  have  dis- 
appeared, and  in  the  hands  and  feet.  Another  distinctive  feature  of  leprous 
spots  is  that  they  rarely  perspire.  In  syringomyelia  the  sensory  and  trophic 
lesions  may  suggest  leprosy,  but  the  macules  will  be  absent,  nor  is  there  enlarge- 
ment of  lymphatic  glands  or  thickening  of  nerve-trunks.  (For  the  diagnosis 
of   nodular    leprosy   from    lupus    vulgaris,    see    under    Nodules.)     Whenever 


MACULES 


425 


doubt   exists,   the   lepra   bacillus  should   be   sought   in  the   lesions   or    in    the 
nasal  discharge. 

The  macular  syphilide  is  one  of  the  most  characteristic  lesions  of  secondary 
syphilis.  The  eruption  {Fig.  121) ,  erythematous  in  character  and  styded  s>-philitic 
roseola,  begins  as  a  macular  mottUng,  resembling  measles  but  rather  more 
dusky,  distributed  over  the  chest  and  abdomen.  It  is  extremely  evanescent, 
often  disappearing  in  a  few  hours  and  coming  out  again   as   suddenly.     The 


Fig:.  121- — Macular  syphilides. 


mucous  membrane  of  the  throat  is  the  seat  of  a  similar  eruption,  and  superficial 
ulcers  may  form  on  the  tonsils.  Generally  about  a  fortnight  from  its  appear- 
ance, the  rash  begins  to  fade,  giving  place  to  a  papular  or  follicular  eruption  on 
the  trunk,  limbs,  face,  and  neck.  Hypereemia  of  the  papilte  here  and  there 
gives  rise  on  the  chest  and  abdomen,  and  often  on  the  flexor  aspects  of  the 
limbs,  to  red  patches  which  may  persist  for  a  longer  or  shorter  time  as  isolated 
blotches,  varying  in  colour  from  a  delicate  rose  to  a  pale  violet  or  dusky-bluish 
or  even  brownish-red.      Scattered  about  among  these  macular  syphilides  may 


426  MACULES 


often  be  seen  papules  (maculo-papular  syphilides),  which  leave  stains  of  varying" 
depth. 

From  the  macular  syphilide  both  tinea  versicolor  and  tinea  circinata  may  be 
distinguished  by  the  fungous  parasites  present  in  the  lesions  of  those  affections, 
and,  in  the  case  of  tinea  versicolor,  by  the  ease  "with  which  the  scaly  patches 
can  be  detached  by  the  finger-nail  ;  the  erythematous  drug  rashes  by  their 
more  vivid  redness  and  the  presence  of  itching  and  burning  ;  seborrhasa  corporis 
■  by  its  more  limited  distribution  ;  measles  by  the  crescentic  character  of  the 
eruption,  the  coryza,  cough,  and  the  different  distribution.*  A  peculiarity  of  this, 
syphilide  which  should  always  be  w"atched  for  in  doubtful  cases  is  that  it  varies 
in  colour  with  the  temperature  ;  a  cool  atmosphere  will  bring  it  out  in  vivid 
colours,   even  when  almost  completely  faded.  Malcolm  Morris. 

MAIN-EN-GRIFFE.— (See  Claw-haxd.) 

MARASMUS  literally  means  "  wasting,"  and  therefore  signifies  much  the 
same  as  loss  of  weight.  By  common  consent,  however,  when  speaking  simply 
of  marasmus,  one  generally  has  in  mind  an  infant  or  young  child,  so  that 
lesions  which  cause  loss  of  weight  in  tender  years  will  be  considered  under  the 
present  heading,  whilst  wasting  in  older  patients  is  discussed  under  the  heading 
Weight,  Loss  of. 

The  bodies  of  infants  and  young  children  consist  so  largely  of  water  that 
great  variations  may  occur  within  a  comparatively  short  time,  particularly  in 
association  with  a  disease  which  causes  loss  of  fluid.  The  most  rapid  loss  of 
weight  occurs  as  the  result  of  acute  diarrhoea,  with  or  without  vomiting  ;  in  the 
summer  zymotic  diarrhoea  of  infants  the  subcutaneous  tissues  may  be  seen 
to  shrivel  in  twenty-four  hours  or  less,  the  eyes  become  sunken,  the  fontanelle 
depressed,  and  the  patient  loses  weight  rapidly.  There  are  probabh^  various 
micro-organisms  producing  these  acute  sj^mptoms,  of  which  the  best  known 
are  the  Bacillus  enteritidis  of  Gaertrier  and  Morgan's  bacillus  I.,  but  the  exact 
bacteriological  diagnosis  of  the  symptoms  can  only  be  arrived  at  by  investigation 
of  the  stools  and  perhaps  of  the  patient's  serum  in  special  laboratories.  Acute 
vomiting  without  diarrhoea  generally  causes  loss  of  weight,  but  less  markedly 
than  does  severe  diarrhoea  ;  it  sometimes  does  so  to  a  considerable  extent^ 
nevertheless,  particularly  in  that  periodic  type  of  the  malady  known  as  cyclical 
vomiting  of  infants.  Without  apparent  cause,  a  child  of  tender  years  who  is 
subject  to  this  complaint  is  seized,  without  any  preceding  irregularity  in  diet 
and  apparently  without  anj^thing  definite  to  account  for  the  mischief,  with  most 
severe  and  recurrent  vomiting,  lasting  for  twenty-four,  thirty-six,  or  fortj-- 
eight  hours,  or  even  longer,  nothing  whatever  being  kept  down,  and  the  urine 
at  the  same  time  abounding  as  a  rule  with  diacetic  acid  and  acetone,  the  evidence 
of  acidosis.  Severe  though  the  loss  of  weight  may  temporarily  be,  the  symptoms 
generally  subside  as  rapidly  as  they  come  on,  and  the  patient  remains  in  appar- 
entty  normal  health  until  the  next  period  of  similar  vomiting  with  acidosis  comes 
on.  Besides  cjxlical  vomiting,  severe  attacks  of  vomiting  may  be  caused  by 
errors  of  diet  of  various  kinds,  though  it  is  remarkable  how  children  escape  the 
disorders  of  injudicious  feeding  if  only  virulent  organisms  are  not  administered 
in  the  food  at  the  same  time.  Congenital  hypertrophic  stenosis  of  the  pylorus  is 
nowadays  spoken  of  as  though  it  were  itself  a  disease  ;  it  is  associated  with 
pensistent  vomiting  of  all  foodstuffs,  the  sjrmptoms  coming  on  either  immediately 
after  birth  or  within  a  few  days  or  weeks,  and  in  not  a  few  instances  resulting 
in  death  from  sheer  inanition.  At  the  post-mortem  examination  in  such  cases 
there  is  undoubtedly  both  more  muscle  than  there  should  be  in  the  pylorus,  and 
undue  tightness  of  its  constriction,  but  it  is  very  doubtful  whether  this  is  really 
a  condition  of   congenital  malformation,  and   not  the   result  of  spasm   of   the 


MARASMUS  42^ 


pylorus  produced  by  injudicious  feeding,  especially  the  giving  of  food  before  the 
mother  has  milk  in  her  breasts  ;  the  pyloric  hypertrophy  being,  not  congenital, 
but  the  result  of  the  muscular  contractions  so  induced. 

Simple  starvation  owing  fo  inability  of  the  parents  to  provide  food  will 
naturally  cause  acute  wasting,  though  the  nature  of  the  case  may  not  be  obvious 
to  the  doctor  unless  the  conditions  of  home  life  are  known. 

Defective  feeding  is  one  of  the  commonest  causes  of  lack  of  progress  and  of 
actual  marasmus  amongst  the  children  of  the  lower  classes.  The  amount  of 
dirt  that  reaches  the  child's  mouth  from  its  own  fingers,  from  its  mother's  breasts, 
and  from  the  utensils  in  which  the  food  is  given,  is  by  itself  enough  very  often  to 
upset  the  digestion,  even  if  the  right  food  were  given  in  the  proper  amounts  and 
at  the  right  intervals  ;  when,  in  addition  to  the  dirt,  the  food  supply  is  of  the 
wrong  kind  and  the  intervals  irregular,  it  is  not  at  all  surprising  that  the  child 
does  not  thrive. 

Rickets  is  not  so  much  a  cause  of  marasmus  as  a  concomitant  effect  of  the 
injudicious  feeding — many  rickety  children  being,  indeed,  unduly  fat  and  heavy. 

Congenital  syphilis,  on  the  other  hand,  is  a  very  potent  cause  for  marasmus. 
The  diagnosis  may  sometimes  be  guessed  at  ;  it  may  sometimes  be  obvious 
from  the  snuffles,  skin  lesions.  Parrot's  nodes,  condylomata,  and  so  forth  ;  it 
may  be  known  of  in  the  parents  ;  and  it  may  be  confirmed  by  Wassermann's 
serum  test  in  the  child.  Many  congenital  syphilitic  children,  without  developing 
any  of  the  better  known  evidences  of  syphilis,  fail  from  simple  inability  to  thrive, 
and,  although  born  fine,  healthy-looking  infants,  presently  waste  and  pine,  and 
they  may  be  said  rather  to  cease  to  live  than  in  the  ordinarj^  sense  to  die  of  a 
disease. 

Tuberculosis  is  a  very  important  and  common  cause  for  loss  of  weight  in 
infants,  though  it  is  generally  very  difficult  indeed  to  be  certain  that  a  tubercu- 
lous lesion  is  present.  No  obvious  foci  such  as  tuberculous  glands  in  the  neck, 
kyphosis  from  spinal  caries,  ascites  or  abdominal  lumps  from  tuberculous  periton- 
itis or  tabes  mesenterica,  tuberculous  joints  such  as  the  hip  or  knee,  tuberculous 
dactjditis,  and  so  forth,  may  be  present,  and  yet  there  may  be  some  deep-seated 
lesion,  of  which  the  commonest  by  far  is  caseation  of  the  bronchial  glands. 
Phthisis  pulmonalis  is  almost  unknown  in  infancy  and  childhood  ;  in  phthisical 
patients  there  is  practically  never  caseation  of  the  bronchial  glands  ;  in  infants 
and  young  children  caseous  bronchial  glands  are  very  common,  and  they  occur 
almost  entirely  in  those  who  have  drunk  any  large  quantity  of  milk.  The 
danger  in  such  cases  is  that  the  bacilli  will  not  remain  localized  to  the 
bronchial  glands  :  many  a  child  is  quite  unsuspected  of  having  such  a  lesion 
until  some  intercurrent  malady  such  as  measles  causes  the  mischief  to 
light  up  and  become  generalized  in  the  form  of  general  tuberculosis  and 
meningitis,  and  at  the  post-mortem  examination  caseous  bronchial  glands, 
obviously  of  long  standing,  are  found.  Many  children  recover  completely, 
and  the  nature  of  the  case  at  the  time  when  there  were  loss  of  weight  and  general 
ill -health  may  never  be  determined.  The  child  outgrows  its  delicacy.  It  is 
always  possible,  or  even  probable,  when  obscure  wasting  occurs  in  a  child  who 
objectively  presents  no  particular  abnormality  except  ill-health,  that  the  lesion 
is  tuberculous  absorption  from  infected  niilk,  with  accumulation  of  the  bacilli 
in  the  bronchial  glands.  The  faeces  may  be  examined  for  the  bacilli  after 
special  treatment  in  the  laboratory.  It  may  often  help  the  diagnosis  to  eliminate 
milk  from  the  dietary,  and,  if  need  be,  butter  also,  and  watch  the  effects  of 
giving  the  patient  such  foods  as  are  known  to  contain  no  tubercle  bacilU.  Von 
Pirquet's  skin  reaction  might  also  be  tried,  though  its  results  are  h\  no  means 
pathognomonic,  especially  if  the  tuberculin  used  is  not  prepared  exactly  as  it 
was  in  von  Pirquet's  original  method.  Herbert   French. 


428 


MEL^NA 


MELffiNA. — This  term  is  correctly  applied  to  black  motions  containing  altered 
blood.  The  colour  is  due  to  the  action  of  the  digestive  juices  upon  haemoglobin, 
and  the  condition  is  usually  associated  with  some  ulcerative  lesion  of  the  stomach 
or  duodenum. 

Melcena  may  be  simulated  by  the  presence  of  sulphide  of  iron  or  of  bismuth 
in  the  stools  of  patients  taking  either  of  these  metals.  The  slatey-black  colour 
of  these  sulphides  does  not  very  closely  resemble  the  tarry  motions  of  haemorrhage. 
In  case  of  doubt,  the  microscope  may  be  used  to  reveal  blood-corpuscles,  or  the 
chemical  tests  for  blood  may  be  employed.      (See  Blood  per  Anum.) 

W.  Cecil  Bosanguet. 
MEL  ANURIA. — (See  Urine,  Abnormal   Coloration   of.) 

MEMBRANE  PER  VAGINAM.— (See  Discharge,  Vaginal.) 

MENORRHAGIA. — By  this  symptom  is  meant  an  excessive  amount  of  the 
menstrual  flow,  or  an  undue  prolongation  of  the  time  during  which  it  takes 
place.  It  is  important  to  remember  that  in  this  condition  the  patient  is  free 
from  bleeding  during  the  intermenstrual  periods,  the  term  Metrorrhagia  {q.v.) 
being  reserved  for  bleeding  which  occurs  between  the  periods.  The  careful 
distinction  between  these  symptoms  often  serves  to  distinguish  very  important 
conditions,  and  they  should  on  no  account  be  confounded  with  one  another  or 
considered  as  the  same  entity.  Pure  menorrhagia  is  an  important  symptom 
of  many  well-defined  conditions  which  do  not,  as  a  rule,  give  rise  to  irregular 
bleeding.  Both  these  terms  must  be  carefully  limited  to  patients  who  menstruate, 
and  must  not  be  used  for  bleeding  after  the  menopause.  The  term  Metrostaxis 
(q.v.)  is  the  best  for  bleeding  occurring  after  menstrual  life  has  passed. 

Causes   of   Menorrhagia. 


I.  Generative 

SySTEM. 

2.  Circulatory  System. 

3.  Nervous  System. 

Uterine  congestion 

Uncompensated  valvular 

Excessive  coitus 

Endometritis 

disease  of  the  heart 

Prevention  of  conception 

Retroversion  and  flexion 

Cirrhosis  of  the  liver 

Fibromyoma 

Emphysema  of  the  lungs 

A  Single  Excessive  Period 

Salpingo-oophoritis 

Fright 

Sub-involution 

The  Circulation 

Violent  emotion 

Passive  hyperaemia  from : 

Sudden  changes  of   tem- 

Acute Infectious 

Diseases 

Constipation 

perature 

Influenza 

Tight-lacing 

Cold  bath 

Enteric 

Sewing  machine 

Dancing 

Cholera 

Gymnastics 

Scarlatina 

The  Blood  Itself 

Bicycling,  etc. 

Variola 

Deficient  coagulabihty 

Rheumatism 

Scorbutus 

Malaria 

Purpura 

Diphtheria 

Haemophilia 

Measles 

High  Blood-pressure 
Arteriosclerosis 
Disturbance  of   internal 
secretions 

Perusal  of  the  above  table  will  make  it  clear  that  the  causes  of  pure  menor- 
rhagia can  be  grouped  under  the  three  headings  of  diseases  of  the  generative 
organs,  circulatory  organs,  and  the  nervous  system.  In  attempting  to  differentiate 
these  causes  from  one  another,  the  first  point  to  ascertain  is  whether  there  is 
any  disease  of  the  generative  system,  and  failing  this,  to  make  such  systematic 
examinations  as  will  place  the  cause  under  one  of  the  other  two  headings. 


MENORRHAGIA  429. 


I.  In  considering  the  Gsnerative  System  it  is  clear  that  some  diseases  will 
be  easy  to  discover,  others  will  require  some  special  method  of  examination. 

For  instance,  of  all  the  causes  of  pure  menorrhagia,  fibromyoma  of  the  uterus 
stands  out  by  itself  as  the  only  important  growth  associated  with  this  symptom, 
and  a  simple  bimanual  examination,  as  a  rule,  suffices  to  show  that  such  a  tumour 
exists,  the  chief  characteristics  of  a  fibromyoma  of  the  uterus  being  these  : 
the  uterus  itself  is  enlarged,  and  in  almost  every  instance  the  enlargement  is 
asymmetrical,  the  typical  shape  of  the  organ  being  altered.  As  there  may  be 
more  than  one  tumour  in  the  uterus,  its  shape  may  be  exceedingly  irregular. 
The  consistence  of  the  tumour  is  hard  and  unyielding  as  a  rule,  but  pathological 
changes  in  these  tumours  are  common,  some  of  them  leading  to  softening,  others 
to  cystic  changes  which  may  give  a  fluid  thrill.  The  tumour  and  cervix  always 
move  together  if  the  organ  can  be  moved  at  all.  The  only  difficulty  in  diagnosis, 
as  a  rule,  lies  in  distinguishing  a  fibromyoma  of  the  uterus  from  an  ovarian  cyst, 
and  sometimes  this  is  exceedingly  difficult,  for  it  is  not  always  possible  to  say- 
that  a  given  tumour  is  actually  the  enlarged  uterus.  It  must  be  remembered, 
however,  that  the  symptom  which  has  led  to  this  difficulty  is  menorrhagia,  and 
ovarian  tumours  almost  never  give  rise  to  it.  Ovarian  tumours  usually  cause 
no  disturbance  of  menstruation  at  all,  unless  they  are  double  and  completely 
destroy  both  ovaries,  in  which  case  they  cause  amenorrhosa.  If  the  tumour 
cannot  be  diagnosed  by  simple  examination,  there  still  remains  examination  by 
the  uterine  sound.  If  no  possibility  of  pregnancy  exists — and  with  pure  menor- 
rhagia pregnancy  is  impossible — the  sound  may  be  passed  into  the  uterus  with 
every  precaution  against  sepsis.  In  all  cases  of  fibromyoma  the  sound  passes 
beyond  the  normal  distance,  and  it  may  pass  as  much  as  six  inches,  or  even  more. 
In  cases  of  subperitoneal  fibroids,  the  uterus  may  not  be  much  enlarged,  but  in 
such  cases  menorrhagia  is  not  usually  present.  In  ovarian  tumours  the  length 
of  the  uterine  cavity  is  not  increased  unless  a  condition  of  endometritis  co-exists, 
which  is  very  uncommon  ;  and  if  it  did  not  exist,  the  amount  of  elongation  of  the 
uterine  cavity  would  be  small.  In  general,  however,  it  is  quite  unnecessary  to 
use  the  sound  for  the  diagnosis  of  a  fibromj^oma. 

Uterine  Congestion  and  Endometritis. — These  lesions  can  only  be  inferred  in 
cases  of  pure  menorrhagia  when  the  uterus  is  not  enlarged  to  any  appreciable 
extent,  and  when,  in  addition,  there  are  leucorrhoea  and  backache.  These  three 
cardinal  symptoms,  Pozzi's  syndrome,  point  always  to  endometritis,  whatever 
other  lesion  of  the  generative  system  may  be  present.  As  a  rule,  the  subjects  of 
these  are  married  and  have  had  pregnancies  or  abortions,  but  endometritis  may 
occur  in  a  virgin,  the  result  of  infection,  without  any  pregnancy  having  taken 
place.  The  presence  of  endometritis  cannot  be  proved  without  the  removal  of 
the  endometrium  by  the  operation  of  curettage  and  the  microscopical  examina- 
tion of  sections  of  the  material  so  removed. 

Retroversion  and  flexion  of  the  uterus  and  salpingo-oophoritis  are  very  definite 
and  obvious  lesions  which  are  associated  with  menorrhagia,  but  the  actual 
prime  cause  is  again  endometritis  and  uterine  congestion. 

So  also  with  sub-involution,  which  necessarily  can  only  follow  labour  orabortion ; 
though  a  relaxed  uterine  muscle  and  a  dilated  uterine  cavity  are  present,  endo- 
metritis and  congestion  are  present,  too,  and  are  the  real  causes  of  menorrhagia .. 

Exanthemata. — The  various  exanthems  are  liable  to  cause  menorrhagia  except 
in  those  instances  where  they  give  rise  to  anaemia.  It  has  been  shown  bacterio- 
logically  that  an  acute  endometritis  may  be  set  up  by  various  zymotic  diseases, 
and  therefore  it  is  not  surprising  that  in  some  instances  this  condition  becomes- 
chronic  and  causes  a  lasting  menorrhagia. 

2.  Circulatory  System. — Under  this  heading  there  can  be  no  doubt  that  definite 
causes  of  menorrhagia  exist,  but  in  the  absence  of  well-defined  lesions  of  hearty 


430 


MENORRHAGIA 


liver,  or  lungs  it  may  be  a  matter  of  considerable  difficulty  to  make  a  differential 
diagnosis.  It  is  obvious  that  any  lesion  of  the  heart,  liver,  or  lungs,  which  leads 
to  back-pressure  through  the  venous  system,  may  cause  hypersemia  of  the 
pelvic  organs  and  consequently  lead  to  excessive  ruenstrual  losses.  It  does  not 
follow,  however,  that  this  will  be  the  case,  because  the  sufferers  from  these  diseases 
are  sometimes  anaemic  as  far  as  the  quality  of  the  blood  goes,  and  consequently 
may  lack  the  stimulus  to  menstruate  at  all.  However,  it  not  uncommonly 
happens  that  menorrhagia  is  caused  by  uncompensated  valvular  lesions  of  the 
heart,  cirrhosis  of  the  liver,  or  emphysema  of  the  lungs. 

Passive  hypevcBmia  of  the  pelvic  organs  may  occur  from  constipation,  tight 
lacing,  or  certain  occupations  such  as  the  working  of  a  treadle  sewing-machine  : 
but  it  must  not  be  forgotten  that  endometritis  may  also  be  present  and  be  the 
real  underlying  cause  of  excessive  flow. 

AncBWiia. — That  the  quality  of  the  blood  itself  may  be  a  cause  of  menorrhagia 
is  undoubted,  and  particularly  if  it  be  deficient  in  calcium  salts,  leading  to  retarda- 
tion of  the  coagulation-time.  Modern  methods  of  estimating  coagulation-time 
enable  us  to  distinguish  these  cases  with  some  certainty,  and  thus  point  out  a 
line  of  treatment.  Unfortunately  there  is  no  simple  clinical  method.  Doubt 
also  has  recently  been  thrown  on  the  view  that  the  calcium  salts  have  any 
effect  on  coagulation-time.  The  well-known  signs  of  scorbutus  in  its  minor 
degrees,  purpura,  and  haemophilia  may  draw  attention  to  cases  of  this  class. 

Menorrhagia  in  young  girls  at  the  time  of  puberty  and  commencement  of 
menstruation  depends  upon  excessive  ovarian  activity,  and  we  must  conclude, 
therefore,  a  disturbance  of  the  balance  between  the  internal  secretions.  It  is 
often  associated,  too,  with  retardation  of  the  coagulation-time  of  the  blood, 
especially  in  the  subjects  of  chilblains,  cold  hands  and  feet,  "  dead  fingers,"  etc. 
It  must  not  be  forgotten  that  young  girls  may  have  a  malignant  growth  of  the 
uterus,  such  as  sarcoma,  but  this  is  more  likely  to  cause  irregular  bleeding  as 
well  as  menorrhagia. 

Finally,  high  blood-pvessure  must  be  reckoned  with  as  a  cause  of  menorrhagia 
at  any  period  of  life,  but  particularly  when  nearing  the  onset  of  the  menopause. 
Menopause  menorrhagia  much  more  often  depends  upon  one  of  the  well-defined 
lesions  of  the  uterus  above  described  than  on  high  blood-pressure,  but  cases  occur 
in  which  the  blood-pressure  is  alone  responsible.  In  connection  with  this 
must  not  be  forgotten  the  arteriosclerosis  which  is  likely  to  affect  the  uterine 
vessels  about  this  period  of  life,  and  which  may  contribute  its  share  to  the 
causation  of  a  menorrhagia.  This  high  blood-pressure,  and  possibly  the 
arteriosclerosis  also,  may  eventually  prove  to  be  connected  with  the  internal 
secretions  of  the  ductless  glands.  Though  still  considerably  a  matter  of  theory, 
normal  menstruation  consists  in  part,  at  least,  of  the  normal  balance  being 
preserved  between  the  various  internal  secretions,  the  ovarian  and  thyroid  on 
the  one  hand  being  balanced  by  the  suprarenal  and  pituitary  on  the  other,  and 
any  disturbance  of  this  balance  may  result  in  amenorrhoea  (as  in  myxoedema) , 
or  in  menorrhagia,  as  sometimes  occurs  in  exophthalmic  goitre  and  at  the  meno- 
pause. In  the  absence,  however,  of  definite  lesions  of  ductless  glands,  we  have 
not  much  evidence  at  present  before  us  which  will  enable  us  to  say  which  gland 
is  at  fault.  It  is  very  fascinating  to  believe  that  high  blood-pressure  may  be 
due  to  the  unbalanced  action  of  the  suprarenal  and  pituitary  secretions,  and  to 
suggest  a  remedy  in  consequence. 

3.  The  Nervous  System  alone  is  never  likely  to  be  a  cause  of  lasting  menor- 
rhagia, but  that  a  single  profuse  period  may  result  from  some  disturbance  of  the 
nerve  mechanism  of  menstruation  has  long  been  believed.  There  certainly  are 
cases  of  the  kind  in  which  no  other  causation  can  be  recognized,  and  in  which 
the  excessive  flow  is  not  repeated.     The  effect  of  sexual  intercourse  upon  the 


METEORISM 


431 


menstrual  flow  is  difficult  to  determine,  but  cases  do  occur  in  which  excessive 
menstruation  has  been  cured  by  abstention,  and  we  cannot  but  believe  that 
excesses  in  this  direction  must  therefore  have  been  the  cause.  Such  cases  occur 
chiefly  in  the  newly  married.  The  part  played  by  incomplete  coitus,  coitus 
interruptus,  or  prevention  of  conception  by  other  means,  is  still  difficult  to 
determine,  but  we  have  no  real  evidence  to  hand  which  proves  that  any  menstrual 
disturbances  arise  on  these  accounts.  In  any  case,  however,  we  are  not  justified 
in  assuming  that  the  nervous  system  is  to  blame  for  a  menorrhagia  until,  by 
careful  examination,  we  have  eliminated  the  other  more  important  causes. 

T.  G-  Stevens. 
MENSTRUATION,  ABNORMALITIES  OF.— (See  Dysmenorrhcea,   Amenor- 

RHCEA,    JNIeNGRRHAGIA,    METRORRHAGIA.) 

MERYCISM. — The  term  merycism  is  almost  equivalent  to  cud-chewing  or 
rumination  ;  it  is  a  very  rare  condition  amongst  human  beings  ;  even  when  it 
does  occur  it  is  no  evidence  of  disease.  It  has  to  be  distinguished  from  pyrosis 
and  from  flatulence  ;  in  typical  cases  there  is  no  difficulty,  for  with  merycism 
the  act  may  be  voluntary  to  some  extent :  actual  food  returns  to  the  mouth 
instead  of  merely  acrid  fluid,  as  in  the  case  of  pyrosis,  and  there  is  none  of  the 
belching  of  flatulence.  One  curious  feature  of  the  condition  is  that  it  sometimes 
develops  in  several  different  members  of  the  same  family  ;  this  may  be  a  question 
of  imitation,  but  it  is  due  quite  as  likely  to  some  congenital  peculiarity.  The 
diagnosis  depends  mainly  upon  the  patient's  own  account  of  what  he  feels 
taking  place  inside  him,  upon  the  history  of  a  similar  condition  affecting  other 
members  of  the  family,  and  upon  the  absence  of  objective  evidence  of  gastric, 
intestinal,  intracranial,  or  renal  disease.  Herbert  French. 

METEORISM,  or  tympanites,  is  the  term  used  to  denote  enormous  distention 
of  the  abdomen  with  gas,  the  latter  generally  being  within  the  alimentary  canal, 
though  it  may  be  free  in  the  peritoneal  cavity.  It  is  seldom  a  symptom  in 
itself  of  diagnostic  importance,  the  nature  of  the  case  being  determined  usually 
on  other  grounds.  It  is  apt  to  be  very  troublesome  in  cases  of  general  peritonitis, 
even  when  operation  has  been  performed  ;  the  diagnosis  will  depend  upon  the 
history,  which  may  suggest  a  cause  for  peritonitis,  such  as  gastric  or  duodenal 
ulcer,  appendicitis,  tj'phoid  fever  ;  and  upon  the  persistent  vomiting,  the  dry 
furred  tongue,  the  motionless  rigid  abdomen,  the  rising  rapidity  of  pulse,  the 
facies  Hippocratica,  the  impairment  of  note  in  the  flanks,  the  rub  over  the  liver 
or  spleen,  and  the  absence  of  borborygmi. 

Intestinal  obstruction,  whether  acute,  subacute,  or  chronic,  and  whether  due 
to  strangulated  hernia,  peritoneal  band,  volvulus,  new  growth,  intussusception, 
or  other  cause,  often  leads  to  extreme  meteorism,  with  visible  peristalsis,  the 
passage  of  neither  faeces  nor  flatus,  and  persistent  vomiting  which  will  become 
ffeculent  if  the  case  is  not  operated  upon.  Peritonitis  ultimately  supervenes  ; 
but  previous  to  this,  intestinal  obstruction  is  differentiated  from  general 
peritonitis  by  the  absence  of  rigidity  of  the  abdominal  wall,  by  the  presence  of 
borborygmi  and  visible  peristalsis,  the  absolute  constipation  in  spite  of  enemata, 
the  slower  pulse,  and  the  relatively  better  condition  of  the  patient. 

Acute  pancreatitis,  whether  hsemorrhagic  or  not,  may  cause  acute  meteorism. 
The  symptoms  are  variable,  but  they  nearly  always  suggest  an  acute  abdominal 
condition  requiring  immediate  laparotomy,  the  diagnosis  being  then  suggested 
directly  the  areas  of  fat  necrosis  are  seen  in  the  omental  fat.  Previous  to 
laparotomy,  the  symptoms  are  rather  those  of  acute  intestinal  obstruction  than 
of  general  peritonitis  ;  the  usual  history  of  acute  pain  in  the  epigastriuni  may 
at  first  suggest  perforated  gastric  ulcer,  but  the  abdomen  remains  supple  as  in 
obstruction  niore  often  than  it  becomes  rigid  as  in  peritonitis. 


432 


METEORISM 


Meteorism  in  cases  of  typhoid  fever,  dysentery,  dengue,  and  other  severe 
illnesses  in  which  the  bowel  is  affected,  is  chiefly  of  importance  in  that  it  may 
lead  to  a  suspicion  of  perforation  and  general  peritonitis.  The  diagnosis  is 
often  very  difficult,  and  there  may  be  grave  anxiety  and  doubt  as  to  whether  the 
abdomen  should  be  opened  or  not.  One  important  point  in  typhoid  fever  is 
that  perforation  is  generally  accompanied  by  a  sudden  drop  in  the  temperature 
and  an  equally  sudden  rise  in  the  pulse-rate,  whereas  meteorism  by  itself  would 
not  cause  this. 

When  the  vessels  in  the  mesentery  are  affected  by  thrombosis  or  embolism, 
acute  meteorism  results,  with  all  the  signs  of  intestinal  obstruction,  rapidly 
followed  by  peritonitis.  The  nature  of  the  case  may  be  quite  obscure  until 
laparatomy  is  performed,  unless  the  existence  of  a  cause  is  known,  such  as 
fungating  endocarditis. 

Interference  with  the  solar  and  mesenteric  plexuses  of  nerves  has  sometimes 
led  to  severe  meteorism  in  cases  of  tabes  mesenterica,  or  infiltrating  intra-abdominal 


J''i£:  122. — Hirschsprung's  disease  ;    or,  idiopathic  dilatation  of  colon.      Note  the  distended 
coils  of  intestine.     (From  Professor  Rutherford  Morison's  Introduction  to  Surgeiy.) 


new  growth.  The  symptom  occurs  late,  and  the  diagnosis  will  generally  have 
been  made  on  other  grounds. 

Affections  of  the  spinal  cord  may  lead  to  paralysis  of  the  bowel  and  tympanites. 
This  may  result  from  transverse  "myelitis,"  whether  due  to  primary  softening  of 
the  cord  from  syphilitic  or  other  spinal  arterial  thrombosis,  from  compression 
by  spinal  caries,  new  growth,  aneurysm,  or  from  destruction  of  the  dorsal  region 
of  the  cord  by  a  stab,  a  crushing,  or  a  bullet  wound.  There  will  generally  be 
Paraplegia  {q.v)  to  indicate  the  nature  of  the  case. 

Diabetes  mellitus  often  indicates  its  impending  termination  in  coma  by  the 
onset  of  abdominal  pains,  with  more  or  less  meteorism.  The  diagnosis  will  be 
known  already  on  account  of  the  glycosuria.  Meteorism  is  also  common  in  the 
late  stages  of  cirrhosis  of  the  liver. 

Particular  mention  may  be  made  of  Hirschsprung's  disease — idiopathic 
enormous  distention  of  the  sigmoid  colon  in  children  and  young  people 
{Fig.     12.1).       Careful     examination     indicates     that    the     enormous     gaseous 


METRORRHAGIA 


433 


distention  of  the  abdomen  is  not  due  to  general  tympanites,  but  to  ballooning 
of  what  may  seem  at  first  to  be  stomach,  but  which  is  proved  not  to  be  this  by 
the  absence  of  immediate  effect  on  the  gas-containing  cavity  when  fluid  or  gas 
is  given  by  the  mouth,  by  the  swelling  appearing  to  arise  from  the  left  iliac 
fossa,  and  if  need  be  by  the  x-iay  shadows  after  a  bismuth  meal.  Obstinate 
constipation,  or  even  symptoms  of  recurrent  intestinal  obstruction,  are  usual 
in  these  cases,  and  the  diagnosis  is  confirmed  by  the  laparotomy  that  is 
generally  required,  in  the  end,  to  reheve  the  patient. 

Hysteria,  or  rather  functional  derangement  of  the  nervous  system,  can  lead 
to  almost  any  symptom,  including  meteorism.  Two  difficulties  arise  in  the 
diagnosis  :  namel}',  to  be  sure  :  (i)  That  the  condition  is  meteorism  at  all,  and  not 
pregnancy,  ascites,  ovarian  cyst  or  other  tumour — phantom  tumours  are  difficult 
to  diagnose  without  examination  under  an  anassthetic,  and  even  laparotomy 
may  be  undertaken  before  the  absence  of  a  tumour  is  certainly  established  ;  and 
(2)  That  the  meteorism  has  no  organic  basis — the  circumstances  may  sometimes 
suggest  this  at  once,  but  in  some  cases  the  exclusion  of  an  organic  cause  for  the 
tympanites  may  take  much  time,  careful  enquiry  into  symptoms  and  physical 
signs,  and  considerable  anxiet}'  meanwhile.  Herbert  French. 

METH^MOGLOBINURIA.— (See  Hemoglobinuria.) 

METRORRHAGIA. — Metrorrhagia  means  the  loss  of  blood  from  the  uterus 
in  the  intermenstrual  periods,  and  naturally  the  term  can  only  be  applied  to 
irregular  haemorrhages  during  menstrual  life.  It  is  not  strictly  correct  to  apply 
it  to  haemorrhages  connected  with  pregnancy,  for  in  pregnancy  menstruation  is 
in  abeyance.  It  may,  however,  be  used  with  propriety  in  those  cases  remotely 
connected  with  pregnancy  in  which  menstruation  has  been  re-established.  The 
term  may  be  used  for  losses  of  actual  blood,  or  for  blood-stained  discharges  in 
which  mucus  is  mixed  with  the  blood. 

Causes   of  Metrorrhagia. 


I.  Generative  System. 

2.  Circulatory  System. 

3.  Nervous  System. 

Malignant  Growths  : 

High  blood-pressure  due  to  : 

Sexual  excess 

Carcinoma 

Internal  secretions 

Squamous  epithelioma 

Arteriosclerosis 

Sarcoma 

At  the  menopause 

Chorion-epithelioma 

Undue  congestion  due  to : 

Benign  Growths  : 

Internal  secretions 

Submucous  fibroid 

Deficiency  of  calcium  at 

Fibroid  polypus 

the  onset 

Mucous  polypus 

Blood  Changes  .- 

Inflammatory  Lesions  : 

Purpura 

1 

Erosion  of  cervix 

Scorbutus 

' 

Endometritis 

Haemophilia 

Tuberculosis  of  the  uterus 

Leucocythaemia 

The  Generative  System. — The  lesions  of  the  generative  organs  which  give  rise 
to  metrorrhagia  are  well  defined  as  a  rule,  and  in  the  case  of  growths  of  the 
cervix  uteri  are  often  self-evident.  Where  growths  of  the  body  of  the  uterus 
are  present,  differential  diagnosis  is  often  a  matter  of  great  difficulty,  and  cannot 
be  made  in  many  instances  without  a  preliminary  curettage  and  microscopical 
examination  of  the  material  removed.  In  fact,  with  the  exception  of  obvious 
mucous  polypi,  fibroid  polypi,  and  advanced  growths  of  the  cervix,  all  the 
growths  of  the  uterus  require  a  preliminary  histological  examination  for  their 
D  28 


434  METRORRHAGIA 


exact  diagnosis  unless  the  symptoms  demand  a  radical  operation.  In  such 
cases  it  is  sufficient  to  diagnose  the  actual  nature  of  the  growth  after 
removal. 

It  is  not  out  of  place  here  to  suggest  the  best  way  to  make  histological  prepara- 
tions from  curetted  material,  a  matter  often  of  great  importance  to  the  patient, 
because  it  is  often  difficult  to  distinguish  between  cancer  and  endometritis  unless 
the  very  best  microscope  sections  can  be  obtained.  The  curetted  material 
must  be  obtained  after  dilatation,  with  a  sharp  curette,  and  the  larger  the  frag- 
ments removed  the  more  easy  will  the  histologist's  work  be  made.  Anassthesia, 
therefore,  is  always  essential  except  in  the  case  of  cervical  growths.  In  doubtful 
cervical  growths  a  wedge  should  be  cut  out,  including  some  normal  tissue,  if 
possible.  Curetted  fragments  should  be  washed  free  from  blood  for  a  minute  or 
two,  but  should  not  be  left  to  soak  in  water.  They  should  then  be  placed  imme- 
diately in  an  ef&cient  fixing  fluid,  and  the  best  all-round  fluid  for  this  purpose 
is  lo  per  cent  of  formalin  in  -75  per  cent  saline  solution  (formalin  loc.c,  -75  per 
cent  salt  solution  90  c.c).  Twenty-four  hours  in  this  fluid  lead  to  good  fixation, 
after  which  the  tissues  can  be  dehydrated  in  successive  alcohols,  cleared  in  xylol, 
and  finally  embedded  and  infiltrated  with  paraffin  wax.  Sections  cut  from  these 
paraf&n  blocks  are  the  best  obtainable,  far  superior  to  any  freezing  method  or 
celloidin  infiltration.  If  the  stained  sections  are  submitted  to  a  histologist  who 
has  experience  of  uterine  growths,  there  should  not  be  two  per  cent  of  doubtful 
specimens.  If,  however,  the  tissues  are  improperly  fixed,  thick  sections  are 
cut,  and  badly  stained,  then  the  most  skilled  histologist  will  be  unable  to  give  a 
definite  and  reliable  diagnosis. 

Cancer  of  the  body  of  the  uterus,  cancer  of  the  cervical  canal,  early  cancer  of 
the  cervix,  sarcoma  of  the  uterus,  chorion-epithelioma,  some  sloughing  fibroids, 
tubercle,  and  endometritis  can  only  be  distinguished  from  one  another  by  investi- 
gations carried  out  on  these  lines.  The  fact  that  all  these  lesions  produce  metror- 
rhagia, and  may  give  rise  to  haemorrhage  on  coitus,  walking,  straining  at  stool, 
and  bimanual  manipulation  of  the  uterus,  makes  it  imperative  that  we  should 
have  histological  confirmation  of  the  nature  of  the  lesion  before  making  an 
exact  diagnosis. 

The  relation  of  fibromyoma  to  metrorrhagia  as  opposed  to  pure  menorrhagia, 
which  is  the  rule  with  these  tumours,  is  interesting.  Fibroids  only  produce 
irregular  bleeding  when  they  are  submucous  and  in  process  of  extrusion,  when 
they  are  infected  and  sloughing,  or  when  they  are  actually  polypoid.  The 
reason  for  this  is  that  in  these  conditions  the  tumours  are  always  partly  strangu- 
lated by  uterine  contractions,  and  therefore  in  a  state  of  gross  venous  congestion  ; 
hence  they  bleed  more  or  less  constantly,  without  provocation.  The  occurrence 
of  irregular  bleeding  in  a  person  who  is  known  to  have  fibroids  almost  always 
means  one  of  these  conditions,  and,  commonly,  extrusion  of  the  tumour  from 
the  uterus.  On  the  other  hand,  it  must  not  be  overlooked  that  carcinoma  may 
develop  in  the  endometrium  with  a  fibroid  also  present,  or  that  a  fibroid  may 
become  sarcomatous,  or  that  a  sarcoma  may  arise  de  novo  in  the  uterus,  and 
attack  a  pre-existing  fibroid. 

Rapid  enlargement  of  a  uterus,  with  irregular  haemorrhage,  is  very  suspicious 
of  a  sarcoma,  but  as  it  is  not  uncommon  for  several  fibroids  to  be  present  in 
the  same  uterus,  it  is  also  common  for  rapid  enlargement  to  occur  as  a  result 
of  cystic  changes  in  one  of  them,  whilst  haemorrhage  may  take  place  due  to 
extrusion  of  another. 

Pure  carcinoma  of  the  body  of  the  uterus  rarely  produces  much  enlargement  of 
the  organ,  and  any  increase  in  size  is  not  very  rapid. 

Chorion-epithelioma  follows  hydatidiform  mole  in  about  50  per  cent  of  the 
recorded  cases,  and  it  always  follows  pregnancy,  never  having  been  seen  in  the 


METROSTAXIS  435 


uterus  in  a  case  where  pregnancy  could  be  excluded.  It  is  associated  especially 
with  profuse  bleeding  and  the  rapid  development  of  a  foetid  discharge  due  to 
decomposition  of  blood  and  necrosing  tissues  in  utero.  Carcinoma  of  the  body 
of  the  uterus  rarely  produces  foul  discharges  until  the  condition  is  very  advanced 
and  has  become  exposed  to  the  air. 

The  differential  diagnosis  of  bleeding  due  to  cancer,  erosion,  and  tubercle  of 
the  cervix  is  often  difficult  in  the  early  stages.  In  advanced  cancer  the 
friable  hardness  of  the  growth  distinguishes  it  at  once  from  the  tough  leathery 
hardness  present  in  erosions.  In  the  former^  the  growth  can  be  broken  down 
with  the  finger  ;  in  the  latter,  the  soft  velvety  erosion  can  be  scraped  off  the 
tough  leathery  and  fibrous  cervix  beneath.  Nothing,  however,  but  sections 
made  from  wedges  removed  from  the  cervix  will  assist  us  to  distinguish  cancer 
or  erosion  from  tubercle  in  the  early  stages.  Tubercle  of  the  cervix  is  usually 
mistaken  for  cancer,  but  the  difference  is  of  course  clear  enough  in  microscope 
sections. 

Mucous  polypi  and  fibroid  polypi  are  common  causes  of  intermenstrual  bleeding, 
and  are  usually  quite  definite  growths.  The  mucous  polypus  is  soft,  strawberry- 
red  in  colour,  often  pedunculated,  and  contains  cystic  spaces  filled  with  glairy 
mucus.  It  almost  never  gives  rise  to  a  malignant  growth.  The  fibroid  polypus 
is  hard,  and  shows  the  glistening  whorled  appearance  so  well  known  in  fibro- 
myomata  on  section.  These  growths  are  liable  to  infection  and  sloughing,  and 
are  then  apt  to  be  mistaken  for  cancer  or  sarcoma.  The  microscope  alone  will 
enable  the  difference  to  be  made  out. 

Endometritis  rarely  causes  severe  metrorrhagia,  but  is  often  associated  with  a 
bloodstained  watery  discharge.  In  a  doubtful  case  there  is  absolutely  no  way 
of  distinguishing  it  except  with  the  microscope. 

The  Circulatory  System  is  sometimes  responsible  for  metrorrhagia,  just  as  it 
is  for  menorrhagia,  and  the  actual  causes  are  much  the  same.  It  is,  however, 
especially  at  the  onset  and  the  decline  of  menstruation  that  irregular  bleeding 
is  likely  to  occur  from  this  cause.  The  same  disturbance  of  the  internal  secretions 
which  may  cause  menorrhagia  at  these  periods,  sometimes  acts  in  the  same  way 
in  causing  irregular  bleeding.  It  is  fairly  common  to  find  young  girls  at  the 
onset  of  menstruation  having  menorrhagia  and  metrorrhagia,  and  it  is  often 
very  difficult  to  be  certain  of  a  cause.  It  depends,  however,  very  largely  on 
two  definite  factors,  namely  :  (i)  Unusual  uterine  congestion  the  result  of  an 
excess  of  the  biochemical  stimulus  (internal  secretions)  of  menstruation,  and 
(2)  deficient  coagulation  power  possibly  due  to  a  want  of  calcium  in  the  blood. 
The  former  cannot  be  diagnosed  by  any  defined  investigation,  but  the  latter  is 
determined  by  estimating  the  coagulation-time.  Purpura,  scorbutus,  and 
hsemophilia  are  readily  diagnosed  when  they  act  as  causal  agents.  Leuco- 
cythasmia  is  sometimes  responsible  for  irregular  uterine  bleeding,  and  is  readily 
diagnosed  by  making  a  total  and  differential  leucocyte  count. 

The  Nervous  System  seldom  causes  metrorrhagia,  but  there  is  no  doubt  that 
sexual  excess,  often  seen  in  the  first  months  of  married  life,  is  a  reflex  cause 
of  uterine  congestion,  and  may  cause  metrorrhagia  as  well  as  menorrhagia. 

T.  G.  Stevens. 

METROSTAXIS. — Metrostaxis  is  the  term  applied  to  uterine  haemorrhage 
at  any  period  of  life,  unconnected  with  menstruation,  or  at  times  when  menstrua- 
tion is  in  abeyance.  It  is  convenient  to  keep  this  form  of  haemorrhage  separate 
from  the  other  varieties,  because  in  this  way  all  the  pregnancy  haemorrhages 
can  be  carefully  differentiated.  Metrostaxis  may  be  classified  according  to 
whether  the  uterus  is  pregnant  or  not.  The  bleeding  which  occasionally 
occurs  from  the  vagina  in  new-born  infants  is  usually  thought  to  depend  upon 
uterine  congestion  subsequent  to  the  cessation  of  the  placental  circulation.     It 


436 


METROSTAXIS 


never  depends  upon  any  lesion  requiring  definite  investigation,  and  is  usually 
trivial.     A  fatal  case,  however,  was  reported  by  McKerron. 

Causes  of  Metrostaxis. 


NON'-PREGNANT   UtERUS. 

Pregnant  Uterus. 

Uterine  bleeding  in  the  new-born 

Malignant  growths 

Polypi 

Senile  endometritis 

Senile  granular  vaginitis 

Pyoraetra 

Secondary  post-partum  haemorrhage 

Sub-involution 

Threatened  abortion 
Ante-partum  hsemorrhage 
Extra-uterine  gestation 
Malignant  growths  of  cervix 

or  vagina 
Erosions 
Polypi 

The  differentiation  of  malignant  growths,  polypi,  and  senile  endometritis  can 
only  be  established  in  the  same  manner  as  in  cases  occurring  during  menstrual 
life.  Senile  adhesive  vaginitis  must  not  be  overlooked  as  a  possible  cause.  In 
this  condition  the  vaginal  walls  at  the  fornices  are  liable  to  become  inflamed  and 
form  granulation  tissue,  which  may  bleed  if  the  surfaces  rub  together.  On 
examining  such  cases,  too,  the  surfaces  may  be  partly  adherent,  and  the  separa- 
tion brought  about  by  the  finger  may  cause  bleeding.  In  any  doubtful  case,  the 
routine  dilatation  and  curettage  of  the  uterus  must  never  be  omitted.  An 
unsuspected  pyometra,  or  distention  of  the  uterus  with  pus,  may  cause 
haemorrhage,  along  with  a  foul  discharge,  and  although  it  is  almost  always 
accompanied  by  a  malignant  growth,  may  be  only  the  result  of  infection  and 
granulation-tissue  formation. 

In  relation  to  a  recent  pregnancy,  haemorrhage  may  result  from  simple  sub- 
involution, from  retained  products  of  conception,  and  from  chorion- epithelioma. 
The  differentiation  of  these  conditions  can  only  be  established  by  exploration  of 
the  uterine  cavity,  with,  if  necessary,  the  assistance  of  the  microscope.  Such 
conditions  may  be  termed  secondary  post-partum  haemorrhage  in  cases  occurring 
within  a  few  days  of  delivery. 

Haemorrhage  from  the  pregnant  uterus  almost  always  means  separation  of  the 
embryo  from  its  attachments,  or  separation  of  the  placenta  ;  but  malignant 
growths  of  the  cervix,  erosions,  and  polypi  may  have  to  be  considered.  Haemor- 
rhage from  a  pregnant  uterus  is  never  due  to  malignant  growths  of  the  body 
of  the  organ,  because  pregnancy  is  practically  impossible  together  with  such 
lesions.  There  are,  however,  two  great  difficulties  in  connection  with  pregnancy 
haemorrhages  :  these  are  to  differentiate  (i)  the  uterine  haemorrhage  which  occurs 
along  with  extra-uterine  gestation  from  that  due  to  threatened  abortion  ;  and  (2) 
to  distinguish  the  bleeding  of  placenta  prcBvia  from  that  due  to  the  separation  of 
a  normally  situated  placenta. 

In  the  first  case,  arising  very  early  in  pregnancy,  it  must  be  remembered 
that  the  haemorrhage  occurs  when  the  extra-uterine  gestation  is  separated  from 
its  tubal  or  other  attachments  and  is  converted  into  a  tubal  mole,  when  it  becomes 
extruded  from  the  fimbriated  extremity  of  the  tube,  or  when  the  tube  ruptures. 
Therefore,  there  may  be  history  of  acute  abdominal  pain,  faintness,  and  possibly 
collapse  from  internal  haemorrhage.  Along  with  this,  the  uterus  will  not  be 
found  obviously  enlarged,  whilst  there  is  some  sort  of  swelling  in  one  or  the 
other  posterior  quarter  of  the  pelvis. 

Haemorrhage  due  to  threatened  abortion  cannot  be  diagnosed  unless  the 
presence  of  an  intra-uterine  pregnancy  can  be  established.     Therefore,  in  this 


MICTURITION,     ABNORMALITIES     OF  437 

case  we  must  look  for  the  definite  signs  of  a  normal  pregnancy,  which  in  the 
early  months  will  be  :  amenorrhoea,  morning  sickness,  breast  changes,  enlarge- 
ment of  the  uterus,  Hegar's  sign,  and  Braun's  sign.  The  former  consists  in  the 
extreme  softening  of  the  upper  part  of  the  cervix  and  lower  part  of  the  uterine 
body,  combined  with  the  as  yet  unsoftened  vaginal  portion  and  globular  tense 
fundus  ;  it  is  found  from  the  sixth  to  the  eighth  week.  The  latter  consists  in  the 
irregular  shape  of  the  uterus  from  the  eighth  to  the  t^velfth  week.  One  side  is 
larger  than  the  other,  and  an  ill-defined  groove  is  found  between  them. 

In  the  second  case,  occurring  generally  after  the  sixth  month  of  pregnancy,  it 
is  of  the  greatest  importance  to  be  able  to  diagnose  placenta  prcsvia.  The  only 
definite  sign  is  the  feeling  of  the  placenta  through  the  cervix,  when  it  will  admit 
of  this  method  of  investigation.  The  suggestive  signs  are  those  due  to  the  filling 
up  of  the  lower  uterine  segment  by  the  placenta.  The  presenting  part  remains 
high  up  and  movable,  not  engaged  in  the  brim,  and  there  is  a  sensation  of  great 
increase  of  thickness  between  the  vaginal  fornices  and  the  presenting  part.  In 
any  case  of  severe  hemorrhage,  however,  the  cervix  must  be  dilated  so  as  to 
admit  a  finger,  as  treatment  depends  upon  diagnosis,  and  no  patient  with  a 
placenta  praevia  is  safe  until  she  is  delivered  and  bleeding  has  ceased. 

T.  G-  Stevens. 

MICROPSIA. — (See  Vision,  Defects  of.) 

MICTURITION,  ABNORMALITIES  OF. —  A  person  in  health  micturates 
about  five  times  during  the  twenty-four  hours,  the  total  amount  of  urine  passed 
being  about  1500  c.c,  or  50  ounces.  This  varies  according  to  the  amount  of 
fluid  taken  and  the  amount  lost  by  perspiration,  and  so  forth.  The  act  of 
micturition  is  controlled  by  a  nervous  mechanism,  a  stimulus  from  the  vesical 
mucous  membrane  starting  an  impulse  which  causes  contraction  of  the 
detrusor  muscle,  and  at  the  same  time  relaxation  of  the  sphincter  at  the  urethral 
orifice.  The  special  centres  controlling  the  motor  functions  of  the  bladder  are 
in  the  spinal  cord  at  the  level  of  the  third  sacral  nerve,  whilst  the  brain  controls 
these  centres  in  response  to  sensory  impulses  received.  The  abnormalities  of 
micturition  which  are  met  with  in  practice  depend  partly  upon  lesions  of  some 
portion  of  the  urinary  apparatus,  and  partly  upon  some  change  in  the  nervous 
mechanism  controlling  the  act,  and  will  be  discussed  from  these  points  of  view 
under  the  following  headings  : — 

1.  Increased  frequency  of  micturition 

2.  Changes  in  the  stream  during  micturition 

3.  Difficulty  in  micturition 

4.  Retention  and  incontinence  of  urine 

5.  Pain  during  micturition 

6.  Micturition  through  fistulas 

7.  Disorders  of  micturition  from  diseases  of  the  nervous  sj'stem 

8.  Enuresis  (q-v.). 

Increased  Frequency  of  Micturition. — A  large  number  of  diseases  of  the 
genito-urinary  tract  are  accompanied  by  increased  frequency  of  micturition, 
and  it  is  necessary  to  ascertain  if  the  increased  frequency  of  micturition  depends 
upon  an  increased  amount  of  urine  to  be  passed.  Thus  in  diabetes  or  chronic 
interstitial  nephritis,  the  increased  amount  of  urine  will  cause  an  increased 
frequency  of  desire  to  micturate,  provided  the  capacity  of  the  bladder  is 
unaltered.  If  the  total  amount  of  urine  remains  normal,  any  increased  frequency 
of  micturition  will  be  caused  by  some  lesion  of  the  genito-urinary  apparatus, 
and  a  due  consideration  of  the  other  symptoms  of  a  case  will  often  point  to  a 
definite  diagnosis.  It  must  be  remembered,  however,  that  increased  frequency 
does   not  necessarily  imply  that  the  bladder  is  the  seat  of  the  disease,  as  the 


438  MICTURITION,     ABNORMALITIES     OF 

symptom  is  present  with  any  form  of  renal  pyelitis — commonly  calculous  or 
tuberculous — or  with  prostatic  enlargement. 

It  is  important  to  ascertain  the  relationship  between  micturition  during  the 
da}^  and  during  the  night.  Normalh-,  a  health}-  person  should  not  wake  during 
the  night  to  pass  urine,  unless  an  excess  of  fluid  has  been  taken  ;  but  if  any 
inflammatory  condition  is  present  in  the  bladder,  micturition  will  be  present 
during  the  night,  as  well  as  increased  in  frequenc}^  during  the  day.  Any  form 
of  cystitis  or  acute  inflammatory  conditions  of  the  prostate  or  neighbouring 
organs,  will  cause  increased  frequency  during  both  the  day  and  night.  In 
patients  with  chronic  nephritis  who  are  passing  normal  quantities  of  urine 
during  the  day,  frequent  micturition  at  night  is  common,  and  is  due  to  delayed 
excretion  of  fluid  from  the  body  bj-  the  kidneys. 

In  vesical  calculus  there  is  increased  frequency  during  the  day,  but  often  no 
urination  is  necessary  during  the  night.  The  frequencj"  during  the  day  is 
increased  with  activity  or  exercise,  or  by  the  jolting  movements  of  travelhng, 
but  is  absent  during  a  period  of  rest.  If  the  presence  of  a  calculus  has  excited 
cystitis,  increased  frequency  of  micturition  will  be  present  during  both  day  and 
night. 

In  prostatic  enlargement,  whether  simple  or  carcinomatous,  the  increased 
frequency  is  most  marked  at  night,  and  is  commonly  the  first  symptom  of  the 
disease  noticed  by  the  patient,  generally  a  man  of  about  sixty  years  of  age.  The 
mucous  membrane  of  the  prostatic  urethra  becomes  stretched  by  the  enlarging 
gland,  and  often  pushed  upwards  into  the  bladder  by  the  intravesical  enlarge- 
ment, and  the  contact  of  this  with  urine  in  the  bladder  causes  the  stimulus  to 
micturition.  Further,  with  prostatic  enlargement,  the  bladder  is  not  completely 
emptied,  so  that  the  addition  of  a  relatively  small  amount  of  urine  from  the 
kidneys  soon  fills  up  the  incompletely  emptied  viscus  and  sets  up  afresh  the 
desire  to  micturate. 

In  vesical  carcinoma,  increased  frequencj-  of  micturition  is  present  during  both 
the  day  and  night,  as  the  infiltration  of  the  vesical  wall  prevents  the  bladder 
from  being  distended  without  pain,  and  it  is  frequently'  associated  with  cystitis. 

In  renal  colic  caused  by  calculus  or  blood-clot,  or  in  the  torsion  of  a  movable 
kidney,  there  may  be  increased  desire  to  micturate,  and  the  sj-mptom  may  be 
present  in  inflammatory  diseases  in  the  pelvis,  such  as  salpingitis,  pyosalpinx, 
or  a  low-placed  appendicitis,  or  in  the  secondary  infiltration  of  the  bladder  in 
carcinoma  of  the  uterus  or  rectum. 

Increased  frequency  of  micturition  may  be  produced  by  mechanical  obstruc- 
tion to  the  normal  vesical  distention  by  a  tumour  occupjdng  the  pelvis,  and  is 
commonly  seen  in  ovarian  cyst,  uterine  fibroid,  or  with  a  retroverted  gravid  uterus  ; 
these  tumours  will  be  found  upon  vaginal  examination. 

In  children,  increased  frequencj^  of  micturition  may  be  due  to  phimosis, 
balanitis,  a  small  urinary  meatus,  worms,  penile  calculus,  oxaluria,  coli  bacilluria, 
or  to  hyperacidity  of  the  urine. 

Changes  in  the  Stream  of  Urine. — An  abnormahty  of  the  stream  of  urine 
may  be  due  to  a  congenital  deficiency  of  the  terminal  urethra,  as  in  hypospadias 
or  epispadias,  or  to  some  lesion  mechanically  obstructing  the  stream.  Most 
commonly  this  is  due  to  a  stricture  of  the  urethra.  If  the  stricture  be  situated  in 
the  penile  portion,  the  stream  of  urine  is  of  small  calibre  but  of  fair  force,  whilst 
if  the  stricture  is  in  the  bulbous  urethra,  the  mechanical  effect  upon  the  stream 
of  urine  passing  through  the  stricture  into  the  urethra  of  wider  calibre  beyond 
the  stricture,  is  that  the  force  is  diminished,  whilst  the  actual  stream  as  it  leaves 
the  meatus  is  not  thinned.  A  stricture  at  or  near  the  urethral  meatus  forms  a 
thin  but  forcible  stream ;  but  no  rehance  can  be  placed  upon  the  complaint  of 
a  "  twisted  stream." 


MICTURITION,     ABNORMALITIES     OF  439 

The  obstruction  to  micturition  by  an  enlarged  prostate  causes  the  stream  of 
urine  to  be  slowed  and  forceless,  so  that  it  may  fall  vertically  from  the  meatus 
instead  of  in  the  usual  arched  manner.  This  same  dribbling  of  urine  will  be 
seen  when  a  urethral  stricture  becomes  much  narrowed,  or  again  when  the 
bladder  musculature  has  lost  its  contractile  power,  or  in  disease  of  the  nervous 
system  affecting  the  motor  paths  to  the  bladder. 

In  any  case  presenting  an  abnormality  in  the  stream  of  urine,  careful  enquiry 
should  be  made  to  ascertain  if  the  stream  has  become  gradually  and  progressively 
narrowed,  as  in  stricture,  or  if  the  alteration  in  the  force  of  the  stream  is  accom- 
panied by  increased  frequency  of  urination,  as  in  prostatic  hypertrophy  in  an 
elderly  patient,  or  by  urethral  discharge  in  a  case  suggestive  of  acute  prostatitis. 
A  stricture  may  be  diagnosed  with  certainty  by  a  careful  endoscopic  examina- 
tion under  air-distention,  or,  failing  this,  by  the  obstruction  offered  to  the 
passage  of  a  catheter  or  bougie.  Prostatic  enlargement  or  inflammation  will  be 
suggested  by  the  history  of  the  case,  and  confirmed  by  a  digital  examination 
of  the  gland  by  the  rectum  ;  in  the  absence  of  a  mechanical  obstruction  in  the 
urethra,  examination  should  be  conducted  for  any  disease  of  the  spinal  cord, 
by  testing  the  knee-jerk  and  other  reflexes. 

Sudden  stoppage  of  the  flow  of  urine  during  micturition  may  be  caused  by  a 
small,  movable  vesical  calculus,  if  the  latter  happens  to  engage  in  the  internal 
urethral  orifice  or  becomes  impacted  in  the  urethra.  The  same  sudden  cessation 
of  the  flow  is  caused  occasionally  by  a  tuft  of  a  vesical  villous  tumour  blocking 
the  urethral  opening  during  micturition.  Usually  the  flow  will  be  resumed  after 
a  few  seconds,  unless  the  calculus  has  passed  into  the  urethra,  when  it  may  be 
passed  naturally  or  require  to  be  removed  by  surgical  means.  If  the  symptom 
recurs,  a  cystoscopic  examination  of  the  bladder  will  readily  distinguish  between 
the  two  conditions. 

The  same  sudden  cessation  of  the  stream  may  occur  without  any  intra- 
vesical lesion  as  the  result  of  spasmodic  contraction  of  the  vesical  sphincter. 
Patients  subject  to  this  trouble  (so-called  stammering  bladder)  can  at  times 
pass  urine  quite  normally,  but  at  others  the  stream  is  frequently  interrupted, 
or  they  may  be  unable  to  pass  urine  at  all,  especially  in  the  presence  of  a 
second  person. 

Difficulty  in  Micturition. — Frequently  associated  with  some  change  in  the 
character  of  the  stream  of  urine,  a  patient  may  complain  of  difficulty  in  mic- 
turition, either  as  a  hesitation  in  commencing  the  flow  or  a  need  to  strain  to 
maintain  it.  This,  again,  is  most  common  with  urethral  stricture  or  prostatic 
enlargement,  or  may  be  due  to  the  impaction  of  a  calculus  in  the  urethra  or  to  the 
formation  of  blood-clot  in  the  bladder.  A  calculus  may  be  passed  into  the  urethra 
and  become  arrested  in  the  canal,  but  not  so  that  it  wholly  obstructs  the  passage 
of  urine.  It  is  not  uncommon  for  a  calculus  to  occupy  the  dilated  portion  of 
the  urethra  behind  a  stricture,  or  occasionally  a  prostatic  calculus  projects 
from  the  gland  into  the  lumen  of  the  posterior  urethra.  A  calculus  so  placed 
may  increase  in  size  by  the  further  deposition  of  urinary  salts  whilst  in  the 
urethra,  and  cause  difficulty  in  micturition  ;  it  may  be  felt  in  the  canal  from 
the  outside,  upon  rectal  examination,  or  upon  passing  a  soft  bougie  into  the 
urethra.  Even  if  placed  behind  a  stricture,  it  may  be  felt  by  a  fine  guide  or 
bougie  passed  to  dilate  the  stricture. 

Difficulty  in  micturition  due  to  the  presence  of  blood-clot  in  the  bladder  will 
usually  be  indicated  by  the  previous  passage  of  blood-stained  urine  and  by  the 
constant  efforts  to  micturate. 

Difficulty  in  micturition  in  the  female  may  be  caused  by  a  pelvic  tumour  by 
the  drag  or  direct  pressure  on  the  urethra  or  vesical  neck.  This  may  occur 
with  a  uterine  fibroid  or  a  pregnant  retroverted  uterus.     Occasionally,  difficulty 


440  MICTURITION,     ABNORMALITIES     OF 

is  produced  by  the  direct  infiltration  of  the  urethra  by  a  carcinoma  of  the  vaginal 
wall  or  vulva. 

Difficulty  in  micturition  is  n"ot  uncommon  in  disease  of  the  nervous  system, 
causing  paralysis  or  paresis  of  the  detrusor  muscle  of  the  bladder.  This  may 
be  due  to  trauma  and  pressure  on  the  spinal  cord  by  blood-clot,  or  to  myelitis 
or  tabes.  It  must  be  remembered  that  it  is  not  uncommon  for  the  early  cord- 
changes  of  tabes  to  affect  the  urinary  organs,  and  that  difficulty  in  passing 
urine  may  be  complained  of  when  the  urethra  and  bladder  are  normal. 

Atony  of  the  bladder  wall  without  any  affection  of  the  nervous  mechanism,  from 
recurring  over-distention  of  the  bladder,  may  cause  difficulty  in  micturition. 

Retention  of  Urine — by  which  is  implied  the  gradual  accumulation  of  urine 
in  the  bladder,  with  inability  to  pass  any  per  urethram — may  arise  from  mechanical 
causes  obstructing  the  urethra,  or  from  derangement  of  the  nervous  system. 
Retention  of  urine  must  be  distinguished  from  anuria,  or  failure  of  the  kidneys 
to  secrete  urine,  for  in  retention  the  kidneys  are  still  functioning,  and  the  urine 
is  collecting  in  the  distended  bladder.  Retention  of  urine  occurring  suddenly, 
produces  very  severe  pain  and  strangury,  but  in  cases  of  old-standing  obstruction 
the  bladder  may  be  enormously  distended  before  pain  becomes  severe.  If  the 
retention  remains  unrelieved,  urine  may  continually  dribble  away  per  urethram, 
when  a  condition  resembling  incontinence  of  urine  is  produced  ;  but  it  is  most 
important  to  distinguish  the  condition  from  true  incontinence  of  urine  due  to 
injury  or  paralysis  of  the  vesical  sphincter  muscle.  In  true  incontinence,  the 
bladder  remains  empty,  urine  flows  away  as  soon  as  it  passes  down  into  the 
bladder,  and  there  is  no  obstruction  in  the  urethra  ;  whereas,  in  the  condition  of 
involuntary  passage  of  urine  from  an  unrelieved  distended  bladder — incontinence 
from  overflow,  or  false  incontinence — the  bladder  may  be  felt  distended  in  the 
suprapubic  region,  and  there  exists  some  mechanical  obstruction  in  the  urethra, 
or  at  the  internal  urethral  orifice. 

The  common  causes  of  retention  of  urine  are  urethral  stricture  and  prostatic 
enlargement.  In  stricture,  it  does  not  necessarily  follow  that  the  urethra  is 
entirely  occluded  by  the  fibrosis,  but  rather  that  some  spasm  or  congestion  is 
present  at  the  stricture,  from  exposure  to  cold  or  indulgence  in  alcohol,  when  a 
small  catheter  may  be  passed.  In  elderly  men  with  prostatic  hypertrophy ,  acute 
retention  may  occur  early  in  the  disease  from  a  congested  condition  of  the 
enlarged  gland,  or  in  the  later  stages  be  due  to  actual  obstruction  of  the  urethra 
by  a  localized  enlargement  from  either  lateral  lobe  or  the  so-called  third  lobe 
which  acts  as  a  ball- valve  to  the  internal  urethral  orifice  in  such  a  manner 
that  each  forced  attempt  at  urination  closes  the  orifice  more  securely.  In  these 
cases  of  prostatic  enlargement,  a  large  coude  catheter  can  usually  be  passed 
readily ;  but  in  cases  of  acute  retention,  especially  in  those  of  old-standing 
obstruction  in  which  the  kidneys  are  probably  affected  by  the  backward  pressure, 
it  must  always  be  remembered  that  if  a  catheter  is  passed,  the  urine  must  be 
drawn  off  very  slowly,  either  by  a  fine  catheter,  a  few  ounces  at  a  time,  or  by 
replacing  some  of  the  fluid  withdrawn  by  sterile  boracic  lotion,  so  that  the 
increased  intrarenal  tension  may  be  lessened  slowly  ;  otherwise,  fatal  anuria 
may  be  induced. 

A  case  of  acute  retention  of  urine  from  stricture  of  the  urethra  will  generally 
be  that  of  a  comparatively  young  patient,  who  will  give  a  history  of  gradually 
increasing  difficulty  in  micturition,  with  narrowing  of  the  stream,  and  inability 
to  finish  the  flow  completely  without  some  dribbling  of  urine.  Examination  of 
the  urethra  by  an  endoscope,  or  by  the  passage  of  olivary-pointed  flexible 
bougies,  will  reveal  the  presence  of  a  stricture. 

In  prostatic  enlargement  the  patient  is  usuallj^  above  the  age  of  fifty-five  years, 
has  been  troubled  with  increasing  frequency  in  micturition,  especially  at  night, 


MICTURITION,     ABNORMALITIES     OF  441 

with  straining  and  loss  of  force  in  the  stream  of  urine.  Per  rectum,  the  prostate 
may  be  found  to  be  enlarged  both  from  above  downwards  and  laterally ;  it  may 
be  smooth,  elastic,  and  movable  in  the  pelvic  space  in  the  case  of  adenomatous 
enlargement,  or  nodular,  hard,  irregular,  and  fixed  in  the  case  of  carcinoma, 
the  subjective  symptoms  of  both  of  which  are  very  similar.  In  some  cases  the 
prostate  may  not  appear  to  be  much  enlarged  upon  rectal  examination,  though 
it  is  causing  an  intravesical  tumour  which  obstructs  urination,  or  a  firm  fibrous 
collar  around  the  internal  urethral  orifice  which  gives  rise  to  marked  prostatic 
symptoms.  In  prostatic  cases,  a  catheter  of  coude  form  can  usually  be  passed 
into  the  bladder  readily. 

Acute  retention  of  urine  may  be  produced  by  other  causes  than  the  above. 
A  small  calculus  may  be  passed  into  the  urethra  and  totally  obstruct  the  passage 
of  urine.  This  may  occur  at  any  age,  and  the  calculus  become  arrested  at  some 
narrow  portion  of  the  canal — usually  at  the  meatus  or  at  the  membranous 
urethra.  The  urethra  may  lodge  a  calculus  for  some  time  with  comparatively 
little  pain  ;  but  more  often  the  calculus  passes  into  the  canal  during  micturition, 
causing  a  sudden  pain,  with  cessation  of  the  flow  of  urine  and  the  dribbling  of 
a  few  drops  of  blood.  The  calculus  may  be  palpated  if  it  lies  in  the  penile 
urethra  or  in  the  perineum,  or  will  be  felt  on  passing  a  metal  instrument  into 
the  urethra. 

Retention  may  be  caused  by  the  blockage  of  the  internal  urethral  orifice  by 
the  free  portion  of  a  pedunculated  vesical  tumour.  On  any  attempt  at  micturition 
the  growth  is  forced  into  the  orifice  and  obstructs  it.  These  cases  are  rare,  but 
in  one  under  the  care  of  the  writer,  a  man,  owing  to  his  inability  to  pass  any 
urine,  had  been  condemned  to  catheter  life  on  the  assumption  that  he  had 
prostatic  enlargement.  No  enlargement  could  be  felt  per  rectum,  but  upon 
cystoscopic  examination,  a  papilloma  was  found  in  the  bladder,  attached  by  its 
pedicle  just  above  the  urethral  orifice  and  obstructing  the  flow  of  urine. 

Retention  of  urine  may  also  occur  with  paralysis  of  the  motor  nerves  of  the 
detrusor  muscle  of  the  bladder,  or  interference  with  the  spinal  centres  by 
compression  paraplegia,  locomotor  ataxia,  or  myelitis,  each  being  diagnosed 
on  examination  of  the  nervous  system  ;  or  as  a  reflex  spasm  of  the  vesical 
sphincter  after  operations  upon  the  rectum  or  neighbouring  organs. 

In  other  cases,  retention  of  urine  is  present  in  association  with  other  sym- 
ptoms of  hysteria ;  but  care  must  be  taken  not  to  give  a  diagnosis  of  hysteria 
until  all  other  causes  of  retention  are  excluded.  These  cases  usually  occur  in 
children  or  in  young  women. 

Pain  during  Micturition. — Pain  may  be  present  during  or  immediately  after 
micturition,  and  it  is  important  to  ascertain  not  only  the  period  at  which  pain 
is  present,  but  also  the  actual  location  of  the  pain.  If  pain  is  present  in  the 
urethra  during  micturition,  it  usually  indicates  that  a  stricture  or  some  inflam- 
matory process  is  present,  the  latter  being  evidenced  by  a  urethral  discharge  (see 
Discharge,  Urethral).  If  pain  is  experienced  immediately  after  micturition, 
and  felt  as  a  tingling  or  pricking  sensation  in  the  glans  penis,  there  is  some  inflam- 
matory or  irritant  process  at  the  trigonal  region  of  the  bladder.  Formerly  this 
symptom  was  looked  upon  as  diagnostic  of  vesical  calculus,  and  though  it  is 
almost  a  constant  symptom  of  the  latter,  provided  the  calculus  is  not  trapped  in  a 
post-prostatic  pouch,  it  is  also  present  in  cystitis,  tuberculous  or  otherwise,  in 
vesical  carcinoma  which  is  infiltrating  the  bladder  base,  and  in  acute  or  subacute 
prostatic  infections.  Prostatic  infection  can  be  diagnosed  by  the  history  of  the 
case,  usually  following  an  acute  urethritis,  and  by  a  rectal  examination.  Tuber- 
culous cystitis  usually  occurs  in  young  adults,  and  frequently  other  tuberculous 
lesions  are  present  in  the  genito-urinary  organs,  such  as  the  epididymis,  vas 
deferens,  seminal  vesicles,  or  prostate,  whilst  the  urine  contains  not  only  blood 


442  MICTURITION,     ABNORMALITIES     OF 

and  pus,  but  tubercle  bacilli.  Cystitis  from  other  causes,  and  vesical  growth  or 
calculus,  can  be  ascertained  upon  cystoscopic  examination. 

Pain  ma}'  be  felt  in  the  perineum  during  and  after  micturition  in  cases  of 
prostatic  disease,  especially  if  much  straining  occurs  during  micturition,  or  ma}^ 
be  felt  in  both  the  perineum  and  the  anal  area  in  vesical  carcinoma. 

In  the  female,  pain  is  felt  at  the  urethral  orifice  and  in  the  vulva  after  mic- 
turition in  cases  of  cystitis  or  vesical  carcinoma. 

It  should  be  noted  that  in  either  sex,  severe  pain  may  be  present  at  the  termi- 
nation of  the  urethra  after  micturition,  Avhen  a  calculus  is  impacted  in  the  vesical 
end  of  a  ureter,  especially  if  the  latter  is  partially  prolapsed  into  the  bladder. 
In  one  such  case  the  patient  would  hold  her  urine  for  hours  rather  than  pass  it, 
owing  to  the  pain  that  followed  micturition. 

Micturition  through  Fistulse.  —  Urine  may  pass,  either  whoUy  or  in  part, 
through  a  fistulous  tract  communicating  -^dth  the  urinary  organs,  such  opening 
being  the  result  of  preceding  disease  or  trauma.  Occasionally,  owing  to  con- 
genital malformation  of  the  urethra  or  bladder,  urine  passes  by  an  opening  in 
the  perineum,  pubes,  or  into  the  vagina  ;  but  these  cannot  be  regarded  as  fistulae. 

Urinarj-  fistulae  are  most  common  in  connection  vritii  the  urethra  as  the  result 
of  peri-urethral  abscess,  stricture,  or  from  the  result  of  some  operation  ;  and  in 
a  case  in  which  a  penile  fistula  is  present,  it  is  necessan,-  to  ascertain  if  the 
cahbre  of  the  urethra  is  in  any  way  narrowed  by  cicatricial  inflammation.  A 
fistula  may  open  in  the  perineum  as  the  result  of  inflammation  and  extravasation 
behind  a  fistula,  following  an  operation  upon  the  lower  urinarj'  organs,  or  in 
the  female  into  the  vagina  from  trauma  during  parturition  or  some  vaginal 
operation.  In  cases  in  which  a  fistula  opens  into  the  vaginal  fornix,  the  urine 
may  leak  from  the  bladder  or  from  the  lower  end  of  the  ureter,  and  an  accurate 
diagnosis  must  be  made  before  any  attempt  at  repair  is  performed.  The  opening 
of  the  fistula  is  usually  smaU  and  embedded  in  an  area  of  cicatricial  tissue,  so 
that  it  is  ver\-  difficult  to  pass  a  probe  along  the  tract.  In  these  cases,  evidence  of 
the  nature  of  the  fistula  may  be  obtained  by  filling  the  bladder  with  some  sterile 
coloured  solution,  such  as  weak  meth^-lene  blue  ;  if  the  opening  is  in  communi- 
cation -^^-ith  the  bladder,  coloured  solution  vnil  appear  in  the  vagina,  but  if  the 
urine  comes  from  the  ureter,  no  stain  "\^-ill  be  found.  Evidence  may  also  be 
obtained  by  means  of  the  cj'stoscope,  when  a  cicatricial  area  may  be  found  in 
the  bladder  surrounding  a  retracted  fistulous  opening,  or  the  ureteric  orifice 
of  the  one  side  maj^  be  found  displaced  from  its  normal  situation  by  the  scar 
contraction  when  the  ureter  is  at  fault.  In  these  cases  it  maj-  be  impossible  to 
pass  a  bougie  into  the  ureter  more  than  a  ver\^  short  distance,  the  tip  being 
arrested  by  the  scar  tissue. 

A  urinary-  fistula  may  be  present  in  the  suprapubic  area  in  connection  with 
the  bladder,  or  in  the  lumbar  area  communicating  with  the  kidney,  as  the  result 
of  operation  measures  on  these  two  organs.  A  fistula  has  been  seen  in  the  ihac 
fossa  as  the  result  of  an  operation  on  the  ureter,  and  after  the  opening  of  an 
abscess  formed  around  the  ureter  from  the  ulceration  caused  by  a  ureteric 
calculus. 

Disorders  of  Micturition  from  Diseases  of  the  Nervous  System. — In  most  of 
the  foregoing  paragraphs  it  will  be  noticed  that  symptoms  referable  to  the  urinary 
organs  have  been  stated  to  be  due  in  some  cases  to  disease  of  the  nervous  system, 
such  as  myehtis,  tabes  dorsahs,  or  hemiplegia  ;  in  spite  of  repetition  it  is 
advisable  to  gather  these  under  one  heading.  The  control  of  the  act  of  mic- 
turition depends  upon  the  integrity  of  the  nervous  system  ;  for  although  special 
centres  exist  in  the  lower  segments  of  the  spinal  area  presiding  over  the  motor 
functions  of  the  bladder,  the  impulse  calhng  for  action  of  these  centres  is  supplied 
by  the  brain  after  a  stimulus  has  been  convej-ed  to  the  latter  by  the  sensory 


MUCUS     IN     THE     STOOLS  443 

nerve  fibres  from  the  bladder.  There  are  two  centres  in  the  lower  spinal  segment, 
by  one  of  which  the  detrusor  muscle  of  the  bladder  is  brought  into  action,  and 
by  the  other  the  sphincter  muscle  surrounding  the  vesical  outlet  is  maintained 
in  tonic  contraction  until  inhibited  by  the  same  stimulus  which  produces  con- 
traction of  the  detrusor.  The  two  vesical  muscles  are  thus  antagonistic  in 
their  action,  the  detrusor  contracting  and  the  sphincter  relaxing  in  answer  to 
the  stimulus  to  micturition.  In  the  diagnosis  of  all  neuroses  of  the  bladder, 
it  is  most  important  to  exclude  all  lesions  of  the  urinary  apparatus,  and  not  to 
overlook  the  fact  that  vesical  symptoms  are  often  produced  by  some  lesion  in 
the  kidney,  when  the  bladder  on  careful  examination  appears  quite  normal. 

(a).  Irritability  of  the  Sensory  Nerves  of  the  Bladder. — Some  patients  experience 
an  urgent  and  frequent  desire  to  pass  urine,  often  every  half-hour,  though 
no  objective  symptoms  of  disease  can  be  found,  and  all  inflammatory  lesions 
can  be  excluded  ;  there  is  no  pain  and  no  increased  frequency  of  micturition 
during  the  night.  The  cases  have  received  the  name  of  cystalgia,  hypercssthesia 
vesiccB,  and  irritable  bladder,  and  they  must  be  carefully  distinguished  from 
those  in  which  there  is  some  lesion  of  the  urinary  organs,  the  rectum,  and  of 
the  female  pelvic  organs. 

[b).  Irritability  of  the  Motor  Nerves  of  the  Bladder. — In  this  conditon  there  is 
a  spasmodic  contraction  of  the  sphincter  muscle  of  the  bladder,  with  resulting 
retention  of  urine  or  great  difficulty  in  micturition.  There  is  no  stricture  or 
urethral  obstruction  present,  as  is  shown  by  the  ease  with  which  a  catheter 
is  passed,  nor  is  there  any  prostatic  enlargement.  The  neurosis  is  not  confined 
to  the  male  sex,  and  is  seen  in  hysteria  as  well  as  in  those  nervous  affections 
which  affect  the  spinal  centres,  such  as  myelitis,  lateral  sclerosis,  and  tabes 
dorsahs. 

(c).  Paralysis  of  the  Motor  Nerves  of  the  Bladder  may  affect  the  peripheral 
nerves  or  spinal  elements,  but  the  results  as  regards  the  bladder  are  the  same. 
If  the  nerves  supplying  the  detrusor  muscle  or  its  spinal  centre  be  paralyzed, 
retention  of  urine  occurs,  and  the  patient  can  only  expel  urine  by  the  force 
of  the  abdominal  wall.  If  the  sphincter  muscle  is  affected,  it  becomes  relaxed, 
and  urine  dribbles  away.  In  many  cases  only  part  of  the  motor  tract  is 
affected,  so  that  the  power  of  the  bladder  is  not  abolished  but  diminished, 
and  a  portion  of  the  urine  is  retained  in  the  bladder  after  micturition.  The 
bladder  may  be  thus  affected  in  compression  of  the  spinal  cord  by  fracture,  or 
haemorrhage  into  the  membranes,  in  myelitis,  Paraplegia  (q.v.),  and  locomotor 
ataxia. 

(d).  Destruction  of  the  Spinal  Centres  for  Micturition,  by  injury,  softening, 
or  compression,  gives  rise  to  incontinence  without  distention  of  the  bladder. 
The  urine  dribbles  from  the  urethra  as  fast  as  it  enters  the  bladder. 

R.  H.  Jocclyn   Swan. 

MUCUS  IN  THE  STOOLS.— This  occurs  in  such  a  variety  of  conditions  that 
it  is  impossible  to  give  a  complete  differential  diagnosis  of  them  here.  Its 
presence  always  indicates  organic  disease,  usually  of  the  large  bowel,  for  if 
it  comes  from  the  small  bowel  it  wUl,  unless  the  motions  are  very  fluid,  be  so 
incorporated  with  them  that  it  cannot  be  seen.  It  occurs  in  malignant  disease 
of  the  colon  as  a  clear  glairy  raucus,  often  bloodstained,  and  it  has  the  same 
characters  in  intussusception,  for  the  obstruction  in  both  these  cases  accounts 
for  the  absence  of  faecal  colouring.  It  is  often  seen  in  constipated  motions,  the 
hard  motion  having  led  to  irritation  of  the  large  bowel,  with  consequent  excessive 
secretion  of  mucus  ;  if  this  has  lain  some  time  in  the  bowel  it  has  become 
coagulated  into  white  shreds,  which  can  be  seen  attached  to  the  motion  and 
look  like  parasitic  worms.  In  severe  cases  a  motion  may  consist  almost  entirely 
of  these  shreds  ;   there  may  be  little  fascal  matter  ;  if  it  has  not  lain  so  long  in 


444  MUCUS     IN     THE     STOOLS 

the  bowel,  it  appears  like  a  jelly  outside  the  motion.  Sometimes,  especially  in 
adult  women  who  are  constipated,  complete  casts  of  the  bowel  formed  of  coagu- 
lated mucus  are  passed ;  they  may  be  a  foot  or  raore  in  length  {Fig.  123).  Often, 
however,  by  the  time  they  are  passed,  they  have  become  broken  into  fragments 
which  the  patient  describes  as  skins,  and  which  look  not  unlike  segments  of 
tape-worm.  Patients  passing  this  variety  of  mucus  are  said  to  have  mem- 
branous colitis.     In  the  more  acute  varieties  of  inflammation  of  the  bowel,  the 


■Fi[?.  123. — Tubular  mucous  cast  of  large  intestine,  from  a  case  of  muco-membranous  colitis. 
The  cast   measured  255  inches  in  length. 

mucus  passed  is  jellj^-like  and  semi-fluid,  of  varying  colour  according  to  the 
amount  of  faecal  staining.  In  severe  cases  of  enteritis  the  motions  consist  of 
nothing  but  mucus  and  blood.  It  is  impossible  to  attempt  to  differentiate  here 
between  all  the  numerous  varieties  of  enteritis.  w.  Hale  White  • 

MUCUS  IN  THE  URINE  is  generally  of  little  chnical  significance.  Many 
normal  urines,  particularly  those  of  women,  develop  a  faint  or  even  a  more 
definite  deposit  of  mucus,  which  may  remain  in  suspension  or  may  accumulate 
as  a  light  fioccular  deposit  at  the  bottom  of  the  specimen-glass.  Such  mucus 
is  a  normal  product  of  the  epithelial  cells  of  the  urinary  passages.  It  is  not 
possible  by  merely  looking  to  say  whether  it  is  in  excess  or  not.  It  may 
indicate  catarrh  of  the  mucous  membranes  ;  but  such  catarrh  will  be  shown 
more  decisively  by  the  occurrence  of  epithelial  cells  or  actual  pus  corpuscles, 
or  bj'  a  cause  for  catarrh  such  as  Oxaluria  [q.v.)  ;  diagnosis  depending  not  upon 
the  mucus  but  upon  the  other  substances  present  with  it.  It  is  important  not 
to  mistake  elongated  strands  of  mucus  for  tube-casts  ;  the  error  is  particularly 
apt  to  occur  if  the  cover-glass,  on  being  pressed  down  on  a  specimen  stained 
with  methjdene  blue,  shps  slightly  and  draws  out  the  mucus  into  long  narrow 
strands.  When  large  numbers  of  these  are  seen  all  parallel  with  one  another, 
they  are  not  likely  to  be  mistaken  for  casts.  Mucus  stains  readily  either  with 
methylene  blue  or  with  eosin,  but  exhibits  no  structure  beyond  granular 
particles,  or  cells  that  may  have  become  entangled  in  its  meshes. 

If  a  male  patient  has  formerly  suffered  from  gonorrhoea,  a  residual  catarrh  of 
the  glands  in  the  prostate  often  persists  long  after  the  cure  may  have  seemed 
to  be  complete.  Urine  from  such  a  case,  looked  at  in  a  tall  glass  vessel,  often 
exhibits  numerous  filaments  or  "prostatic  threads,"  consisting  for  the  most 
part  of  mucus  coming  in  the  form  of  casts  from  the  prostatic  tubules. 

Herbert  French. 

MYDRIASIS. — (See  Pupil,  Abnormalities  of  the  ) 

MYOSIS — (See  Pupil,  Abnormalities  of  the.) 

NAILS,  AFFECTIONS  OF  THE. — Various  pigmentary  and  degenerative  changes 
may  occur  in  the  nails  as  the  result  of  occupation,  as  in  dj^ers,  washerwomen, 
jewellers,  and  others  ;    or  the  condition  known  as  pterygium  may  arise,  the  fold 


NAILS,     AFFECTIONS     OF     THE  445 

of  skin  at  the  proximal  end  of  the  nail  adhering  and  growing  over  the  nail,  like 
a  "  wing."  These  appendages  are  liable  to  attack  also  in  such  cutaneous  affec- 
tions as  ringworm,  favus,  eczema,  psoriasis,  and  epidermolysis  bullosa.  The 
differences  between  the  onychomycosis  due  to  ringworm  and  that  due  to  favus 
are  described  in  the  article  on  Fungous  Affections  of  the  Skin.  In  eczema, 
usually  the  first  sign  of  involvement  of  the  nails  is  pitting,  which  gives  them  an 
appearance  somewhat  resembling  orange-rind.  They  become  discoloured  and 
thinned,  transverse  and  longitudinal  splitting  follows,  and  finally  exfoliation 
may  occur.  In  long-standing  cases  they  may  be  thickened  to  the  extent  of 
deformity.  In  psoriasis,  if  the  matrix  of  the  nails  is  attacked,  they  become 
furrowed  transversely,  and  dull  in  colour  ;  later  the  nails  split  and  may  be  shed, 
but  not  permanently.  In  other  cases,  instead  of  the  matrix  being  affected,  the 
nails  are  discolored  about  the  free  border,  and  they  become  thickened  as  the 
discoloration  extends  downwards  to  the  root.  In  epidermolysis  bullosa  there 
may  be  repeated  bleb-formation  at  the  finger-ends,  causing  atrophy  of  the  skin 
and  loss  of  nails.  The  signs  of  nail  involvement  in  these  three  conditions  are 
sufficiently  distinctive  to  obviate  confusion  between  them  ;  and  the  lesions  else- 
where will  aid  the  diagnosis. 

Trophic  changes  in  the  nails  may  also  be  consequent  on  acute  illness  or  senile 
decay,  or  they  may  occur  without  any  apparent  cause  :  the  longitudinal  striae 
may  be  exaggerated,  transverse  furrows  may  appear,  or  white  spots  may  develop, 
and  a  large  part  or  the  whole  of  the  nail  may  become  white  (leuconychia). 
With  this  condition  spoon-nails  may  be  associated  ;  the  nail  becomes  thin  and 
hollowed,  either  from  side  to  side  or  antero-posteriorly.  Shedding  of  the  nails 
may  occur  not  only  in  distinctively  cutaneous  affections,  but  also  in  diabetes 
mellitus  and  syphilis,  in  locomotor  ataxy  and  other  nervous  disorders.  Either 
without  definite  etiology,  or  in  connection  with  inflammation  of  the  finger-tips, 
the  nail  may  be  separated  from  its  bed  without  being  actually  shed.  Onychia, 
or  inflammation  of  the  nail,  is  in  some  instances  due  to  syphilitic  or  tuberculous 
infection  ;  in  the  latter  case  associated  scrofulous  lesions  will  often  be  found  in 
the  eyelid  and  elsewhere.  Onychia,  however,  may  also  be  due  to  trauma,  or 
may  be  idiopathic.  Whatever  the  cause,  the  condition  cannot  be  mistaken.  If 
the  process  is  acute  there  is  great  pain,  with  redness  ;  suppuration  takes  place 
beneath  the  nail,  which  becomes  thickened  and  discoloured,  and  is  ultimately 
shed,  leaving  an  unhealthy  sore.  If  this  should  fail  to  heal,  the  lymphatics  may 
be  involved,  and  the  case  becomes  one  of  paronychia,  or  whitlow.  This  condition 
is  sometimes  caused  by  the  pressure  of  tightly-fitting  boots,  or  by  irritation  set 
up  by  the  edge  of  a  badly-cut  nail — usually  that  of  the  big  toe.  Onychorrhexis, 
brittleness  of  nails,  may  be  either  congenital  or  acquired.  It  is  sometimes  present 
in  cheiropompholyx,  and  in  other  cases  is  associated  with  nervous  affections  and 
anomalies  of  development.  In  onychauxis,  hypertrophy  of  the  nail,  there  may 
be  overgrowth  in  one  or  in  all  directions,  accompanied  by  distortion  or  discolora- 
tion, and  sometimes  by  inflammation.  In  some  cases  the  free  end  may  grow  to 
a  great  length,  and  may  become  twisted  like  a  ram's  horn  (onychogryphosis). 
This  curious  distortion  is  often  found  in  connection  with  congenital  ichthyosis. 
A  rarer  condition  of  modified  nutrition  is  that  known  as  egg-shell  nail,  which  is 
intimately  associated  with  hyperidrosis  ;  it  has  been  met  with  in  debilitated 
young  women  ;  the  nail  tends  to  grow  upwards  rather  than  forwards  ;  its 
connection  with  the  distal  portion  of  the  bed  is  enfeebled  ;  and  in  typical  cases 
the  colour  is  precisely  that  of  the  inner  face  of  the  shell  of  a  hen's  egg — a  delicate 
combination  of  white  and  purple.  It  has  been  suggested  that,  owing  to  the 
maceration  of  the  distal  portion  of  the  nail-bed  due  to  hyperidrosis,  there  is 
interference  with  the  normal  cornification  of  the  nail-plate.  Whatever  the 
process,  the  diagnosis  is  clear.  Malcolm  Morris. 


446  NAPKIN-REGION     ERUPTIONS 

NAPKIN-REGION  ERUPTIONS.— Infantile  eruptions  in  this  region,  when 
they  are  a  manifestation  of  congenital  syphilis,  are  usually  erytheraatous  or 
papular,  but  they  may  also  be  pustular,  bullous,  squamous,  or  polymorphic  ; 
in  all  cases  alike  they  are  symmetrically  distributed  on  the  buttocks.  Frequently, 
around  the  anus  and  the  genital  organs  the  papules  are  moist  and  coalescent, 
and  form  flatfish  condylomata.  Similar  lesions  are  also  found  on  the  soles, 
palms,  forehead,  and  around  the  mouth,  and  in  these  regions  also  the  distribution 
is  symmetrical.  The  eruption  is  as  a  rule  transitory.  The  other  symptoms  of 
hereditary  syphilis  are  so  characteristic  that  the  lesions  here  described  are  seldom 
liable  to  misinterpretation.  The  skin  eruption  is  usually  preceded  by  a  chronic 
coryza  ("  snuffles  ")  and  laryngitis.  Often  the  nails  are  severely  affected  coin- 
cidently  with  the  skin.  The  colour  of  the  lesions,  approximating  to  the  char- 
acteristic raw-ham  tint,  the  loose,  dry,  cafe-au-lait  skin,  the  senile  aspect  of  the 
face,  the  accompanying  cachexia,  form,  with  the  symptoms  mentioned  above, 
a  distinctive  clinical  picture. 

A  napkin-area  eruption  which  was  often  mistaken  for  congenital  syphihs 
until  Jacquet  showed  that  it  had  no  specific  character,  is  that  which  is  styled 
by  Adamson  the  infantile  erythema  of  Jacquet.  It  is  a  process  which  manifests 
itself  in  :  (i)  Simple  erythematous,  (2)  Erythemato-vesicular,  (3)  Papular, 
(4)  Ulcerating  forms.     These  may  develop  consecutively  or  coincidently. 

The  most  common  forms  are  the  erythematous  and  the  papular.  All  alike 
are  probably  due  in  part  to  the  irritation  set  up  by  moist  or  soiled  napkins, 
but  vasomotor  irregularities  and  gastro-intestinal  toxaemia  may  also  be  con- 
cerned in  the  etiology.  The  preference  sites  of  all  four  forms  of  the  eruption 
are  the  convex  surfaces  of  the  buttocks,  of  the  thighs,  and  of  the  scrotum  or 
vulva. 

In  the  simple  erythemas,  of  which  the  usual  subjects  are  quite  young  infants, 
the  rash  may  be  limited  in  mild  cases  to  the  genitalia,  the  inner  sides  of  the 
thighs,  and  the  perineum,  while  in  severer  cases  it  may  extend  to  the  lumbar 
region,  the  lower  abdomen,  and  the  calves  and  heels. 

In  the  erythemato-vesicular  form  there  appear  on  the  convex  surfaces  towards 
the  centre  of  the  erythematous  areas  small  bright-red  erosions  which,  form- 
ing groups  of  from  two  or  three  to  a  dozen  or  more,  may  become  confluent. 
The  earlier  form  of  the  erosion  is  a  vesicle,  and  this  typical  lesion  may  usually 
be  found  near  the  borders  of  the  reddened  area. 

The  third  or  erythemato-papular  form  of  the  eruption  is  met  with  when  the 
erosions  just  described  have  thrown  up  flattened  granulations,  which  give  to  the 
lesions  the  appearance  of  flat,  reddish  papules.  In  this  stage  the  heels  and  the 
lower  abdomen  may  be  involved  in  the  erythema. 

In  the  fourth  form  of  the  eruption,  the  erosions,  failing  to  granulate,  develop 
into  ulcers,  with  sharply  defined  borders  or  coalescing  into  vermicular  lesions. 
They  are  confined  to  the  convex  surfaces,  the  folds  always  escaping. 

Attention  to  the  appearance  and  distribution  of  the  lesions,  and  the  course 
they  run,  together  with  the  absence  of  the  more  familiar  signs  and  symptoms 
of  congenital  syphilis,  will  prevent  confusion  with  that  disease,  or  with  the 
condition  which  Colcott  Fox  has  styled  vacciniform  ecthyma  of  infants. 

Pemphigus  neonatorum  consists  of  an  eruption  of  bullae  on  the  thighs  and 
buttocks  in  new-born  infants.  It  is  not,  however,  confined  to  this  region,  but 
attacks  other  parts,  including  the  face,  and  this  is  true  also  of  the  bullous 
impetigo  of  older  babies,  which  Adamson  believes  to  be,  like  pemphigus  neonat- 
orum, a  form  of  the  impetigo  contagiosa  of  Tilbury  Fox.  The  diagnosis  of  these 
affections  has  been  given  under  Bull.'e. 

The  "  seborrhoeic  eczema  of  infants  "  has  been  styled  "  seborrhoeic  dermatitis 
of  infancy  "  by  Adamson,  who  was  the  first  to  lay  stress  upon  its  special  incidence 


NIGHTMARES  447 


upon  the  napkin  region,  and  who  does  not  regard  it  as  a  form  of  eczema.  The 
whole  napkin  region  is  occupied  by  a  uniform  bright-red  rash,  for  the  most  part 
covered  with  moist  or  greasy  yellowish  scales,  though  in  prominent  parts  the 
surface  may  be  smooth  and  polished.  The  margins  of  the  area  are  sharply 
defined.  The  rash  often  extends  downwards  to  the  thighs  and  calves,  and 
upwards  to  the  umbilicus,  while  beyond  this  area  there  are  smaller  patches  and 
many  pin-head,  red,  scaly  papules.  Other  parts  that  are  frequently  attacked  are 
the  bends  of  the  knees,  the  flexures  of  the  elbows,  the  axillae,  the  side  of  the 
neck,  the  naso-labial  fissure,  and  behind  the  ear.  On  the  scalp  will  always  be 
found  a  red,  squamous  or  crusty  eruption.  The  diagnosis  rests  upon  the 
distribution  and  the  sharply  defined  margins,  with  the  patches  and  crusted 
papules.  It  is  assisted  by  the  readiness  with  which  the  eruption  yields  to  mild 
local  parasiticidal  applications.  In  cases  of  congenital  syphilis  which  mimic 
this  condition,  the  presence  of  the  concomitant  specific  signs,  as  enumerated 
above,  will  prevent  confusion  between  that  disease  and  "  seborrhoeic  eczema." 

In  adults  the  same  region,  known  as  the  bathing-drawers  area,  is  liable  to 
attack  in  a  number  of  affections.  In  eczema  marginatum  (tinea  marginata,  as  I 
prefer  to  term  it),  dhobie's  itch,  and  erythrasma  the  eruption  occurs  exclusively,  or 
almost  exclusively,  in  this  region  ;  of  these  affections  the  differential  diagnosis 
has  been  given  under  Ringworm  (p.  272).  In  pediculosis  pubis  the  pubes  may 
alone  be  affected,  or  the  parasite  may  wander  to  the  abdomen,  the  thorax,  the 
axillae,  and  may  even  reach  the  beard,  whiskers,  and  eyelashes.  The  diagnosis  of 
this  condition  can  present  no  difficulty.  In  scabies  the  lesions  may  be  very  slight 
on  the  hands  and  wrists,  and  the  brunt  of  the  attack  may  be  borne  by  the  penis 
and  scrotum,  the  lower  part  of  the  abdomen,  and  the  thighs.  (For  the  diagnosis 
see  Vesicles.)  In  psoriasis  the  eruption  is  sometimes  very  severe  in  the 
bathing-drawers  area,  of  which  the  surface  is  an  almost  uniform  deep  red,  and 
is  the  seat  of  profuse  desquamation,  while  on  the  special  sites  of  election — the 
arms  and  legs — the  lesions  may  be  quite  insignificant.  (For  the  diagnosis,  see 
Scales.)  In  eczema  intertrigo  and  eyythema  intertrigo  the  folds  in  the  area  under 
consideration  are  only  liable  to  attack  in  common  with  folds  in  other  parts. 
The  diagnosis  of  these  affections  has  been  given  elsewhere  ;  but  it  may  here  be 
mentioned  that  in  diabetes,  eczema  may  begin  on  the  penis  or  the  vulva,  and  may 
spread  thence  to  other  regions.  Other  conditions  which  may  specially  affect 
this  area  are :  acute  traumatic  erysipelas,  pruritus  ani  (see  Pruritus),  small-pox 
in  the  prodromal  stages,  and  the  various  forms  of  syphilis.  In  syphilis  the 
commonest  site  for  the  moist  papule  is  around  the  anus  and  genitalia  (see 
Papules)  .  Malcolm  Morns . 

NEURITIS,  OPTIC — -(See  Ophthalmoscopic  Appearances,  Notes  on.) 

NIGHTMARES  may  occur  at  any  age,  but  they  are  particularly  common 
in  children  between  four  and  eight,  when  they  may  be  so  bad  and  persistent 
as  to  merit  the  term  night-terrors.  The  commonest  cause  for  a  nightmare  in 
an  adult  is  some  indiscretion  in  diet,  the  last  meal  having  been  taken  too  late 
in  the  evening,  or  else  having  contained  some  injudicious  article.  The  symptom 
is  not  otherwise  of  diagnostic  import,  though  some  individuals,  particularly  those 
of  nervous  inheritance,  are  more  liable  to  nightmare  than  others,  and  the 
tendency  is  certainly  increased  by  such  excitement  as  the  reading  of  thrilling 
novels  or  participating  in  unusual  events.  Children  are  particularly  prone  to 
night-terrors  during  term-time,  when  they  are  working  at  high  pressure  ;  during 
the  holidays  the  symptom  often  disappears.  Those  who  are  keenest  upon  their 
school  work  are  apt  to  suffer  most,  and  similar  evidence  of  excitability  of  the 
nervous  system  is  exhibited  particularly  by  those  who  have  a  tendency  to  acute 


448  NIGHTMARES 


rheumatism  in  the  form  of  chorea.  Night-terrors  may  occur  in  these  patients 
without  any  other  cause  than  over-pressure,  particularly  if  they  he  upon  the  back 
rather  than  upon  one  side  during  sleep  ;  but  the  tendency  is  much  increased  by 
errors  of  diet,  such  as  the  eating  of  unripe  fruit  and  so  forth,  by  the  presence 
of  intestinal  worms,  and  by  the  existence  of  adenoids,  with  or  without  enlarged 
tonsils,  so  that  when  night-terrors  are  a  prominent  symptom  in  the  case, 
particular  examination  for  any  of  these  exciting  causes  should  be  made. 

Herbert  French. 

NODULES. — In  ordinary  dermatological  usage,  the  term  nodule  or  node  is 
applied  to  solid  elevations  larger  than  a  papule  and  smaller  than  a  tumour. 
This  definition,  however,  makes  no  pretence  to  scientific  exactitude,  for  while 
some  new  growths  of  quite  small  size  are  classified  as  tumours,  certain  lesions 
of  leprosy  and  tertiary  syphilis,  for  example,  although  smaller  than  a  pea,  are 
styled  nodules.  To  formulate  a  definite  canon  of  size  would  be  an  arbitrary  and 
unprofitable  proceeding  ;  and  from  this  article  no  lesion  commonly  accepted  as  a 
nodule  will  be  excluded  because  it  does  not  conform  to  a  rule-of- thumb  definition. 
The  term  "  tubercle  "  is  sometimes  employed  as  a  synonym  for  "  nodule,"  but 
now  that  it  has  acquired  a  special  meaning  as  denoting  the  characteristic  lesion 
of  tuberculosis,  its  use  in  the  older  sense  should  be  discontinued. 

Nodules  differ  from  papules  not  only  in  size  but  also  in  their  greater  tendency 
to  downward  growth  ;  the  substantial  difference  between  a  nodule  and  one  of 
the  larger  papules  is  that  the  one  is  a  solid  lesion  extending  upwards,  while  the 
other  is  a  solid  lesion  projecting  both  upwards  and  downwards.  Nodules  maj^ 
be  neoplastic,  or  hypertrophic  and  inflammatory.  The  ordinary  colour  is  a  dull 
or  brownish  red,  but  they  may  be  pink,  or  a  dark  purple.  Generally  rounded, 
they  are  sometimes  flatfish,  conical,  or  of  irregular  shape.  They  vary  from 
each  other  in  the  course  they  run,  not  less  than  in  colour  and  form.  They  may 
be  absorbed,  as  papules  so  frequently  are ;  they  may  degenerate  and  ulcerate, 
and  be  followed  by  scars,  or  they  may  persist  indefinitely. 

Little  need  be  said  here  of  the  nodules  met  with  in  some  malignant  diseases, 
for  the  differential  diagnosis  of  carcinoma  and  of  sarcoma  will  be  found  under 
Tumours  of  the  Skin.  Fibroma,  myoma,  and  cysts  are  also  dealt  with  under 
this  heading,  and  glanders  in  the  article  on  Pustules. 

The  nodules  of  lupus  vulgaris,  arising  in  either  the  superficial  or  the  deep  part 
of  the  corium,  are  soft,  brownish-red,  and  translucent,  resembling  apple  jelly. 
At  first  buried  in  the  skin,  they  presently  appear  as  discrete  papules  the  size  of 
a  pin's  head,  arranged  in  groups  or  in  irregular  circles,  dull  red  at  the  outset  but 
afterwards  pale.  Gradually  the  papules  develop  into  nodules,  the  intervening 
skin  meanwhile  becoming  thickened  by  cellular  infiltration,  reddened  by  inflam- 
matory stasis,  and  raised  into  a  patch  which  is  covered  with  fine  branny  scales. 
Around  the  edge  of  the  patch  new  nodules  spring  up,  and  thus  a  large  area  of  skin 
may  be  invaded.  The  disease  usually  starts  from  a  single  focus,  but  others  may 
arise  and,  spreading  separately,  may  involve  large  areas  of  cutaneous  surface. 
The  patch  may  undergo  slow  involution  and  be  followed  by  scarring  ;  but  much 
more  often  ulceration  occurs,  the  sore  being  covered  with  a  greenish- black  crust, 
around  the  ragged  edges  of  which  will  be  seen  apple-jelly  nodules  in  various 
stages  of  development.  In  parts  like  the  nose  there  may  be  necrosis  of  cartilage, 
but  there  is  never  erosion  of  bone. 

The  apple-jelly  nodule  is  the  chief  diagnostic  feature  of  lupus  vulgaris.  In 
typical  cases  the  patch  described  above,  with  its  infiltrated,  raised  surface,  its 
well-defined  edge  studded  with  the  nodules,  and  its  covering  of  fine  scales,  can 
hardly  admit  of  misinterpretation.  Less  typical  cases  may  require  to  be  differ- 
entiated from  lupus  erythematosus,  rodent  ulcer,  epithelioma,  scrofuloderma  and 


NODULES  449 


syphilis.  Lupus  erythematosus  begins  as  minute  red  points,  not  as  dull-red 
papules,  and  the  lesions  never  develop  into  apple-jelly  nodules,  nor  do  they 
ever  ulcerate  or  extend  to  the  deeper  parts  and  erode  cartilage.  They  are 
symmetrical  in  distribution,  as  lupus  vulgaris  scarcely  ever  is,  and  the  affection 
seldom  appears  before  puberty,  as  lupus  vulgaris  almost  invariably  does.  It  is 
only  when  the  lesions  peculiar  to  lupus  vulgaris  are  masked  by  cedematous 
swelling  that  the  two  affections  can  be  confused  ;  but  if  the  skin  at  the  spreading 
edge  be  stretched,  small  amber-coloured  nodules  can  usually  be  seen. 

In  rodent  ulcer  there  is  usually  but  one  lesion,  which  runs  a  much  more  sluggish 
course  than  the  nodules  of  lupus  vulgaris  ;  the  ulcer  has  an  indurated  border 
and  a  firm  base,  and  penetrates  deeply  into  the  tissues  ;  and  the  disease  is 
essentially  one  of  later  life  (see  Ulceration  of  the  Face).  Epithelioma,  again, 
is  a  disease  of  later  life.  The  hard,  everted  edge  of  the  growth,  the  foul  base, 
frequently  roughened  with  warty  formations  or  sprouting  with  caulifiower- 
like  excrescences,  the  implication  of  neighbouring  glands  (which  very  occasionally, 
however,  occurs  in  lupus),  and  the  secondary  deposits,  form  quite  a  different 
clinical  picture  from  that  of  lupus  vulgaris. 

In  one  form  of  scrofulodermia  nodules  develop  under  the  skin,  and  an  ulcer  is 
formed  which  is  bordered  by  dark  bluish,  thin,  undermined  skin  that  has  too 
little  vitality  to  allow  of  repair.  But  there  is  no  infiltration,  as  in  lupus  vulgaris, 
the  nodules  do  not  present  the  apple-jelly  aspect,  and  other  evidences  of  the 
disease  will  be  found  on  the  neck  or  elsewhere,  in  the  form  of  enlarged  glands  or 
scars.  As,  however,  the  two  conditions  frequently  co-exist,  and  the  treatment  is 
virtually  the  same,  diagnosis  between  the  two  is  of  little  practical  importance. 

In  the  diagnosis  from  "  lupoid  "  tertiary  syphilis,  again,  the  apple- jelly  nodule 
of  lupus  vulgaris  plays  the  chief  part.  The  syphilitic  process,  further,  is  much 
more  rapid,  nor  is  acquired  syphilis  generally  a  disease  of  early  life.  The  nodules 
and  ulcers  of  late  syphihs — neoplasms  that  grow  by  infiltration  of  the  surrounding 
parts  and  often  break  down  into  ulcers  which  are  prone  to  become  serpiginous, 
and  show  little  or  no  tendency  to  spontaneous  cure — have  in  turn  to  be  differ- 
entiated from  other  conditions.  They  may  be  mistaken  for  abscess,  but  if 
opened  they  give  issue  not  to  pus  but  to  a  gummy  hquid.  If  the  ulcer  into 
which  the  gumma  breaks  down  be  on  the  leg,  it  may  resemble  callous  ulcer,  but 
its  obduracy  to  ordinary  treatment  and  its  response  to  the  iodides  will  reveal  its 
true  nature.  From  syphilitic  ulcer  rodent  ulcer  differs  in  its  hard  edge,  and  red, 
shining,  dry  floor,  as  well  as  in  its  favourite  situations  ;  from  epithelioma, 
in  that  a  process  of  new  growth  has  preceded  the  ulceration  ;  from  scrofulodermia, 
in  the  undermined  border  of  the  ulcers  and  the  slow  rate  of  the  pathological 
process. 

In  yaws,  as  in  syphilis,  the  nodule  is  the  most  characteristic  lesion  of  the 
tertiary  stage.  It  arises  in  the  subcutaneous  tissue,  and  generally  leads  to  the 
formation  of  superficial  ulcers  which  spread  serpiginously,  like  the  ulcers  of 
tertiary  syphilis.  New  nodules  frequently  appear  in  the  neighbourhood  of  the 
older  ones,  and  masses  resembling  syphilitic  gummata  may  form  and  break 
down  into  ulcers.  These  late  ulcers  mostly  appear  on  the  lower  part  of  the  leg, 
especially  around  the  ankle,  but  they  are  not  uncommon  about  the  lips,  and 
indeed  may  occur  in  any  part  of  the  body.  The  clavicle,  sternum,  ulna,  tibia, 
and  the  metacarpal  and  metatarsal  bones,  are  often  the  sites  of  nodules  which 
may  occasion  permanent  thickening,  or  break  down  and  cause  ulcers. 

Between  yaws  and  syphilis  there  are  obvious  resemblances  in  the  tertiary  stage, 
but  there  are  marked  differences  in  the  primary  and  secondary  stages.  In  yaws 
the  inoculation  lesion  is  not  indurated,  there  is  seldom  distinct  glandular  enlarge- 
ment, the  mucous  membrane  lesions  of  syphilis  are  absent,  and  the  niost  char- 
acteristic lesion,  which  appears  in  the  secondary  period,  is  the  framboesial 
D  29 


450  NODULES 


granulomatous  excrescence  known  as  the  yaw  (see  Scabs).  In  yaws,  the  exan- 
them,  the  alopecia,  the  iritis,  the  affection  of  the  permanent  teeth,  the  bone  lesions, 
the  polymorphism,  the  nerve  lesions  and  the  gummata  of  syphilis  are  wanting. 
Yaws  is  never  hereditary  nor  congenital  ;  yaws  and  syphilis  confer  no  immunity 
as  against  each  other,  nor  does  one  ever  give  rise  to  the  other  ;  and  as 
Manson  remarks,  yaws  may  die  out  in  a  community  while  syphilis  remains,  or 
it  may  be  universal  in  a  community  where  syphilis  is  unknown.  The  minute 
histology  of  the  lesions  of  the  two  diseases  also  furnishes  important  differences. 
From  tuberculosis  yaws  differs  (apart  from  the  tubercle  bacillus)  in  the  absence 
of  the  characteristic  tuberculous  architecture  with  its  giant-cells  and  daughter 
plasma-cells,  more  marked  disintegration  of  the  fibrous  stroma  and  complete 
disappearance  of  the  blood-vessels. 

In  leprosy  the  nodule  {Fig.  124)  marks  one  of  the  three  types  of  that  affection,  the 
others  being  nerve  or  anaesthetic  leprosy,  and  mixed  or  complete  leprosy.  In 
nodular  (or  tubercular)  leprosy  the  macules  which  are  always  the  primary  lesion 
are  transformed  into  nodules  by  sudden  increase  of  inflammatorj^  infiltration. 
When  fully  developed  they  vary  in  size  from  a  small  shot  to  a  filbert,  or  larger, 
are  round  or  oval,  but  raised  considerably  above  the  level  of  the  skin.  They  may 
mimic  lupous  nodules,  syphilitic  papules,  rosacea,  erythema  nodosum,  or  sycosis. 
Sometimes  telangiectases  may  be  observed  on  their  surface.  They  are  elastic 
to  the  touch,  are  at  first  sometimes  hyperjesthetic,  but  later  very  •  frequently 
become  temporarily  or  permanently  anaesthetic.  Nodules  on  the  mucous 
membranes  are  red  or  grey,  and  may  resemble  syphilitic  lesions.  Both  on  skin 
and  on  mucous  membrane  they  tend  to  break  down,  but  in  exceptional  cases 
they  either  undergo  cicatricial  shrinking  or  reach  the  ulceration  stage  by  way  of 
suppuration.  The  differential  diagnosis  of  leprosy  in  the  macular  stage  is  given 
under  Macules.  In  the  later  stages  the  identification  of  the  disease  seldom 
presents  difficulty.  The  nodules  of  leprosy  may  resemble  those  of  lupus  vulgaris 
and  the  tubercular  syphilide,  but  the  lupous  and  syphilitic  eruptions  are  both  of 
limited  extent,  and  there  is  no  anaesthesia.  The  syphilide  also  is  serpiginous, 
or  occurs  in  crescentic  groups.  In  the  early  stage  of  nodular  leprosy  the  lesions 
may  strongly  resemble  those  of  erythema  nodosum,  and,,  as  in  that  affection, 
there  may  be  pains  about  the  joints.  But  if  the  case  be  one  of  erythema  nodosum 
the  nodules  will  disappear  within  a  fortnight,  though  successive  crops  may 
arise  for  three  or  four  weeks  longer. 

To  differentiate  erythema  nodosum  from  other  conditions  than  nodular  leprosy 
its  clinical  features  must  be  briefly  described.  Preceded  and  accompanied  by 
pains  about  the  joints,  by  pyrexia  and  other  symptoms  of  constitutional  dis- 
turbance, oval  nodules,  ranging  in  size  from  a  walnut  to  a  hen's  egg,  appear  on 
the  legs  and  feet  and,  less  frequently,  elsewhere.  In  colour  they  are  at  first  bright 
red,  but  soon  become  bluish  in  the  centre  and  purple  at  the  periphery,  exhibiting 
as  they  subside  the  changes  of  tint  presented  by  a  bruise.  Erythema  nodosum 
is  an  affection  of  adolesence,  and  girls  are  attacked  by  it  twice  as  often  as  boys. 
There  is  never  ulceration,  and  this,  with  the  pains  and  swellings  about  the  joints, 
distinguishes  it  from  syphilitic  nodules.  The  same  features  distinguish  it  also 
from  an  erythema  of  the  legs,  the  result  apparently  of  excessive  standing,  to  which 
young  girls  are  sometimes  subject,  and  from  the  node-like  swellings  which  some- 
times occur  in  the  legs  of  women  suffering  from  varicose  veins. 

The  absence  of  ulceration  and  the  presence  of  joint-pains  are  points  which 
differentiate  erythema  nodosum  from  erythema  induratum  scrofulosorum  (Bazin's 
disease).  Here  the  nodules,  which  occur  chiefly  on  the  legs,  are  at  first  sub- 
cutaneous, and  can  only  be  felt,  not  seen.  They  are  generally  discrete,  but 
may  become  fused  together  into  a  solid,  infiltrated  mass,  and  are  apt  to  break 
down  into  irregular  ulcers.     They  differ  from  the  nodules  of  erythema  nodosum 


NODULES 


451 


not  only  in  the  features  already  noted,  but  also  in  colour,  being  violet  instead 
of  bright  red,  and  undergoing  successive  changes  of  tint.  From  gummata  they 
differ  in  being  less  painful  and  inflammatory,  and  in  running  a  less  rapid  course, 
as  well  as  in  being  more  numerous,  and  in  attacking  both  legs.  The  only 
effect  of  antisyphilitic  treatment  is  to  aggravate  the  condition.  The  nodules 
of  erythema  keratodes  differ  from  those  both  of  erythema  nodosum  and  of 
erythema  induratum  scrofulosorum  in  that  they  appear  only  on  the  back  of  the 
finger-joints,  while  on  the  palms  and  soles  there  is  overgrowth  of  the  horny 
tissue,  accompanied  by  oedema  and  tenderness. 


Fig:  124. — A  tj'pical  case  of  nodular  leprosy  in  a  Norwegian. 

(From  a  j>hotograph  by  Dr.  Arinauer  Hansen.) 


The  condition  which  Boeck  designated  multiple  benign  sarcoid,  or  miliary 
benign  lupoid,  presents  some  resemblance  to  lupus  and  sarcoma.  The  nodules, 
at  first  rose-coloured,  afterwards  become  livid,  then  brownish.  In  size  they  vary 
from  a  millet  seed  to  a  large  bean.  The  favourite  sites  of  the  eruption,  which 
is  always  symmetrical,  are  the  face,  shoulders,  wrists,  and  the  extensor  surfaces 
of  the  upper  limbs ;  but  exceptionally  the  scalp,  the  back,  and  the  lower  limbs  are 
attacked.  Occasionally  the  lymphatic  glands  are  enlarged.  The  nodules 
never  break  down,  but  after  a  period,  it  may  be  of  several  years,   shrink  and 


452  NODULES 


disappear,  leaving  a  slight  atrophic  scar.  The  affection,  which  often  accom- 
panies visceral  tuberculosis,  is  distinguishable  both  from  sarcoma  and  from 
lupus  vulgaris  by  histological  examination,  as  well  as  by  the  course  it  runs. 
From  the  latter  affection  it  is  distinguished  also  by  the  negative  reaction  in 
inoculation  experiments. 

In  a  final  paragraph  I  ma}^  deal  with  nodules  which  belong  rather  to  general 
medicine  than  to  dermatology.  One  is  the  subcutaneous  nodule  of  acute  vheu- 
inatism.  It  generally  presents  over  the  sheaths  of  tendons  and  the  fascia  covering 
bony  prominences,  around  joints,  and  on  the  scalp.  The  nodules  may  be  as 
small  as  a  pin's  head  or  as  large  as  a  bean.  Within  Umits  they  can  be  made  to 
ghde  on  the  underlying  tendon-sheath  or  fascia.  They  are  sometimes  met  with 
in  adults  whose  hearts  have  not  been  damaged  by  the  toxsemia,  but  much  more 
frequently  in  children  with  distinct  valvular  lesions,  and  according  to  some 
authorities  they  are  analogous  to,  if  not  identical  with,  the  nodules  that  have 
been  found  post  mortem  on  the  borders  of  the  mitral  curtain.  The  coincidence 
of  nodules  such  as  these  with  rheumatic  fever  can  leave  no  doubt  as  to  their 
true  nature.  Heberden's  nodes,  the  little  knobs  on  the  finger-joints  which  are 
caused  bv  osteophytic  outgrowths  from  the  bases  of  the  distal  phalanges  in 
certain  elderly  persons  are  unmistakeable.  Multiple  subcutaneous  cysticerci  are 
a  rarit}^  the  diagnosis  of  which  may  be  suggested  by  the  eosinophilia,  but  can 
onh^  be  clinched  by  excision  and  microscopical  examination  of  one  of  the  nodules. 

Malcolm  Morris. 

NOISES  IN  THE  EARS.— (See  Tinnitus.) 

NUMBNESS  OF  THE  FINGERS.— (See  Sensation,  Abnormalities  of.) 

NYCTALOPIA — (See  Vision,  Defects  of.) 

NYSTAGMUS. — Several  varieties  of  associated  tremor  of  the  two  eyes  are 
comprised  in  nystagmus.  These  are  :  (i)  Searching  movements  ;  (2)  Pseudo- 
nystagmus  ;  and    (3)    Nystagmus  proper. 

1.  Wide  purposeful  and  slow  movements  of  the  ej^es  in  all  directions  are 
usually  seen  in  people  who  are  born  blind  or  have  lost  the  power  of  fixation  as 
the  result  of  some  obstruction  of  the  retina  or  choroid  at  the  yellow  spot.  The 
eyes  appear  to  be  seeking  for  something  but  never  rest  on  any  definite  object. 

2.  Pseudo-nj^stagmus,  which  is  commonly  confused  with  true  nystagmus, 
is  the  term  applied  to  rapid  jerking  movements  of  the  eyes  when  they  are  carried 
to  the  extremit}^  of  an  excursion  in  any  direction.  The  eyes,  instead  of  remaining 
fixed  on  the  object,  rapidly  recede  from  their  position  and  return  to  it  at  the 
rate  of  four  or  five  oscillations  a  second.  This  condition  is  a  characteristic 
symptom  in  Friedreich' s  or  hereditary  ataxy,  and  is  also  met  with  in  40  or  50 
per  cent  of  cases  of  disseminated  sclerosis  and  in  many  cases  of  cerebellar 
tumour.     For  the  differential  diagnosis  of  these  conditions  see  Paraplegia. 

3.  Nystagmus  proper  is  the  term  applied  to  the  condition  in  which  the  eyes 
make  rapid  regular  oscillations  about  a  fixed  point,  not  only  at  the  extremity  of 
an  excursion,  but  when  the  eyes  are  otherwise  at  r-est,  and  looking  directly 
forward.  The  oscillations  may  be  in  the  vertical  or  the  horizontal  meridian,  or 
may  in  some  cases  exhibit  a  rotatory  form.  The  condition  is  usuall}^  bilateral, 
though  it  is  occasionally  met  with  affecting  one  eye  only,  and  in  some  rare 
cases  the   character  of  the  nystagmus  may  differ  in  the  two  eves. 

True  nystagmus  is  caused  by  : — 

{a).  Conditions  causing  defective  vision  in  the  early  months  of  life.  As  a 
result  of  such  affections,  the  macular  region  is  not  differentiated  from  the  sur- 
rounding portions  of  the  retina  as  is  the  usual  course  in  the  early  months  of 
infant  life,   and  power  of  fixation  is  never  acquired.     Conditions  which  may 


OBESITY 


453 


thus  cause  nystagmus  are  ophthalmia  of  the  new-born,  congenital  cataract, 
colour  blindness,  albinism,  and  certain  cases  in  which  there  is  an  unusual  distri- 
bution of  the  retinal  pigment.  The  diagnosis  of  these  various  conditions  depends 
on  an  accurate  examination  of  the  eye. 

[b).  Conditions  developing  in  later  life  due  to  constant  strain  from  peculiar 
occupations,  as  for  example  miners'  nystagmus,  which  is  due  to  the  continued 
work  in  a  cramped  position  with  the  eyes  constantly  directed  upwards.  As  a 
rule  it  improves  on  the  cessation  of  the  occupation  which  causes  it. 

(c).  Aural  irritation,  in  which  it  is  usually  associated  with  vertigo. 

{d).  Nj^stagmus  may  also  occur  in  about  12  per  cent  of  all  cases  of  dissemin- 
ated sclerosis. 

{e).  In  certain  cases  of  cerebellar  tumours  it  is  a  marked  symptom,  and  it  may 
occur  : — 

(/).  In  various  rare  conditions,  after  traumatism  or  poisoning,  and  possibly 
s>Tingomyelia.  H.  L.  Eason. 


OBESITY  implies  an  excessive  accumulation  of  fatty  tissue  in  the  body.  It 
is  not  necessarily  pathological,  but  even  in  otherwise  healthy  persons  obesity 
ultimately  incommodes  them,  and  is  very  liable  to  lead  to  cardiac  symptoms 
due  to  fatty  changes  in  and  around  the  heart.  The  following  are  some  of  the 
chief  causes  : — 


Testicular  atrophy  or  excision 

Ovarian  insufficiency 

Hypothyroidism 

Hj^pernephroma 

Adiposis  dolorosa       )  or  Dercum's 

Diffuse  lipomatosis    )  disease. 

The  majority  of  the  above  need  little  discussion.     Families  in  which  all  the 
members  tend  to  run  to  fat  are  familiar  enough ;    the  individuals  maj'  weigh 


Heredity 

Continued  over-eating 

Continued  drinking  of  malt  liquors 

Too  little  exercise 

A  pre-glycosuric  state 

Chronic  parenchynaatous  nephritis 


J^!^.  125. — A  girl,  aged  6,  suffering  from  hypernephroma,  which  proved  fatal  from  secondarj- 
deposits  in  the  lungs  :  the  photograph  shows  the  premature  development  of  pubic  hair,  which 
in  this  case  appeared  at  the  age  of  eighteen  months. 


anything  from  i6  to  30  stone,  without  necessarily  being  ill.  Over-eating,  over- 
drinking, and  under-exercising  are  generally  obvious  if  the  patient's  mode 
of  living  is  known.  The  pre-glycosuric  state  is  particularly  important  from 
the  point  of  view  of  life  insurance :  when  a  young  man  or  woman  under  thirty- 
five  begins  to  run  to  fat  without  apparent  cause,  it  is  clear  that  there  is  an  error 
in  his  metabolism  ;    there  may  be   no  glycosuria   at  this  time,  but  in  quite  a 


454 


OBESITY 


number  of  these  cases  the  error  of  metaboUsm  develops  as  time  goes  on,  until 
presently  there  is  glycosuria,  and  finally  typical  diabetes  mellitus. 

Chronic  parenchymatous  nephritis  sometimes  gives  rise  to  a  large,  pale  person, 
who  looks,  and  is,  fat  and  flabby.  Part  of  the  apparent  fatness  may  be  due  to 
excess  of  fluid  in  the  tissues,  but  there  need  be  no  obvious  oedema  with  pitting 
on  pressure.  There  may  or  may  not  be  a  history  of  previous  acute  nephritis — 
some  of  these  cases  arise  insidiously  :  the  diagnosis  is  not  difficult,  however, 
where  renal  tube  casts  and  an  abundance  of  albumin  are  found  in  the  urine, 
particularly  if  there  is  a  big  heart,  a  prolonged  first  sound  at  the  impulse,  a 

ringing    aortic    second    sound,    a    high  blood- 
pressure,  and  perhaps  albuminuric  retinitis. 

Testicular  atrophy  or  excision  as  a  cause  for 
undue  fatness  is  best  exemplified  by  eunuchs  ; 
similar  fat  accumulation  sometimes  occurs  in 
less  degree  as  the  result  of  atrophy  after  bi- 
lateral gonococcal  orchitis  or  epididymitis  ;  it 
does  not  follow  tuberculous  destruction,  for  the 
patient  then  wastes  instead.  Palpation  of  the 
scrotum  may  indicate  the  diagnosis. 

Ovarian  insufficiency  is  probably  a  potent 
cause  in  certain  women  for  undue  stoutness, 
but  it  is  difficult  to  prove  this,  because  many 
of  the  patients  suffer  from  hypothyroidism  at 
the  same  time :  there  is  a  close  inter-relation- 
ship between  the  thyroid  gland  and  the  ovaries. 
Only  a  small  proportion  of  those  cases  in 
which  both  ovaries  have  been  excised  become 
obese  ;  but  when  the  normal  ovarian  activities 
are  beginning  to  abate,  especially  at  and 
immediately  after  the  menopause,  it  is  common 
for  women  to  become  very  stout.  They  develop 
at  the  same  time  peculiar  nervous  symptoms, 
and  it  is  remarkable  how  easily  both  the  latter 
and  the  obesity  may  be  relieved  by  relatively 
small  doses  of  thyroid  extract ;  such  cases  may 
be  termed  sufferers  from  hypothyroidism,  even 
though  they  may  not  have  the  typical  signs  of 
complete  myxoedema  —  increasing  stoutness, 
loss  of  strength,  broad  features,  increasing 
slowness  of  the  intellect,  broadening  and  thick- 
ening of  the  fingers  and  hands,  malar  flush, 
and  falling  out  of  hair  and  eyebrows.  The 
best  test  of  the  diagnosis  is  the  effect  of  ad- 
ministering carefully  graduated  doses  of  thyroid 
extract. 
There  are  certain  boys  and  girls — especially  boys — who  tend  to  become 
enormously  fat  long  before  they  reach  the  age  of  puberty.  The  papers  were 
full  of  a  typical  example  of  this  malady  a  while  ago — the  Fat  Boy  of  Peckham. 
There  is  reason  to  suppose  that  this  abnormal  development  of  fat  and  size  is 
a  disease  associated  with  an  affection  of  a  suprarenal  capsule  or  kidney — 
hypernephroma.  The  latter  does  not  always  cause  this  overgrowth,  however, 
for  in  another  type  of  patient  the  tumour  leads  merely  to  premature  develop- 
ment of  the  pubic  hair  and  external  genitalia.  Figs.  125  and  126  are  from  a  girl, 
aged  seven,  who  had  had  thick  pubic  hair  since  she  was  eighteen  months  old. 


Fig'.  126  — Thesame  case  as  Fig.  125, 
after  removal  of  the  pubic  hair  :  show- 
ing the  hypertrophy  of  the  external 
genitalia,  without  development  of  the 
breasts. 


(EDEMA,     ASYMMETRICAL  455 

The  clitoris  was  enlarged,  but  there  had  been  no  menstruation.  The  diagnosis 
was  confirmed  post  mortem,  the  congenital  suprarenal  tumour  having  produced 
secondary  deposits  in  the  lungs  after  seven  years. 

Adiposis  dolorosa,  diffuse  lipomatosis,  and  Dercum's  disease  all  seem  to 
be  closeh'  related.  There  are  two  types — the  alcohohc  and  the  congenital 
syphilitic  ;  the  former  is  the  commoner,  and  occurs  in  older  patients  than 
does  the  other.  Extreme  fatness  develops,  but  not  quite  universally  ;  the 
abdominal  wall,  especially  on  either  side  of  the  umbihcus,  the  neck,  shoulders, 
arms,  forearms,  thighs,  and  legs  may  become  enormous,  but  the  hands,  feet, 
scalp,  ears,  nose,  and  forehead  escape.  The  patient's  muscular  power,  as  tested 
by  the  dynamometer,  is  very  small,  sometimes  not  a  tenth  of  the  normal ;  and 
when  any  of  the  fat  parts  are  taken  hold  of  firmly,  without  any  pinching  or 
other  procedure  that  would  be  unpleasant  to  an  ordinary  patient,  some  of 
these  cases  experience  acute  pain  —  the  name  adiposis  dolorosa  describing 
the  tr\vo  main  symptoms  of  the  malady.  There  are  often  mental  symptoms 
at  the  same  time  ;  a  patient  of  thirty  may  periodically  imagine  she  is  only  eight, 
and  behave  and  speak  as  though  for  the  time  being  she  were  a  child  again  ;  and 
so  on  in  other  cases,  the  types  of  mental  symptoms  being  protean.  Superficially 
these  cases  may  simulate  myxoedema,  but  a  moment's  observation  will  show 
that  there  is  no  affection  of  the  hands  and  feet,  which  are  just  the  parts  to  be 
first  broadened  and  thickened  by  myxoedema,  besides  which  thyroid  treatment 
does  not  bring  about  material  improvement.  Herbert  French. 

OBSTIPATION.— (See  Constipation.) 

OBSTRUCTION,  INTESTINAL (See  Vomiting.) 

(EDEMA,   ASYMMETRICAL. — By  this  is  meant  oedema   of   one   leg   or   arm 
which  is  not  due  to  such  a  cause  as  renal  insufficiency  or  cardiac  failure,  but  to 
obstruction  to  the  venous  or  lymphatic  outflow  from  the  limb.     It  may  be  due 
to  any  of  the  following  causes  : — 
Congenital. 

Constriction  by  amniotic  bands 
Communications  between  arteries  and  veins. 
Acquired. 

Blockage  of  veins : 

1.  From  within — non-infective  thrombus,  varicose  veins 

infective  thrombus,  e.g.,  white  leg 

2.  By  pressure  from  without — by  glands,  tumours,  aneurj^sms,  etc. 
Blockage  of  lymphatics,  e.g.  in  cellulitis,  filaria,  etc. 

Artificial,  by  hgature 
Angioneurotic  oedema. 

Congenital  Causes. — These  are  so  easily  identified  that  no  further  mention 
of  them  need  be  made. 

Acquired  Causes. — The  diagnosis  may  be  obvious  :  For  instance,  there  may 
be  a  well-marked  cellulitis,  with  red  streaks  extending  up  the  limb  showing  the 
course  of  acutely  inflamed  lymphatics.  It  is  only  rarely  that  a  cellulitis  presents 
any  difficulty  in  recognition  ;  namely,  when  the  inflammation  is  not  very  acute, 
and  when  there  is  no  obvious  source  of  infection,  such  as  an  abraded  toe  or  a 
suppurating  wound  of  a  finger.  Cellulitis  may  then  be  confounded  with  gout ; 
but  the  history,  the  presence  of  leucocytosis,  and  the  absence  of  other  gouty 
manifestations  will  indicate  the  real  complaint.  There  may  be  considerable 
pyrexia  in  acute  gout,  so  that  the  temperature  chart  does  not  serve  to 
distinguish  it  from  cellulitis. 


456 


(EDEMA ,     A  S  YM  METRIC  A  L 


Varicose  veins  are  a  frequent  cause  of  asj^mmetrical  oedema,  especiallj^  in  the 
lower  limb,  and,  if  there  is  thrombosis  as  well,  very  marked  swelling  is  the  result. 
The  thrombus,  however,  does  not  always  lie  in  a  superficial  varicose  vein,  and 
if  it  is  in  one  of  the  deep  veins  such  as  the  popliteal,  femoral,  or  iliac,  the  case 
may  not  be  so  clear.  The  thrombus  in  these  cases  is  often  due  to  septic  infection, 
and  the  common  source  is  sepsis  in  connection  with  the  uterus  following  parturi- 
tion— white  leg — or  in  the  course  of  typhoid  fever. 

When  none  of  these  causes  is  present  it  is  necessary  to  examine  carefully, 
in  order  to  ascertain  whether  there  is  any  swelling  pressing  on  and  obstructing 
the  veins,  such  as  an  aneurysm  in  the  popliteal  space  or  a  mass  of  malig- 
nant  glands  ;    and  not   only   must  the  whole  limb  be  examined,  but  also  the 

rectum,  vagina,  and  lower  part  of 
the  abdomen,  and  the  neck  and 
upper  thorax  in  the  case  of  the 
leg  and  arm  respectively.  For 
instance,  there  may  be  a  tumour 
springing  from  some  structure  in 
the  pelvis  causing  pressure  on  the 
iliac  veins  ;  and  swelling  of  the 
arm  might  be  caused  by  an  aneur- 
ysm, subclavian  or  thoracic,  or  by 
a  mediastinal  new  growth. 

Lymphatic  Obstruction. — In  the 
case  of  oedema  due  to  venous 
obstruction  there  will  be  marked 
pitting  on  pressure,  but  where 
the  lymphatics  only  are  blocked 
the  oedema  is  much  more  solid  ; 
this  may  be  an  important  diagnos- 
tic point. 

As  has  been  mentioned,  cellu- 
litis is  a  fertile  cause  of  h'mphatic 
obstruction. 

Elephantiasis. — In  England  it 
is  not  conrmon  to  find  true  ele- 
phantiasis, that  is  to  saj'  blockage 
of  lymphatics  by  the  parasite 
filaria  sanguinis  hominis,  though 
a  pseudo  -  elephantiasis,  due  to 
long-standing  hmrphatic  obstruc- 
tion, with  resulting  roughening, 
thickening,  and  fibrotic  changes 
in  the  skin  and  underlying  tissues, 
is  not  uncommon,  and  maj-  result 
from  long  continuance  of  a 
tumour,  or  be  associated  with  a 
badly-united  fracture,  or  follow  some  operation  in  which  the  Ijmiphatics  have 
been  removed,  e.g.  after  amputation  of  the  breast  and  axillar}-  contents  for 
carcinoma.  Probably  the  most  difficult  group  of  all  cases  to  diagnose  is  that 
in  which  there  is  a  thrombus  of  one  of  the  deep  veins  of  the  leg  without  any 
obvious  disease,  and  in  this  event  the  diagnosis  can  only  be  arrived  at  by  a 
process  of  exclusion.  Milroy's  Disease  {Fig.  127)  is  diagnosed  from  the  family 
history  (see  p.  460). 

Ligature. — It  sometimes  happens  that  a  patient,  generallj'  a  female,  presents 


Pig.  127. — Milroy's  or  Meige'.s  disease  :  A  case  ol 
unilateral  hereditary  trophcedema  of  the  leg.  The 
condition  had  developed  spontaneously  in  a  girl  who 
had  never  been  out  of  England,  and  who  suffered  little 
inconvenience  from  the  affection.  She  was  21  when  the 
photograph  was  taken,  and  had  had  the  swelling  for 
years. 


(EDEMA,     SYMMETRICAL  457 


herself  with  an  oedema  of  a  hmb  for  which  no  explanation  can  be  offered.  It 
has  to  be  borne  in  mind  that  there  are  some  neurotic  individuals  who  will  tie  a 
ligature  round  their  limbs  in  order  to  simulate  disease  or  to  excite  sj^mpathy, 
and  who  have  even  gone  so  far  as  to  suffer  amputation.  It  is  often  extremely 
difficult  to  detect  the  fraud ;  but  if  the  possibility  be  suspected,  the  nurse  in 
charge  must  be  instructed  to  keep  watch,  and  at  unexpected  times  to  search  the 
patient,  when  a  handkerchief  or  a  piece  of  string  may  be  found  constricting  the 
limb.  The  fact  that  the  upper  limit  of  the  oedema  is  sharply  defined  should 
awaken  suspicion.  It  may  be  difficult  to  differentiate  this  from  angioneurotic 
cedema,  but  the  latter  condition  is,  as  a  rule,  transitory,  and  affects  different 
parts  of  the  body,  e.g.  the  tongue,  lips,  eyelid,  hands,  etc.,  at  different  times 
{Fig.  128,  p.  458)  ;  the  family  history,  and  the  fact  that  the  patient  has  had 
previous  attacks,  generally  point  to  the  diagnosis  at  once.  George  E.  Gask. 

(EDEMA,  SYMMETRICAL.  —  Owing  to  accidents  of  posture— such,  for 
instance,  as  the  patient  sitting  with  one  leg  to  the  ground  and  the  other  supported 
upon  a  chair,  or  lying  in  bed  turned  well  over  to  one  side,  and  remaining  in  this 
asymmetrical  position  for  a  long  time — it  is  possible  for  oedema  which  would 
really  be  symmetrical  to  appear  asymmetrical.  Allowing  for  this  source  of 
fallacy,  however,  the  causes  of  symmetrical  oedema  are  different  from  those  of 
asymmetrical  oedema  (see  above).  One  may  subdivide  cases  into  three  main 
groups,  namely  : — 

1.  Those  in  which  the  cedema  is  universal. 

2.  Those  cases  of  cedema  in  which  the  swelling  involves  the  face,  neck,  and 
arms,  but  not  the  legs  or  the  lower  half  of  the  trunk. 

3.  Those  in  which  the  oedema  affects  the  legs,  or  the  legs  and  lower  half  of  the 
trunk,  but  not  the  arms,  neck,  or  face. 

(Edema  of  the  legs  is  by  far  the  commonest  type,  and  by  far  the  most  important 
point  in  the  diagnosis  is  to  decide  as  soon  as  possible  whether  this  cedema  is  due 
to  Bright's  disease,  heart  failure,  or  to  some  other  cause. 

The  broad  distinction  into  these  groups  is  seldom  difficult.  The  urine  should 
be  tested  at  once  ;  if  albumin  be  present,  microscopic  examination  for  renal 
tube-casts  is  essential,  their  presence  indicating  renal  mischief,  their  absence 
probably  excluding  it,  unless  the  renal  lesion  is  very  acute,  in  which  case  there 
will  be  renal  epithelial  cells  even  if  there  are  no  tube-casts  ;  if  there  be  no  albu- 
min in  the  urine,  renal  inflammation  as  a  primary  cause  of  oedema  of  the  legs 
is  unlikely. 

It  will  be  easy  as  a  rule  to  decide  whether  there  is  failure  of  cardiac  compen- 
sation or  not  ;  if  there  is,  the  differentiation  between  the  four  main  groups  of 
causes  of  heart  failure,  namely,  primary  valvular,  primary  muscular,  primary 
lung  affections,  and  primary  arterial  or  renal  conditions,  will  be  made  upon 
the  lines  indicated  upon  p.  18. 

Other  causes  for  oedema  of  the  legs  will  be  suggested  by  other  symptoms  in 
the  case  or  by  the  history,  but  they  cannot  be  diagnosed  with  certainty  until 
both  renal  inflammation  and  heart  failure  have  been  excluded.  It  seems  worth 
while,  however,  to  discuss  in  rather  greater  detail  each  of  the  main  groups 
indicated  above. 

I.  Cases  in  which  the  (Edema  is  Universal. — When  a  patient  has  a  tendency 
to  universal  symmetrical  oedema,  the  great  probability  is  that  he  is  suffering 
from  either  primary  acute  nephritis  or  acute  nephritis  superposed  upon  chronic 
nephritis  ;  the  diagnosis  is  indicated  by  the  occurrence  of  albumin  with  tube- 
casts.  The  degree  of  oedema  exhibited  in  different  regions  varies  partly  by 
reason  of  the  looseness  of  the  subcutaneous  tissues  in  different  places,  and 
partly  by  reason  of    the    effects    of    gravity.       Other   things    being    equal,   the 


458 


(EDEMA ,     S  YMMETRICA  L 


oedema^shows  raost  in  the  legs,  lumbar  region  (lumbar  cushion),  penis,  scrotum, 
labia,  eyelids,  and  face,  though  careful  examination  may  show  that  there  is  some 
degree  of  oedema  in  every  tissue  from  scalp  to  toes  ;  it  is  due  to  the  influence 
of  gravity  that  when  the  patient  is  up  and  about  the  oedema  is  most  marked 
in  the  legs  ;  is  very  marked  in  the  lumbar  cushion  and  the  genital  organs  when 
the  patient  sits  propped  up  in  bed  ;  and  is  most  prominent  in  the  eyelids  when 
the  patient  has  been  lying  horizontally,  as  during  sleep. 

Other  causes  lor  universal  oedema  are  rare,  but  it  may  sometimes  be  due  to  a 
universal  condition  of  angioneurotic  cedema  {Fig.  128),  though  this  is  much  more 
often  asymmetrical  ;  or  to  overloading  of  the  tissues  with  fluid, — for  instance, 
as  the  result  of  excessive  transfusion  or  infusion,  or  in  patients  who  have  been 
swilling  beer  day  after  day  until  their  bodies  have  become  sodden.     Such  cases 

present  an  appearance  highly 
suggestive  of  acute  nephritis,  but 
the  absence  of  albumin  from  the 
urine,  the  history  of  excessive 
drinking  over  long  periods,  and 
the  complete  recovery  when  the 
drinking  is  stopped,  point  to  the 
diagnosis. 

Certain  poisons  may  produce 
universal  oedema,  though  rarely ; 
iodide  of  potassium  has  been 
known  to  do  so  to  a  mild  degree ; 
one  of  the  effects  of  snake-bite 
also  is  to  produce  universal 
oedema  with  or  without  albu- 
minuria, though  as  a  rule  the 
part  originally  bitten  is  very 
much  more  swollen  than  are  the 
other  portions  of  the  body. 

Only  in  very  rare  cases  does 
heart  failure  produce  oedema  of 
the  hands  and  arms  as  well  as 
of  the  legs,  and  when  it  does  so 
the  patient  usually  has  been  ill 
some  time,  the  diagnosis  has 
already  been  made,  and  the  end 
is  not  far  off. 
2.  (Edema  of  the  Face,  Neck,  and  Arms,  but  not  of  the  Legs  or  Lower  Half  of  the 
Trunk,  is  nearly  always  due  to  obstruction  to  the  superior  vena  cava  or  to  the 
main  branches  which  go  to  form  this,  and  the  commonest  causes  of  this  obstruc- 
tion are  thoracic  aneurysm,  mediastinal  new  growth,  or  gumma,  chronic  mediastinal 
fibrosis,  and  thrombosis  spreading  to  the  main  trunk  from,  for  instance,  an 
axillary  vein  infected  from  a  whitlow  or  from  other  sources  of  phlebitis.  When 
the  swelling  comes  on  acutely,  as  it  may  in  any  of  the  above  conditions,  acute 
Bright's  disease  may  be  simulated  on  account  of  the  extreme  puffiness  of  the 
eyes  ;  but  further  examination  will  show  a  remarkable  limitation  of  the  oedema 
to  the  head  and  upper  limbs,  whilst  the  urine  will  probably  not  contain  albumin. 
If  the  obstruction  to  the  superior  vena  cava  persist,  there  will  be  evidence  of 
collateral  circulation  in  the  form  of  varicose  veins  upon  the  chest  wall  (see 
Veins,  Varicose  Thoracic). 

It  only  remains  to  add  that,  instead  of  being  asymmetrical,  inflammatory 
lesions  may  sometimes  produce  almost  symmetrical  oedema  of  the  face  or  neck. 


Fi^.  128. 


—Angioneurotic  cedema  of  the  eyelids 
simulating  acute  nephritis. 


(EDEMA,     SYMMETRICAL  459 

in  -which  connection  one  may  mention  erysipelas,  celluliHs,  anthrax,  angina 
Ludovici,  the  differential  diagnosis  of  which  is  based  upon  the  history,  the 
constitutional  symptoms,  the  local  appearances  of  the  inflammation,  and  the 
results  of  bacteriological  examination. 

Similar  symmetrical  swelling  may  be  produced  in  the  hands  or  arms  either 
hj  angioneurotic  oedema  (Fig.  128),  or  by  allied  vasomotor  neuroses,  such 
as  Raynaud's  disease.  Swelling  of  the  eyes  and  face  suggestive  of  oedema 
maj''  sometimes  be  due  to  bouts  of  crying,  prolonged  attacks  of  coughing, 
as  for  instance  in  whooping-cough,  or  as  the  result  of  catarrh  due  to  a 
coinnion  cold,  measles,  or  to  the  effect  of  such  remedies  as  potassium  iodide 
or  arsenic. 

3.  (Edema  of  the  Legs  and  Lower  Part  of  the  Trunk,  without  any  of  the  Neck  or 
Face,  is  suggestive  of  heart  failure  or  of  nephritis,  and  the  main  points  that  arise 
in  the  differential  diagnosis  have  been  discussed  above.  If  both  of  these  main 
groups  of  causes  can  be  excluded,  however,  it  is  important  to  remember  how 
often  the  legs  may  swell  as  the  result  of  poverty  of  the  blood  in  any  condition 
of  An.^mia  [q.v.].  This  is  perhaps  seen  best  of  all  in  cases  of  chlorosis,  for  patients 
suffering  from  the  severer  tj'pes  of  anaemia,  such  as  pernicious  ancemia,  lymphatic 
or  splenomedullary  leukcemia,  Hodgkin's  disease,  splenic  ancemia,  pseudo- 
leukcsrnia.  infantum,  are  less  continuously  up  and  about  than  are  many  cases  of 
chlorosis.  The  same  applies  to  the  severe  ancBniia  which  follows  loss  of  blood 
from  haemoptysis,  haematemesis,  post-partum  and  other  haemorrhages  ;  or  to 
the  less  acute  anaemias  that  result  from  parasitic  infections  such  as  Bothrio 
cephalus  latus  ox  Ankylostomum  duodenale,  or  the  effects  of  certain  drugs  ;  or  to 
cachectic  conditions  such  as  result  from  carcinoma,  sarcoma,  syphilis,  tuberculosis, 
starvation,  malaria  and  various  other  tropical  infections.  The  differential  dia- 
gnosis of  the  various  conditions  thus  enumerated  will  seldom  depend  upon  the 
presence  of  oedema  alone,  and  each  of  the  maladies  will  be  found  discussed  under 
the  heading  of  some  other  symptom. 

Obstruction  to  the  inferior  vena  cava  may  lead  to  extreme  oedema  of  the  legs  ; 
if  due  to  phlebitis,  the  clotting  of  the  inferior  vena  cava  itself  is  nearly  always 
preceded  by  that  of  the  veins  of  one  leg,  so  that  even  when  the  final  result  is 
symmetrical,  the  history'  nearly  always  points  to  it  having  begun  asjonmetrically. 
When  the  inferior  vena  cava  is  obstructed  by  new  growth  or  by  the  pressure 
of  ascitic  fluid,  the  diagnosis  will  depend  upon  the  discovery  of  some  abnormal 
mass,  or  upon  the  interpretation  of  the  cause  of  the  Ascites  [q.v.).  Much  difficulty 
sometimes  arises,  as  in  a  case  mentioned  on  p.  8. 

The  influence  of  the  vasomotor  nerves  in  controlling  the  balance  of  h^mph 
production  and  lymph  absorption  in  the  legs  is  sometimes  interfered  with. 

One  sees  a  good  example  of  this  in  the  oedema  which  develops  in  the  lower 
extremities  in  convalescent  patients  when,  having  been  long  in  the  horizontal 
position  from  any  cause,  they  first  begin  to  walk  about  ;  it  is  probable  that  a 
perfectly  normal  person  kept  at  rest  in  bed  for  three  months,  would  suffer  from 
oedema  of  the  legs  in  varying  degree  for  some  days  or  weeks  after  first  beginning 
to  use  his  limbs,  and  the  tendency  is  still  more  marked  in  those  who  have 
been  laid  up  hy  gastric  or  duodenal  ulcers,  typhoid  fever,  fractured  femur, 
and  so  on.  The  oedema  of  the  legs  in  convalescents  is  a  common  symptom 
which  may  at  first  arouse  a  suspicion  of  some  kidney  lesion,  though  the  absence 
of  albumin,  and  the  way  in  which  the  oedema  disappears  spontaneously  in  time, 
especially  under  the  influence  of  massage,  indicate  the  diagnosis  when  the 
histor\'  is  known  of  illness  confining  the  patient  to  a  horizontal  position  for  some 
time  previously.  Diseased  conditions  of  the  vasomotor  system  may  produce 
even  more  marked  oedema,  as  seen  in  elderly  people,  in  some  cases  of  Raynaud's 
disease  ;      in    angioneurotic    oedema  ;      in    association    with     peripheral    neuritis, 


460 


(EDEMA ,     S  YMMETRICA  L 


especially  in  the  tropical  varietjr  called  heri-ben,  an  epidemic  febrile  illness 
associated  with  peripheral  neuritis,  and  generally  seen  in  this  countrj'  only  in 
seaport  towns,  as  the  result  of  an  outbreak  amongst  seamen  on  board  ships  in 
which  the  diet  has  consisted  largely  of  not  quite  fresh  rice. 

There  is  a  peculiar  hereditary  disease  in  which  oedema  of  the  lower  extremities, 
occurring  in  many  members  of  a  familj^  (Fig.  129),  ma}'  be  a  prominent  feature; 
in  the  early  stages  this  oedema  is  asymmetrical,  affecting  one  leg  before  the 
other^  but  sooner  or  later  both  legs  may  become  in^-olved,  until,  if  the 
family  and  personal  history  were  not  known,  the  oedema  of  Bright's  disease 
might  be  suspected.  The  affection  is  known  as  Milroy's  disease,  Meige's  disease, 
or  hereditary  trophoedema.  The  sudden  demarcation  between  the  swollen  and 
the  non-swollen  parts  at  the  level  of  a  joint — ankle,  knee,  or  hip — is  a  character- 
istic feature  in  many  of  these  cases.     There  is  sometimes  a  historj^  of  periodic 

acute  attacks  of  pjTexia,  and  of  gastric 
disorder,  associated  with  an  increase  in 
the  swelling,  not  altogether  unlike  those 
occurring  in  angioneurotic  oedema. 
The  swelling  ma}-  cease  at  the  ankles  in 
the  early  stages  ;  when  a  subsequent 
spread  occurs,  it  may  reach  almost 
suddenly  up  to  the  knees,  ceasing  there 
for  a  variable  number  of  j^ears,  until 
ultimately  it  spreads  to  the  groins, 
above  which  it  seldom  extends.  The 
diagnosis  is  easy  when  the  family  history 
is  obtainable. 

Myxoedema  is  a  condition  in  which  the 
swelling  of  the  legs  ma}'  simulate  actual 
oedema  very  closely,  and  indeed  in  not 
a  few  cases  the  subcutaneous  tissues  of 
the  feet  and  legs  do  pit  to  a  certain 
extent,  on  pressure.  When  there  is 
actual  oedema  as  well  as  myxoedema, 
considerable  doubt  as  to  whether  there 
may  not  be  a  cardiac  or  other  factor, 
as  well  as  th}Toid  insufficiency,  will  arise. 
The  urine  will  generally  be  found  to 
contain  no  albumin,  however  ;  the 
patient  is  nearly  always  a  woman  of 
middle  age,  who  has  recenth'  begun  to 
get  much  stouter,  and  at  the  same  time 
less  active  both  mentally  and  phvsically. 
The  diagnosis  of  myxoedema  will  be  confirmed  if  the  untoward  S}anptoms  and 
the  abnormal  state  of  the  subcutaneous  tissues  disappear  under  the  influence 
of  thyroid  medication. 

It  is  not  easy  to  include  all  the  possible  causes  of  oedema  in  a  classified  list, 
but  the  following  include  those  which  have  been  discussed  above  : — 

I.  Universal  (Edema. 

Primary  acute  nephritis 

Acute  nephritis  as  an  exacerbation  of 

chronic  nephritis 
Angioneurosis 
Excessive  transfusion  or  infusion 


J^i^.  129. — Bilateral  hereditary  trophoedema 
of  the  legs  in  a  girl  of  21,  twelve  other  members 
of  the  family  being  affected  by  the  complaint 
also.  She  had  never  been  out  of  England. 
There  was  no  abnormality  above  Poupart's 
ligament.  Milroy's  or  ]Meige's  disease.  (For  a 
full  account  see  Hope  and  French,  Quart.  Jour, 
of  Med.,  vol.  i,  No.  3,  p.  312.) 


Soddening  from  beer  drinking 
Iodide  of  potassium 
Snake-bite 
Heart  failure. 


PLA  TE      VII. 

OPHTHALMOSCOPIC   APPEARANCES 


Cnpy  right 
IN'DEX     OF      DIAGNOSIS 


A.   U\  Head,  del. 


OPHTHALMOSCOPIC     APPEARANCES 


461 


2.  CEdema  of  Face,  Neck,  and  Arms, 

Obstruction  to  the  superior  vena  cava 
by: 

Thoracic  aneurysm 

Mediastinal  new  growth 

Mediastinal  gumma 

Mediastinal  fibrosis 

Thrombosis 
Erysipelas 
Cellulitis 

3.  CEdema  of  the  Legs,  without  any 

Heart  failure  secondary  to  : 
Valvular  disease 
Myocardial  affections 
Chronic  lung  affections 
Renal  or  arterial  affections 

Chlorosis 

Pernicious  anaemia 

Lymphatic  leukaemia 

Splenomedullary  leukaemia 

Hodgkin's  disease 

Splenic  anaemia 

Pseudo-leukaemia  infantum 

Anjemia  following  excessive  blood  loss 

Parasitic  affections,  especially  : 
Bothriocephalus  latus 
Ankylostomum  duodenale 


OLIGOCYTHEMIA. — (See  Anemia. 
OLIGURIA — (See  Anuria.) 


but  not  of  Legs. 

Anthrax 

Angina  Ludovici 

Raynaud's  disease 

Angioneurosis 

Crying 

Coughing 

Measles 

Common  cold 

Ptomaine  poisoning,  shell-fish  variety 

of  the  Neck  or  Face. 

Cachectic  states  due  to  : 

Carcinoma 

Sarcoma 

Syphilis 

Tuberculosis 

Starvation 

Malaria 

Tropical  affections 
Inferior  vena  cava  obstruction  by  : 

Thrombosis 

New  growths 

Ascites 
Convalescence 
Old  age 

Raynaud's  disease 
Angioneurosis 
Beri-beri 
Milroy's     disease 
Myx  oedema. 


[oedema) 

(hereditary     troph- 

Herbert  French. 


OPHTHALMOPLEGIA. — (See  Strabismus  ;   and  Pupil,  Abnormalities  of.) 

OPHTHALMOSCOPIC   APPEARANCES,  NOTES  OYi.~{Plates  VII  and   VIII.) 

Fig.  a. — A  Physiological  Cup  may  vary  in  size,  but  usually  occupies  the  centre 
of  the  disc.  The  retinal  vessels  dip  over  the  edge,  which  is  usually  steeper  on 
the  nasal  side,  the  temporal  slope  being  more  gradual.  At  the  bottom  of  the 
cup  is  seen  the  lamina  cribrosa,  which  is  mottled  by  the  openings  through 
which  pass  the  retinal  nerve  fibres. 

A  physiological  cup  is  distinguished  from  that  caused  by  glaucoma  [Fig.  v) 
by  the  fact  that  it  occupies  only  the  centre  and  not  the  whole  of  the  disc. 

Fig.  h. — Congenital  Crescents  are  common,  and  usually  situated  at  the  lower 
part  of  the  disc,  in  contrast  to  myopic  crescents  {Figs.  Ji  and  i),  which  are  seen 
on  the  outer  side.  They  are  probably  due  to  an  uneven  distribution  of  connective 
tissue  in  the  lamina  cribrosa,  and  are  often  associated  with  hypermetropia. 

Fig.  c. — Pigmented  Crescent  in  Disc  Margin. — The  disc  margin  is  always  more 
or  less  pigmented,  the  amount  varying  from  a  small  crescent  to  a  complete 
ring.     The  pigment  has  no  pathological  significance. 

Fig.  d. — Coloboma  of  the  Choroid  is  a  congenital  deficiency,  and  it  may  be 
recognized  by  its  situation  below  the  disc,  the  small  amount  of  pigment  at  the 
edge  of  the  wliite  area,  and  the  presence  of  healthy  retinal  vessels  on  its  surface. 


462  OPHTHALMOSCOPIC     APPEARANCES 

It  mav  be  associated  ^\-itli  other  congenital  abnormalities,  such  as  coloboma  of 
iris,  optic  disc,  or  lens. 

Figs,  e,  f- — Opaque  Nerve  Fibres  exist  normally  in  the  retinae  of  some 
mammals,  e.g.,  the  rabbit.  The  condition  is  due  to  the  persistence  of  the 
medullary  nerve  sheath  of  the  retinal  iibres,  the  sheath  being  lost  usually  at 
the  passage  of  the  nerve  fibre  through  the  lamina  cribrosa.  The  condition  may 
be  recognized  by  the  brilliant  white  colour  of  the  nerve  fibres,  the  striated  appear- 
ance of  the  white  patch,  and  the  fact  that  the  retinal  vessels  are  more  or  less 
embedded  among  the  nerve  fibres. 

Pig_  g_ — Advanced  Syphilitic  Choroiditis. — In  advanced  choroiditis  the  inflam- 
matorv  process  has  ended  in  the  total  destruction  of  the  choroid  in  patches, 
which  in  some  places  have  joined  to  disclose  large  bare  areas  of  sclerotic.  There 
are  large  masses  of  pigment,  usually  surrounding  the  white  areas,  the  pigment 
being  chief!}-  derived  from  the  choroid.  The  retinal  pigment  is  also  increased 
in  the  great  majority-  of  cases,  and  vision  is  rendered  extremeh^  defective. 
Macular  choroiditis  is  degenerative  in  origin,  and  does  not  usually  appear  till 
middle  hfe.  It  probablv  commences  in  the  form  of  macular  hemorrhages, 
which  lead  to  destruction  and  fibrosis  of  the  retina. 

Figs,  h,  i. — The  Myopic  Crescent  is  usuaUj-  found  on  the  outer  side  of  the 
disc,  and  mav  vary  in  size  and  extent  from  a  thin  crescent  to  a  large  atrophic 
area  surrounding  the  whole  disc  (posterior  staphyloma).  Usually,  the  size  of 
the  crescent  varies  with  the  amount  of  the  myopia  and  increases  with  age. 

Figs,  k,  I. — Recent  Optic  Neuritis  is  characterized  by  the  swelling  of  the 
disc  and  the  blurring  of  its  outhne  by  retinal  oedema.  The  retina  is  greyish  and 
striated  in  appearance,  owing  to  oedema  between  the  retinal  nerve  fibres,  and 
the  veins  are  extremely  dilated  and  tortuous.  Flame-shaped  hemorrhages 
are  also  seen  on  the  disc  and  in  the  surrounding  retina,  and  numerous  small 
retinal  vessels  on  the  disc,  usually  invisible,  become  dilated  and  apparent.  In 
the  later  stages  of  the  neuritis  the  hcemorrhages  may  disappear,  and  the  whole 
disc  become  greyer  and  paler,  the  condition  ultimately  terminating  in  post- 
neuritic atroph}-  {Fig.  I).  The  outUne  of  the  disc  is  entirely  lost,  and  in  severe 
cases  the  disc  may  be  so  swoUen  as  to  resemble  a  small  mushroom  in  shape. 
Radiating  lines  of  white  patches  may  also  be  seen  in  the  macular  region, 
resembling  albuminuric  retinitis  (Figs,  p,  q,  ?'.)• 

Figs.  Ill,  n. — Primary  Optic  Atrophy  {Fig,  n)  is  characterized  b}-  the  pallor  of 
the  disc,  white  or  bluish-white,  sharply  defined  lamina  cribrosa,  well-marked 
edge,  and  retinal  vessels  of  normal  size.  In  post-nenritic  atrophy  {Fig.  m)  the 
disc  is  covered  with  fibrous  tissue,  which  fills  up  the  phj'siological  cup  ;  the 
colotur  is  greyish- white,  the  retinal  vessels  are  thin  and  tortuous,  and  the  edge 
of  the  disc  is  irregular.  In  some  cases  of  old  post-neuritic  atrophy  or  fibrosis, 
following  slight  optic  neuritis,  it  maj^  be  impossible  to  distinguish  the  condition 
from  primary  atrophy. 

Fig.  o. — Thrombosis  of  the  Central  Retinal  Vein. — In  thrombosis  of  the  centra 
retinal  vein  the  disc  is  extremely  swoUen  and  oedematous,  the  edge  being  indis- 
tinct and  blurred.  All  the  retinal  veins  are  enormously  dilated  and  tortuous, 
and  the  fundus  is  covered  with  flame-shaped  and  petechial  haemorrhages.  The 
oedema  of  the  retina  from  the  obstruction  of  the  venous  circulation  maj^  be 
so  great  that  the  vein  mav  occasionally  be  hidden  entirely. 

Figs.  JO,  Q,  r. — Albuminuric  Retinitis  is  characterized  by  the  presence  of 
flame-shaped  haemorrhages  in  the  nerve-fibre  layer  of  the  retina,  and  white 
patches.  The  white  patches  are  of  t%vo  kinds.  Those  seen  in  the  earh*  stages 
of  the  disease  are  ill  defined  and  woolly,  scattered  about  the  macular  region  in 
an  irregular  manner.  These  are  due  to  exudate  in  the  nerve-fibre  la^-er  of  the 
retina.      In  the  later  stages,  smaller  white  patches  may  be  seen  usually  arranged 


PLA  TE      VIII. 

OPHTHALMOSCOPIC   APPEARANCES 


Copyright 
INDEX     OF      DIAGNOSIS 


A.    IF.  Head,  del. 


OPISTHOTONOS  463 


in  radiating  lines  from  the  macula,  which  are  well  defined,  and  glistening  or 
chalky  white. 

Fig.  s.— Embolism  of  the  Central  Retinal  Artery. — In  embolism  of  the  central 
retinal  artery  the  retina  is  generally  pale  grey  or  white,  owing  to  the  anaemia 
consequent  on  the  obstruction  of  the  artery.  The  macula  itself  being  adherent 
to  the  choroid  does  not  share  in  the  general  pallor,  and  appears  as  a  bright 
cherry-red  spot  in  conttast.  The  retinal  arteries  are  extremely  small,  being 
only  fine  white  threads  in  places,  and  the  veins  may  be  nearly  empty.  The 
optic  disc  is  white,  blurred,  and  indistinct. 

Fig.  f. — -Detachment  of  the  Retina. —  The  detached  portion  of  the  retina  is 
silvery-grey  in  colour,  and  raised  above  the  surrounding  fundus.  In  cases  due  to 
serous  exudate,  the  detached  part  of  the  retina  is  transparent,  arranged  in 
billowy  folds,  and  may  float  about  on  movement  of  the  eye.  When  the  detach- 
ment is  due  to  growth,  the  retina  is  usually  smooth  and  opaque.  The  retinal 
vessels  are  small,  very  tortuous,  and  dark  in  colour. 

Fig.  IV— Glaucomatous  Discs. — The  excavation  of  the  optic  disc  maybe  distin- 
guished from  the  physiological  cup  by  the  fact  that  it  affects  the  whole  of  the 
disc,  the  edge  often  being  surrounded  by  an  atrophic  ring.  The  retinal  vessels 
bend  sharply  over  the  edge,  and  may  disappear  from  view  behind  the  overhanging 
margin  of  the  disc,  reappearing  on  the  bottom  of  the  cup.  The  lamina  cribrosa 
is  well  marked,  and  the  disc  is  white  and  atrophic. 

Fig.  w. — Tubercles  In  the  Choroid  are  seen  as  ill- defined  circular  masses,  usually 
four  or  five  in  number,  varj'ing  in  size  from  a  pin's  head  to  masses  nearly  the 
size  of  the  optic  disc.  They  are  usually  associated  with  miliary  tuberculosis, 
grow  rapidly,  but  rarely  attain  any  great  size  owing  to  the  death  of  the  patient. 
It  is  stated  that  they  occur  most  commonly  in  the  neighbourhood  of  the  disc, 
but  this  is  due  to  the  fact  that  only  the  posterior  portion  of  the  fundus  is  visible 
with  the  ophthalmoscope.      Post  mortem  fhey  are  found  all  over  the  choroid. 

Fig.  X. — Hypermetrophie  Astigmatism. — In  hypermetropic  astigmatism  the  disc 
is  often  oval  in  shape  and  ill  defined.  The  phj^siological  cup  is  absent,  the  disc 
is  red,  and  the  margin  is  ill  defined.  The  vessels  may  be  tortuous  though  not 
dilated,  and  unless  the  error  of  refraction  is  observed,  the  condition  may  be 
mistaken  for  optic  neuritis.  Herbert  L.  Easan 

OPISTHOTONOS. — This  is  a  rare  but  characteristic  condition,  in  which  all 
the  muscles  of  the  neck,  back,  and  legs  are  rigidly  contracted  in  such  a  way 
that  the  body  is  over-extended  in  the  form  of  an  arch,  supported  by  the  occiput 
above  and  by  the  heels  below.  This  position  may  be  maintained  ;  but  more 
often  it  is  assumed  periodically,  with  partial  or  complete  relaxations  between 
the  tetanic  seizures. 

Its  chief  cause  is  tetanus,  but  it  may  also  be  due  to  strychnine  poisoning, 
spinal  meningitis,  urcemia,  and  hysteria. 

Tetanus. — The  history  will  often  point  to  the  correct  diagnosis.  If  there  has 
been  a  punctured  wound  recentty,  and  if  stiffness  of  the  neck  muscles,  and  of 
the  lower  jaw  (trismus  or  lockjaw),  has  set  in,  to  be  followed  within  a  day  or  so 
by  generalized  rigidity,  with  severe  paroxysmal  exacerbations,  the  opisthotonos 
is  almost  certainly  due  to  tetanus.  The  fixed  smile — risus  sardonicus — is 
common  to  tetanus  and  to  strychnine  poisoning.  An  attempt  will  be  made 
to  obtain  the  drumstick  bacilli  [Plate  XII,  Fig.  i)  from  the  suspected  wound, 
very  often  without  success.  In  some  cases  there  will  be  no  obvious  wound 
or  contusion  ;  but  although  the  source  of  contagion  will  then  be  obscure,  the 
early  lockjaw  and  the  course  of  the  disease  will  point  to  tetanus  beyond  doubt. 

Strychnine  poisoning  does  not  give  rise  to  lockjaw,  and  the  paroxysms  of 
opisthotonos  are  separated  by  intervals  of  far  more  complete  relaxation  of  the 


464  OPISTHOTONOS 


muscles  than  is  the  case  in  tetanus  ;  moreover,  there  may  be  direct  evidence  of 
the  source  of  the  poisoning,  either  accidental,  suicidal,  or  homicidal,  in  the  form  of 
a  bottle,  a  hypodermic  syringe  and  needle,  a  packet  of  vermin-destroyer,  or 
something  of  that  kind.  In  some  cases  the  diagnosis  can  only  be  arrived  at  by 
analysis,  either  of  the  gastro-intestinal  contents,  or  of  the  viscera  post  mortem. 

Spinal  meningitis  seldom  causes  difficulty  in  the  diagnosis,  for  it  is  generally 
part  of  acute  cerebrospinal  meningitis,  of  which  the*  general  symptoms  and 
pyrexia  will  have  existed  some  days,  if  not  a  week  or  more,  before  opisthotonos 
is  likely  to  occur.  Optic  neuritis  may  be  found,  and  in  some  cases  the  bacterio- 
logical and  cytological  results  of  lumbar  puncture,  especially  the  discovery 
of  the  meningococcus,  may  clinch  the  diagnosis. 

Urcemic  convulsions  are  associated  with  complete  coma,  whereas  in  tetanus 
and  in  strychnine  poisoning  consciousness  is  perfectly  retained  ;  the  convulsions 
are  epileptiform  rather  than  tetanic  ;  there  is  no  persistent  lockjaw  ;  and  the 
urine  will  nearly  always  contain  albumin  and  renal  tube-casts. 

Hysteria  sometimes  takes  a  form  that  may  for  the  moment  be  very  difficult 
indeed  to  distinguish  from  tetanus  or  from  strychnine  poisoning.  Unlike 
malingering,  hysterial  contractions  that  are  even  violent  enough  to  cause 
opisthotonos,  do  not  always  make  the  patient  perspire,  and  they  do  not  lead  to 
fatigue  in  the  way  that  similar  voluntary  efforts  certainly  would.  The  diagnosis 
of  hysteria  is  generally  arrived  at  by  watching  the  case.  Persistent  lockjaw 
may  be  present,  as  in  tetanus  ;  but  whereas  in  strychnine  poisoning  and  in 
tetanus  there  is  a  great  similarity  between  one  exacerbation  and  the  next, 
hysterical  convulsions  are  apt  to  be  polymorphous  ;  the  more  the  writhing  and 
the  change  of  attitude  and  position,  the  less  likely  is  the  attack  to  be  organic. 
The  mind  remains  perfectly  clear  in  tetanus  and  strychnine  poisoning,  though 
the  outward  expression  of  the  mind  may  be  prevented  by  the  muscular 
paroxysms  ;  in  hysteria,  the  mental  attitude  is  in  one  way  or  another  obviously 
abnormal  for  the  time  being.  In  arriving  at  a  diagnosis,  it  may  be  of 
very  great  assistance  to  know  full  details  of  the  patient's  previous  medical 
history,  for  there  may  have  been  similar  hysterical  outbursts  on  former 
occasions.  Herbert  French. 

OPTIC  ATROPHY. — (See  Ophthalmoscopic  Appearances,  Notes  on.) 

OPTIC  NEURITIS — (See  Ophthalmoscopic  Appearances,  Notes  on.) 

ORTHOPNCE  A,  or  the  inability  to  breathe  unless  propped  above  the  horizontal 
position,  may  be  due  to  many  causes,  which  may  be  grouped  as  follows  : — 

Failure  of  the  Right  Side  of  the  Heart : — 

Secondary  to  valvular  disease  of  the  left  side  of  the  heart  : 


Aortic    disease    with    secondary 
mitral  regurgitation. 


Mitral  stenosis 

Mitral  regurgitation 

Mitral  stenosis  and  regurgitation 
Secondary  to  affections  of  the  heart  muscle  : 

Fatty  heart  [         Adherent  pericardium 

Fibroid  heart  |  Some  cases  of  pericarditis 

Secondary  to  high  systemic  blood-pressure  : 

Arteriosclerosis  |         Granular  kidney. 

Secondary  to  lung  affections  : 


Emphysema 
Chronic  bronchitis 


Fibroid    lung    with    or   without 

bronchiectasis 
Pneumothorax. 


ORTHOPNCEA 


46: 


Obstruction  to  the  Larynx  or  Trachea 

Acute  oedema  of  the  laryiix 

Acute  abductor  paralysis 

Post-pharj'ngeal  abscess 

Laryngeal  diphtheria 

Larj^ngismus  stridulus 

Catarrhal  laryngitis,  especially 
at  the  onset  of  certain  cases 
of  measles 

Acute  pneumococcal  or  strepto- 
coccal laryngitis 

Qidema  due  to  potassium  iodide 


Laryngeal  crises  of  locomotor  ataxia 
Foreign  body 
Enlarged  thyroid  gland 
Enlarged  thymus  gland 
Aortic  aneurysm 
Mediastinal  new  growth 
Malignant  glands  in  the  neck 
Lymphadenomatous  glands  in  neck 
Irruption  of  a  caseous  gland   into 

the  trachea 
CEsophageal  tumour. 


Acute  Obstruction  of  the  Bronchi  and  Bronchioles  :- 


Acute  bronchitis 

Acute  capillary  bronchitis 

Some  cases  of  acute  broncho- 


Asthma 
Whooping-cough. 


New  growth 
Hydrothorax. 

Neurosis  or  hysteria 
Solid  or  cystic  tumours. 


pneumonia 
Mediastinal  Masses  : — • 

Aneurysm 

Huge  heart 
Enormous  Distention  of  the  Abdomen  by- 

Ascites 

Tympanites 

By  far  the  commonest  cause  of  orthopnoea  is  heart  failure  of  some  kind  or 
another,  and  the  differential  diagnosis  of  the  variety  of  heart  failure,  and  whether 
it  is  due  to  valvular  disease,  to  myocardial  degeneration,  to  arteriosclerosis, 
to  granular  kidney,  or  to  the  effect  of  difficulties  in  the  pulmonary  circulation 
from  bronchitis  and  emphysema  or  fibroid  lung,  has  to  be  decided  upon  the 
various  grounds  that  are  discussed  on  p.  18. 

When  orthopnoea  is  due  to  obstruction  to  the  larynx  or  trachea  the  fact  is 
generally  obvious  on  account  of  other  symptoms  such  as  stridor,  up-and-down 
movements  of  the  larynx  itself,  sucking  in  above  and  below  the  clavicles  and 
of  the  lower  intercostal  spaces,  the  main  difficulty  in  some  of  these  patients 
being  to  decide  whether  the  obstruction  is  sufficiently  near  the  larynx  to  be 
relievable  by  tracheotomy,  or  whether  it  is  due  to  mischief  lower  down  in  the 
trachea,  bronchi  or  bronchioles.  The  nearer  the  obstruction  is  to  the  larynx 
the  greater  will  be  the  spasmodic  up-and-down  movements  of  the  thyroid 
cartilage,  and  the  stridor.  If  the  evidence  is  that  the  obstruction  is  in  the  larynx 
itself,  and  if  the  orthopnoea  and  difficulty  with  respiration  are  extreme,  the 
probability  is  that  tracheotomy  will  be  resorted  to  as  an  urgency  measure, 
the  precise  diagnosis  being  determined  later.  The  history,  or  a  local  examination, 
would  serve  to  diagnose  or  exclude  acute  ,abductor  paralysis,  post-pharyngeal 
abscess,  foreign  body,  enlarged  thyroid  gland,  malignant  glands  in  the  neck, 
lymphadenomatous  glands  in  the  neck.  Enlargement  of  the  thymus  gland  can 
seldom  be  more  than  conjectured,  or  diagnosed  by  a  process  of  exclusion,  unless 
there  is  definite  dullness  behind  the  upper  part  of  the  sternum  in  a  child  under 
ten  years  of  age,  together  perhaps  with  an  x-ra.Y  shadow  of  the  gland.  Aortic 
aneurysm  or  mediastinal  new  growth  obstructing  the  trachea  will  generally  have 
given  rise  to  other  characteristic  symptoms  at  the  same  time  ;  particularly  in 
the  case  of  mediastinal  new  growth,  to  obstruction  of  the  innominate  veins  or 
the  superior  vena  cava,  with  varicose  distention  in  the  superficial  thoracic  veins 
by  way  of  collateral  circulation.  The  ;r-rays  may  be  useful  in  confirming  the 
diagnosis. 

D  30 


466  ORTHOPNCEA 

In  a  great  many  cases,  particularly  in  children,  none  of  the  above  will  be  the 
least  likeh'j  and  if  foreign  bodj^  and  post-phar\Tigeal  abscess  have  been  excluded 
by  digital  examination,  the  first  suspicion  will  be  that  the  patient  is  suffering 
from  laryngeal  diphtheria.  This  may  be  confirmed  by  the  presence  of  a  small 
quantity  of  membrane  on  the  pharynx,  the  uvula,  or  elsewhere,  though  quite 
commonly  when  laryngeal  diphtheria  is  extensive  there  is  no  obvious  exudate 
upon  any  of  the  visible  parts  at  the  back  of  the  mouth.  The  existence  of  cases 
of  diphtheria  in  the  same  house  or  in  the  neighbourhood  may  point  to  the 
diagnosis ;  but  in  every  case  swabbings  should  be  obtained  from  as  far  back  in 
the  throat  as  possible,  and  examined  for  Klebs-Loeffler  bacilh,  both  in  films  and 
in  cultures  incubated  at  bod}'  temperature  in  a  bacteriological  laboratory.  Until 
laryngeal  diphtheria  can  be  excluded  bj-  the  absence  of  Klebs-Loeffler  bacilh — 
and  a  single  negative  result  does  not  necessarih^  exclude  the  disease — the  nature 
of  the  case  will  probably  remain  in  doubt.  Acute  oedema  of  the  larynx  is  nearly 
always  due  to  some  microbial  infection,  and  therefore  in  a  sense  it  includes  acute 
pneumococcal  or  streptococcal  laryngitis,  the  diagnosis  of  which  depends  upon 
bacteriological  cultivations  from  swabbings  from  the  throat.  CEdema  may 
also  be  due  to  similar  infection  of  ulcerated  places  in  the  throat  developing  in 
the  course  of  tuberculous,  syphilitic,  malignant,  lupoid,  traumatic,  or  post-typhoidal 
laryngeal  ulceration.  The  previous  history,  the  results  of  previous  examination 
of  the  lungs,  larynx,  and  sputum  will  indicate  the  diagnosis  of  these  various 
conditions. 

The  laryngeal  crises  of  locomotor  ataxia  are  exceedingly  rare  ;  the}'  might 
be  suggested  if  the  patient  were  known  to  have  no  knee-jerks  and  Argj'll 
Robertson  pupils,  but  even  then  there  might  be  doubt  as  to  whether  they 
were  really  crises  and  not  the  result  of  syphilitic  ulceration,  or  due  to  the 
administration  of  potassium  iodide  in  these  cases.  Acute  oedema  of  the  lar\Tix 
is  sometimes  spoken  of  as  one  of  the  complications  of  acute  Bright's  disease, 
but  it  is  very  rare  in  this  malady,  rarer  than  acute  cedema  of  the  lungs  ;  it 
is  usually  a  terminal  factor,  the  diagnosis  of  nephritis  having  been  made 
previously  on  account  of  general  oedema  and  albuminuria  with  tube  casts. 
Laryngismus  stridulus  is  a  dangerous  diagnosis  to  make,  for  many  cases  thought 
to  be  this  are  really  examples  of  diphtheria  :  if  laryngismus  stridulus  does  occur, 
it  is  to  be  expected  in  rickety  children  who  show  a  tendency  to  spasmodic 
muscular  contractions  in  other  parts  besides  the  larynx,  such  for  instance  as 
convulsions  from  slight  causes,  or  the  carpo-pedal  contractions  of  infantile 
tetany.  It  is  supposed  that  similar  spasmodic  contractions  of  the  muscles  of 
the  larynx  produce  paroxysms  of  larvngeal  obstruction  with  acute  dyspnoea, 
orthopnoea  and  cyanosis ;  but  no  such  cases  should  be  diagnosed  as  simply 
neuro -muscular  until  every  precaution  has  been  taken  to  exclude  all  other  causes 
of  laryngeal  obstruction,  especiallv  diphtheria.  Now  and  then  one  meets  with 
a  case  in  which  an  apparently  healthv  child  is  suddenly  seized  with  acute 
dyspnoea,  cyanosis,  orthopnoea  and  general  respiratory  distress,  without  any 
signs  of  laryngeal  obstruction,  the  result  of  irruption  of  a  caseous  bronchial  or 
mediastinal  gland  into  the  lower  part  of  the  trachea  or  a  main  bronchus.  The 
symptoms  are  preciselj^  such  as  one  would  expect  if  the  patient  had  suddenly 
inhaled  a  foreign  bodj^  of  some  size,  and  if  one  can  be  quite  sure  that  no  such 
foreign  body  has  been  inhaled  the  correct  diagnosis  may  sometimes  be  guessed 
at.  It  would  be  confirmed  if,  as  occasionally  happens,  a  sudden  effort  of 
coughing  leads  to  the  caseous  or  cretaceous  mass  being  expectorated. 

The  difficulty  of  being  certain  whether,  in  a  given  case  of  severe  respiratory 
distress  with  evidence  of  obstruction,  the  mischief  lies  in  the  lar5-nx  or  in  the 
lungs  is  sometimes  considerable  ;  in  either  case  there  may  be  marked  c^'anosis, 
orthopnoea,  dyspnoea,  sucking  in  above  and  below  the  clavicles  and  of  the  lower 


OTORRHCEA  467 

intercostal  spaces  :  the  most  important  point  is  whether  the  larynx  itself  remains 
stationary  as  when  the  mischief  is  in  the  lungs,  or  whether  it  moves  up  and 
down  with  the  respiratory  movements  as  it  does  when  the  trouble  is  in  the 
larynx.  Very  often  both  the  lungs  and  the  larynx  are  involved,  and  it  maj' 
then  be  very  difficult  to  decide  which  is  the  more  so,  and  consequently  whether 
tracheotomy  is  indicated  or  not.  The  chief  point  on  which  to  lay  stress,  besides 
the  movements  of  the  larynx,  is  the  result  of  a  physical  examination  of  the 
chest  for  evidence  of  acute  bronchitis  or  of  bronchopneumonia. 

True  asthma  is  a  spasmodic  variety  of  dyspnoea,  the  diagnosis  of  which,  and 
the  difficulty  of  distinguishing  between  asthma  complicated  by  bronchitis  and 
bronchitis  simulating  asthma,   are  discussed  elsewhere. 

Whooping-cough  is  seldom  difficult  to  diagnose,  for  even  when  the  patient 
himself  does  not  exhibit  the  typical  whoop,  he  will  be  affected  by  a  severe 
paroxysmal  cough,  possibly  leading  to  vomiting,  and  at  the  same  time  relatives 
or  friends  may  be  affected  by  cough  which  gives  rise  to  the  typical  whoop. 

Mediastinal  masses,  such  as  aneurysm,  a  huge  heart,  new  growth,  hydro- 
thorax  with  marked  displacement  of  the  heart,  and  enormous  distention  of 
the  abdomen  by  ascites,  tympanites,  or  by  large  tumours,  will  generally  have 
been  diagnosed  before  they  reach  the  stage  of  producing  orthopnoea.  The 
chief  reason  why  a  very  large  heart  or  a  thoracic  aneurysm  may  produce 
orthopnoea,  even  when  there  are  no  signs  of  failure  of  the  cardiac  compensation, 
is  that  when  a  patient  sits  up  there  is  a  greater  distance  between  the  sternum 
and  the  vertebrae  than  when  he  hes  back.  The  cause  for  the  orthopnoea 
is  thus  mechanical,  the  patient  sitting  up  to  allow  a  bigger  space  for  the 
accommodation  of  the  abnormal  mass  ;  hence  in  some  of  these  cases  he  may 
be  able  to  walk  about  and  see  to  his  business  without  distress  during  the  daytime, 
and  yet  be  unable  to  lie  down  at  night.  The  cause  of  the  orthopnoea  associated 
in  this  way  with  a  huge  heart,  is  quite  different  from  that  in  which  there  is 
failure  of  the  right  side,  the  former  being  a  mechanical  means  of  giving  a  big 
mass  more  room,  whilst  the  latter  is  due  to  the  need  of  maximum  assistance  from 
the  respiratory  blood-pump.  Herbert  French. 

OTORRHCEA. — Discharge  from  the  ear  is  a  very  common  symptom  which 
may  result  from  a  great  variety  of  causes,  some  of  which  are  of  a  trivial 
nature,  while  others  are  of  the  most  serious  import.  The  skin  of  the  normal 
external  auditory  meatus  contains  numerous  ceruminous  and  sebaceous  glands, 
the  secretion  of  which,  known  as  cerumen  or  wax,  escapes  either  as  small 
niasses  or  as  a  thick  oily  fluid.  It  may  give  rise  to  trouble  by  forming  a  hard 
solid  plug  which  becomes  impacted  in  the  meatus  and  gives  rise  to  such  serious 
s^^mptoms  as  deafness,  tinnitus,  and  vertigo.  Though  not  usually  included 
under  the  heading  of  "  discharge,"  impacted  cerumen  may  be  the  cause  of 
a  purulent  discharge  from  the  ear. 

When  a  patient  complains  of  an  aural  discharge,  the  colour,  amount,  and 
character  should  be  ascertained.  Any  offensive  odour  should  also  be  noted.  The 
discharge  may  be  purulent,  muco-purulent,  or  serous,  but  occasionally  it  consists 
of  blood,  either  alone  or  mixed  with  one  of  the  above-mentioned  varieties. 

A  discharge  of  blood  from  the  external  auditory  meatus  {otorrhagia)  may  be 
the  result  of  an  injury.     The  following  lesions  may  cause  this  symptom  : — 

Fracture  of  the  base  of  the  skull.  "When  the  line  of  fracture  crosses  the  middle 
fossa  it  traverses  the  petrous  portion  of  the  temporal  bone  and  opens  the 
tympanic  cavity,  tearing  the  tympanic  membrane. 

Injury  to  the  external  auditory  meatus,  usually  at  the  junction  of  the  carti- 
laginous and  osseous  portions,  the  result  of  a  blow  on  the  chin,  the  force  being 
transmitted  backwards  along  the  inferior  maxilla. 


468  OTORRHCEA 

Rupture  of  the  tympanic  membrane,  which  may  occur  as  the  result  of  the 
introduction  of  a  foreign  body  through  the  external  auditory  meatus,  or  after 
a  fall  or  blow  on  the  head  without  any  injury  to  the  base  of  the  skull. 

Bleeding  from  the  ear  is  thus  by  no  means  diagnostic  of  fracture  of  the  middle 
fossa  ;  indeed,  in  the  greater  number  of  cases  the  skull  is  not  injured.  Care  must 
always  be  taken  to  make  sure  that  the  blood  has  not  trickled  into  the  meatus 
from  some  small  wound  of  the  scalp  or  of  the  external  ear.  If  the  external 
auditory  meatus  has  been  injured,  the  source  of  the  haemorrhage  may  be  dis- 
covered by  mopping  the  blood  away  with  plugs  of  cotton-wool  and  examining 
with  a  speculum.  A  tear  in  the  tympanic  membrane  may  be  visible  if  the 
haemorrhage  comes  from  the  tympanum.  If  the  skull  is  fractured,  the  haemor- 
rhage is  usually  profuse  (otorrhagia),  while  if  the  membrane  alone  is  injured 
it  is  comparatively  slight.  The  hearing  should  be  tested,  for  if  the  base  of  the 
skull  is  fractured,  injury  of  the  auditory  nerve  is  an  occasional  complication. 

A  variety  of  acute  inflammation  of  the  middle  ear  known  as  acute  hcemcvrhagic 
otitis  is  characterized  by  a  discharge  of  blood.  This  trouble  is  usually  associated 
with  influenza,  but  may  also  occur  in  haemophilic  patients.  The  hcemorrhage 
is  preceded  by  pain,  and  the  membrane  is  markedly  hypersemic,  or  may  show 
petechial  spots.  A  haemorrhage  or  blood-stained  purulent  discharge  occurring 
in  the  course  of  chronic  suppurative  otitis  media  will  probably  be  due  to  the 
presence  of  polypi  or  of  masses  of  granulations.  A  similar  blood-stained  discharge 
may  be  present  in  malignant  disease  of  the  external  or  middle  ear. 

Very  rarely  erosion  of  the  internal  carotid  artery  may  lead  to  a  severe  fatal 
haemorrhage  from  the  external  auditory  meatus.  The  artery  in  its  course 
through  the  carotid  canal  is  separated  from  the  anterior  part  of  the  tympanic 
cavity  by  only  a  thin  plate  of  bone,  which  may  be  deficient.  Owing  to  chronic 
suppuration,  this  portion  of  bone  may  be  destroyed  and  the  walls  of  the  artery 
weakened,  so  that  it  may  suddenly  give  way,  leading  to  a  quickly  fatal  bleeding 
from  the  ear,  nose,  and  mouth.  A  similar  severe  or  fatal  haemorrhage  may 
result  from  erosion  of  the  lateral  sinus  from  a  similar  cause. 

Cerebrospinal  fluid  may  escape  from  the  external  auditory  meatus  after  a 
fracture  of  the  middle  fossa,  and  its  presence  may  be  regarded  as  diagnostic  of 
this  injury.  The  flow  is  usually  copious,  and  may  last  for  some  days.  Liquor 
Cotunnii  may  escape  when  the  labyrinth  is  injured.  In  appearance  it  resembles 
cerebrospinal  fluid,  but  the  amount  is  very  small.  In  chronic  suppurative  otitis 
media  the  discharge  may  be  serous  in  character,  and  may  bear  some  resem- 
blance to  cerebrospinal  fluid,  from  which  it  may  have  to  be  distinguished  in 
a  patient  unconscious  as  the  result  of  a  head  injury.  Apart  from  examina- 
tion of  the  membrane  through  a  speculum,  this  can  be  effected  by  collecting 
some  of  the  fluid  and  testing  for  albumin.  The  serous  septic  discharge  contains 
much  albumin,  while  cerebrospinal  fluid  has  only  the  merest  trace. 

Purulent  Discharges. — In  by  far  the  greater  number  of  cases  the  discharge 
is  obviously  purulent,  muco-purulent,  or  sero-purulent.  Such  a  discharge  may 
arise  from  some  lesion  of  the  external  auditory  meatus,  from  disease  of  the 
middle  ear,  or  from  suppuration  in  some  adjacent  structure,  the  pus  making 
its  way  into  the  external  or  middle  ear  and  so  draining  from  the  external 
auditory  meatus. 

The  following  lesions  of  the  external  auditory  meatus  give  rise  to  such  a 
discharge  : — 

Eczema.  The  discharge  in  this  case  may  be  serous.  The  trouble  may  be 
caused  by  the  irritation  of  a  plug  of  impacted  cerumen,  or  it  may  be  associated 
with  eczema  of  the  auricle  or  of  some  other  region  of  the  body.  It  must  be 
remembered  that  eczema  of  the  external  auditory  meatus  and  of  the  external 
ear  may  be  caused  by  a  discharge  o^  pus  from  the  middle  car,  and  hence,  when 


OTORRHCEA  469 


the  external  auditor^'  meatus  is  eczematous,  every  care  must  be  taken  to  make 
sure  that  chronic  middle-ear  suppuration  is  not  also  present. 

The  presence  of  a  foreign  body,  such  as  a  plug  of  cotton-wool  which  has 
been  inserted  and  forgotten,  or  of  such  foreign  bodies  as  children  occasionally 
insert,  may  produce  a  dermatitis  of  the  meatus  leading  to  a  discharge  of  pus. 
This  condition  is  recognized  easily'  on  examination  with  the  speculum. 

Fiirunciilosis. — This  not  uncommon  trouble  gives  rise  to  very  acute  pain  and 
swelling  of  the  meatus,  followed  by  a  discharge  of  thick  pus.  A  furuncle  may 
usually  be  seen  on  otoscopic  examination,  and  the  trouble  may  be  diagnosed 
from  the  extreme  tenderness  and  swelling  of  the  meatus,  and  the  presence  of 
an  opening  from  which  the  pus  escapes. 

Secondary  Syphilis. — In  this  disease  condylomata  may  occur  in  the  external 
meatus.  The  discharge  is  usually  serous  in  character,  and  may  have  a  very  foul 
odour.  The  diagnosis  will  depend  upon  the  presence  of  other  secondary  troubles 
or  the  history  of  the  primary  sore.  Tertiary  syphilitic  ulceration  may  also 
occur  at  the  orifice  of  the  meatus. 

Suppurating  Sebaceous  Cyst. — The  cutaneous  lining  of  the  external  auditory 
meatus  is  well  supplied  with  sebaceous  glands,  which  may  give  rise  to  cysts, 
and  which  mav  inflame  and  suppurate.  The  signs,  symptoms,  and  appearances 
closely  resemble  those  of  furunculosis. 

Diphtheritic  InfJatnmation. — This  is  a  rare  trouble.  Diphtheritic  membrane 
is  present,  associated  with  much  swelling  and  a  muco-purulent  discharge.  The 
Ivlebs-Lofilier  bacillus  (Plate  XII,  Fig.  L)  is  found  in  the  discharge  and  the 
membrane. 

Epithelioma  of  the  external  auditory  meatus.  In  this  trouble  the  meatus  may 
be  occluded  completely.  The  appearance  is  characteristic,  and  the  diagnosis 
presents  no  difficulty.  It  must  be  remembered,  however,  that  a  rodent  ulcer 
occasionally  occurs  in  this  situation,  and  in  appearance  closely  resembles  an 
epithelioma. 

Caries  or  necrosis  of  the  bony  external  auditory  meatus  will  give  rise  to  a 
profuse  purulent  discharge,  associated  with  the  presence  of  polj^pi  or  of  masses 
of  granulations. 

The  diagnosis  of  the  above  causes  of  an  aural  discharge  may  be  easy,  but  on 
the  other  hand  it  may  be  a  difficult  matter  to  make  sure  that  there  is  no  disease 
of  the  middle  ear,  for  there  is  likely  to  be  so  much  swelling,  and  probably  tender- 
ness of  the  meatus,  that  it  is  impossible  to  get  a  view  of  the  membrane.  It  must 
also  be  borne  in  mind  that  when  there  is  a  discharge  of  pus  from  the  middle  ear 
the  lining  membrane  of  the  canal  is  frequently  swollen,  inflamed,  and  eczematous. 

The  most  frequent  cause  of  a  purulent  discharge  from  the  ear  is  suppurative 
otitis  media,  either  acute  or  chronic.  In  the  former  case,  the  discharge  is  preceded 
by  acute  pain,  usually  paroxysmal,  with  pjTexia  and  more  or  less  severe  con- 
stitutional symptoms.  The  discharge  usualh^  consists  of  thick  pus,  and  there 
is  much  swelling  of  the  meatus  which  may  prevent  a  satisfactory  view  of  the 
membrane.  \Mien  this  can  be  seen  it  has  a  characteristic  hyperasmic  and  swollen 
appearance,  and  the  perforation  through  which  the  pus  escapes  can  be  made  out. 

Tuberculous  disease  of  the  middle  ear  is  a  not  uncommon  cause  of  purulent 
discharge.  Deafness  and  tinnitus  are  also  present,  but  there  is  usually  no 
p\Texia,  and  pain  is  remarkably  absent.  Examination  shows  a  swollen  condition 
of  the  membrane,  which  is  dull  red  or  pink  in  colour,  while  a  perforation,  often 
in  the  anterior  region,  may  be  made  out  after  cleansing  the  meatus.  In  this 
disease,  rapid  destruction  of  the  bone  may  also  occur  without  pain. 

In  chronic  suppurative  middle-ear  disease  the  character  and  quantity  of  the 
discharge  vary  enormously.  Thus  there  may  be  only  a  slight  serous  discharge 
in  some   cases,   while    in    others   there    may   be    a   profuse    flow    of   foul    pus, 


47° 


OTORRHOEA 


Frequently  the  amount  and  character  vary  from  time  to  time,  and  occasionally 
the  flow  is  intermittent.  The  presence  of  other  symptoms,  such  as  deafness, 
tinnitus,  pain,  and  vertigo,  must  always  be  inquired  for.  The  membrane  must 
be  examined  after  syringing  out  and  drying  the  meatus.  In  practically  every 
case  a  perforation  will  be  found,  though  occasionally  the  pus  may  make  its  way 
along  some  bony  track  which  opens  into  the  external  auditory  meatus.  The 
position  of  the  perforation  should  be  ascertained,  whether  it  is  in  the.membrana 
propria  or  in  Shrapnell's  membrane.  In  the  latter  case  the  suppuration  occurs 
chiefly  in  the  attic,  and  the  ossicles  are  likely  to  be  carious.  Generally  speaking, 
perforations  in  the  anterior  portion  of  the  membrana  propria  are  of  less  serious 
nature  than  those  in  the  posterior  portion.  The  presence  of  polypi  or  granu- 
lations must  be  noted,  and  if  possible  the  site  from  which  they  spring  must  be 
determined. 

In  addition  to  the  above  causes  of  an  aural  discharge,  abscesses  in  adjacent 
structures  may  occasionally  burst  into,  and  lead  to  a  copious  discharge  of  pus 
through,  the  external  auditory  meatus.  An  acute  mastoid  abscess  may  discharge 
in  this  way  through  a  sinus  which  opens  on  the  posterior  aspect  of  the  meatus. 
In  chronic  mastoid  suppuration,  pus  may  make  its  way  from  the  mastoid  air- 
cells  in  a  similar  manner.  Rarely  a  cerebral  abscess  in  the  temporo- sphenoidal 
lobe  may  burst  into  the  tympanum  and  discharge  through  the  external  auditory 
meatus.  Occasionally,  an  abscess  in  the  parotid  gland  may  extend  backwards 
and  discharge  through  the  anterior  wall  of  the  meatus.  A  similar  result  may 
happen  with  an  abscess  which  originates  in  disease  of  the  temporo-mandibular 
joint.  Philip  Turner. 


OXALURIA. — This  term  is  generally  used  to  include  any  condition  under 
which  crystals  of  calcium  oxalate  are  to  be  found  on  microscopical  examination 
of  the  urine.  They  occur  in  two  forms,  of  which  by  far  the  most  characteristic 
and  common  is  familiarly  described  as  the  "  envelope  "  crystal — really  a  regular 

octahedron  ;  when  crystallization  has 
occurred  imperfectly,  a  spheroidal  form 
with  a  central  constriction  like  that  of 
a  "dumb-bell"  may  occasionally  be 
seen  (Fig.  130).  Either  form  is  trans- 
parent, highly  refractive,  and  usually 
quite  colourless.  If  the  precipitate  is 
suflicjpntly  abundant  to  be  visible  to 
the  naked  eye,  it  is  generally  pure 
white  ;  it  often  comes  down  after  more 
or  less  mucus  has  already  gone  to  the 
bottom  of  the  specimen  glass,  so  that 
a  dense  white  layer  is  seen  lying  on  the 
top  of  a  less  white  flocculent  mass  ;  this 
appearance  has  been  described  as  that 
of  the  "  powdered  wig." 
The  crystals  are  soluble  in  any  mineral  acid,  but  they  are  insoluble  in  water 
or  ordinary  acetic  acid  solution.  They  may  be  found  in  any  urine,  whether 
acid  or  alkaline,  but  are  commonest  in  acid  urines.  They  may  be  in  the  urine 
when  it  is  voided  ;  more  often  they  form  as  the  urine  stands  in  the  specimen 
glass,  and  it  is  important  to  remember  that,  if  a  slide  is  prepared  from  the 
centrifugalized  deposit  of  a  urine  and  allowed  to  stand  for  a  while  before  it 
is  examined  under  the  microscope,  numbers  of  very  minute  calcium  oxalate 
crystals  may  appear,  even  when  none  are  to  be  found  in  a  similar  specimen 
examined  at  once. 


-Varieties  of  crystals   of  calcium 
oxalate  (high  power). 


OXALURIA  4TL 


The  deposition  of  calcium  oxalate  is  by  no  means  necessarily  pathological  ; 
indeed  upwards  of  20  milligrams  are  excreted  in  the  urine  daily,  even  35 
milligrams  not  being  bej-ond  the  normal  limit.  So  long  as  the  oxalic  acid  is 
combined  to  form  soluble  salts  such  as  those  of  sodium  or  potassium,  no 
envelope  crj^stals  appear,  but  it  is  common  for  the  proportion  of  oxalic  to 
other  acids  on  the  one  hand,  and  of  calcium  to  other  bases  upon  the  other, 
to  be  such  that  the  insoluble  oxalate  of  lime  is  formed  and  precipitated,  either 
in  the  urinar^r  passages  or  after  the  specimen  has  been  voided. 

Circumstances  which  cause  an  absolute  increase  in  the  amount  of  oxalic 
acid  excreted  will  naturally  increase  the  tendency  to  visible  oxaluria.  The 
best-known  exogenous  sources  of  oxalic  acid  are  certain  vegetable  products, 
of  which  the  following  in  particular  may  be  mentioned  :  tea,  cocoa,  spinach, 
gooseberries,  figs,  coffee,  chicory,  chocolate,  peas,  beans,  beetroot,  artichokes, 
tomatoes,  and  beer.  It  is  probable,  however,  that  there  is  also  an  endogenous 
source  for  oxalate  of  lime,  for  even  a  starving  person  still  excretes  oxalates  in 
his  urine.  The  source  of  these  is  still  obscure,  but  it  is  held  by  many  that  uric 
acid,  creatinin,  and  possibly  other  alhed  substances,  may  be  a  source  of 
oxalate.  The  fact  that  uric  acid  cr\'stals  and  those  of  oxalate  of  lime  are  to  be 
seen  not  infrequently^,  either  together,  or  alternating  with  one  another  on 
different  days,  would  seem  to  favour  this  view,  and  gouty  persons  are  perhaps 
more  liable  than  others  to  oxaluria.  Calcium  oxalate  crystals  may  be  found 
in  the  urine  at  any  age,  however,  from  infanc}^  onwards. 

In  great  part,  oxaluria  is  physiological  and  dietetic  ;  nevertheless  there  is  a 
decided  tendency  now-a-days  to  revert  to  the  older  view  that  when  a  patient's 
metaboHsm  is  such  as  to  cause  a  constant  deposition  of  calcium  oxalate  cry'Stals 
in  the  urine,  it  is  also  apt  to  lead  to  a  group  of  symptoms  of  which  nervous 
dyspepsia,  neurasthenia,  and  even  hypochondriasis  are  the  chief.  The  dis- 
covery of  calcium  oxalate  crystals  in  the  urine  of  such  patients  therefore  might 
be  of  assistance  in  determining  the  nature  of  the  dietetic  and  other  treatment 
that  should  be  adopted  for  the  cure  of  the  other  general  symptoms. 

There  are  at  least  three  other  ways  in  which  the  knowledge  of  the  existence 
of  oxaluria  may  be  decidedly  important  : — 

1.  Concerns  patients  who  present  symptoms  that  may  be  due  to  renal  or 
vesical  calculus.  Microscopical  examination  of  the  centrifugalized  urinary^ 
deposits  in  such  a  case  may  serve  to  detect  not  only  pus  cells  and  red  blood- 
discs,  but  also  calcium  oxalate  cr^-stals  that,  instead  of  being  all  separate  from 
one  another,  as  is  the  rule  in  a  dietetic  or  neurasthenic  case,  may  be  obviously 
agglomerated  into  minute  calculi  ;  if  there  are  clinical  symptoms  of  stone, 
the  discovery  of  microscopic  aggregations  of  crv^stals  is  highly  suggestive  of 
there  being  a  larger  calculus  present  somewhere  in  the  urinary  system. 

2.  If  oxalate  crystals  are  deposited  in  numbers  in  the  urine  whilst  it  is  still 
in  the  bladder,  irritability^  of  the  latter  is  apt  to  follow,  with  a  tendency  to 
undue  frequency  of  micturition  ;  such  oxaluria  is  not  altogether  infrequent 
as  the  cause  for  persistent  nocturnal  enuresis  in  girls  and  boys. 

3.  In  some  ways  this  is  one  of  the  most  important  features  of  oxaluria.  The 
same  irritation  by  oxaluria  that  may  produce  the  nocturnal  enuresis  in  girls 
and  boys  may  lead  to  the  urine  of  adults  containing  a  considerable  excess  of 
nucleo-proteid,  and,  in  the  male,  numbers  of  spermatozoa.  There  may  be  no 
symptoms  whatever,  and  in  that  case  the  only  importance  of  the  condition 
lies  in  the  fact  that  the  nucleo-proteid  may  be  mistaken  for  albumin  ;  for  if 
the  boiling  test  is  applied  to  a  specimen  containing  nucleo-proteid  in  excess, 
a  cloud  of  phosphates  may  come  down,  and  then  when  acetic  acid  is  added 
to  dissolve  up  this  cloud,  a  residual  haze  may  remain  behind  because  the  acetic 
acid,  at  the  same  time  that  it  dissolves  the  phosphates,  precipitates  some  of 


472  PAIN,     ABDOMINAL 


the  nucleo-proteid.  This  source  of  fallacy  may  be  obviated  in  either  of  two 
ways  :  the  haze  of  nucleo-proteid  will  clear  up  on  addition  of  a  drop  of  nitric 
acid,  whereas  a  similar  haze,  due  to  albumin,  will  remain  ;  or,  to  make  quite 
certain,  three  test-tubes  may  be  used  :  into  the  first,  put  plain  urine  without 
any  boiling  ;  into  the  second,  urine  plus  acetic  acid  without  boiling  ;  and  into 
the  third,  urine  plus  acetic  acid,  the  mixture  being  thoroughly  boiled.  If  the 
haze  is  due  to  a  nucleo-proteid  only,  it  will  be  equally  marked  in  the  second 
and  third  tubes,  whereas  if  there  is  albumin  as  well,  the  haze  in  tube  three  will 
be  denser  than  that  in  tube  two. 

Just  as  oxaluria  may  lead  to  nocturnal  enuresis  in  adolescents,  so  in  a  few 
adult  males  it  has  been  regarded  as  a  factor  in  the  causation  of  excessive 
nocturnal  emissions  or  spermatorrhoea.  Herbert  French. 

PAIN,  ABDOMINAL  (GENERAL).— Most  abdominal  pain  is  local,  e.g.,  that 
due  to  a  renal  or  biliary  stone.  The  most  serious  cause  of  general  abdominal 
pain  is  acute  general  peritonitis.  If  this  be  perforative,  at  first  the  pain  is  local 
at  the  seat  of  perforation,  and  the  abdomen  is  retracted  ;  but  soon,  whether  the 
peritonitis  is  or  is  not  perforative,  the  abdomen  becomes  distended  from 
paralysis  of  the  bowel,  and  the  pain  becomes  general.  Increase  in  the  rate  of 
the  pulse  and  immobility  of  the  abdominal  wall  on  breathing  are  most  important 
signs  for  diagnosis.  Quickly  the  pulse  becomes  more  rapid  and  wiry,  the  patient 
looks  ill,  the  temperature  is  raised  a  little,  the  bowels  are  constipated,  and 
there  is  some  nausea,  perhaps  vomiting.  There  is  often  a  rapidly  progressive 
leucocytosis.  It  is  often  said  that  the  drawing  up  of  the  knees  on  to  the  abdomen 
is  of  importance  ;  sometimes  it  is  very  striking,  but  in  many  patients  with  acute  - 
general  peritonitis  the  legs  are  not  drawn  up,  and  they  may  be  drawn  up  in  other 
conditions.  The  early  diagnosis  of  acute  general  peritonitis  is  of  the  utmost 
importance.  It  has  been  estimated  that  in  many  cases  each  hour's  delay  in 
opening  the  abdomen  means  that  the  chances  of  death  are  increased  5  per  cent. 
Morphia  should  never  be  given  when  it  is  thought  there  is  even  a  remote 
possibility  that  any  illness  is  acute  general  peritonitis,  for  it  makes  the  subsequent 
diagnosis  so  difficult.  The  onset  of  pneumonia  is  sometimes  announced  by  an 
abdominal  pain  so  acute  that  the  patient  is  thought  to  have  acute  general 
peritonitis. 

Chronic  General  Peritonitis. — This  usually  causes  a  dull  feeling  of  heaviness 
rather  than  a  general  acute  pain.  The  chief  points  to  be  observed  in  arriving 
at  a  diagnosis  are  the  chronicity  of  the  trouble,  the  presence  of  fluid  in  the 
peritoneal  cavity,  and  the  fact  that  masses  of  thickened  peritoneum  can  often 
be  felt.  The  most  usual  sign  is  the  puckered,  thickened  omentum,  which  is  to  be 
felt  as  a  tumour  lying  transversely  at  the  middle  of  the  abdomen  ;  sometimes 
other  lumps  can  also  be  felt.  It  must  not  be  forgotten  that  an  infiltration  of 
the  stomach  with  new  growth  will  give  rise  to  a  tumour  lying  transversely  across 
the  abdomen,  and  so  may  a  diseased  colon.  The  presence  of  these  peritoneal 
thickenings  often  gives  the  abdomen  a  dough-like  feel.  The  commonest  cause 
of  chronic  peritonitis  is  tubercle.  Often  there  is  no  discoverable  tubercle 
elsewhere  to  help  as  to  a  diagnosis,  but  the  hectic,  irregular  temperature  maj^ 
be  a  guide.  As  the  fluid  increases,  the  umbilicus  becomes  flattened  out  (see 
Ascites),  and  in  tuberculous  peritonitis  sometimes  red. 

Intestinal  Colic. — This  is  due  to  many  causes  which  lead  to  painful  contraction 
of  the  intestinal  muscles.  The  pain  is  always  paroxysmal  and  usually  recurrent, 
so  that  a  severe  attack  consists  of  frequently  recurring  paroxysms.  There  are 
all  degrees,  from  quite  a  slight  pain  to  one  that  causes  the  patient  to  shriek  and 
break  out  into  a  cold  sweat.  The  temperature  is  usually  normal,  but  is 
occasionally  slightly  raised.     The  pulse  is  usually  of  normal  rate  unless  the 


PAIN,     BEARING-DOWN  473 

temperature  be  raised.  The  abdomen  is  generally  distended,  and  in  a  bad  case 
peristaltic  movements  of  the  coils  of  intestine  may  be  seen.  Often  the  abdominal 
muscles  are  reflexly  contracted  and  rigid.  The  pain  maj^  come  on  without 
warning,  or  may  be  accompanied  by  nausea,  eructations,  and  borborygmi.  It 
is  usually  felt  at  the  umbilicus,  from  which  region  in  a  severe  case  it  spreads 
over  the  whole  abdomen.  The  patient  tosses  about  in  the  severity  of  it, 
and  finally  selects  a  position  in  which  he  can  bring  pressure  to  bear  on  the 
abdominal  wall  ;  in  peritonitis  this,  so  far  from  relieving  the  abdominal  pain, 
increases  it.  Intestinal  colic  is  usually  brought  on  by  eating  some  indigestible 
article  of  food,  so  the  history  will  help  us ;  but  it  may  be  due  to  obstruction. 
In  children,  intestinal  colic  is  recognized  by  their  cries,  restlessness,  and  the 
drawing  up  of  the  legs. 

Acute  or  subacute  Intestinal  Obstruction  is  a  common  cause  of  general  abdominal 
pain,  and  requires  most  careful  diagnosis  (see  Vomiting). 

Lead  Colic. — This  is  diagnosed  by  the  symptoms  of  colic,  as  given  above, 
bv  the  history  and  occupation,  and  by  the  presence  of  other  signs  of  lead 
poisoning,  of  which  the  most  characteristic  is  a  blue  line  on  the  gums. 

Gastric  Crises  may  cause  general  abdominal  pain,  but  they  will  be  recognized 
by  the  absence  of  knee-jerks  and  other  signs  of  tabes  dorsalis. 

Abdominal  Neuralgias. — This  phrase  is  applied  to  severe  abdominal  pains 
unassociated  with  any  organic  disease.  The  greatest  caution  must  be  exercised, 
and  a  diagnosis  of  abdominal  neuralgia  must  be  looked  upon  wdth  great  supsicion, 
for  there  is  no  doubt  that  such  a  diagnosis  is  often  wrong,  the  patient  really 
having  organic  disease.  The  pain  may  be  local,  e.g.,  those  neuralgias  of  the 
kidney  which  resemble  renal  calculus,  or  it  may  be  general.  Disease  of  the 
spine  must  be  excluded  carefully.  Often  these  patients  have  neuralgia  elsewhere. 
The  cases  last  a  long  while  ;  they  are  commoner  in  women  than  men.  In  a  few, 
opening  the  abdomen  has  shown  that  the  small  intestine  or  colon  is  spasmodically 
contracted  (enterospasm),  and  indeed,  it  may  be  felt  through  the  abdominal 
wall  as  a  swelling  like  a  thick  cord.  These  patients  are  often  given  morphia, 
but  this  should  not  be  done.  It  is  not  infrequent  to  find  that  severe  abdominal 
pain  is  apparently  due  to  the  administration  of  morphia,  for  the  pain  ceases 
when  the  drug  is  withheld.     I  have  seen  two  such  cases  recently. 

General  Visceroptosis  often  causes  a  general  dull,  dragging  abdominal  pain. 
It  can  easily  be  diagnosed  by  feeling  the  displaced  liver  or  kidney,  by  looking 
at  the  abdominal  outline  seen  from  the  side  when  the  patient  stands  up,  and  bj' 
observing  the  displaced  stomach  (see  Fig.  105,  p.  353  ;  see  also  Constipation) 
or  intestines  by  the  ;r-rays  after  the  administration  of  bismuth.       w.  Hale  White. 

PAIN,    BEARING-DOWN This  form  of  pain   is   a   very  frequent   symptom 

in  diseases  of  women,  and  is  an  associate  of  many  pelvic  conditions.  It  is  impos- 
sible in  many  instances  to  dissociate  it  from  chronic  aching  pain  ;  but  it  is  not 
every  chronic  pain  which  has  the  bearing-down  character.  It  is  usually  the 
result  of  impaction  of  some  pelvic  structure,  and  owes  its  character  more  parti- 
cularly to  pressure  on  the  rectum,  and  sometimes  on  the  bladder.  Displacement 
of  pelvic  organs,  or  even  simple  congestion  of  them,  will  sometimes  produce  it. 
Its  source  is  not  always  strictly  gynsecological,  as  it  may  be  the  result  of  actual 
rectal  disease,  such  as  cancer,  ulcer,  or  haemorrhoids.  It  is  thus  closely  associ- 
ated with  rectal  tenesmus.  The  commonest  cause  is,  perhaps,  backward  dis- 
placement of  the  uterus,  and  it  is  most  marked  in  retroversion  of  the  pregnant 
uterus,  especially  if  impaction  of  the  organ  occurs.  Impaction  of  a  pelvic 
tumour  may  produce  it,  uterine  fibroids,  ovarian  tumours,  and  pelvic  haematocele 
being  the  chief  swellings  which  give  rise  to  it.  These,  no  doubt,  produce  pain 
of  a  different  character  in  addition,  due  to  pressure  on  nerves  ;   but  the  bearing- 


474  PAIX,     BEARIXG-DOWN 

down  character  is  more  particularly  referred  to  the  rectum,  hence  it  is  commonh^ 
believed  to  have  some  relation  to  pressure  on  the  rectum.  A  pelvic  abscess  of 
peritoneal  origin  is  an  unusual  impacted  swelling,  which  gives  rise  to  very  severe 
bearing-down  pain  :  impacted,  because  it  is  bound  down  by  peritoneal  adhe- 
sions, and  exercising  pressure  because  of  the  tension  in  it.  The  bearing-down 
character  becomes  most  marked  if  the  abscess  involves  the  rectal  wall,  as  it  so 
frequenth^  does,  causing  a  flow  of  mucus  and  much  irritation  of  the  rectum. 

The  differential  diagnosis  of  the  causes  of  this  t^-pe  of  pain  can  only  be  made 
after  a  complete  pelvic  examination  b}'  abdominal  palpation,  and  bimanual 
examination  by  the  vaginal  and  by  the  rectal  touch.  Further,  it  may  be 
necessary  to  examine  the  bladder  by  the  cystoscope,  or  the  rectum  by  the  finger 
or  sigmoidoscope.  The  difl'erential  diagnosis  of  the  pelvic  disorders  mentioned 
is  discussed  under  Swelling,  Pelvic.  t.  G.  Stevens. 

PAIN,  GIRDLE.— (See  Girdle  Pain.) 

PAIN,  INTERSCAPULAR.— Interscapular  pain  may  be  due  to  caries  of  the 
dorsal  vertehrcs.  There  will  then  be  stiffness  of  the  back,  with  perhaps  promi- 
nence of  the  spines  of  one  or  more  of  the  dorsal  vertebrae,  with  tenderness  on 
pressure  over  them,  or  on  applying  a  hot  sponge  down  the  back  (see  Tenderness 
IN  THE  Spine)  .     A  skiagram  may  reveal  disease  of  the  bones. 

A  tumour  of  the  cord  may  cause  pain  between  the  scapulas  ;  in  that  case  there 
will  probabh'  be  indications  of  pressure  on  nerve  roots,  and  perhaps  on  the  cord 
itself — exaggeration  of  the  knee-jerks,  bladder  sj-mptoms,  etc. 

Aneurysm  of  the  descending  aorta,  or  a  mediastinal  tumour,  may  cause  severe 
interscapular  pain.  In  such  cases  there  are  often  indications  of  pressure  on  the 
oesophagus,  or  upon  a  bronchus  ;  and  an  examination  with  the  ;ir-rays  may 
make  the  diagnosis  clear. 

Interscapular  pain  is  often  felt  in  cases  of  gastric  ulcer,  or  carcinoma  of  the 
cardiac  end  of  the  stomach,  and  sometimes  also  when  gall-stones  are  present. 
(For  differential  diagnosis,  see  Pain  in  the  Epigastrium,  and  Pain  in  the 
Hypochondrium,  Right).  In  such  cases  there  is  not  uncommonly  tenderness 
in  the  neighbourhood  of  one  or  two  of  the  lower  dorsal  spines.  An  accumulation 
of  gas  in  the  fundus  of  the  stomach  may  also  cause  a  pain  between  the  scapula. 
(See  Indigestion  ;  and  Flatulence.)  Robert  Hutchison. 

PAIN  IN  THE  ANKLE.— (See  Joints.  Affections  of.) 

PAIN  IN  THE   ARM. — (See  Pain  in  the  Extremity,  Upper.) 

PAIN  IN  THE  BACK. — From  occiput  to  anus,  a  pain  referred  to  the  spinal 
axis  is  a  frequent  complaint,  and  the  diagnosis  of  its  cause  is  very  often  a  most 
troublesome  problem. 

We  start  with  the  broad  generalization  that  a  pain  in  any  area  must  be  due 
to  irritation,  either  of  the  trunk  or  the  terminals  of  the  sensory  nerves  supplying 
the  spot,  or,  it  may  be,  of  a  nerve  which  is  in  immediate  anastomosis  with  that 
to  the  painful  area.  Pain  referred  to  any  one  spot  and  due  to  central  (cerebral) 
irritation  is  so  rare  as  not  to  require  mention  here  (except  that  arising  from 
gross  cerebral  trouble,  which  will  be  referred  to  b}'  the  patient  as  headache)  ; 
and  applying  this  principle  to  the  spinal  axis,  we  find  that  the  sensory  divisions 
of  the  spinal  nerves,  from  the  first  cervical  to  the  coccj'geal,  all  divide  into 
branches  for  {a)  the  skin,  [b]  the  bones  and  meninges  of  the  spinal  canal,  (c)  the 
muscles  lying  on  the  vertebral  column,  and  {d)'  the  viscera  contained  in  the 
cranium,  neck,  thorax,  abdomen,  and  pelvis.  Consequently,  to  interpret  rightly 
the  meaning  of  a  pain  in  the  back,  we  must  look  not  only  to  general  conditions 


PAIN     IN     THE     BACK  475 

affecting  the  blood  (fevers  of  all  sorts  are  often  associated  with  a  general  backache 
as  a  prominent  feature),  but  to  the  condition  of  the  organs  contained  in  that 
spinal  segment  (or  the  one  immediately  above  or  below  it)  in  which  the  pain  is 
complained  of. 

Another  very  useful  generalization  is  this.  We  may  draw  a  distinction 
between  a  pain  spontaneously  complained  of  in  a  spot  not  associated  with 
tenderness  on  firm  pressure,  and  one  in  which  such  tenderness  is  present.  In 
the  latter  case,  the  tender  spot  is  located  in  all  probability  as  the  seat  of  the 
trouble  ;  in  the  former  case  it  is  probable  that  the  pain  is  one  referred  by  the 
brain  to  the  spot,  but  not  really  arising  there — a  "  referred  pain,"  as  it  is  termed  ; 
and  this  is  the  more  likely  if  we  find  that  the  skin  over  the  area  is  very  sensitive 
to  light  stimulus,  but  not  more  sensitive — perhaps  even  less  so — to  a  stimulus 
which  is  rather  rougher,  a  pressure  rather  firmer  than  a  light  touch.  Carrying 
this  to  its  extreme,  we  have  the  paradoxical  phenomenon  of  severe  pain  being 
complained  of  in  an  area  the  skin  over  which  is  absolutely  ansesthetic  ;  this 
indicates  a  complete  lesion  of  the  trunk  of  the  nerve  concerned. 

Coming  now  to  the  practical  diagnosis  of  a  pain  in  the  back,  we  can  pretty 
easily  and  accurately  eliminate  those  cases  owning  a  pyrexial  origin  by  observing 
that  the  patient  not  only  complains  of  a  pain  in  the  back  but  looks  acutely  ill ; 
if  he  does  so,  take  his  temperature,  and  if  this  be  found  to  be  raised  above  100°  F., 
we  may  be  sure  that  we  have  to  deal  with  a  zymotic  disease  at  its  onset,  with 
meningitis,  perhaps  myelitis  or  acute  rheumatism,  or  at  any  rate  with  a  con- 
dition in  which  the  pain  in  the  back  is  only  an  obtrusive  but  misleading 
symptom,  to  which  will  very  soon  be  added  some  of  the  signs  distinctive  of 
the  disease. 

Such  a  history  is,  however,  comparatively  uncommon,  and  we  have  much 
more  usually  to  deal  with  cases  in  which  the  patient,  except  for  the  pain  in  the 
back,  is  comparatively  well,  and  he  is  concerned  to  know  what  it  means. 

Two  or  three  questions  immediately  arise  in  such  a  case,  the  answers  to  which 
will  throw  very  great  light  on  the  nature  of  the  trouble.  Obviou.sly,  the  first 
thing  is  to  ask  him  to  locate  the  pain  ;  the  next  to  enquire  how  did  it  arise, 
i.e.,  did  it  come  suddenly  after  a  blow  ?  after  some  unusual  exertion  ?  after 
some  unintentional  movement,  say  of  the  head  and  neck,  or  a  slip  off  a  pavement  ? 
And  then  again,  how  long  has  he  had  it,  and  has  he  ever  had  a  similar  pain  before  ? 
Again  we  proceed  to  ask,  is  it  constant  or  intermittent  ?  If  the  latter,  what 
action  on  the  patient's  part  will  cause  it  to  return,  or  what  position  will  ease  it 
when  it  is  present  ? 

It  is  but  seldom  that  we  have  not  by  these  questions  arrived  at  a  provisional 
diagnosis  in  our  own  minds,  but  we  must  never  omit  to  make  a  careful  physical 
examination  for  points  which  will  corroborate  or  correct  this  diagnosis. 

Inspection  may  reveal  skin  conditions,  such  as  a  patch  of  herpes,  etc.,  which 
may  be  either  the  real  cause  or  an  outward  manifestation  of  a  cord  or  bone  lesion  ; 
swellings  or  redness  may  be  apparent,  or  undue  prominence  of  a  spinal  process  ; 
bruises  or  purpura  may  be  seen,  or  a  pulsating  tumour  proving  aneurysm  ;  glands 
may  be  visible  in  the  posterior  triangle  of  the  neck.  It  will  also  reveal  any 
trace  of  lateral  curvature,  a  frequent  source  of  backache  in  young  people. 

Palpation  may  reveal  great  tenderness  on  pressure,  either  of  muscles  or 
bone  ;  it  may  show  fluctuation  (remember  that  this  fluctuation  must  be  vertical, 
not  lateral,  to  be  very  reliable)  ;  per  contra,  it  may  prove  the  absence  of  tender- 
ness, and  may  also  show  hypersesthesia  of  the  skin,  suggestive  of  pain  referred 
from  a  viscus.  A  very  useful  hint  is  frequently  derived  from  the  observation  of 
the  results  of  palpation  ;  sometimes  these  can  better  be  seen  when  a  special 
stimulus  such  as  an  electric  current  or  persistent  rubbing  is  applied  to  the  skin  ; 
thus  it  may  be  found  that  over  one  small  area  a  blush  is  more  easily  raised,  or  is 


476  PAIN     IN     THE     BACK 

more  persistent,  than  elsewhere  ;  this  is  strong  evidence  pointing  to  visceral 
disease  as  the  cause  of  the  pain ;  it  is  due  to,  and  proves  disorganization 
ofj  the  sympathetic  nerve  distributed  to  the  viscus.  This  method  will  also 
reveal  hypersesthesia  or  anaesthesia  if  testing  be  conducted  with  a  light  touch 
and  a  pin. 

The  next  step  is  to  apply  tests  for  disease  of  the  bony  walls  of  the  canal  ;  tap 
each  spinal  process  in  turn  with  a  percussion  hammer,  and  note  whether  pain  is 
elicited  at  any  spot  ;  jar  the  heels  alternately  with  the  leg  held  rigid  from  the 
hip  ;  letting  the  patient  come  down  on  the  heels  himself  is  more  risky  and  less 
satisfactory  ;    also  test  for  pain  on  resisted  movements  of  the  limbs  or  trunk. 

We  may  then  find  if  pain  is  aroused  by  movements  of  any  kind — flexion, 
extension,  and  rotation. 

Lastly,  with  the  patient  lying  on  his  back,  a  careful  examination  must  be 
made  from  the  front  in  the  ordinary  way  for  evidence  of  any  visceral  disease, 
or  of  growth  of  any  kind. 

If  the  cause  of  the  trouble  should  still  remain  obscure,  or  perhaps  in  any  case 
for  future  reference,  two  or  three  ;(r-ray  photographs  of  the  painful  area  will 
be  taken. 

We  may  now  consider  the  reverse  order  of  procedure,  and  ask  what  are  the 
local  diseases  associated  with  pain  in  the  back,  and  what  are  their  distinguishing 
points.     We  may  enumerate  these  according  to  the  structures  involved,  thus  : 

Skin. — Ulcers,  herpes,  etc.  ;  obvious  on  inspection  and  requiring  no  further 
notice  here. 

Muscles. — Abscesses,  trauma,  acute  inflammations  ;  so-called  rheumatism, 
stiff  neck,  lumbago,  etc.  ;    simple  debility  ;    overwork. 

Joints. — Rheumatism  ;   implication  in  caries  or  in  rheumatoid  arthritis,  etc. 

Bones. — Caries,  aneurysm,  and  other  growths  eroding,  invading,  or  primary  ; 
trauma. 

Meninges. — Inflammations  and  growths. 

Cord  itself. — Tumours  ;    inilammation  ;    trauma. 

Viscera  in  front. — Aneurysm  ;  gastric  ulcers  ;  dyspepsia  ;  uterine  trouble  or 
ovarian  ;    appendix  ;    rectum  ;    bladder  and  vesiculae  seminales  ;    kidneys. 

It  would  be  impossible  within  the  limits  of  this  article  to  give  a  complete 
differential  diagnosis  of  all  the  above,  but  the  procedures  of  investigation  which 
we  have  already  noticed  will  almost  certainly  enable  us  to  come  to  some  con- 
clusion, and  it  remains  here  only  to  indicate  a  few  of  the  more  special  points  in 
differential  indications,  and  a  few  of  the  commoner  mistakes. 

Lumbago  v.  Tumours. — If  a  patient  complains  of  "  lumbago  "  of  some  standing, 
it  is  essential  to  test  the  nervous  system,  the  knee-jerks  and  other  leg  reflexes, 
and  to  contrast  them  on  the  two  sides ;  to  look  for  wasting  of  muscles,  especially 
on  one  side,  to  investigate  the  power  of  the  muscles  in  walking  and  in  simpler 
movements  ;  to  examine  the  pelvic  organs  and  the  abdomen  for  growths  of  any 
kind.  Only  when  all  these  points  yield  negative  results  can  we  permit  our- 
selves to  think  that  it  is  simple  lumbago.  Lumbago  is  almost  always  on  both 
sides  ;  a  tumour  most  frequently  gives  one-sided  symptoms  first,  though  they 
may  gradually  spread  to  the  other  side  later.  Rectal  examination  should  never 
be  omitted,  and  in  suitable  cases  vaginal  examination  should  be  made  also. 

Aneurysm  in  Thorax  v.  Indigestion,  etc. — It  cannot  be  said  that  this  is  a  common 
mistake,  for  aneurysms  eroding  the  thoracic  vertebrae  are  certainly  not  very 
common  ;  but  the  mistake  is  a  very  serious  one.  The  difficulty  is  that,  when 
an  aneurysm  behaves  in  this  way,  it  is  extremely  hard  to  recognize  it  when  it 
arises  frona  the  descending  arch  ;  bruits  are  usually  absent,  and  it  is  perhaps 
only  when  a  pulsating  tumour  in  the  back  appears,  that  the  diagnosis  is  made. 
The  severity,  the  dull,  aching  character,  and  the  persistence  of  the  pain  are  the 


PAIN     IN     THE     CHEST  477 


main  features  that  may  help  to  suggest  such  a  serious  cause.  The  patient 
should  be  investigated  by  the  A--rays,  either  by  photograph  or  screen. 

Occipital  Headaches  v.  Caries  of  Spine. — Owing  to  the  frequency  with  which 
delicate  patients,  particularly  women  and  young  subjects,  complain  of  pain  in 
the  neck,  it  is  well  to  draw  special  attention  to  this  locality,  though  diagnosis 
is  fairly  easy.  The  occipital  headache  due  to  a  tumour  is  unmistakable  by  its 
severity,  and  the  almost  invariable  association  of  vomiting  and  optic  neuritis. 
The  dull,  constant,  wearing  pain  of  caries,  worse  on  any  slight  jar,  and  the  fixed 
position  in  which  the  patient  holds  the  head,  are  sufficient  to  arouse  suspicion, 
and  then  the  ;ir-rays  applied  to  this  region  will  almost  certainly  clear  up  the 
diagnosis.  A  simple  stiff  neck  is  acute  in  its  onset,  and  generally  preceded  by 
a  definite  history  of  sitting  in  a  draught.  A  "  crick  in  the  neck,"  possibly  the 
equivalent  for  the  rupture  of  a  few  ligamentous  or  muscular  fibres,  can  be 
recognized  by  its  sudden  occurrence  in  the  midst  of  health  with  no  history  of 
previous  pain. 

Debility  in  Youth,  or  Lateral  Curvature  v.  Caries. — The  shapes  of  the  curves  are 
usually  sufficient ;  but  care  must  be  taken  to  examine  the  integrity  of  the  bones 
by  the  tests  given  above,  and  one  must  not  be  satisfied  until  all  the  bone  tests 
have  been  tried  and  found  negative.  Local  rigidity  over  the  painful  area,  best 
tested  by  making  the  patient  stoop  and  rise  again,  whilst  the  physician  feels 
the  spine  with  the  fiat  of  the  hand,  is  strong  evidence,  if  persistent,  of  caries. 

Pelvic  Organ  Trouble  v.  Lumbago. — This  mistake  is  of  course  more  frequent 
in  women  than  in  men.  The  only  rule  to  be  laid  down  is  always  to  think  of 
these  organs  when  a  woman  complains  of  "  lumbago  "  or  "  backache,"  and  to 
enquire  carefully  into  the  history  of  confinements  and  menstruation,  and  to 
make  a  thorough  examination  of  the  organs. 

In  conclusion,  more  mistakes  are  made  in  the  diagnosis  of  a  pam  in  the  back 
from  want  of  thought  and  from  carelessness  in  examination,  than  from  any 
inherent  difficulties  in  the  diagnosis,  at  any  rate  in  so  far  as  the  more  serious 
causes  are  concerned.  Fred.  J .  Smith. 

PAIN  IN  THE  CHEST. — Chest-pains  are  very  common  in  all  sorts  of  disorders. 
Except  in  the  case  of  highly  intelligent  persons,  or  of  patients  whose  fortune  it 
has  been  to  have  a  large  experience  of  chest-pains  due  to  various  causes, 
no  great  amount  of  help  in  diagnosing  the  cause  of  such  pains  can  be 
obtained  by  enquiring  into  their  individual  characters.  More  assistance  is 
furnished  by  investigation  of  the  circumstances  in  which  the  pain  is  chiefly  felt, 
and  the  conditions  that  ease  or  aggravate  it.  Thus  chest-pains  due  to  disease 
of  the  heart  will  be  increased  by  anything  that  makes  the  heart  beat  more 
rapidly  ;  those  due  to  lung-disease  by  anything  causing  the  patient  to  breathe 
faster  or  cough  ;  those  caused  by  disorders  of  the  stomach  will  generally  be 
aggravated  by  or  soon  after  taking  food.  For  clinical  purposes,  pains  in  the 
chest  are  best  classified  according  to  their  pathology,  and  the  nature  and 
situation  of  the  disorders  to  which  they  are  due.  For  pains  in  the  back  wall 
of  the  chest,  see  Pain  in  the  Back. 

Pains  in  the  chest  may  be  classified  as  follows  : — 

I.   Pains  due  to  Diseases  of  the  Tissues  composing  the  Thoracic  Walls  ;   the 

pain  is  in  most  cases  a  direct  pain  : — 

Inflammation  of  the  skin  and  sub-   j  Neuralgia  :    mastodynia 

cutaneous  tissues  Herpes  zoster 

Adiposis  dolorosa  ;   neurofibroma-   '  Pressure  on  nerves 

tosis  Disease  of  the  bones  of  the  chest. 


Myalgia  :   pleurodynia  :   stitch 


478  PAIN    IN     THE     CHEST 

2.   Diseases   of  the   Thoracic  or  Abdominal  Viscera  ;    the    pain    is   in   most 
cases  a  referred  pain  : — • 

Pleurisy ;  diaphragmatic  pleurisy  ; 

empyema 
Pneumothorax 


Pneumonia 

Heart   disease — Valvular  disease, 

aortitis ;    angina   pectoris,  true 

and  false 


Pericarditis 

Aneurysm  ;    dissecting   aneur3'sm 

Mediastinal  new  growths 

Mediastinitis 

Qisophageal  obstruction 

Diseases  of  the  spinal  cord. 


I.  Diseases  of  the  Thoracic  Wall. — Pain  in  the  chest  due  to  inflammation  of 
its  superficial  tissues  should  not  be  hard  to  diagnose.  The  pain  will  be  confined 
to  the  inflamed  parts  and  their  immediate  neighbourhood,  and  the  other  three 
cardinal  signs  of  inflammation — heat,  redness,  swelling — will  not  be  absent. 
In  most  cases  a  superficial  wound  or  abrasion  will  be  found  ;  in  others,  the 
inflammation  will  have  spread  to  the  surface  from  some  deep-seated  lesion, 
caries  of  a  rib,  for  example,  or  an  empyema  or  hepatic  abscess,  or  a  metastatic 
abscess  arising  in  the  course  of  pyaemia.  The  diagnosis  must  be  made  on  general 
lines  in  these  unusual  cases.  The  inflammatory  phenomena  of  herpes  zoster 
are  considered  below. 

The  very  rare  condition  known  as  adiposis  dolorosa,  or  Dercum's  disease,  is 
characterized  by  symmetrical  and  painful  deposits  of  fat  about  the  body  and 
limbs.  It  occurs  in  middle-aged  women  of  full  habit.  Neurofibromatosis  is 
characterized  by  the  growth  of  multiple  benign  false  neuromata  on  the  nerves, 
which  give  rise  to  pain  ;  but  they  are  not  tender  on  pressure,  and  so  contrast 
with  the  single  false  neuromas,  which  equally  give  rise  to  pain  over  the  area 
of  distribution  of  the  nerves  on  which  they  are  situated. 

When  pain  is  felt  in  the  intercostal  or  other  muscles  about  the  chest,  and  can 
be  referred  to  nothing  more  definite  than  "  muscular  rheumatism,"  the  condition 
is  referred  to  as  one  of  myalgia  or  pleurodynia.  Tenderness  of  the  affected 
muscles  is  the  only  physical  sign  present,  and  it  is  important  that  graver  mischief, 
such  as  pleurisy,  should  be  excluded  before  the  diagnosis  of  pleurodynia  is  made. 
The  sudden  pain  in  the  side  familiar  to  untrained  athletes  as  stitch  comes  on  after 
sudden  exertion,  and  is  in  all  probability  due  to  overstrain  of  the  fibres  of  part 
of  an  intercostal  muscle.  All  these  muscular  pains  are  relieved  by  rest  or 
pressure,  and  aggravated  by  exertion. 

Pains  in  the  chest  may  be  due  to  neuralgia,  a  term  which  is  theoretically 
applied  to  pain  felt  in  a  nerve  that  shows  no  evidence  of  active  or  old  disease. 
Practically,  however,  neuralgia  is  the  name  also  given  to  nerve-pains  that 
follow  organic  disease  both  in  the  nerve  itself  (herpes,  neuritis,  etc.)  and  in 
other  parts  of  the  body  (gout,  tabes,  etc.)  In  intercostal  neuralgia  the  pain 
is  felt  along  the  course  and  distribution  of  one  or  more  of  the  intercostal  nerves. 
There  is  marked  tenderness  on  pressure  in  the  affected  intercostal  space,  with 
three  points  of  maximum  tenderness  corresponding  to  the  posterior  primary, 
lateral  cutaneous,  and  anterior  cutaneous  branches  of  the  nerve,  given  off  near 
the  vertebral  spines,  the  mid-axillary  region,  and  the  costosternal  articulations. 
The  pain  is  increased  by  movement  or  breathing.  Unilateral  intercostal 
neuralgia  often  follows  herpes,  and  must  be  carefully  distinguished  from  pains 
that  may  be  felt  in  organic  disease,  such  as  tabes,  aneurysm  or  mediastinal 
tumour,  and  vertebral  caries,  in  which  the  intercostal  nerve  is  directly  or 
indirectly  involved.  In  phrenic  or  diaphragmatic  neuralgia,  a  rare  condition,  the 
pain  is  felt  in  the  lower  part  of  the  thorax  along  the  line  of  insertion  of  the  dia- 
phragm, which  may  be  tender  on  pressure  ;  coughing  and  breathing  are  acutely 
painful,   but  there  will  be  no  physical  signs  of  disease  except  the  tenderness 


PAIN     IN     THE     CHEST  479 

on  pressure.  The  diagnosis  must  be  made  from  diaphragmatic  pleurisy  or 
peritonitis,  acute  hepatic  or  splenic  disorders,  and  spinal  caries,  on  general  lines. 
Mastodynia,  mammary  neuralgia,  or  the  "  irritable  breast  "  of  Astley  Cooper, 
occurs  in  women  during  pregnancy  or  lactation,  or  in  connection  with  pelvic 
disease.  The  pain  is  constant,  with  paroxysmal  exacerbations,  and  its  severity 
may  lead  to  the  fear  of  cancer.  Local  changes — redness,  swelling,  tenderness 
— will  be   found  about  the  breast  and  nipple. 

Pains  in  the  chest  are  habitually  felt  in  herpes  zoster  of  the  intercostal  nerves, 
sometimes  before,  always  during,  and  often  after  the  attack  :  the  third,  fourth, 
and  fifth  intercostals  are  those  most  often  involved.  Groups  of  vesicles  arise 
over  the  area  of  distribution  of  the  affected  nerve,  filled  with  serum  and 
implanted  on  an  inflamed  base  ;  they  are  most  marked  about  the  exits  of  the 
posterior  primary,  lateral  cutaneous,  and  anterior  cutaneous  branches.  The 
axillary  glands  become  enlarged  if  the  herpes  is  above  the  seventh  dorsal  nerve, 
the  inguinal  if  it  is  below  it.  In  a  week  or  so  the  eruption  scabs  over  ;  in  all 
but  the  mild  cases,  small  whitish  scars  remain  as  permanent  evidence  of  the 
attack.  The  diagnosis  is  obvious  in  cases  presenting  the  eruption  or  its  scars, 
but  may  be  difficult  until  the  herpetic  vesicles  have  appeared.  It  is  especially 
in  older  patients  that  severe  neuralgic  pains  are  likely  to  remain  for  months 
or  years  as  a  legacy  from  herpes. 

Pains  in  the  chest  will  be  felt  whenever  there  is  pressure  on  an  intercostal 
nerve  ;  in  many  cases  such  pressure  is  bilateral,  when  the  patient  will  com- 
plain of  girdle-pains.  Injury  or  fracture  of  the  spinal  column  may  involve 
the  posterior  nerve-roots  or  the  intercostal  nerves,  either  at  once  by  the  pressure 
of  fractured  bone  or  of  effused  blood,  or  later  by  the  pressure  of  callus  ;  abscesses, 
aneurysms,  or  primary  or  secondary  new  growths,  may  press  on  the  nerves  and 
give  rise  to  severe  pain  in  their  areas  of  distribution.  In  the  great  majority  of 
cases  there  will  be  other  physical  signs  or  symptoms  to  point  to  the  diagnosis  ; 
but  where  there  are  none,  and  the  pain  is  due,  perhaps,  to  a  minute  carcinoma 
in  the  spinal  canal,  or  to  a  small  thoracic  aneurysm  that  strikes  backwards  and 
presses  on  an  intercostal  nerve,  there  is  no  little  danger  lest  the  patient  be  treated 
for  functional  disorder  or  malingering.  The  pains  are  very  severe,  and  persist 
for  months  in  spite  of  treatment,  while  the  patient  is  likely  to  lose  health,  weight, 
and  strength.  It  is  true  that  these  phenomena  may  also  be  observed  in 
functional  cases  ;  but  the  diagnosis  of  functional  disease  or  neuralgia  should 
not  be  made  until  the  most  careful  physical  examination,  including  the  use 
of  the  ;v-rays,   has  excluded  organic  disease  of  all  sorts. 

Chest-pains  are,  of  course,  common  in  inflammations  or  injuries  of  the  bones 
of  the  chest — coccal  infections,  tuberculosis,  hydatid  disease,  etc. — or  of  the 
joints  connected  with  these  bones.  In  few  such  cases  will  the  diagnosis  of 
inflammation  present  difficulty. 

2.  Diseases  of  the  Viscera. — Pain  in  the  chest  is  extremely  common  in  the 
various  diseases  of  the  thoracic  viscera,  whether  inflammatory  or  otherwise. 
In  acute  pleurisy  the  onset  is  often  insidious,  and  the  pain  felt  most  acutely  in 
the  mammary  or  axillary  region,  being  made  worse  on  breathing  deeply  or 
coughing.  The  pain  is  stitch-like,  lancinating,  described  as  resembling  "  a 
knife,"  "  stabbing,"  "  tearing  "  ;  it  is  relieved  by  anything  that  assists  in 
immobilizing  the  affected  side.  The  intercostal  spaces  are  tender  to  pressure 
in  pleurisy,  just  as  they  are  in  intercostal  myalgia.  The  diagnosis  turns  on  the 
discovery  of  other  physical  signs  of  pleurisy,  whether  with  or  without  effusion, 
particularly  of  pleural  friction-sounds.  In  diaphragmatic  pleurisy,  the  pain 
is  felt  in  two  chief  sites  :  one  near  the  costal  margin,  corresponding  to  the 
attachment  of  the  diaphragm  ;  the  other  about  the  crest  of  the  shoulder, 
corresponding  to  the  cutaneous  distribution  of  the  fourth  cervical  nerve  ;    this 


4So  PAIN     IN     THE     CHEST 

is  a  referred  pain,  due  to  afferent  stimuli  coming  up  the  phrenic  nerve  to  the 
spinal  centre  of  the  fourth  cervical  nerve.  The  pleuritic  friction  sounds  often 
fail  to  make  themselves  heard  in  diaphragmatic  pleurisy.  The  pain  in  empyema 
is  much  like  that  of  pleurisy  ;  it  should  be  noted  that  the  appearance  of  a 
pleural  effusion,  whether  serous  or  purulent,  often  coincides  with  a  diminution 
in  the  amount  of  pain  felt,  because  the  two  inflamed  pleural  surfaces  become 
separated  b}^  the  fluid  and  cease  to  be  rubbed  together  by  the  respiratory  and 
other  movements.  The  pleura  itself  appears  to  be  insensitive,  just  as  is  the 
greater  part  of  the  peritoneum  ;  no  doubt  the  pain  of  pleurisy  is  due  to  stimula- 
tion of  the  sensory  nerve-endings  in  the  periosteum,  muscles,  and  other  tissues 
of  the  intercostal  spaces.  Chronic  pleurisy  and  old  pleural  adhesions  no  doubt 
give  rise  to  much  of  the  chronic  pain  in  the  chest  and  shoulders  and  root  of  the 
neck  that  occurs  from  time  to  time  in  patients  with  pulmonary  tuberculosis. 
In  many  of  these,  no  doubt,  the  pain  is  evidence  of  spread  of  the  pulmonary 
infection  ;  in  others,  it  appears  to  depend  on  the  amount  of  coughing,  increasing 
when  the  cough  becomes  worse  ;  in  yet  others,  it  would  seem  to  depend  vaguely 
enough  upon  the  weather.  Pain  and  tightness  in  the  chest  are  common  in 
bronchitis,  with  or  without  emphysema  ;  here  the  diagnosis  will  not  be  difficult 
if  pleurisy  can  be  excluded,  and  much  of  the  pain  is  probably  due  to  over- 
strain of  the  intercostal  muscles. 

In  pneumothorax,  about  half  the  cases  show  an  acute  onset,  with  the  sense 
of  something  tearing  or  giving  way  in  the  chest  as  the  patient  coughs,  and  sudden 
very  severe  pain  in  the  side,  aggravated  by  breathing.  In  addition  the  patient- 
exhibits  dyspnoea,  prostration,  cyanosis,  and  rapid  and  feeble  action  of  the  heart. 
The  onset  in  more  than  half  the  cases  is  insidious,  and  the  condition  subacute 
or  chronic,  with  comparatively  little  complaint  of  pain.  The  diagnosis,  if  not 
made  frora  the  history,  should  be  manifest  on  consideration  of  the  physical 
signs.  The  affected  side  of  the  chest  moves  very  little  on  respiration,  and  is 
increased  in  measurement ;  vocal  fremitus  is  absent ;  the  note  on  percussion 
is  usually  tympanitic,  in  rare  cases  dull  ;  and  the  voice-  and  breath-sounds 
are  absent  on  auscultation.  If  the  pneumothorax  is  at  all  extensive,  the  heart 
wiU  be  displaced  considerably  towards  the  sound  side.  Examination  with  the 
,r-ra5^s  will  show  that  the  diaphragm  is  immobile  on  the  affected  side,  and  the 
air-containing  pleural  cavity  extremely  translucent ;  the  lung  forms  a  shrunken 
mass  near  the  middle  line  and  against  the  spinal  column.  After  a  few  days, 
more  or  less  evidence  of  pleural  effusion  at  the  base  of  the  pleural  cavity  will 
usually  be  found. 

In  pneumonia,  chest-pain  is  extremely  common,  and  is  due  to  pleurisy.  If 
the  physical  signs  characteristic  of  pneumonia  delay  their  appearance,  as  is 
sometimes  the  case,  and  if  the  pleural  friction  escapes  detection,  the  diagnosis 
of  some  relatively  harmless  condition  such  as  pleurodynia  or  intercostal 
neuralgia  may  incautiously  be  made.  This  mistake  should  never  occur  ;  nor 
is  it  hkely  to  do  so  if  due  attention  be  paid  to  the  patient's  temperature,  aspect, 
pulse,  and  pulse-respiration  ratio. 

Pain  in  the  chest  is  common  in  acute  pericarditis,  and  is  referred  to  the 
precordia  generally,  or  to  the  lower  part  of  the  sternum.  In  man}'  cases  no 
complaint  of  pain  is  made  ;  but  in  a  few  instances  the  pain  has  been  exceedingly 
severe,  resembling  that  of  angina  pectoris.  The  diagnosis  will  turn  on  the 
discovery  of  other  signs  or  symptoms  of  pericarditis,  particularly  of  pericardial 
to-and-fro  friction-sounds  ;  the  patient  is  often  pale  and  anxious-looking,  and 
very  short  of  breath.  It  should  be  remembered  that  the  friction-sounds  often 
remain  unchanged  when  a  dry  pericarditis  has  been  converted  into  a  wet  one  by 
the  effusion  of  fluid.  Pericardial  friction-sound  is  characteristically  a  superficial 
grating,  rubbing,  or  creaking,  usually  double  or  to-and-fro  ;  in  rhythm  it  is  often 


PAIN     IN     THE     CHEST 


not  synchronous  with  either  systole  or  diastole,  beginning  in  one  and  being 
carried  on  into  the  other.  It  can  often  be  altered  by  pressure  with  the  bell  of 
the  stethoscope  or  by  changing  the  patient's  position  ;  often  it  varies  from  day 
to  day  ;  and  it  is  not  conducted  well  in  any  direction  beyond  the  precordia, 
being  heard  within  an  area  that  often  does  not  correspond  with  the  areas  of 
audition  of  valvular  murmurs.  These  characters  should  suffice  to  distinguish 
pericardial  friction-sounds  from  the  murmurs  of  valvular  disease  ;  but  it  may  be 
verv  difftcult  in  certain  cases  to  distinguish  pericardial  from  pleuropericardial 
friction-sounds  —  that  is -to  say,  friction-sounds  generated  in  pleurisy  by  the 
lieart's  movements.  If  there  is  pleurisy  of  the  thin  anterior  edge  of  the  left 
lung  that  comes  between  the  parietal  and  pericardial  pleurae,  the  beating  of  the 
heart  will  readily  give  rise  to  friction-sounds  that  have  a  cardiac  and  not  a 
respiratory  rhythm,  but  are  due  to  pleurisy  and  not  to  pericarditis.  Pain  in  the 
chest  will  be  felt  in  either  case  ;  the  two  may  generally  be  discriminated  by 
the  influence  of  deep  inspiration  and  expiration  on  the  fi^iction-sound.  In 
pericarditis,  expiration  will  strengthen  and  inspiration  will  weaken  (but  not 
abolish)  the  friction-sounds.  Pleuropericardial  friction  will  in  all  probability 
be  altered  profoundly  by  respiration,  being  much  increased  in  one  phase  (whether 
inspiration  or  expiration),  much  diminished,  or  lost,  in  another. 

Pain  in  the  chest  is  common  in  cases  of  heart  disease,  taking  in  general  two 
forms:  (i)  precordial  pain;  and  (2)  Palpitation  [q.v.).  There  is  nothing 
characteristic  about  the  precordial  pain  felt  in  heart-disease,  except  the  fact 
that  it  is  brought  on  most  often  by  exertion  or  excitement.  Very  similar  pain 
may  be  experienced  by  patients  with  sound  hearts  who  are  suffering  from 
flatulent  dyspepsia  ;  here  the  pain  is  usually  felt  after  meals,  bur  may  be  brought 
on  by  exertion  if  the  latter  is  made  soon  after  food  has  been  taken.  The 
diagnosis  must  be  based  on  the  general  signs  and  symptoms  exhibited  by  the 
cardiac  patient.  In  aortic  incompetence,  the  precordial  pain  is  sometimes 
exceptionally  severe,  taking  the  character  of  angina  pectoris,  and  radiating 
down  the  left  arm  or  through  to  the  back.  The  sensory  nerves  of  the  heart  are 
connected  with  the  spinal  cord  from  the  first  to  the  eighth  dorsal  nerve  roots  ; 
the  first  and  also  the  most  painful  impressions  are  usually  received  at  the  second 
dorsal  roots,  which  are  described  as  being  most  central  to  the  paths  of  pain  from 
the  heart.  The  painful  impressions  received  from  the  heart  at  these  root- 
centres  are  referred  to  the  corresponding  areas  of  cutaneous  nerve  distribution. 
Those  from  the  ventricle  ascend  from  the  second  to  the  fifth  ;  from  the  auricle, 
the  fifth  to  the  eighth  ;  from  the  ascending  aorta,  the  third  and  fourth  cervical, 
and  the  first  to  the  third  dorsal  root-centres.  These  anatomical  connections, 
made  out  by  Head  and  others,  explain  the  distribution  of  the  pains  in  the  chest 
and  elsewhere  felt  in  diseases  of  the  heart  and  aorta.  Severe  pain  in  the  chest, 
often  of  anginal  character,  is  felt  in  acute  or  chronic  aortitis  occurring  in  young 
syphilitic  or  rheumatic  patients,  with  or  without  valvular  disease  ;  the  pain  is 
most  marked  when  the  base  of  the  aorta  and  the  coronary  orifices  are  involved. 

Pains  in  the  chest,  together  with  mental  anguish,  are  the  outstanding  features 
of  true  angina  pectoris,  and  are  in  most  cases  brought  on  by  exertion.  The 
pain  is  in  the  region  of  the  heart,  and  suggests  that  the  heart  has  been  caught 
in  a  vice,  so  excruciating  is  it.  A  sense  of  impending  dissolution,  or  of  a  pause 
in  the  operations  of  nature,  has  been  described  as  added  to  the  physical  torture. 
Radiations  of  the  pains  through  to  the  shoulder,  down  the  left  arm's  inner  side 
to  the  little  and  ring  fingers  (less  often  down  the  right  arm),  up  the  neck,  into 
the  supra-orbital  region,  are  very  common.  The  patient  becomes  faint  and 
collapsed,  pale,  and  clammy  ;  the  pulse  changes  ;  flatulence  and  the  passage  of 
abundant  pale  urine  follow  the  attack,  which  may  last  for  a  few  seconds  or 
minutes,  or  may  continue,  with  varying  intensity,  for  hours.  Attacks  of  true 
D  31 


4S2  PAIN     IN     THE     CHEST 

angina  are  always  serious,  as  any  one  of  them  may  cause  death.  The  diagnosis 
will  rest  on  the  extreme  severity  of  the  pain,  its  association  with  valvular  disease 
or  arteriosclerosis,  or  both,  and  the  fact  that  the  attacks  are  almost  always 
brought  on  by  exertion  or  severe  emotion.  The  true  must  be  distinguished 
from  false  angina  pectoris,  also  called  pseudo-angina  or  vasomotor  angina 
pectoris.  This  commonly  has  a  neurotic,  less  often  a  toxic  (tobacco,  tea, 
coffee)  basis  ;  it  is  less  severe,  and  is  never  fatal.  It  is  far  commoner  in  women 
than  in  men  ;  often  comes  on  when  the  patient  is  at  rest,  or  at  night  ;  may 
occur  at  any  age,  and  is  not  associated  with  cardiac  or  vascular  disease.  The 
attacks  of  false  angina  last  fo,r  an  hour  or  two,  and  come  on  spontaneously ;  the 
extremities  are  chilly  in  the  vasomotor  type  of  the  disease.  True  angina  is 
perhaps  ten  times  commoner  in  men  than  in  women,  and  occurs  between  the 
ages  of  forty  and  sixty  as  a  rule  ;  false  angina  is  perhaps  five  times  as  common 
in  women  as  in  men,  and  occurs  in  younger  patients.  From  what  has  been  said 
above,  it  is  clear  that  typical  cases  of  the  two  conditions  will  be  readily  distin- 
guished from  one  another,  but  every  gradation  between  the  two  may  be  met 
with,  and  it  may  be  impossible  to  refer  intermediate  cases — for  example,  patients 
with  severe  heart-attacks  and  valvular  or  myocardial  lesions — with  logical 
precision  either  to  one  class  or  the  other. 

Chronic'  or  recurrent  pain  in  the  chest  is  a  very  variable  symptom  of  aortic 
aneurysm.  In  some  patients,  a  large  aneurysm  may  erode  rib-cartilages  and 
intercostal  spaces,  and  present  itself  at  the  surface  of  the  body  without  having 
made  itself  felt.  In  others,  agonizing  pain  (true  angina  pectoris)  may  be 
occasioned  before  an  aneurysm  at  the  root  of  the  aorta  has  grown  large  enough 
to  produce  any  physical  signs  at  all  ;  in  these  the  pain  is  no  doubt  due  to  aortitis 
or  mesaortitis  for  the  most  part,  or  to  obstruction  at  the  coronary  orifices. 
Speaking  generally,  the  pain  of  aortic  aneurysm  may  arise  in  two  ways  :  (i) 
From  changes  in  the  aortic  wall,  already  considered  ;  and  (2)  From  pressure 
on  neighbouring  structures,  particularly  the  walls  of  the  chest.  As  has  been 
already  noted,  pressure-erosion  of  the  sternum  or  costal  cartilages  may  be 
comparatively  painless  in  fortunate  cases.  Erosion  of  the  vertebral  bodies 
commonly  gives  rise  to  intense  and  continuous  boring  pains  in  the  chest  that 
wear  the  patient  out  and  make  life  insupportable  ;  girdle-pain  may  result  from 
pressure  on  the  intercostal  nerves  (direct  pain),  and  referred  pains  up  the  neck 
or  down  the  inner  side  of  the  arm  may  also  be  felt.  Pressure  on  the  oesophagus 
may  give  rise  to  dysphagia  and  pain,  the  pain  being  increased  by  swallowing. 
Compression  of  the  lung  may  lead  to  pulmonary  collapse  and  inflammation, 
when  pain  from  pleurisy  will  probably  be  felt.  It  appears  that  no  particular 
complaint  of  pain  follows  compression  of  the  trachea,  bronchi,  phrenic  or  vagus 
nerves,  or  heart.  An  acute  and  severe  pain,  on  the  other  hand,  may  arise  should 
the  aortic  aneurysm  perforate  and  allow  blood  to  escape  into  the  adjoining 
parts.  Such  perforation  may  take  place  into  the  air-passages,  oesophagus, 
large  intrathoracic  pulmonary  or  systemic  veins,  pericardium,  heart,  pleura, 
peritoneum,  or  spinal  canal.  The  appearance  of  the  appropriate  physical 
signs  will  suggest  the  diagnosis  of  such  a  perforation.  If  the  effused  blood  is 
limited  in  amount,  the  patient  will  appear  more  or  less  blanched  and  collapsed  ; 
if  a  great  quantity  escapes,  rapid  or  sudden  death  may  occur.  Particular 
mention  may  here  be  made  of  the  pain  due  to  the  formation  of  a  dissecting 
aneurysm.  The  arteries  are  acutely  sensitive  to  pain,  as  may  be  seen  when 
an  artery  is  ligatured  in  a  conscious  patient  ;  the  establishment  of  a  dissecting 
aneurysm  is  a  terribly  painful  experience,  and  is  equivalent  to  an  attack  of  true 
angina  pectoris.  If  the  escape  of  blood  is  limited  by  the  walls  of  the  aorta, 
recovery  is  likely  to  occur.  The  diagnosis  of  such  an  incident  could  onl}'  be 
made  on  grounds  of  probability. 


PA  IX     IN     THE     CHEST 


483 


Pain  in  the  chest  is  usually  an  early  symptom  of  mediastinal  new  growth,  and 
varies  in  its  nature  and  distribution  with  the  cause  and  site  of  its  origin.  If 
the  growth  is  in  the  anterior  mediastinum,  the  pain  will  be  behind  the  sternum  ; 
if  in  the  posterior  mediastinum,  pressure  on  or  erosion  of  the  vertebrae  will 
set  up  the  severe  continuous  boring  pain  referred  to  above  as  occurring  in 
aortic  aneurysm  ;  if  one  side  of  the  chest  is  involved,  the  pain  will  be  felt  in  the 
side,  and  down  the  arm  if  the  brachial  plexus  is  pressed  upon.  It  is  often  of  a 
darting  and  lancinating  character,  shooting  up  into  the  neck  and  head,  or  down 
into  the  abdomen.  It  may  be  constant,  intermittent,  or  paroxysmal  ;  in  some 
cases  it  is  a  discomfort  rather  than  a  pain  that  is  felt,  the  complaint  being  of 
fullness  or  tightness  in  the  chest.  Other  symptoms  of  mediastinal  tumour  are, 
lirst  and  foremost,  continuous  or  paroxysmal  dyspnoea  ;  evidences  of  pressure 
on  the  air-passages,  oesophagus,  or  nerves  ;  cough,  expectoration,  haemoptysis, 
alterations  in  the  voice  or  cough  ;  disturbances  in  the  action  of  the  heart,  and 
evidences  of  venous  obstruction. 
Anaemia  or  even  cancerous  ca- 
chexia are  not  rare.  The  general 
diagnosis  of  mediastinal  tumour 
(including  aneurysm)  is  seldom 
difficult  once  pressure-symptoms 
of  any  sort  have  appeared,  for 
these  are  very  rarely  caused  by 
other  lung-conditions  associated 
with  pain  in  the  chest,  such  as 
bronchitis,  bronchiectasis,  or  pul- 
monary tuberculosis.  But  it  may 
be  very  difficult  to  decide  between 
aortic  aneurysm  and  mediastinal 
new  growth  in  certain  cases. 
Aneurysm  is  commoner  in  men 
than  in  women,  and  rare  in  per- 
sons who  have  not  had  syphilis ; 
anginal  pains  and  the  very  severe 
pain  of  bone-erosion  are  commoner 
in  aneurysm  than  in  mediastinal 
new  growth  ;  anaemia,  cachexia, 
and  irregular  pyrexia  are  in  favour 
of  new  growth ;  and  so  is  the 
discovery  of  new  growth  in  other 
parts  of  the  body  and  of  second- 
arily-infected lymphatic  glands.  Examination  under  the  ;ir-rays  will  prove  of 
the  greatest  help  {Fig.  74,  p.  236,  and  Fig.  131),  the  rays  being  passed  through 
the  patient's  thorax  in  a  number  of  horizontal  directions  successively  ;  if  ^this 
be  done,  the  presence  of  an  aneurysm  and  its  connection  with  the  t  aorta 
can  almost  always  be  established  when  one  is  present,  to  the  exclusion  of 
mediastinal  new  growth.  r    1 

In  acute  mediastinitis  and  mediastinal  abscess — both  of  them  rare  disorders  and 
due  to  syphilitic,  tuberculous,  or  other  infection  of  the  mediastinum — pain  behind 
the  sternum  is  commonly  the  chief  complaint,  with  marked  superficial  tenderness 
and  a  tendency  to  radiation  through  into  the  back  or  shoulder.  Local  signs 
of  fullness  and  inflammation  may  develop,  particularly  about  the  intercostal 
spaces  in  front  and  the  episternal  notch  ;  and  mediastinal  crepitations  resem- 
bling pleural  friction  have  been  heard  about  the  sternum.  The  diagnosis  should 
not   be    difficult. 


Fig.  131. — Skiagram  ot  an  aneurysm  of  the  innominate 
artery  (A),  with  dilated  aortic  arch  (B)- 

{By  Dr.  Alfred  C.  Jo7-dan.) 


PAIN    IN     THE     CHEST 


In  chronic  mediastinitis  or  mediastino-pericarditis,  another  rare  condition 
due  to  inflammation  arising  in  the  mediastinum,  or  spreading  to  it  from  the 
pericardium,  and  seen  in  youth  or  early  adult  life,  chronic  pain  behind  the 
sternum  and  a  sense  of  tightness  and  dragging  in  the  chest  may  be  present. 
But  the  main  symptoms  will  be  cardio-vascular,  valvular  disease  of  the  heart 
and  adherent  pericardium  leading  to  cardiac  troubles,  and  the  mediastinitis 
causing  venous  obstruction.  Dyspnoea,  lividity,  anasarca,  ascites,  and  progres- 
sive distention  of  the  thoracic  veins,  are  the  main  features  upon  which  the 
diagnosis  of  mediastino-pericarditis  must  be  made,  new  growth  being  excluded 
by  the  duration  of  the  case. 

Deep-seated  pain  within  the  chest  and  at  the  bottom  of  the  sternum  may  be 
felt  in  diseases  of  the  oesophagus,  being  evoked  by  the  act  of  swallowing.  In 
cicatricial  stricture  or  carcinoma  of  the  tube,  pain  is  less  prominent  than 
Dysphagia  {q-v.),  and  progressive  emaciation  is  the  rule.  In  younger  and 
neurotic  patients,  on  the  other  hand,  spasmodic  stricture  of  the  oesophagus  may 
give  rise  to  difficulty  in  swallowing,  with  much  complaint  of  pain  and  constriction 
in  the  throat  and  chest.  This  condition,  termed  oesophagismus,  occurs  in  hys- 
terical young  persons  and  in  hypochondriacal  old  ones  ;  it  is  improved  or  cured 
by  the  passage  of  a  bougie  ;  is  associated  with  other  evidences  of  the  neurotic 
temperament ;    and  must  be  diagnosed  from  organic  oesophageal  stenosis. 

Pain  in  the  chest  is  very  frequently  met  with  in  diseases  of  the  abdominal 
viscera,  particularly  of  the  stomach.  "  Pains  round  the  heart,"  often  accom- 
panied by  or  productive  of  Palpitation  (q.v-),  are  the  common  basis  upon  which 
patients  build  when  they  come  complaining  of  "  heart-disease  "  or  "  weak 
heart,"  while  as  a  matter  of  fact  they  are  suffering  from  the  less  serious  condition 
of  gastritis,  or  flatulent  dyspepsia.  The  pain  is  felt  at  the  bottom  of  the  sternum 
and  in  the  epigastrium  ;  it  is  often  of  a  dull  boring  character,  and  radiates  out 
towards  the  left  breast  and  through  to  the  back  between  the  blade-bones.  It  is 
definitely  connected  with  the  taking  of  food,  and  relieved  by  vomiting  or  the 
eructation  of  wind  ;  and  these  are  the  characters  by  which  it  must  be  diagnosed. 
In  other  instances,  the  complaint  is  of  "  heart-burn,"  a  burning  pain  felt  over 
the  lower  part  of  the  sternum,  and  probably  due  to  the  regurgitation  into  the 
oesophagus  of  the  gastric  contents  during  digestion.  It  is  a  referred  pain  felt  in 
the  area  of  distribution  of  the  fifth  dorsal  nerve,  and  is  often  associated  with 
pyrosis  or  water-brash,  the  regurgitation  of  acrid  watery  gastric  contents  into  the 
mouth.  For  the  most  part,  however,  pain  due  to  gastric  disorders  (such  as  ulcer, 
new  growth)  is  referred  to  the  upper  part  of  the  abdomen  rather  than  the  chest. 

Pains  in  the  chest  are  not  rare  in  various  diseases  of  the  spinal  cord.  Girdle 
pains  or  girdle  sensations  are  common  in  tabes  dorsalis,  the  patient  feeling  as  if 
constricted  by  a  hot  or  painful  girdle.  They  occur  early  in  the  disease,  and  so 
are  often  set  down  vaguely  to  gout  or  rheumatism,  when  a  more  careful  examina- 
tion would  yield  early  evidences  of  tabes.  In  transverse  myelitis,  or  fracture 
of  the  dorsal  column  with  injury  to  the  cord,  girdle  pains  round  the  chest  may 
be  felt  at  the  level  of  the  cord  lesion,  with  loss  or  abolition  of  sensation  below  it. 

A.  J.  J  ex-Blake. 

PAIN  IN  THE  EAR.— (See  Earache.) 

PAIN  IN  THE  ELBOW. — (See   Joints,  Affections   of.) 

PAIN     IN     THE     EPIGASTRIUM. 

A.  Sudden,  severe  epigastric  pain  may  result  from  the  rupture  of  a  gastric 
or  duodenal  ulcer,  of  a  gangrenous  appendix,  or  from  acute  pancreatitis.  The 
pain  in  such  a  case  is  attended  by  severe  shock  and  signs  of  collapse,  and  it  may 
be  difficult  to  say  to  which  of  the  above  causes  it  is  due.  The  past  history  of  the 
patient,  however,  and  a  careful  study  of  the  other  signs  present,  may  guide  one 


PAIN     IN     THE     EPIGASTRIUM  485 

to  a  correct  conclusion  ;  but  as  all  the  conditions  mentioned  require  immediate 
surgical  treatment,  the  differential  diagnosis  is  not  a  matter  of  great  importance. 

It  should  be  borne  in  mind,  however,  when  the  diagnosis  of  an  abdominal 
emergency  has  to  be  considered,  that  "  if  the  history,  symptoms,  and  signs  do 
not  exactly  fit  acute  intestinal  obstruction,  or  stomach  or  duodenal  perforation, 
perforating  appendix,  or  acute  cholecystitis,  and  yet  have  some  resemblance 
to  each  of  them,  pancreatitis  is  the  most  probable  cause  "  (Morison). 

B.  Chrcnic  or  recurrent  pain  in  the  Epigastrium  may  be  due  to  a  variety  of 
causes  : — 

(i).  It  should  be  remembered,  in  the  first  place,  that  epigastric  pain  may  be 
due  to  extra-abdominal  causes.  Amongst  these  are  spinal  caries  (especially  to 
be  thought  of  in  children),  pleurisy,  and  intercostal  neuralgia.  The  first  two  of 
these  can  easil}'  be  distinguished  by  the  usual  signs  ;  intercostal  neuralgia  is  to 
be  diagnosed  by  the  presence  of  tender  points  along  the  course  of  the  nerve. 

A  dilated  right  ventricle  may  also  be  the  cause  of  severe  epigastric  pain,  which 
may  even  simulate  the  pain  of  gastric  ulcer  or  gall-stones.  In  cases  of  emphy- 
sema, or  heart  failure,  this  should  be  borne  in  mind.  In  such  cases  the  pain  is 
aggravated  by  exertion. 

Small  epigastric  hernicB  may  cause  recurring  attacks  of  severe  epigastric  pain. 
They  can  be  detected  b}^  careful  palpation,  usually  in  the  linea  alba. 

Affections  of  the  abdominal  muscles,  e.g.,  strain  from  coughing,  or  rheumatism 
(in  children),  may  also  cause  pain  in  the  epigastrium. 

(2).  Assuming  these  to  be  excluded,  the  cause  of  the  pain  may  be  looked  for 
in  the  following  organs  : — 

(a).  Stomach. — The  chief  causes  of  gastric  pain  are  carcinoma,  ulcer,  hyper- 
chlorhydria,  and  gastralgia.      (See  Indigestion.) 

The  pain  in  carcinoma  is  usually  more  or  less  continuous,  although  apt  to  be 
temporarily  aggravated  by  food.  A  tumour  may  be  felt.  Vomiting  is  usually 
present,  and  the  gastric  contents  show  absence  of  free  HCl  (in  most  cases) . 

In  cases  of  ulcer  the  pain  is  more  definitely  related  to  the  taking  of  food,  and 
often  passes  through  to  the  back.  Vomiting  is  usually  a  feature,  with  or  without 
h^ematemesis.  There  is  localized  deep  tenderness  on  pressure,  often  over  quite 
a  small  and  well-defined  area.  The  gastric  contents  usually  show  the  presence 
of  an  excess  of  acid. 

In  cases  of  hyperchlorhydria  the  pain  is  less  severe  than  in  either  of  the  above 
conditions  ;  it  occurs  in  the  late  period  of  digestion,  and  is  relieved  temporarily 
by  the  taking  of  food.  There  is  an  absence  of  other  signs  and  symptoms,  and 
of  local  tenderness  ;   and  a  test-meal  shows  the  presence  of  an  excess  of  acid. 

Gastralgia  should  only  be  diagnosed  when  all  other  possible  causes  of  gastric 
pain  have  been  excluded.  The  patient  is  usually  a  young  woman  ;  the  pain 
may  occur  even  when  the  stomach  is  empty,  but  is  aggravated  by  food,  even  by 
liquids.  Vomiting  is  usually  absent,  and  on  physical  examination  there  is 
diffuse  deep  tenderness  over  the  whole  of  the  gastric  area. 

Epigastric  pain  may  also  be  felt  to  a  greater  or  less  degree  in  all  conditions  of 
the  stomach  associated  with  flatulence,  and  in  that  case  it  is  relieved  by  the 
bringing  up  of  wind.     (See  Flatulence.) 

The  gastric  crises  of  tabes  may  be  attended  by  severe  epigastric  pain,  and  as 
these  may  occur  in  the  pre-ataxic  stage  of  the  disease,  before  other  signs  are 
present,  the  diagnosis  may  be  in  doubt.  The  characteristic  features  are  the 
sudden  onset  of  the  pain,  and  the  fact  that  it  is  usually  attended  by  urgent 
vomiting.  There  is  no  rise  of  temperature,  but  during  the  attack  the  blood- 
pressure  is  raised  ;  whereas  in  aU  other  forms  of  acute  abdominal  pain  (except 
lead  colic)  it  is  lowered.  Absence  of  the  knee-jerk,  and  the  characteristic 
pupil  signs  of  tabes  are  not  necessarily  present. 


4S6  PA  IX     IX     THE     EPIGASTRIUM 

Perigastric  adhesions  are  a  possible  cause  of  epigastric  pain,  but  are  difficult 
to  diagnose  with  any  certainty-.  If  the  pain  is  much  influenced  bj'  muscular 
movements,  or  change  of  posture,  it  is  in  favour  of  adhesions  being  the  cause  ;  but 
except  for  this,  it  has  no  other  characteristic  features. 

(b).  Liver  and  Gall-bladder. — Epigastric  pain  mav  be  produced  by  congestion 
of  the  liver,  either  active  (hepatitis),  or  passive,  as  in  mitral  disease.  It  is  also 
produced   by   such   conditions   as   hepatic   abscess   and   carcinoma    (see  Liver, 

EXLARGEMENT  OF  THE)  . 

Stone  in  the  gall-bladder  may  sometimes  be  a  cause  of  epigastric  pain,  which 
ma^-  even  be  definitely  related  to  meals,  or  to  the  taking  of  a  particular  article 
of  food.  Pressure  over  the  gall-bladder  will  often  ehcit  tenderness  ;  and  if  the 
patient  is  made  to  take  a  deep  breath  Avhilst  the  pressure  is  applied,  there  will 
be  a  painful  catch  in  the  breath  as  the  diaphragm  descends. 

In  a  doubtful  case,  in  which  the  diagnosis  lies  between  gall-stones  and  gastric 
ulcer,  the  following  points  are  in  fa\-our  of  gall-stones  :  (i)  The  occurrence  of 
the  pain  at  rather  long  intervals,  with  comparative  freedom  from  s^^mptoms 
bet^veen  ;  (ii)  Long  duration  of  the  attack  of  pain  ;  (iii)  Continuance  of  the 
pain  in  spite  of  vomiting  ;  (iv)  The  occurrence  of  shght  shivering  and  rise  of 
temperature  with  the  attacks. 

(c).  Pancreas. — Pancreatic  calcuh,  chronic  pancreatitis,  or  new  growth,  may 
all  be  the  cause  of  epigastric  pain.  An  accurate  diagnosis  of  these  conditions 
is  difficult,  and  often  impossible  ;  but  there  may  be  present  other  signs  of 
disturbed  function  of  the  pancreas,  such  as  fattj-  diarrhoea,  or  a  "  pancreatic 
reaction  "  (p.  115)  in  the  urine.  A  tumour  also  may  be  felt.  Glycosuria  may  be 
present,  but  is  not  invariable.  In  cases  of  chronic  pancreatitis  there  is  usually 
a  histon,-  of  gall-stones.     (See  also  Pain  in  the  Hypochondrium,  Right.) 

[d).  Abdominal  Aorta. — An  abdominal  aneurysm  mav  cause  pain  in  the  epigas- 
trium, but  the  pain  is  more  marked  in  the  back.  The  patient  is  usually  a  young 
man  with  a  sj-phihtic  histor\-,  and  a  pulsating  expansile  tumour  can  be  felt  on 
deep  palpation.     The  ;!r-rays  will  confirm  the  diagnosis. 

Abdominal  angina,  which  is  associated  with  arterial  atheroma  and  a  high 
blood-pressure,  is  an  occasional  cause  of  severe  epigastric  pain,  which  comes  on 
in  paroxysms,  especially  upon  exertion.  The  pain  in  such  a  case  tends  to 
radiate  Uke  that  of  true  angina,  and  is  often  attended  by  flatulence,  tenesmus, 
and  other  abdominal  s}.-mptoms.  There  are  usually  signs  of  atheroma  in  the 
peripheral  vessels  ;  and  the  diagnosis  mav  be  confirmed  by  the  yielding  of  the 
pain  to  vascular  depressants,  and  especiall}-  to  diuretin. 

(3).  Colon. — Spasmodic  contraction  of  the  transverse  colon  (enterospasm) 
may  be  a  cause  of  epigastric  pain,  which  may  simulate  gastric  pain  by  being 
induced  b\-  the  taking  of  food.  Such  pain,  however,  tends  to  be  relieved  by 
pressure,  and  by  the  passage  of  gas  per  anum.  Obstinate  constipation  is  usually 
a  feature  of  the  case,  and  there  are  often  mucus  and  shreds  of  membrane  in  the 
motions  (muco-membranous  colitis).  A  similar  pain  may  be  due  to  phtmbism, 
for  the  diagnosis  of  which  see  Colic.  Robert  Hutchison. 

PAIN  IN  THE  EXTREMITY  (LOWER).— The  causes  of  pain  in  the  lower 
limbs  are  so  numerous  that  much  space  would  be  required  if  any  attempt  were 
made  to  discuss  them  in  full.  Fortunately  the  majority  are  easily  detected 
when  attention  is  paid  to  the  site,  nature,  and  history  of  the  pain,  and  the  painful 
spot  is  examined.  An  attack  of  gout  in  the  big  toe,  an  ingrowing  toenail,  a  flat 
foot,  a  synovitis  of  the  knee  or  ankle,  phlebitis  of  a  varicose  vein,  a  tumour  of 
one  of  the  long  bones,  and  many  other  localized  pathological  processes  require 
only  an  elementar}-  medical  knowledge,  and  the  enlightened  use  of  eyes  and 
fingers  on  the  part  of  the  medical  man,  in  order  that  a  correct  diagnosis  may 


PAIN    IN     THE     LOWER     EXTREMITY  487 

be  arrived  at.  On  the  other  hand,  there  are  many  conditions  of  which  pain  of  a 
more  or  less  diffused  type  is  a  prominent  sj-mptom,  and  which  require  very 
careful  investigation  if  mistakes  are  to  be  avoided  and  diagnostic  traps  escaped. 
The  fact  that  the  nerves  of  the  leg  spring  from  the  lower  part  of  the  spinal  cord 
in  the  dorso-lumbar  part  of  the  vertebral  column,  and  that  they  have  a  some- 
what lengthy  course  within  the  lumbo-sacral  vertebral  canal  and  the  pelvic 
cavity,  where  they  are  comparatively  inaccessible,  before  they  reach  the  limb, 
explains  why  the  origin  of  some  pains  referred  to  the  lower  extremity  is  rendered 
obscure.  ^Moreover,  some  of  the  painful  conditions  met  with  are  connected 
only  indirect!}'  with  the  nervous  paths,  and  are  more  directly  associated  with 
morbid  conditions  of  other  structures,  such  as  joints,  blood-vessels,  etc. 

The  classification  of  the  various  painful  conditions  in  the  lower  extremity 
which  need  our  attention  from  the  point  of  view  of  diagnosis  is  no  easy  matter. 
One  may  consider  first  those  which  are  primarily  nervous  in  origin,  and  use 
them  as  a  basis  for  comparison  with  those  due  to  disease  of  other  tissues. 

I.  Pains  of  Neuralgic  or  Neuritic  Origin. 

Sciatica. — This  name  is  comnaonly  applied  to  a  condition  of  the  sciatic 
nerve  which  may  sometimes  be  described  as  a  neuralgia  and  sometimes  as 
a  neuritis,  according  to  the  severity  of  the  attack  and  the  amount  of 
alteration  in  nervous  function  to  which  it  gives  rise.  It  is  characterized 
by  pain  of  a  neuralgic  type  referred  to  a  part  or  the  whole  of  the  course 
of  the  sciatic  nerve  and  its  branches,  from  the  sciatic  notch  to  the  sole 
of  the  foot.  Usually  the  pain  is  most  severe  along  the  back  of  the  thigh 
and  along  the  outer  side  of  the  leg.  Tenderness  is  found  on  pressure  over  the 
gluteal  region,  over  the  sciatic  notch,  and  generally  all  along  the  nerve.  Exacer- 
bation of  pain  is  produced  by  stretching  the  nerve,  for  instance  by  forcibly 
flexing  the  thigh  on  the  trunk  with  the  knee  fully  extended.  The  pain  is  intensi- 
fied by  muscular  exertion,  and  is  often  severe  at  night,  especially  when  the 
patient  lies  on  his  back.  Sciatica  is  often  associated  with  lumbago,  pain  and 
tenderness  in  the  muscles  of  the  lumbar  region.  In  long-standing  cases  the 
nutrition  of  the  affected  leg  suffers  and  the  muscles  appear  generally  smaller 
than  those  of  the  other  limb,  but  localized  atrophy  picking  out  individual  muscles 
suggests  that  there  is  something  more  than  a  simple  neuralgia  or  neuritis  at 
work.  Numbness,  and  even  slight  cutaneous  ansesthesia,  may  be  found  on  the 
dorsum  of  the  foot,  in  the  distribution  of  the  musculo-cutaneous  branch,  in 
cases  of  simple  sciatic  neuritis.  The  knee-jerk  is  never  affected  in  sciatica, 
but  the  ankle- jerk  is  often  diminished  or  lost,  and  may  remain  absent  for  a  long 
period  after  the  pain  has  disappeared.     The  plantar  reflex  is  of  the  flexor  type. 

Before  making  a  diagnosis  of  sciatica  or  sciatic  neuritis  in  a  patient  who 
complains  of  pain  in  the  course  of  that  nerve,  the  physician  must  satisfy  himself 
that  there  is  no  gross  disease  in  the  hip  joint,  pelvis,  or  spinal  column  which  could 
give  rise  to  the  symptoms.  The  mobility  of  the  hip  joint  must  be  investigated 
carefully,  and,  if  doubt  exists  with  regard  to  its  integrity,  the  joint  should  be 
subjected  to  skiagraph}'.  The  pelvis  should  be  examined  externally  and 
internally  per  rectum  or  per  vaginam.  The  writer  has  seen  a  case  of  sarcoma 
of  the  innominate  bone  mistaken  for  sciatica,  when  a  glance  at  the  pelvis  as  a 
whole  was  sufficient  to  demonstrate  the  swelling  on  the  affected  side.  In  the 
same  way  the  mistaken  diagnosis  of  sciatica  has  frequently  been  made  when  a 
rectal  or  vaginal  examination  would  detect  a  pelvic  inflammatory  or  malignant 
mass  pressing  on  the  nerve.  Even  a  retroverted  uterus  may  sometimes  cause  pain 
in  the  sciatic  distribution.  Tuberculous,  gummatous,  or  malignant  disease  of  the 
lumbo-sacral  vertebrcs,  tumour,  or  meningitis  involving  the  lower  part  of  the  spinal 
cord  and  caiida  equina,  are  also  capable  of  producing  pain  which  resembles  that 
of  sciatica.      In  such  cases,  inquiry  into  the  action  of  the  sphincters  of  the  bladder 


4-88  PAIN     IN     THE     LOWER     EXTREMITY 

and  rectum  may  suggest  the  position  of  the  lesion,  and  should  always  be  made 
in  patients  complaining  of  sciatica.  Skiagraphy  of  the  lower  part  of  the  vertebral 
column  may  help  to  disclose  disease  of  that  structure.  Lumbar  puncture  may 
be  necessary  for  the  purpose  of  diagnosing  syphilitic  meningitis.  In  most 
cases  of  this  kind,  however,  a  careful  scrutiny  of  the  lower  limb  will  show  that 
the  pain  is  not  limited  to  the  distribution  of  the  sciatic  nerve,  that  the  latter  is 
not  acutely  tender  on  pressure,  that  there  are  atrophy  and  paresis  of  certain 
groups  of  muscles,  some  of  which  are  supplied  by  other  branches  of  the  lumbo- 
sacral plexus,  that  there  are  patches  of  anaesthesia  corresponding  to  root  rather 
than  nerve  areas,  or  that  the  knee-jerk  is  lost  and  perhaps  the  plantar  reflex 
altered  in  character.  It  should  also  be  remembered  that  sciatica  is  nearly 
always  unilateral,  whereas  growths  or  inflammation  within  the  vertebral  canal 
tend  to  produce  signs  and  symptoms  in  both  legs  at  a  comparatively  early  stage. 

The  frequency  with  which  sciatica  is  diagnosed  when  some  much  more  serious 
disease  is  really  present,  is  sufficient  excuse  for  laying  emphasis  on  the  above 
points,  and  every  practitioner  would  do  well  to  make  it  his  invariable  rule,  when 
faced  with  a  case  apparently  conforming  to  the  picture  of  sciatica,  to  inquire 
into  the  action  of  the  sphincters,  to  inspect  carefully  and  palpate  the  pelvis  and 
spine,  to  make  a  rectal  examination,  and  finally  to  keep  a  sharp  look-out  for  signs 
of  present  or  past  malignant  disease  in  other  parts  of  the  body.  In  all  cases  of 
neuralgic  or  neuritic  pain  the  urine  should  be  examined  for  the  presence  of  sugar. 

Anterior  Crural  Neuralgia. — Neuralgia  in  the  distribution  of  the  anterior 
crural  nerve  is  much  less  common  than  sciatica,  and  precautions  similar  to  those 
just  mentioned  must  be  adopted  before  the  diagnosis  is  made.  In  this  condition, 
the  pain  and  tenderness  involve  the  front  of  the  thigh  as  far  as  the  knee,  and 
the  knee-jerk  is  sometimes  diminished.  In  some  cases  the  pain  extends  along 
the  saphenous  branch  to  the  ankle,  inner  aspect  of  foot,  and  big  toe.  Occasionally 
it  is  associated  with  sciatica. 

Obturator  Neuralgia. — Pain  in  the  distribution  of  the  obturator  nerve  is  rarely 
of  simple  neuralgic  origin.  Disease  of  the  hip  joint  and  obturator  hernia  are  two 
of  the  conditions  which  may  give  rise  to  it. 

Neuralgia  parcesthetica  is  the  name  given  to  a  variety  of  pain  which  is  referred 
to  the  course  of  the  external  cutaneous  nerve  of  the  thigh.  The  relations  of 
this  nerve  to  the  psoas  muscle  and  the  fascia  lata  render  it  liable  to  stretching 
or  pressure  in  standing  or  walking,  with  the  result  that  the  neuralgia  is  intensified 
by  the  maintenance  of  the  erect  posture.  In  certain  instances  of  great  obesity, 
prolonged  sitting  has  been  supposed  to  play  a  part  in  producing  this  type  of 
neuralgic  discomfort.  There  is  sometimes  a  painful  pressure-spot  just  below 
the  anterior  iliac  spine.     A  liat-foot  is  met  with  not  uncommonly  in  these  cases. 

Metatarsal  Neuralgia,  or  Morton's  Affection  of  the  Foot. — This  neuralgia  is  of 
the  paroxysmal  type,  and  is  described  as  dull  throbbing  pain  in  the  base  of  the 
fourth — sometimes  of  the  second — toe,  and  spreading  up  the  leg.  There  is 
tenderness  on  pressure  over  the  metatarsus.  In  a  certain  number  of  cases  the 
pain  is  probably  related  to  the  wearing  of  tight  or  ill-fitting  boots,  or  to  the 
presence  of  flat-foot. 

Calcanodynia  is  another  form  of  pain  liable  to  occur  in  neuralgic  subjects 
who  are  doing  much  walking.  The  pain  is  often  bilateral,  worse  in  the  evening 
and  at  night,  and  tends  to  spread  from  the  heel  to  the  base  of  the  toes.  There 
are  no  objective  signs  of  disease.  One  patient  who  consulted  me  for  this  con- 
dition returned  a  year  or  two  later  with  a  typical  brachial  neuralgia. 

Multiple  Neuritis. — The  lower  extremities  are  often  the  site  of  multiple 
neuritis  giving  rise  to  great  pain,  but  the  diagnosis  is  rarely  difficult  owing  to 
the  association  of  atrophic  palsy  of  the  muscles,  the  electrical  reaction  of  degener- 
ation,  dulling  of  cutaneous  sensibility  below  the  knees,  and  loss  of  the  knee- 


PAIN     IN     THE     LOWER     EXTREMITY  489 

and  ankle-jerks.  Perhaps  the  most  characteristic  and  constant  phenomenon 
in  such  cases  is  the  presence  of  marked  tenderness  of  the  muscles  on  pressure. 
The  nerve  trunks  are  sometimes  hypersensitive  also,  but  not  so  constantly  as 
are  the  muscles  below  the  knees.  The  pain  in  multiple  neuritis  is  often  acute, 
worse  at  night,  and  aggravated  by  movement  and  the  pressure  of  bed-clothes. 

Tabes  Dovsalis. — The  pains  of  tabes  are  more  often  complained  of  in  the  legs 
than  in  any  other  part  of  the  body.  Unlike  the  neuralgias,  they  are  usually 
bilateral  and  not  referred  to  the  distribution  of  any  particular  peripheral  nerve. 
The  "  lightning  "  pains  are  so  characteristic  that  they  can  hardly  be  compared 
with  painsof  any  other  origin.  "Whether  trivial  and  "  niggling,"  or  so  intenseas 
to  draw  sweat  and  cries  from  the  most  heroic  of  sufferers,  they  are  always  short 
and  lightning-like  in  duration,  often  rapidly  repeated  in  the  paroxysms,  irregu- 
larly periodic  in  their  attacks,  and  fleeting  or  hovering  in  their  locahzation.  It 
is  a  practical  point  of  importance  to  remember  that  many  patients,  when  asked 
if  they  suffer  from  pains,  emphatically  deny  it,  but  readily  admit  to  "  rheumatics," 
and  then  describe  in  a  graphic  manner  the  lightning  pains  of  tabes.  The  idea 
of  rheumatics  is  evolved  from  the  fact  that  these  pains  are  often  provoked  by 
changes  in  the  weather. 

In  addition  to  lightning  pains,  sufferers  from  tabes  often  complain  of  dull 
aching  or  boring  pains,  which  are  more  continuous  and  less  intermittent  than 
those  just  described. 

It  is  certain  that  tabetic  pains  may  precede  all  other  signs  and  symptoms  of 
the  disease,  in  which  case  their  diagnosis  may  be  difficult.  The  following  points 
should  be  investigated  carefully  when  pains  answering  to  the  description  given 
above  are  complained  of  :  (i)  A  history  of  syphilis,  congenital  or  acquired. 
The  writer  has  known  a  woman,  probably  the  subject  of  congenital  syphilis, 
to  suffer  from  lightning  pains  from  early  childhood  up  to  forty  years  of  age, 
when  she  presented  other  signs  of  tabes  ;  (2)  The  presence  or  absence  of  a 
positive  Wassermann  serum  reaction  ;  (3)  The  presence  or  absence  of  a 
Ivmphocytosis  in  the  cerebrospinal  fluid  ;  (4)  The  reaction  of  the  pupils  to 
light  ;  (5)  The  condition  of  the  knee-  and  ankle-jerks  ;  (6)  The  presence  of 
deep  and  superficial  analgesia  over  the  legs  ;  (7)  A  history  of  gastric  crises  ;  and 
(8)  The  condition  of  the  sphincter  vesicae.  Particular  attention  is  drawn  to  a 
valuable  sign  of  tabes  which  is  not  referred  to  so  commonly  as  are  Argyll  Robert- 
son pupils  and  absent  knee-jerks,  i.e.,  the  impaired  pain-sensibility  in  the  calf 
and  other  muscles  when  they  are  squeezed. 

AcroparcBsthesia. — (Sec  p.  493.) 

2.  Pain  in  connection  with   Disturbances   of    the   Circulation. 

Intermittent  Claudication. — This  term  is  applied  to  a  condition  the  pathology  of 
which  is  still  obscure,  but  which  certainly  depends  on  an  insufficient  blood-supply 
to  the  muscles  of  the  lower  extremities  when  they  are  called  into  activity  during 
locomotion.  It  may  lead  eventually  to  gangrene.  The  malady  occurs  chiefly 
in  men  over  forty  years  of  age,  and  particularly  in  those  who  have  indulged 
freely  in  tobacco,  who  have  contracted  syphilis,  or  who  have  thrown  strain  upon 
their  legs  over  a  long  period  of  time.  The  patient  complains  of  pain  in  one  or 
both  legs,  generally  in  the  calf  muscles,  coming  on  after  walking  a  certain  distance, 
and  disappearing  with  rest.  The  pain  becomes  so  intolerable  that  he  is  obliged 
to  stand  or  sit  still  until  it  passes  off.  As  time  goes  on  the  distance  he  can  walk 
in  comfort  becomes  progressively  shorter.  Examination  of  the  affected  limbs 
reveals  nothing  obvious  ;  they  are  well  nourished,  powerful,  and  normal  in 
regard  to  sensation  and  reflexes.  Probably,  however,  the  observer  will  fail  to 
detect  pulsation  in  the  arteries  of  the  foot,  and  perhaps  he  may  not  feel  the 
popliteal  artery  behind  the  knee-joint.  The  femoral  artery  can  usually  be  felt 
to  pulsate  in  a  normal  manner.     After  the  exertion  of  walking,  the  foot  may 


490 


PAIN    IN     THE     LOWER     EXTREMITY 


appear  unduly  pale.  ^Yith  rest,  the  returning  flush  of  normal  colour  spreads 
gradually  over  its  surface.  In  several  cases  of  this  kind  the  writer  has  noticed 
myokymia  of  the  calf  muscles  ;  that  is  to  say,  slow  worm-like  contractions  of 
individual  muscle  bundles  without  any  movement  of  the  foot. 

The  condition  is  not  verj^  uncommon,  and  its  diagnosis  is  not  difficult  if  the 
characteristic  history  of  pain  coming  on  during  the  act  of  walking  is  borne  in 
mind  and  leads  to  the  search  for  the  signs  referred  to  above.  The  importance 
of  its  recognition  needs  no  emphasis  in  view  of  its  tendency  to  go  on  to  gangrene. 

Raynaud's  Disease. — The  pain  attendant  on  the  local  syncope  and  local 
asphyxia  which  characterize  this  disease  may  be  severe,  but  the  diagnosis  is 
obvious  owing  to  the  onset  of  symmetrical  pallor  or  cyanosis  of  the  toes  preceding 
the  acutely  painful  stage  (see  Gangrene).  The  hands  are  nearly  always  affected 
at  the  same  time. 

Erythromelalgia. — In  this  condition,  which  may  affect  various  parts  of  the  bod}', 
but  which  is  seen  most  commonly  in  the  feet,  pain  raay  precede  any  other  phe- 
nomenon. The  pain  is  more  or  less  continuous,  with  paroxysmal  exacerbations, 
and  it  is  aggravated  by  the  dependent  position  of  the  limb  as  well  as  by  warm 
applications.  The  raising  of  the  foot  to,  or  above,  the  level  of  the  body,  and 
the  application  of  cold,  are  attended  by  alleviation.  Local  patches  of  cutaneous 
flushing  follow,  or  sometimes  precede,  the  pain,  and  are  often  found  about  the 
ball  of  the  big  toe  or  along  one  edge  of  the  foot.  These  patches  are  generally 
rose-pink  in  colour,  but  may  become  purplish-red  in  severe  paroxysms.  The  local 
temperature  is  raised,  and  pulsation  of  the  vessels  may  be  observed.  Superficial 
and  deep  tenderness  is  also  present,  but  no  changes  in  the  reflexes  are  noted. 
In  long-standing  cases  a  certain  amount  of  oedema  results.  Erythromelalgia 
occurs  in  persons  who  are  apparently  healthy  in  other  respects  ;  on  the  other 
hand,  it  may  be  an  early  symptom  of,  or  be  associated  with,  some  disease  of  the 
spinal  cord,  such  as  disseminated  sclerosis,  tabes  dorsalis,  or  syringomyelia. 

The  following  table  is  drawn  up  with  a  view  to  summarizing  the  chief  points 
in  the  differential  diagnosis  of  intermittent  claudication,  Raj'naud's  disease, 
and  erythromelalgia:  — 


Intermittent 
Claudication 

Raynaud's  Disease 

E  RYJ'H  ROM  ELALGI  A 

Age 

40  and  over 

All  ages 

20    to    60 

Sex 

Males  more  than  females 

Females  more  than  males 

Males  more  than  females 

Site          -j 

As   a  rule    symmetrical 
in  calf  muscles 

Sj^mmetrical  in  toes 

AsA'mmetrical     in     feet, 
rarely  bilateral 

( 

Pain       -' 

Onset  while  walking 

Worse  in  cold  weather 
Only  with  exercise 

No  sensory  change 

During   syncopal  phase 

or  absent 
Unaffected  by  postion 

May  be  excited  by  cold 
Paroxj'smal 

Ana?sthesia    and     anal- 
gesia during  paroxj^sm 

Precedes  vasomotor  phe- 
nomena 

Aggravated  by  depen- 
dent posture 

Cold  beneficial 

More  or  less  continuous, 
with  exacerbations 

Superficial  and  deep  ten- 
derness 

Vaso- 
motor      J 
changes 

No  change  or  slight!}-  pale 
Absence  of  pulsation  in 
arteries.      Feet  some- 
times cold 
Gangrene  occasional 

Pallor  and  lividity 
Ischaemia  and  local  cold 

Gangrene  common 

Pink  to  purplish  flush 
Increased  pulsation  and 
local  heat 

Gangrene  rare 

Associa-  \ 
1  tions      1 

Arteriosclerosis 

Tobacco 

Syphilis 

General  vasomotor  dis- 
turbances 

Functional   and  organic 
disease   of  the  central 
nervous  svstem 

PAIN     IN     THE     UPPER     EXTREMITY  491 

3.  Referred  Pain  in  Visceral  Disease.- — In  the  lower  extremity  the  referred 
pain  of  visceral  disease  is  not  so  often  recognized  as  that  of  cardiac  disease  in 
the  upper  extremity.  Disease  of  the  rectum,  bladder,  prostate,  or  uterus  may, 
however,  give  rise  to  pain  and  cutaneous  tenderness,  chiefly  in  the  fifth  lumbar 
and  sacral  areas.  Head  quotes  a  patient  who  suffered  from  prostatitis  and  whose 
complaint  was  as  follows  :  "  My  life  is  a  burden,  for  I  cannot  stand  owing  to 
the  pain  in  the  soles  of  my  feet,  I  cannot  walk  owing  to  the  pain  in  my  calves, 
sit  on  account  of  the  pain  ovei  the  ischial  tuberosities  and  in  the  perineum, 
or  even  lie  owing  to  the  pain  in  my  loins  and  side."  A  careful  examination 
of  the  abdominal  and  pelvic  viscera  is  necessary,  therefore,  in  all  cases  of  pain 
referred  to  the  legs  without  obvious  local  cause.  E.  Farqiihar  Buzzard. 

PAIN  IN  THE   EXTREMITY   (UPPER) Pain  in  some  part  or   other  of   the 

upper  extremity  is  a  common  complaint,  and  one  for  which  relief  is  often  sought. 
In  order  to  relieve  the  pain  it  is  necessary  for  the  medical  man  to  make  a  diagnosis 
of  the  pathological  condition  which  underlies  it.  This  article  makes  no  pretence 
to  deal  with  the  diagnosis  of  cases  in  which  there  is  some  obvious  source  of  pain, 
such  as  an  acute  arthritis  or  a  tumour,  but  is  intended  to  serve  as  a  guide  for 
the  diagnosis  of  cases  in  which  the  pain  is  more  obscure  in  origin. 

In  the  first  place,  it  is  always  essential  to  inquire  into  the  character  of  the  pain, 
its  exact  site,  its  duration,  and,  if  paroxysmal,  its  usual  time  of  onset,  its  relation 
to  movement,  rest,  etc.  In  the  second  place,  a  careful  examination  must  be 
made,  not  only  of  the  offending  limb,  but  of  the  functions  of  various  organs 
and  of  the  nervous  system  in  particular.  It  must  be  remembered  that  the  arm 
is  innervated  by  branches  of  the  brachial  plexus,  and  that  the  latter.. is  made 
up  of  nerve  fibres  derived  from  the  fifth  cervical  to  the  second  dorsal  spinal 
segments  through  their  corresponding  roots.  Consequently,  complete  examina- 
tion may  necessitate  an  investigation  ot  the  spinal  functions,  and  an  inquiry 
into  the  condition  of  the  cervical  vertebral  column  and  the  cervical  meninges  ; 
it  may  even  be  desirable  to  take  a  skiagram  of  the  neck  or  to  make  a  lumbar 
puncture  for  the  purpose  of  a  correct  diagnosis.  Attention  may  be  drawn  espe- 
cially to  the  fact  that  pain  in  any  situation  may  be  a  forerunner,  the  first  symptom 
of  a  nervous  or  spinal  lesion  which  ultimately  leads  to  more  serious  disorders 
of  function,  such  as  paialysis,  loss  of  sensibility,  and  alteration  of  reflexes. 

The  following  are  various  pathological  conditions  of  which  pain  in  the  arm  is 
often  a  prominent  symptom  : — 

Brachial  Neuralgia. — This,  like  neuralgia  in  other  parts,  is  characterized  by 
pain  and  tenderness  in  the  distribution  of  one  or  more  nerves.  The  pain  may 
be  referred  to  the  course  of  all  the  branches  of  the  brachial  plexus,  but  some- 
times is  limited  to  that  of  one  or  two  nerves,  such  as  the  ulnar,  musculo-spiral, 
or  internal  cutaneous.  It  may  occur  only  in  paroxysms,  but  more  commonly 
there  is  a  constant  aching  discomfort,  with  occasional  severe  exacerbations 
excited  by  exertion,  cold,  or  mental  worry.  The  patient  is  generally  glad  to 
rest  the  limb  or  to  carry  it  in  a  sling,  in  order  to  avoid  the  more  acute  attacks  ; 
on  the  other  hand,  the  continuous  aching  drives  him  to  find  temporary  relief 
in  frequent  changes  of  position.  Pressure  over  the  affected  nerves  is  accom- 
panied by  tenderness,  especially  over  the  brachial  plexus  in  the  posterior  triangle 
of  the  neck,  over  the  musculospiral  as  it  winds  round  the  humerus,  and  over 
the  ulnar  along  its  superficial  course  in  the  region  of  the  elbow.  The  tenderness 
so  produced  may  be  associated  with  pain  or  tingling  referred  to  the  more 
peripheral  course  of  the  nerve.  The  skin  may  be  hyperaesthetic  and  show 
vasomotor  changes  in  the  way  of  flushing  or  hyperidrosis. 

In  making  a  diagnosis  of  brachial  neuralgia  it  is  desirable  to  seek  for  some 
cause  to  which  it  can  be  ascribed,  such  as  a  rheumatic  ox  gouty  diathesis,  orahistor}' 


492  PAIN     IX     THE     UPPER     EXTREMITY 

of  some  preceding  toxic  condition,  such  as  influenza,  malaria,  or  alcoholism.  In 
some  cases  no  satisfactory  explanation  beyond  unusual  worry  or  work  in  a 
neuropathic  individual  is  forthcoming.  The  urine  should  be  examined  for  sugar, 
as  neuralgia  is  sometimes  of  diabetic  origin. 

The  presence  of  muscular  atrophy  or  anaesthesia  removes  the  case  from  the 
category  of  neuralgia,  and  the  diagnosis  of  neuritis  or  of  some  more  gross  organic 
affection,  to  which  reference  will  be  maae,  must  be  substituted.  On  the  other 
hand,  it  must  not  be  forgotten  that  a  cervical  rib  may  produce  many  of  the 
symptoms  of  brachial  neuralgia  without  any  definite  muscular  atrophy  or  sensory 
loss.  In  contradistinction  to  some  of  the  conditions  about  to  be  described, 
brachial  neuralgia  is  practically  always  unilateral. 

Brachial  neuralgia  may  be  diagnosed,  therefore,  if  there  is  pain  and  tender- 
ness in  the  distribution  of  the  brachial  plexus  without  paralysis  or  sensory  loss, 
and  if  no  gross  lesion  can  be  found  to  account  for  the  symptoms.  So-called 
muscular  rheumatism  differs  from  brachial  neuralgia  in  that  the  pain  is  generally 
less  acute  and  the  points  of  local  tenderness  are  to  be  found  over  muscular 
insertions  rather  than  over  the  nerve  trunks.  At  the  same  time  it  must  be 
admitted  that  the  muscles  as  well  as  the  nerves  are  hypersensitive  in  severe 
cases  of  neuralgia. 

Brachial  Neuritis. — When  muscular  atrophy  and  sensory  loss  are  found  in 
addition  to  pain  and  tenderness,  the  condition  must  be  regarded  as  one  of  neuritis. 
Unilateral  brachial  neuritis  is  very  uncommon  except  as  a  result  of  some  gross 
lesion,  such  as  pressure  on,  or  irritation  of,  the  nerve-trunks.  Bilateral  brachial 
neuritis  is  common  enough,  but  is  then  a  part  of  a  multiple  peripheral  neuritis 
due  to  alcohol,  arsenic,  lead,  diabetes,  etc.,  in  which  the  lower  extremities  also 
are  generally  involved. 

Before  making  a  diagnosis  of  one-sided  brachial  neuritis,  careful  search  must 
be  made  for  evidence  of  such  conditions  as  cervical  rib,  tumour  in  the  posterior 
triangle  of  the  neck,  glands  in  the  axilla,  aneurysm  of  the  subclavian  artery,  malignant 
disease  or  caries  of  the  cervical  vertebrcB,  cervical  pachymeningitis,  spinal  tumour, 
or  spinal  gliosis.  Neuromata  or  fibroneuromata  are  generally  widely  distributed 
about  the  peripheral  nerves,  but  cases  have  been  recorded  in  which  they  have 
been  limited  to  the  brachial  plexus  and  have  given  rise  to  a  brachial  neuralgia 
or  brachial  neuritis.  Such  tumours  may  be  so  small  as  easily  to  escape  observa- 
tion unless  looked  for.  Adiposis  dolorosa  is  another  rare  condition  which  may 
give  rise  to  neuralgic  pain  in  the  arm,  but  it  is  not  limited  to  one  limb. 

Cervical  Ribs. — A  supernumerary  seventh  cervical  rib,  unilateral  or  bilateral, 
is  a  frequent  congenital  abnormality.  In  a  small  proportion  of  cases  it  may 
give  rise  to  symptoms,  especially  in  adults  who  use  their  arms  and  hands  con- 
tinually in  the  course  of  their  employment.  Women  suffer  more  often  than 
men.  Pain  radiating  from  the  root  of  the  neck  to  the  tips  of  the  fingers,  more 
often  than  not  along  the  ulnar  border  of  the  arm,  is  usually  the  first,  and  may 
be  the  only,  symptom.  The  pain  is  of  an  aching  or  dull  boring  character,  and 
is  much  influenced  by  rest  and  position.  For  instance,  if  a  woman,  who  has 
been  suffering  much  when  at  work,  takes  a  holiday,  and  ceases  to  use  her  arms 
for  scrubbing,  lifting,  etc.,  she  may  lose  the  pain  altogether  until  she  resumes 
her  occupation.  Similarly  the  pain  is  worse  at  night  after  a  day's  work,  and 
may  be  influenced  favourably  by  keeping  the  arm  in  certain  positions.  Lying 
in  bed  with  the  hand  behind  the  head  is  a  favourable  attitude  in  many  cases. 
Very  occasionally  the  pain  spreads  into  the  scapular  region  along  the  course  of 
the  suprascapular  nerve.  There  is  rarely  any  tenderness  along  the  peripheral 
parts  of  the  nerves,  but  pressure  in  the  posterior  triangle  of  the  neck,  just  above 
the  inner  part  of  the  clavicle,  may  give  rise  to  pain  radiating  down  the  arm. 

In  addition  to  pain  there  may  be  disturbances  of  motor,  sensory,  and  vasomotor 


PAIN     IN     THE     UPPER     EXTREMITY  493 

origin.  Atrophic  palsy  of  the  intrinsic  hand  muscles  and  of  the  iiexor  muscles 
in  the  forearm  are  the  common  motor  disturbances,  and  may  lead  to  deformities 
such  as  Claw-hand  {q.v.).  Anaesthesia  along  the  ulnar  border  of  the  forearm, 
and  perhaps  extending  on  to  the  inner  fingers,  is  sometimes  observed.  In  one 
bilateral  case  the  writer  has  observed  intense  vasomotor  disturbances  without 
definite  muscular  atrophy  or  sensory  loss.  Both  hands  were  the  seat  of  a  painful 
cyanosis  involving  the  fingers,  and  almost  amounting  to  the  condition  seen  in 
cases  of  Raynaud's  disease.  Sometimes  there  is  a  diminution  in  the  radial 
pulse  on  the  affected  side. 

The  diagnosis  of  cervical  rib  or  ribs  must  naturally  depend  on  the  use  of  the 
,r-rays  to  reveal  their  presence,  but  it  must  be  borne  in  mind  that  the  pressure 
on  the  trunk  or  trunks  of  the  brachial  plexus  is  usually  exerted  by  a  fibrous 
band  passing  from  the  tip  of  the  cervical  rib  to  the  first  dorsal  rib,  and  that 
therefore  the  size  of  the  rib  shown  by  skiagraphy  affords  no  guide  as  to  the 
importance  of  its  effect.  The  most  rudimentary  rib  is  as  important  from  the 
point  of  view  of  diagnosis  as  one  which  is  fully  developed. 

AcroparSBsthesia.  —  This  term  is  applied  to  a  fairly  common  complaint, 
usually  made  by  women  between  thirty-five  and  fifty-five  years  of  age,  who  are 
continually  using  their  hands,  and  especially  by  those  whose  hands  are  frequently 
immersed  in  waters  of  different  temperatures.  Charwomen,  domestic  servants, 
needlewomen,  and  washerwomen  are  particularly  liable  to  suffer.  IMany  of  the 
victims  indulge  to  a  moderate  extent  in  spirit-drinking.  They  complain  of  a 
burning  pain,  associated  with  tingling  and  numbness,  in  the  fingers  and  palms  of 
their  hands.  It  is  chiefly  noticed  in  the  latter  part  of  the  day  after  their  work 
is  over,  and  becomes  intensified  when  they  are  warm  in  bed.  In  the  early 
morning  their  fingers  are  numb  and  clumsy,  but  the  discomfort  passes  off  while 
they  are  at  work,  only  to  return  again  towards  evening.  As  a  rule,  there  is  little 
to  see  on  examination,  but  there  may  be  redness  or  pallor  of  the  affected  parts, 
associated  with  a  subjective  feeling  of  heat  and  swelling.  Sensibility  is 
unimpaired  if  allowance  is  made  for  the  cutaneous  thickening  usually  present 
in  persons  whose  hands  are  much  exposed  to  moisture  and  friction.  There  is  no 
definite  palsy  or  muscular  atrophy.  Acroparaesthesia  as  a  rule  affects  both 
hands,  and  very  occasionally  it  is  accompanied  by  a  similar  condition  in  the 
feet. 

Similar  paraesthesiae  are  sometimes  complained  of  by  patients  suffering  from 
tabes  dorsalis,  but  in  those  cases  the  pains  are  of  the  lightning  character,  and 
never  limited  to  the  hands.  Other  tabetic  signs,  such  as  Argyll  Robertson 
pupils,  ulnar  analgesia,  impaired  sense  of  position,  and  absence  of  tendon- jerks, 
serve  to  make  a  diagnosis.  In  the  early  stages  of  subacute  combined  degeneration 
of  the  spinal  cord,  paraesthesiae,  sometimes  of  a  markedly  painful  character,  are 
referred  to  the  hands  and  feet.  The  presence  of  some  ataxia  or  spastic  para- 
plegia, with  increased  tendon- jerks  and  extensor  plantar  reflexes,  differentiate  this 
disease  from  the  ordinary  acroparaesthesiae. 

Radicular  Pain. — Under  this  title  may  be  included  all  pains  in  the  arm 
which  radiate  through  the  peripheral  distribution  of  the  posterior  spinal 
roots  from  the  fifth  cervical  to  the  second  dorsal.  These  pains  extend  from 
the  neck  towards  the  periphery  of  the  limb,  and  are  usually  of  a  sharp, 
lancinating  type.  In  the  large  majority  of  cases  they  are  produced  by  some 
gross  morbid  process  involving  the  roots  within  the  spinal  canal  or  in  their 
course  through  the  intervertebral  foramina.  The  morbid  processes  most 
commonly  responsible  are  intravertebral  tumour,  cervical  pachymeningitis,  cervical 
caries,  and  malignant  disease  of  the  cervical  vertebrce.  In  all  these  conditions  the 
radicular  pain  may  precede  all  other  symptoms,  with  the  result  that  the  diagnosis 
is  often  difficult  and  sometimes  impossible  until  further  phenomena  develop. 


494  PAIX     IX     THE      UPPER     EXTREMITY 

The  pain  is  occasionally  unilateral,  more  often  bilateral ;  it  may  be  accompanied 
b}'  tenderness  on  pressure  over  the  vertebrae,  especially  in  the  case  of  vertebral 
caries  or  malignant  disease.  ^lovements  of  the  neck  will  intensify  the  pain  in 
the  latter  conditions.  The  diagnosis  must  be  arrived  at  by  careful  attention  to 
the  following  points  :  (i)  Evidence  of  deformit\%  rigidity  or  tenderness  of  the 
cer^dcal  vertebrae,  supplemented  by  an  A--ray  examination  ;  (2)  The  presence 
of  other  root  S}.Tnptoms,  such  as  localized  atrophic  palsy,  anaesthesia,  and  loss 
of  tendon-jerks  in  the  arms  ;  (3)  Evidence  of  pressure  on  the  spinal  cord,  pro- 
ducing spastic  paralysis  of  the  trunk  and  lower  limbs,  together  with  anaesthesia, 
loss  of  abdominal  reflexes,  increased  knee-jerk,  ankle-clonus,  and  extensor  plante^r 
re.^exes  ;  (4)  The  occurrence  of  oculo-pupillar\'  phenomena  when  the  eighth 
cervical  and  first  dorsal  roots  are  involved  ;  and  (5)  The  condition  of  the 
cerebrospinal  fluid  obtained  b}-  lumbar  puncture. 

In  addition  to  the  gross  extrinsic  processes  affecting  the  spinal  roots,  there 
are  other  cases  in  which  a  spinal  root  is  the  site  of  an  intrinsic  inflammatory  or 
vascular  lesion.  Herpes  zoster  is  a  common  result  of  such  a  lesion,  and  may  be 
found  in  the  peripheral  distribution  of  an}-  of  the  posterior  roots  which  go  to 
form  the  brachial  plexus.  The  pain  which  precedes  the  eruption  and  the  post- 
herpetic neuralgia  are  instances  of  pain  in  the  upper  extremity,  the  latter  being 
sometimes  of  a  persistent  character  and  often  associated  with  marked  hyper- 
esthesia in  the  corresponding  root  area.  Uniradicular  pain,  followed  b}-  atrophy 
of  the  muscles  supphed  by  the  efferent  root  fibres  and  by  sensory  loss  in  the  region 
innervated  by  the  afferent  fibres,  with  or  without  the  development  of  an  herpetic 
rash,  also  occurs  in  rare  instances  as  the  result  of  an  inflammator}-  or  vascular 
lesion  of  the  spinal  nerve  in  the  neighbourhood  of  the  posterior  root  ganglion. 

Referred  Pain  In  Visceral  Disease. — In  disease  of  the  heart  and  aorta,  especially 
with  syphilitic  disease  of  the  acrtic  valves,  or  with  atheroma  or  aneurysm  of 
the  first  few  inches  of  the  aorta,  attacks  of  pain  in  the  left  arm  are  often  com- 
plained of.  The  pain  is  really  radicular  in  distribution,  and  is  referred  to  the 
first  and  second  dorsal  root  areas,  or,  in  other  words,  to  the  ulnar  border  of  the 
arm,  and  sometimes  extends  into  the  httle  finger.  During  the  attacks  of 
pain,  cutaneous  h^-peraesthesia  may  be  present  over  the  same  areas.  In  all 
cases  of  paroxysmal  pain  referred  to  the  left  arm,  a  verjr  careful  examination 
of  the  thoracic  viscera  is  therefore  indicated. 

Occupation  Neuroses. — The  upper  limb  is  the  common  site  of  occupation 
neuroses  (writer's  cramp,  typist's  cramp,  and  so  on),  since  it  has  to  do  with 
writing,  t^-ping,  needlework,  telegraphy,  hair-cutting,  etc.  These  neuroses  are 
mainly  characterized  by  some  form  of  muscular  spasm,  but  pain  of  a  cramp-like 
character  is  a  frequent  accompaniment  of  the  spasm.  The  diagnosis  is  eas^', 
because  careful  inquin,-  will  elicit  the  fact  that  the  pain  and  spasm  are  evoked 
by  the  employment  of  the  limb  in  a  particular  occupation,  and  that  other 
manipulations  involving  the  use  of  the  same  muscles  may  be  carried  out  with 
impunity.  The  acute  pain  associated  with  the  spasm  may  be  followed  by  a 
dull  aching  for  some  hours  after  the  occupation  has  been  indulged  in. 

Finally,  the  term  "Psychalgia  "  may  be  appUed  to  pain  referred  to  the  arm, 
as  well  as  to  other  parts  of  the  body,  by  patients  whose  nervous  and  mental 
resistance  is  undermined  or  exhausted.  Neurasthenic  pain  of  this  kind  is  rarely 
limited  to  the  arm  ;  in  fact,  it  is  more  commonly  referred  to  various  parts  of  the 
head  and  to  particular  regions  along  the  course  of  the  vertebral  column. 

E.  Farquhar  Buzzard. 

PAIN  IN  THE  EYE  is  experienced  commonh'  in  all  inflammaton^  conditions. 
It  is  most  se\'ere  in  glaucoma,  where  it  is  often  accompanied  by  severe  headache 
and  vomiting.  The  pain  of  iritis  is  often  severe  and  neuralgic  in  character, 
and  is  distributed  over  the  whole  trigeminal  area.     Conversely,  pain  produced 


PAIN     IN     THE     FACE  495 


by  irritation  of  the  other  branches  of  the  fifth  nerve  may  be  referred  to  the  eye. 
Hemicrania  and  pain  behind  the  eyes  are  common  symptoms  of  eye-strain  due 
to  errors  of  refraction,  more  particularly  those  of  low  degree  in  persons  of  high 
visual  acuity.     The  character  of  the  pain  alone  is  seldom  diagnostic,  however. 

Herbert  L.  Eascn. 

PAIN  IN  THE  FACE. — The  distinction  between  pain  in  the  face  and  pain 
in  the  head,  though  to  some  extent  artificial,  is  sufficiently  marked  in  most 
instances  ;  the  latter  form  of  pain,  with  its  diagnostic  significance,  is  discussed 
under  Headache.  There  are  certain  etiological  points,  however,  at  which 
face-ache  and  headache  overlap;  for  example,  the  supra-orbital  pain  and  the 
headache  which  may  both  originate  from  ocular  errors  of  refraction. 

Pain  in  the  face,  like  pain  elsewhere,  may  be  due  to  very  obvious  causes, 
such  as  an  inflamed  parotid  gland,  a  gumboil,  or  an  acute  conjunctivitis,  and  it 
is  outside  the  scope  of  this  article  to  discuss  the  diagnosis  of  these  conditions. 
On  the  other  hand,  pain  in  the  face  is  frequently  complained  of  when  superficial, 
and  perhaps  minute,  examination  fails  to  discover  an  adequate  basis.  Guidance 
towards  the  correct  diagnosis  of  such  cases  is  essential  for  their  proper  and 
successful  treatment,  and  may  be  obtained  by  a  consideration  of  the  course, 
signs,  and  symptoms  of  different  clinical  types  of  facial  pain.  In  pursuing  this 
course  I  shall  follow  broadly  the  classification  adopted  by  Dr.  Head,  who  has 
made  a  careful  study  of  these  conditions. 

Major  Trigeminal  Neuralgia  (tic  douloureux  or  epileptiform  neuralgia)  may 
justly  be  regarded  as  a  distinct  disease,  owing  to  the  general  similarity  of  one 
case  to  another.  Its  pathology  is  still  unknown,  but  in  each  case,  as  Head 
points  out,  the  pain  is  attributed  in  its  early  stages  to  some  local  defect,  such  as 
a  carious  tooth,  and  many  sound,  as  well  as  many  diseased,  teeth  are  removed 
in  a  vain  endeavour  to  arrest  this  malady.  Beginning  usually  after  thirty-five 
years  of  age,  tic  douloureux  is  characterized  by  paroxysms  of  acute  pain  in  the 
distribution  of  one  or  more  of  the  divisions  of  the  trigeminal  nerve.  The 
intervals  between  the  paroxysms  vary  from  seconds  to  months,  and  may  be 
influenced  in  their  length  by  many  factors,  such  as  the  general  state  of  health, 
mental  worry,  and  exposure  to  cold.  There  is  a  tendency  for  the  intervals 
to  become  shorter,  and  the  paroxysms  more  severe  and  more  extensive  in  their 
distribution.  The  pain  is  described  as  beginning  in  spots  beneath  the  skin,  and 
radiating  along  the  peripheral  branches  of  the  nerve.  These  spots  correspond 
to  points  where  the  nerve  bundles  penetrate  the  deeper  tissues  to  reach  the 
more  superficial  structures,  and  may  be  recognized  as  places  pressure  upon 
which  is  particularly  liable  to  start  an  attack.  In  severe  cases,  the  lightest  touch, 
a  breath  of  wind,  attempts  at  articulation  or  mastication,  and  even  the  act  of 
defascation  may  be  sufficient  to  provoke  an  agonizing  spasm  in  which  the  violent 
reflex  contraction  of  the  muscles  of  the  corresponding  side  of  the  face  affords 
some  evidence  of  the  suffering  endured.  During  the  paroxysm  the  patient  may 
endeavour  to  obtain  relief  by  firm  pressure  with  his  hand  over  the  starting- 
point  of  the  pain.  In  addition  to  the  muscular  spasm,  the  attack  of  pain  may 
be  accompanied  by  cutaneous  flushing,  photophobia,  lachrymation,  and  saliva- 
tion, as  well  as  by  a  subjective  sensation  of  swelling  in  the  affected  tissues.  When 
the  tongue  is  affected,  a  metallic  taste  is  sometimes  described  by  the  sufferer. 
Trophic  changes  in  the  hair  and  skin  are  also  observed  as  a  result  of  repeated 
attacks. 

From  this  brief  description  it  may  be  inferred  that  the  diagnosis  of  major 
neuralgia  depends  chiefly  on  the  following  points  :  (i)  The  age  of  onset  ;  (2)  The 
absence  of  relief  or  only  temporary  alleviation,  afforded  by  removal  of  possible 
exciting  causes,  such  as  defective  teeth  ;  (3)  The  presence  of  definite  starting- 
points  of  the  pain  corresponding  to  exits  of  branches  of  the  fifth  cranial  nerve, 


496  PAIN     IX     THE     FACE 

and  the  spread  of  the  pain  along  the  corresponding  nervous  paths  ;  (4)  The 
paroxysmal  character  of  the  pain  and  its  intense  severity  ;  (5)  The  excitability 
of  the  attacks  by  peripheral  stimuli ;  and  (6)  The  various  reflex,  vasomotor, 
secretory',  and  trophic  phenomena  to  which  the  attacks  of  pain  give  rise. 

From  a  practical  standpoint  the  most  important  task  in  diagnosis  is  to  dis- 
criminate between  cases  of  idiopathic  major  neuralgia  and  those  which  belong 
to  the  next  group. 

Trigeminal  Neuralgia  due  to  Organic  Lesion  of  the  Nerve  or  its  Roots. — This 
form  of  neuralgia  may  simulate  tic  douloureux  in  everj^  particular,  and  its 
diagnosis  can  be  made  only  by  careful  systematic  examination  of  the  patient, 
with  the  possibility  of  an  organic  lesion  being  the  source  of  pain  before  the 
physician's  mind.  Tumouvs  at  the  base  of  the  brain  in  the  middle  fossa,  tumours 
growing  from  the  base  of  the  skull  in  the  neighbourhood  of  the  foramen  ovale  and 
foramen  rotundum,  as  well  as  tumours  of  the  cranial  nerves  themselves,  are 
amongst  the  causes  of  trigeminal  neuralgia.  Gummatous  meningitis  and  gum- 
matous periostitis  may  be  mentioned  in  the  same  connection.  In  every  case  of 
trigeminal  neuralgia,  therefore,  headache  and  vomiting  should  be  enquired  after, 
and  optic  neuritis  looked  for.  Examination  of  the  functions  of  each  cranial 
nerve  must  be  carried  out,  and  in  particular  those  of  the  fifth  nerve  carefully 
tested.  Any  impairment  of  sensibility  in  the  cutaneous  territory  of  this  nerve 
must  be  regarded  as  evidence  that  the  case  is  not  one  of  idiopathic  neuralgia, 
and  the  same  may  be  said  when  there  is  impaired  motor  power  in  the  muscles 
of  mastication.  In  several  cases  of  severe  trigeminal  neuralgia,  I  have  found 
atrophic  palsy  of  the  masseter  and  temporal  muscles  on  the  same  side,  with 
slight  anaesthesia  on  the  face,  and  these  cases  have  alwaj^s  proved  to  be  instances 
of  growth  involving  the  structures  at  the  base  of  the  skull.  In  one  patient  the 
neoplasm  originated  in  the  sphenomaxillary  fossa. 

Trigeminal  neuralgia  may  also  occur  as  the  result  of  intrinsic  disease  of  the 
Gasserian  ganglion,  e.g.,  in  cases  of  herpes  zoster.  This  condition  is  fairly 
common  in  the  distribution  of  the  first  division  of  the  trigeminus,  much  less 
common  in  that  of  the  second  and  third  divisions.  The  pain  usualh^  precedes  the 
herpetic  eruption  by  some  days,  and  is  associated  with  constitutional  malaise  and 
sometimes  with  pyrexia,  two  important  points  in  diagnosis.  The  latter  becomes 
clear  with  the  development  of  the  rash,  but  even  then  it  is  necessary  to  bear  in 
mind  the  possibility  that  the  Gasserian  ganglion  may  be  affected  by  gross 
external  disease,  such  as  neoplasm  or  gumma,  or  an  extension  of  bony  disease. 
In  persons  over  fifty  years  of  age  it  is  frequently  found  that  pain  of  a  neuralgic 
character  persists  after  the  herpes  has  disappeared,  and  maj^  last  for  months 
and  even  years.  Careful  examination  in  such  cases  generally  reveals  the 
presence  of  cutaneous  scars  corresponding  to  the  site  of  the  previous  vesicular 
eruption 

Neuralgia  Minor. — Under  this  heading  may  be  classed  the  varieties  of  facial 
pain  which  are  secondary  to  disease  of  various  local  structures,  such  as  the 
teeth,  the  eye,  the  ear,  the  nose,  and  the  tongue.  According  to  Head,  the  pain 
in  these  conditions  can  be  distinguished  by  certain  features  as  belonging  to 
one  or  other  of  two  types.  The  first  is  to  be  regarded  as  a  true  neuralgia, 
that  is  to  say,  a  pain  which  is  distributed  along  the  course  of  one  or  more 
divisions  of  the  trigeminal  nerve,  and  usually  starting  in  the  neighbourhood  of 
the  diseased  structure.  The  second  type  is  an  example  of  referred  visceral  pain, 
the  pain  being  referred  to  some  spot  which  may  be  at  a  distance  from  the  disease, 
and  which  is  usually  the  site  of  superficial  hyperaesthesia  or  tenderness. 

The  history  of  a  decaying  tooth  affords  an  example  of  how  these  types  of  pain 
may  arise.  In  the  early  stages  of  caries  the  pain  is  limited  to  the  tooth,  which 
betrays  its  source.     With  inflammation  and  destruction  of  the  pulp,  pain  is 


PAIN     IN     THE     FACE 


497 


referred  to  a  segmental  area  on  the  surface  of  the  face  varying  with  the  particular 
tooth  implicated.  Thus  a  diseased  canine  tooth  is  associated  with  pain  and 
tenderness  in  the  naso-labial  area  [Fig.  132,  Na.L.).  Finally,  after  the  pulp  is 
dead,  local  suppuration  may  start  a  neuralgia  which  may  not  only  spread  along 

The  Segmental  Areas  of  the  Head  and  Xeck,  and  their  Maximal  Points 

[after  Head). 


Inf.L 


/'■/V.  133 


Man. 


Fig-.  134. 


Fp.  N.  Fronto-nasal ;  Fr.  T.  Fronto-temporal  ;  H,  Hyoid  ;  Inf.  L,  Inferior  laryngeal  ;  M,  Mental  ; 
Man,  Mandibular;  Max,  Maxillary;  Mid.  O,  ^lid-orbital ;  Na.  L,  Naso-labial;  Oc,  Occipital; 
P,  Parietal;    R,  Rostral;    Su.   L,  Superior  laryngeal  ;    T,  Temporal;    V,  Vertical. 


the  nerve  branch  which  supphes  the  tooth  socket,  but  may  extend  into  neigh- 
bouring branches  and  into  other  divisions  of  the  trigeminal  nerve. 

The  maximal  points  in  the  segmental  areas  referred  to  are  shown  in  the 
accompanying  diagrams,  and  the  general  relationship  between  individual  teeth 
and  their  segmental  areas  may  be  described  as  follows  : — 

D  32 


498 


PAIN     IN     THE     FACE 


Upper  Jaw. 
Incisors    -     .  .           .  .      Fronto-nasal     |      ist  molar 

Canine  .  .  .  .      Naso-labial        I  2nd       ,, 

ist  bicuspid  .  .  ,,         ,,  3rd        ,, 

2nd         „       Temporal  or  maxillary     | 


Incisors 
Canine    .  . 
ist  bicuspid 
2nd 


Lower  Jaw. 
Mental  ist  molar 

2nd 


Doubtful 


3rd 


Maxillary 
Mandibular 


Hyoid 

Hyoid  or  superior 
laryngeal. 


The  value  of  this  knowledge  in  relation  to  diagnosis  lies  in  the  fact  that  pain, 
with  tenderness,  referred  to  any  one  of  these  segmental  areas,  should  lead  the 
observer  to  seek  for  its  cause  in  disease  of  the  corresponding  viscus. 

The  headache,  sometimes  called  neuralgia,  which  results  from  errors  of  refrac- 
tion, especially  astigmatism,  is  referred  to  the  mid-orbital  area,  where  superficial 
tenderness  may  often  be  discovered  on  examination.  This  form  of  pain  comes 
on  in  the  morning  as  soon  as  the  eyes  are  opened,  and  is  intensified  by  reading 
or  sewing.  It  disappears  under  the  use  of  atropine,  and  wears  off  of  itself  if 
the  eyes  are  not  used  for  near  work.  Occasionall}^  it  takes  on  a  paroxysmal 
character  without  any  particular  relationship  to  the  use  of  the  eyes.  In  iritis 
and  glaucoma,  referred  pain  may  be  intense,  and  it  is  usually  situated  in  the 
temporal  and  maxillary  segmental  areas  as  well  as  in  the  eyeball  itself.  The 
occurrence  of  referred  pain  in  chronic  glaucoma  without  pain  in  the  e^^eball  is 
a  point  which  may  be  of  great  diagnostic  importance,  as  it  may  draw  attention 
to  the  unsuspected  ocular  disease. 

In  ear  disease  the  hyoid  area  is  that  to  which  pain  is  referred  and  in  which 
hyperaesthesia  of  the  skin  may  sometimes  be  found.  In  the  more  severe  types 
of  disease,  such  as  suppuration  in  the  middle  ear,  the  pain  maj^  also  be  referred 
to  the  vertical  and  temporal  areas. 

Lesions  of  the  tongue  may  produce,  in  addition  to  local  pain  in  the  organ  itself, 
referred  pain  in  three  other  areas.  When  the  disease  affects  the  anterior  portion 
of  the  tongue,  pain  may  be  referred  to  the  mental  area  ;  when  the  lateral  portion 
is  involved,  to  the  hyoid  area  ;  and  when  the  dorsum  is  the  site  of  the  lesion,  to  the 
occipital  area. 

In  inflammatory  affections  of  the  nose  and  frontal  sinuses,  pain  is  referred  to 
the  fronto-nasal  and  mid-orbital  areas  on  the  forehead. 

The  various  forms  of  pain  in  the  head  associated  with  disease  of  the  thoracic 
and  abdominal  organs  are  discussed  under  Headache,  and  the  same  article 
deals  with  the  aches  which  accompany  general  constitutional  diseases. 

In  lobes  dorsalis  pains  are  sometimes  described  in  the  face,  and  have  the  same 
characteristics  as  those  in  other  parts  of  the  body.  They  are  paroxysmal,  sudden, 
severe,  and  lightning-like.  They  are  rarely  limited  to  the  face.  They  may  be 
accompanied  by  a  more  continuous  dull,  boring  kind  of  pain.  The  diagnosis  of 
these  cases  is  easy  if  a  systematic  examination  of  the  nervous  system  is  carried 
out.  Argyll  Robertson  pupils,  areas  of  analgesia,  ataxy,  and  absence  of  tendon 
reflexes  are  among  the  physical  signs  which  will  disclose  the  correct  diagnosis. 

Pseudo-neuralgias,  or  psychalgias,  which  are  complained  of  by  hysterical  and 
neurasthenic  individuals,  are  vague  in  their  distribution,  not  limited  to  the 
trigeminal  area,  and  often  bilateral.  They  tend  to  disappear  when  attention  is 
drawn  in  other  directions,  and  are  less  intense  during  eating  and  talking. 

E.  Farqiihar  Blizzard. 

PAIN  IN  THE  FOOT.— (See  Paix  in  the  Extremity,  Lower.) 


FAIN     IX     THE     HYPOCHONDRIUM  499 

PAIN  IN  THE  FOREARM. — (See  Paix  in  the  Extremity,  Upper.) 
PAIN  IN  THE   HAND. — (See  Paix  ix  the  Extremity,   Upper.) 
PAIN  IN  THE  HEAD.— (See  Headache.) 

PAIN  IN  THE  HIP. — (See  Joints,  Affections  of  the.) 

PAIN  IN  THE  HYPOCHONDRIUM  (LEFT).— Pain  ia  the  left  hypochon- 
drium  may  proceed  from  : — 

1.  The  Stomach. — Any  painful  condition  of  the  stomach  may  cause  pain  to  be 
felt  below  the  left  costal  margin.  In  particular,  a  new  growth  or  an  ulcer 
towards  the  cardiac  end  may  produce  it.  For  the  differential  diagnosis,  see 
Indigestion,  and  Pain  in  the  Epigastrium.  Flatulent  distention  of  the 
fundus  may  also  be  a  cause,  which  can  be  diagnosed  by  the  fact  that  the  pain 
disappears  on  eructation. 

2.  The  Spleen. — Some  enlargements  of  the  spleen  are  painful  (see  Spleen, 
Enlargement  of)  ;  or  the  pain  may  be  caused  by  perisplenitis,  in  which  case 
a  friction  sound  can  sometimes  be  heard  on  auscultation  over  it. 

3.  The  Left  Kidney. — Stone  in  the  left  kidney  may  cause  pain  which  has  the 
characters  described  in  the  section  on  pain  in  the  right  hypochondrium  (see 
below) .  A  movable  left  kidney  is  rarely  a  cause  of  pain.  A  perinephric  abscess 
may  cause  pain,  as  it  does  in  the  right  hypochondrium  (see  p.  500). 

4.  The  Colon. — A  new  growth  in  the  splenic  flexure  of  the  colon,  or  obstruction 
of  it  lower  down,  may  cause  pain  in  the  left  hypochondrium.  In  the  former 
case  a  tumour  can  usually  be  felt  on  bimanual  palpation  ;  in  the  latter,  signs  of 
chronic  obstruction  will  be  present  (see  Constipation).  Apart  from  growth,  a 
mere  accumulation  of  fcBces  in  the  transverse  and  descending  colon  may  cause  a 
feeling  of  pain  and  weight  in  the  left  hypochondrium.  The  disappearance  of  the 
pain  after  the  administration  of  a  few  large  enemata  will  establish  the  diagnosis. 

5.  Pleurisy,  intercostal,  Neuralgia  and  Herpes  Zoster  may  all  cause  pain  in 
the  left  hypochondrium.  In  the  first  of  these,  a  friction  sound  will  be  heard  ;  in 
intercostal  neuralgia  there  will  be  tender  points  over  the  course  of  the  intercostal 
nerve.  In  the  case  of  herpes,  the  cause  of  the  pain  will  be  cleared  up  by  the 
appearance  of  the  eruption,  but  pain  may  persist  long  after  this  has  disappeared. 

6.  Subdiaphragmatic  Abscess. — (See  p.  501.) 

Robert  Hutchison. 

PAIN  IN  THE  HYPOCHONDRIUM  (RIGHT).— The  differential  diagnosis  of 
the  cause  of  pain  in  the  right  hypochondrium  is  often  a  matter  of  great  difficulty, 
or  even  of  impossibility,  as  it  may  proceed  from  any  of  the  following  organs  : 
(i)  Liver  and  gall-bladder,  (2)  Duodenum,  (3)  Head  of  the  pancreas,  (4)  Right 
kidney,  (5)  Appendix  vermiformis,  (6)  Colon,  (7)  Uterine  appendages.  Intra- 
thoracic disease,  affections  of  the  chest  wall,  and  subdiaphragmatic  abscess 
may  also  cause  pain  in  this  situation.  The  diagnosis  is  rendered  still  more 
difficult  by  the  fact  that  disease  may  easily  be  present  in  more  than  one  of 
these  situations  at  the  same  time. 

I.  Liver. — Various  forms  of  enlargement  of  the  liver. are  apt  to  be  attended 
by  pain  in  the  right  hypochondrium,  e.g.  hepatitis,  passive  congestion,  hepatic 
abscess,  and  carcinoma  (see  Liver,  Enlargement  of  the). 

Disease  of  the  gall-bladder  must  also  be  thought  of,  e.g.,  gall-stones,  chole- 
cystitis, and  carcinoma.  In  these  it  will  usually  be  found  that  there  is  tenderness 
on  pressure  over  the  gall-bladder,  with  the  characteristic  catch  in  the  breath 
when  the  patient  is  asked  to  take  a  deep  inspiration  while  the  fingers  of  the 
observer  are  pressed  in  over  the  organ.  In  acute  cholecystitis  there  will  be  a 
rise  of  temperature. 


PAIN     IN     THE     HYPOCHONDRIUM 


The  pain  of  biliary  colic  may  be  felt  chiefi}^  in  the  right  hypochondrium,  but 
tends  to  radiate  through  to  the  back  and  up  towards  the  right  shoulder.  It 
may  be  closely  simulated  both  by  the  kinking  of  a  movable  kidney  and  by 
renal  colic  (see  below) . 

It  must  specially  be  noted  that  the  absence  of  jaundice  in  no  way  contra- 
indicates  a  diagnosis  of  gall-bladder  disease. 

2.  Duodenum. — A  duodenal  ulcer  may  cause  deep-seated  pain  in  the  right 
hj^pochondrium,  which  usually  has  the  character  of  hunger  pain.  It  raust 
be  remembered,  however,  that  pain  due  to  chronic  cholecystitis,  or  appendicitis, 
may  also  have  this  character,  and  an  exact  differentiation  of  them  may  not  be 
possible  without  exploration.  Duodenal  ulcer  is  commoner  in  men^  disease 
of  the  gall-bladder  in  women,  whilst  appendicitis  may  occur  with  almost  equal 
probability  in  either  sex.  A  history  of  melaena  would  determine  one  in  favour 
of  ulcer. 

3.  Pancreas. — Malignant  disease  of  the  pancreas  may  cause  pain  in  the  right 
hj^pochondrium.  In  such  a  case  a  deep-seated  tumour  may  be  felt,  and  there 
is  often  jaundice  along  with  a  distended  gall-bladder.  On  the  other  hand,  when 
gall-stones  lead  to  jaundice,  the  gall-bladder  is  not  usually  distended  (see 
Jaundice). 

4.  Right  Kidney. — A  freely  movable  right  kidney  may,  by  ureteral  kinking,  cause 
sudden  attacks  of  pain  in  the  right  hypochondrium  which  may  exactly  simulate 
gall-stone  colic.  Indications  of  intermittent  hydronephrosis  should  be  looked 
for,  e.g.  the  appearance  of  a  renal  tumour,  and  the  occasional  discharge  of  large 
quantities  of  urine. 

Stone  in  the  right  kidney  may  cause  chronic  pain  in  the  right  hypochondrium 
and  back.  The  kidney  is  often  found  to  be  enlarged  and  tender  on  bimanual 
palpation  in  such  a  case,  but  it  must  be  remembered  that  the  urine  may  furnish 
no  diagnostic  indication.  The  ;i;-raj's,  however,  may  make  the  diagnosis  clear,, 
although  a  negative  result  does  not  exclude  the  possibility  of  stone. 

The  pain  of  renal  colic  may  be  difficult  to  diagnose  during  an  attack  from  gall- 
stone colic,  lead  colic,  or  appendicitis,  but  has  a  characteristic  tendency  to  pass 
downwards  into  the  groin.  It  may  be  attended  by  vomiting  and  fever.  During 
or  after  the  attack  there  may  be  blood  and  gravel  in  the  urine  ;  but  it  must  be 
remembered  that  the  urine  may  be  heavily  loaded  with  urates  after  an  attack 
of  biliary  colic. 

Pyelitis  may  also  be  the  cause.  The  urine  will  then  furnish  diagnostic  indica- 
tions (see  Pyuria)  ;  and  the  kidney  may  be  felt  to  be  enlarged  on  bimanual 
palpation. 

A  perinephric  abscess  may  cause  pain  in  the  right  hj'pochondrium  and  lumbar 
region.  A  tumour  will  be  felt,  and  there  will  be  the  usual  signs  of  deep-seated 
suppuration. 

5.  Appendix. — The  pain  of  chronic  appendicitis  may  be  felt  chiefly  in  the 
right  hypochondrium,  and,  as  already  remarked,  maj'  be  of  the  nature  of  a 
hunger  pain.  Tenderness  over  McBurney's  point  should  be  looked  for.  When 
an  acute  attack  of  appendicitis  simulates  gall-stones,  it  may  be  of  help  to 
remember  that  indicanuria  is  common  in  the  former,  but  is  usually  absent  in 
the  latter. 

6.  Colon. — New  growths  in  the  neighbourhood  of  the  hepatic  flexure  may 
cause  pain  in  the  right  hypochondrium  ;  but  in  that  case  a  tumour  can  usually 
be  felt,  and  signs  of  chronic  interstitial  obstruction  are  present. 

7.  Uterine    Appendages. — Salpingitis,  a  twisted  ovarian  pedicle,  and  a  ruptured 
extra-uterine  gestation,  may  all  cause  pain  in  the  right  side  of  the  abdomen  which,  ' 
however,  has  usually  its  maximum  intensity  rather  below  the  hypochondriac 
region.     A  careful  pelvic  examination  will  usually  make  the  diagnosis  clear. 


PA  IX     IX     THE     JAW  5or 

S.  Pleurisy,  Intercostal  Neuralgia,  and  Herpes  Zoster  may  be  causes  of  pain 
in  the  right  hypochondrium. 

9.  Subdiaphragmatic  Abscess. — In  this  case  there  will  be  a  history  pointing 
to  precedent  gastric  or  duodenal  ulcer,  appendicitis,  or  hepatic  abscess.  The 
onset  of  the  pain  may  be  sudden  or  gradual.  There  will  be  pyrexia  and  leuco- 
cytosis,  pointing  to  deep-seated  suppuration.  There  is  usually  an  abdominal 
swelling,  which  does  not  move  with  respiration.  The  note  over  this  may  be 
tympanitic,  from  the  presence  of  gas  in  the  abscess,  and  in  that  event  the  coin- 
sound  will  be  obtained  on  percussion.  There  are  usually  indications  of  pleurisy 
at  the  base  of  the  corresponding  lung,  but  the  liver  is  not,  as  a  rule,  pushed  down. 
The  use  of  the  ,v-rays  may  help  in  locating  the  abscess  ;  but  the  exploring  needle 
should  not  be  used  except  when  the  patient  is  on  the  operating-table,  and  one 
is  prepared  to  open  the  abscess  at  once  if  found.  Robert  Hutchison. 

PAIN  IN  THE  ILIAC  FOSSA  (LEFT). — If  unaccompanied  by  sw-elling  or  any 
other  signs  or  symptoms  of  disease,  pain  in  the  left  iliac  fossa  may  usually  be 
assigned  to  wind  or  to  an  accumulation  of  faeces.  The  administration  of  a 
purge  or  enema  will  quickly  settle  -the  correctness  of  the  decision. 

Pain  associated  with  Diarrhcea  and  Discharge  of  Blood  and  Pus. — Dysentery 
and  colitis,  whether  catarrhal  or  ulcerative,  are  associated  with  colicky  abdo- 
minal pain.  This  is  usually  general,  but  if  the  disease  is  confined  to  the  sigmoid 
and  rectum,  may  be  referred  to  the  left  iliac  fossa.  The  continued  diarrhoea, 
blood-stained  mucous  stools,  and  tenesmus  indicate  the  disease,  but  if  further 
help  be  required,  a  sigmoidoscope  may  be  passed  and  the  state  of  the  mucous 
membrane  examined. 

Carcinoma  of  the  Sigmoid  Flexure,  if  of  the  contracting  variety,  ma}'  go  on 
even  to  the  causation  of  complete  intestinal  obstruction  w-ithout  forming  a 
palpable  lump.  Its  presence  may  be  suggested  by  vague  but  continuous  pains 
in  the  left  iliac  fossa,  and  disorders  of  defaecation  similar  to  those  found  in 
carcinoma  of  the  rectum.  (See  Rectum,  Abnormalities  felt  per.)  It  is 
extremely  important  that  the  diagnosis  of  such  a  case  should  be  made  early, 
and  if  there  is  any  doubt,  a  complete  examination  should  not  be  delayed.  An 
anaesthetic  should  be  given,  a  bimanual  exploration  of  the  rectum  made,  the 
abdomen  palpated,  and  a  sigmoidoscope  passed.  An  exploratory  laparotomy 
may  even  be  necessary. 

I'olvulus  and  kinking  of  an  o\"erloaded  sigmoid  must  be  borne  in  mind  as  a 
possible  cause  of  pain. 

Further  differential  diagnosis  is  discussed  under  Swelling  in  the  Iliac 
Fossa  (Left).  George  E.  Gask. 

PAIN  IN  THE  ILIAC  FOSSA  (RIGHT),  if  it  be  unaccompanied  by  any 
swelhng  or  by  tenderness,  can  usualh"  be  ascribed  to  wind  or  to  an  accumulation 
of  fjeces,  though  it  may  indicate  a  slight  degree  of  tj-phlitis,  or  the  stretching 
of  adhesions  following  an  attack  of  appendicitis.  The  differential  diagnosis  is 
discussed  under  the  headings — Swelling  in  the  Iliac  Fossa  (Right),  and 
Tenderness  in  the  Iliac  Fossa  (Right).  George  E.  Gask. 

PAIN  IN  THE  JAW  (LOWER) — unaccompanied  by  any  sweUing  (see  Swelling 
OF  the  Jaw,  Lower) — is  generally  due  to  dental  caries,  i.e.,  toothache,  and  it  is 
with  this  thought  in  the  mind  that  an  examination  should  first  be  made.  The 
decayed  tooth  may  be  ob\-ious  at  once,  or  it  maj-  be  so  hidden  as  to  call  for 
the  services  of  a  sldlled  dentist.  Occasionally  an  unerupted  molar  may  be  the 
cause  of  the  pain,  and  a  skiagram  may  be  needed  to  complete  the  diagnosis. 

Neuralgia. — -Here,  pain  is  the  essential  feature,  and  it  may  be  of  two  kinds. 
It  either  follows  the  course  of  a  nerve  such  as  the  inferior  dental  in  the  lower 


PAIN     IN     THE     JAW 


jaw,  or  it  affects  a  considerable  part  of  the  jaw  without  special  reference  to  any 
nerve.  It  varies  greatly  in  severity,  being  sometimes  slight,  at  other  times  so 
severe  as  to  call  for  all  the  fortitude  of  the  patient  to  bear  it.  Usually  neuralgia 
of  the  inferior  dental  nerve  is  combined  with  neuralgia  of  the  other  branches 
of  the  fifth  nerve,  and  this  in  conjunction  with  the  spasmodic  character  of  the 
pain  makes  the  diagnosis  easy.  Some  cases  of  neuralgia  are  embarrassing, 
especially  when  sources  of  irritation  in  decayed  teeth  are  present  as  well,  and  it 
may  be  that  the  true  condition  can  only  be  settled  after  all  the  teeth  have  been 
extracted.  George  E.  Cask. 

PAIN  IN  THE  JAW  (UPPER).— What  has  been  said  above  as  to  pain  in  the 
lower  jaw  being  caused  by  dental  caries  and  neuralgia  applies  equally  to  pain 
in  the  upper  jaw,  but  there  is  an  important  additional  cause  to  be  sought  for 
in  the  latter,  and  one  easily  overlooked,  namely,  inflammatory  affections  of 
the  antrum  of  Highmore. 

Abscess  of  the  Antrum  of  Highmore. — The  presence  of  pus  within  the  antrum 
is  indicated  by  local  pain,  generally  dull  in  character,  but  sometimes  acute. 
On  examination  of  the  jaw,  the  gums  will  "often  be  found  tender  and  swollen, 
and  a  carious  tooth  is  frequently  the  source  of  the  infection.  So  far,  the  signs 
are  compatible  with  those  arising  from  a  septic  tooth,  without  implication  of 
the  antrum,  and  further  evidence  is  required  ;  the  most  certain  is  the  periodical 
discharge  of  pus,  which  may  run  from  the  corresponding  nostril  when  the  head 
is  bent  forwards,  or  trickle  down  the  pharynx  Avhen  the  patient  is  lying  on  the 
back.  If  the  normal  opening  of  the  antrum  into  the  nose  becomes  closed,  as 
it  may  from  inflammation,  this  valuable  sign  is  lost,  and  though  local  signs  of 
inflammation  and  general  febrile  disturbances  are  present,  it  ma}^  be  difficult 
to  arrive  at  a  diagnosis,  for  the  condition  is  simulated  by  inflammation  in  the 
nasal  fossae  or  suppuration  in  the  ethmoidal  and  frontal  sinuses.  It  must  also 
be  remembered  that  a  growth,  either  innocent  or  malignant,  starting  in  the 
antrum  and  not  yet  big  enough  to  cause  a  swelling,  may  easily  be  mistaken. 
Recourse,  therefore,  should  be  had  to  the  method  of  transillumination,  and 
the  antra  on  the  two  sides  compared  (see  Fig.  62,  p.  205).  The  position  of  the 
antrum  should  be  shown  by  a  bright  red  area,  and  if  instead  a  shadow 
is  thrown,  there  is  presumably  some  affection  of  the  antrum.  It  does  not 
mean  necessarily  that  there  is  an  abscess,  for  a  growth  or  a  thickening 
of  the  bone  may  cast  a  shadow  equally  well.  In  these  conditions  a  skiagram 
may  help. 

Diagnosis  by  Puncture. — The  only  certain  method  of  diagnosis,  which  is  to 
be  used  if  the  others  fail,  is  to  tap  the  antrum  with  an  exploring  syringe.  This 
can  be  done  through  the  nose  immediately  under  the  anterior  part  of  the 
inferior  turbinate  bone.  The  fluid  withdrawn  may  be  subjected  to  micro- 
scopical and  bacteriological  examination.  George  E.  Gash. 

PAIN  IN  THE  JOINTS. — (See  Joints,  Affections  of  the.) 

PAIN  IN  THE  KNEE. — (See  Joints,  Affections  of  the.) 

PAIN  IN  THE  LEG. — (See  Pain  in  the  Extremity,  Lower.) 

PAIN  IN  THE  LIMBS,  GENERAL, — In  the  great  majority  of  cases  pains  in 
the  limbs  are  the  result  of  some  general  or  systemic  disease  :  in  but  few 
instances  can  they  result  from  symmetrically  distributed  local  lesions.  For 
clinical  purposes  they  may  be  classified  by  their  duration,  according  as  they  are 
acute  or  chronic. 


PAIN     IN     THE     LIMBS,     GENERAL 


503 


I,  Acute  General  Pains  in  the  Limbs  occur  in- 


Muscular  overstrain 

Myositis — 

Acute  polymyositis 
Neuromyositis 

Trichinosis 

Rheumatic  fever 

Acute  rheumatism 


Acute    infections    or    inflammations, 
such  as — 

Acute  coryza 

Tonsillitis 

Febricula  or   chill 

Influenza 

Acute  specific  fevers 

Inflammations  of  the  lungs, 

kidneys,  etc. 
Secondary  syphilis 

Peripheral   neuritis 

Neurasthenia 

Hysteria 

Diseases  of  hot  climates — 
Dengue,  Malta  fever,  etc. 

Chronic  General  Pains  in  the  Limbs  occur  in — 


Peripheral  neuritis 
Tabes  dorsalis 
Tabes  dolorosa 
Chronic  rheumatism 
Myalgia 


Chronic  wasting  diseases,  such  as — 
Pulmonary  tuberculosis 
Gastritis 

Cirrhosis  of  the  liver 
Bronchitis 
Emphysema 
Morbus  cordis 
Severe  ansmia 
Mahgnant  disease 
Nephritis. 

These  general  pains  may  be  felt  most  acutely  sometimes  in  one  tissue  or  part 
of  the  limbs,  sometimes  in  another.  The  muscles,  for  example,  may  be  the 
chief  seats  of  pain  in  a  child  with  rheumatism  ;  in  a  rheumatic  adult  the  pains 
are  usually  worst  in  and  about  the  joints  ;  in  a  patient  with  secondary  S3'phihs 
the  pain  is  often  deep  in  the  bones,  the  so-called  osteocopic  pain.  In  the 
majority  of  instances  the  general  limb-pains  are  made  worse  by  movement,  and 
this  is  particularly  the  case  when  they  are  accompanied  by  inflammatory  changes 
in  the  joints.  But  the  general  pains  of  chronic  rheumatism,  or  the  stift'ness  and 
pains  left  after  muscular  overstrain,  will  often  pass  off  if  the  movements  be 
persisted  in  for  a  little  time.  As  a  rule,  general  pains  in  the  limbs  are  least 
felt  when  the  patient  is  at  rest,  especially  when  he  is  at  rest  in  bed.  But  in 
.some  cases,  rest  appears  to  lead  to  stifthess  and  increased  discomfort,  change  of 
position  giving  temporary  relief  ;  in  others — particularly  the  muscular  pains 
of  rheumatism  and  the  osteocopic  pains  of  specific  disease — the  pains  are  at  their 
worst  as  soon  as  the  patient  gets  warmed  up  by  lying  in  bed. 

I.  Acute  Pains. —  Few  people  can  be  unacquainted  with  the  general  pains 
and  stiffness  due  to  muscular  overstrain,  the  result  of  some  violent  and  unusual 
muscular  exertion — walking,  running,  playing  games,  etc. — undertaken  when 
the  body  was  out  of  training.  The  pains  will  be  accompanied  by  local  tenderness 
of  the  affected  muscles,  and  there  may  be  slight  fever  if,  as  often  happens,  the 
stomach  has  been  loaded  with  more  food  than  it  has  been  able  to  deal  with  in 
the  exhausted  state  of  the  general  bodily  functions.  When  the  history  of  such 
an  attack  has  been  obtained,  the  diagnosis  should  not  be  difficult. 

Myositis,  or  inflammation  of  the  muscles,  is  a  comparatively  rare  cause  of 
general  pain  in  the  limbs.  It  occurs  in  several  varieties,  of  which  only  the 
generalized   forms  need   be   considered.     Acute  polymyositis,   also   described   as 


504  PAIN     IX     THE     LIMBS,     GENERAL 

dermatomyositis  and  as  pseudotrichinosis,  is  characterized  by  pain,  rigidity, 
and  tenderness  in  the  muscles,  oedema  of  the  extremities,  and  a  rash  resembUng 
one  or  other  of  the  exudative  erj-themas.  In  addition,  there  are  the  general 
symptoms  of  malaise,  anorexia,  general  debihty,  and  fever.  It  must  be  dis- 
tinguished from  trichinosis,  in  which  the  aifected  muscles  are  found  to  contain 
Trichinella  spiralis,  the  face  and  eyes  are  oedematous,  and  the  blood  shows 
eosinophiha.  A  second  rare  form  of  myositis  is  the  neuromyositis  described  by 
Senator,  in  which  the  nerves  are  involved  as  well  as  the  muscles.  In  this, 
sensation  is  lessened,  the  reflexes  are  lost,  and  vasomotor  phenomena  are  seen 
in  the  extremities.  The  affected  limbs  are  tender  on  pressure,  and  painful 
when  movement  is   attempted. 

Trichinosis,  or  infection  with  Trichinella  spiralis,  is  verj^rare  in  Great  Britain, 
though  common  in  countries  where  pork  is  eaten  uncooked.  Its  symptoms 
are  due  to  gastro-enteritis,  and  to  invasion  of  the  tissues  of  the  bodj^  particu- 
larh-  the  muscles,  b}^  3-oung  trichinellse.  For  the  first  week  or  ten  days  the  main 
S5Tnptoms  are  gastro-intestinal,  and  ma}-  often  suggest  the  diagnosis  of  cholera. 
Then  the  second  stage  of  trichinosis  comes  on,  with  pains  and  swellings  in  the 
muscles,  particularly  the  flexors.  The  face  and  trunk  are  affected  as  well  as 
the  limbs  ;  the  face  and  e}-es  become  oedematous  ;  profuse  perspirations  are 
common,  and  high  fever  is  not  rare  ;  eosinophiha  and  leucocytosis  are  usual. 
Mvositis  due  to  invasion  of  the  voluntary-  muscles  is  the  characteristic  of  this 
stage  of  trichinosis  ;  it  lasts  for  a  month  or  more,  subsiding  gradually  into  the 
third  stage,  that  of  convalescence,  as  the  larval  trichineUa^  become  enc3^sted 
in  the  muscles.  The  diagnosis  of  trichinosis  is  hkely  to  be  difficult  because  of 
its  ^arit3^  In  the  early  stages,  acute  gastro-enteritis,  enteric  fever,  or  even 
cholera,  will  be  suspected,  the  main  symptoms  arising  from  the  irritation  of  the 
alimentarj^  canal  set  up  by  the  parent  trichinellae  breeding  in  it.  Later, 
rheumatism  will  be  simulated  ;  but  the  pain  and  swelling  are  in  the  muscles, 
not  the  joints,  and  the  occurrence  of  oedema  and  of  changes  in  the  blood  should 
help  in  the  diagnosis.  It  maj-  be  added,  that  adult  trichinellae  may  be  found 
in  the  stools  of  a  patient  with  trichinosis,  and  larval  trichinellae  in  portions  of 
the  affected  muscles  removed  intra  vitam  for  microscopical  examination  : 
encvsted  larvae  wiU  also  be  seen  in  the  infected  meat  that  gave  rise  to  the  attack, 
should  an}-  of  it  have  been  preserved. 

General  pains  in  the  hmbs  are  common  in  rheumatic  fever,  occurring  mainly 
in  the  limbs  in  which  there  is  acute  inflammation  of  the  joints.  Similar  pains 
will  also  be  felt  in  acute  rheumatism.  In  the  severer  cases  of  rheumatism 
the  cause  of  these  pains  wiU  not  readily  be  overlooked  :  it  is  in  the  com- 
parativeh^  mild  cases  in  children  that  failure  to  make  the  proper  diagnosis 
is  likely  to  occur,  when  the  general  pains  in  the  limbs  may  be  set  down  as 
"  growing  pains,"  and  no  careful  examination  be  made  with  the  special 
object  of  detecting  other  evidences  of  the  rheumatic  infection  that  may  be 
latent  in  the  patient.  There  is  no  doubt  that  "  growing  pains  "  occur  in  healthy 
children,  quite  independenth*  of  rheumatism  ;  but  the  t^vo  are  together  in  so 
many  instances,  that  any  complaint  of  growing  pains  should  lead  to  a  careful 
investigation  of  the  patient's  histor}-,  and  of  the  condition  of  his  heart.  In  this 
waj-  a  family  history  or  past  personal  history  of  either  rheumatism  or  chorea 
will  often  be  made  out ;  and  not  rarely,  examination  of  the  heart  will  lead  to  the 
discovery  of  valvular  disease.  The  joint-affections  of  rheumatism  are  far  more 
prominent  in  adults  than  in  children  ;  in  children  the  non-arthritic  lesions  are 
the  most  conspicuous — endocarditis,  chorea,  inflammations  of  the  fibrous  tissues 
generally  and  of  the  skin,  sore  throats. 

Aching  pains  aU  over  the  limbs  or  bod}-,  or  both,  are  quite  common  at  the 
onset  of  man}-  of  the  acute  infectious  disorders,  or  of  acute  diseases  that  mainh- 


PAIN     IX     THE     LIMBS,     GENERAL  505 

affect  one  or  another  of  the  organs  of  the  body.  Associated  with  these  pains  are 
other  general  S3'mptoms,  in  most  instances,  such  as  malaise,  headache,  anorexia, 
and  more  or  less  fever.  Thus,  a  severe  acute  coryza  or  tonsillitis  may  be  ushered  in 
by  general  pains  in  the  limbs  ;  so  may  the  obscure  and  elusive  acute  attack 
known  as  a  febricula  or  a  chill,  in  ■which  the  fever  and  general  symptoms  persist 
for  a  day  or  two,  but  no  localizing  signs  or  symptoms  can  be  detected  to  give 
evidence  as  to  "  where  the  chill  has  settled."  Such  febriculae  may  really  be 
abortive  attacks  of  pneumonia  or  rheumatism,  instances  of  undetected  sore 
throat,  acute  gastro-intestinal  upsets,  cases  of  larval  enteric,  scarlet  fever, 
measles,  or  what  not.  If  they  are  associated  with  much  pain  or  prostration, 
there  is  a  great  tendency  to  apply  the  term  "  influenza  "  to  them  indiscrimin- 
ately, quite  apart  from  considerations  of  fact — evidence  of  infection  with 
Pfeiffer's  bacillus  ;  or  of  probability — the  detection  of  any  source  whence 
influenzal  infection  could  have  been  derived.  But,  however  satisfactory  it  may 
be  to  the  patient,  the  diagnosis  of  influenza  should  not  be  made  without  further 
evidence,  such  as  is  furnished  by  the  discovery  of  the  micrococcus  catarrhalis 
in  the  patient's  nasal  or  bronchial  secretions,  or  by  the  occurrence  of  the  attack 
as  one  of  many  in  an  influenzal  epidemic.  Influenza  is  well  known  to  be  a 
protean  disorder.  In  many  instances  its  main  symptom  is  a  severe  coryza, 
with  headache,  lachrymation,  and  much  prostration.  In  others  the  type  is 
respiratory,  bronchitis  with  cough  and  viscid  expectoration  taking  the  place  of 
the  coryza,  and  leading  up  to  a  bronchopneumonia  or  lobar  pneumonia  that 
not  infrequently  results  in  death.  A  third  variety  of  influenza  is  the  abdominal 
and  gastro-intestinal  ;  abdominal  pain,  vomiting,  diarrhoea,  and  perhaps 
jaundice,  being  the  main  phenomena.  But  in  all  of  these  the  pains,  depression, 
and  prostration  come  on  very  rapidly,  and  appear  severe  out  of  all  proportion 
to  the  objective  signs  of  the  disease,  while  the  fever  is  usually  of  short 
duration.  The  diagnosis  of  epidemic  cases  should  not  be  difficult,  but  in 
the  sporadic  cases  may  be  far  from  easy,  and  must  be  made  on  the  general 
lines  indicated  above. 

It  is  not  necessary  to  refer  in  detail  to  the  many  other  acute  infections  or 
inflammatory  processes  in  which  general  pains  occur  in  the  limbs.  In  measles, 
scarlet  fever,  or  small-pox,  for  example,  the  pains  often  occur  at  the  outset,  but 
are  only  subordinate  features  of  the  attack  ;  and  the  diagnosis  will  be  made  on 
the  other  symptoms,  and  confirmed  by  the  appearance  of  the  characteristic  rash. 
Various  febrile  disorders  of  the  lungs,  such  as  bronchitis,  tuberculosis,  or  pleurisy, 
may  begin  with  similar  pains  ;  so  may  gastro-intestinal  infections,  or  acute 
inflammations  of  the  kidneys.  The  diagnosis  in  these  instances  will  be  made 
from  the  special  symptoms  developed  in  each  ;  the  pains  in  the  limbs  will  rarely 
be  the  only  or  the  most  prominent  complaint. 

In  peripheral  neuritis  of  the  symmetrical  multiple  type,  the  amount  of  pain 
felt  is  very  variable — great  in  some  cases,  little  in  others.  The  peripheral  nerves 
contain  motor,  sensory,  and  vasomotor  fibres  ;  in  peripheral  neuritis,  therefore, 
motor  and  vasomotor  symptoms  are  habitually  present,  as  weU  as  sensory. 
Alcoholism  is  the  commonest  cause  of  multiple  symmetrical  peripheral  neuritis  ; 
the  chief  complaints  are  of  numbness  and  tingling  in  the  extremities,  "  pins 
and  needles,"  sensations  of  "  dead  fingers,"  cramps  in  the  legs,  and  severe 
gnawing  or  aching  pains  in  the  limbs.  Beginning  in  the  hands  and  feet,  they 
tend  to  spread  to  the  trunk  ;  motor  weakness  comes  on,  the  skin  develops 
hyperaesthesia,  the  limbs  become  very  tender  to  pressure.  The  deep  reflexes, 
originally  increased,  are  now  lost ;  the  sphincters  are  hardly  ever  involved  in 
alcoholic  neuritis  unless  the  mind  is  affected.  Mental  symptoms  are  common 
in  alcoholism,  taking  the  form  of  Korsakow's  psychosis  ;  memor}^  for  recent 
events  is  lost :  the  patient  may  forget  his  name  and  address,  and  not  know  where 


PAIN     IN     THE     LIMBS,     GENERAL 


he  is ;  and  in  the  endeavour  to  make  good  the  lacunse  in  his  recollections, 
he  is  likely  to  lie  freely,  and  quite  without  any  definite  wish  to  deceive. 
The  physical  signs  of  arsenical  neuritis  are  very  similar,  but  the  cutaneous 
and  deep  hypercesthesise  are  more  marked  than  in  alcoholic  neuritis,  muscular 
paresis  and  wasting  come  on  earlier,  and  muscular  inco-ordination  is  more 
marked.  In  the  neuritis  due  to  acute  lead  poisoning  the  sensory  signs  are 
entirely  subordinated  to  the  motor,  and  pains  in  the  limbs  are  absent. 
Peripheral  neuritis  is  a  fairly  frequent  legacy  of  influenza,  and  may  then  be 
characterized  by  great  severity  and  persistence  ;  it  may  also  occur  as  a 
complication  of  other  infectious  disorders  —  such  as  diphtheria,  tuberculosis, 
or  sj^philis.  The  diagnosis  of  peripheral  neuritis  will  be  suggested,  speaking 
generally,  if  the  pains  in  the  limbs  are  associated  with  marked  sensory 
changes — anaesthesia,  parsesthesia,  hyperaesthesia — with  tenderness  of  the  skin, 
muscles,  or  along  the  course  of  the  nerves,  and  with  weakness,  atrophy,  and 
the  reaction  of  degeneration  in  the  muscles. 

Hysterical  and  neurasthenic  patients  sometimes  suffer  acutely  from  pains  in 
the  limbs  that  lack  any  objective  basis  on  examination,  and  ma}^  give  rise  to 
much  trouble  in  diagnosis  until  the  functional  character  of  the  disorder  has  been 
securely  established.  It  is  of  the  greatest  importance  that  organic  disease  of 
every  kind  should  be  excluded,  as  far  as  is  possible  before  the  diagnosis  of 
hysteria  or  neurasthenia  is  given  out.  The  hysterical  patient  is  generally  a 
woman,  and  is  likely  to  exhibit  several  of  the  many  phenomena  common  in 
hysteria,  such  as  functional  aphonia,  globus  or  clavus  hystericus,  stocking-and- 
glove  anaesthesia,  hemiansesthesia,  variable  paralyses  often  due  to  the  contraction 
of  antagonistic  muscle-groups,  hysterical  seizures,  and  the  like.  The  signs  and 
symptoms  of  hysteria  change  from  time  to  time,  the  recovery  from  any  particular 
affection  often  being  as  sudden  as  its  onset.  The  neurasthenic  patient,  on 
the  other  hand,  is  oftener  a  man  than  a  woman,  usually  overworked,  run  down 
in  general  health,  and  worried.  The  symptoms  are  those  of  "  brain-fatigue  " 
for  the  most  part  ;  inability  to  attend  to  or  take  interest  in  either  work  or 
pleasure  ;  the  bodily  strength  is  lessened,  and  subjective  sensations  of  all  sorts 
may  be  felt  in  the  back  or  limbs.  Headache  is  a  prominent  feature  in  some 
neurasthenic  patients  ;  dyspepsia  or  palpitation  in  others  ;  imaginary  sexual 
disorder  in  others.  In  all  the  deep  reflexes  tend  to  be  increased,  and  the 
temperature  to  be  subnormal. 

General  pains  in  the  limbs  are  common  in  certain  diseases  of  hot  countries, 
of  which  only  two  need  be  considered  here.  Both  occur  in  Southern  Europe, 
as  well  as  in  more  tropical  regions. 

Dengue  is  an  epidemic  infectious  disease,  much  like  influenza  in  many  respects. 
Its  onset  is  sudden,  with  headache  and  pains  all  over,  fever,  sore  throat,  an 
initial  erythematous  rash,  and  rapid  pulse.  The  pains  may  be  in  the  joints 
mainly,  or  diffused  throughout  the  muscles  of  the  limbs,  and  are  made  worse 
by  movement.  After  two  or  three  days  the  patient  feels  better,  and  begins  to 
get  about  again  ;  but  after  an  interval  of  a  day  or  two  a  slight  or  severe  relapse 
occurs,  with  pains  as  before,  fever,  and  a  secondary  rash  which  is  roseolar,  and 
begins  on  the  hands  and  wrists,  later  spreading  in  patches  over  the  whole  body. 
The  relapse  is  soon  over  ;  but  convalescence  may  be  a  slow  business,  because 
of  persistence  of  the  general  pains  in  the  limbs.  The  diagnosis  should  be  easy 
in  epidemics  of  dengue  ;  the  sudden  onset,  extent  of  the  pains  in  limbs,  head, 
and  loins,  and  the  characteristic  course  of  the  disease,  should  suffice  to  distinguish 
sporadic  cases  from  other  acute  disorders  such  as  measles,  scarlet  fever, 
rheumatic  fever,  etc. 

Malta  fever  occurs  mainly  in  the  Mediterranean  and  on  its  shores  :  it  is  a 
chronic    fever,    characterized    by    perspirations,    constipation,    and    rheumatic 


PAIN     IN     THE     LIMBS,     GENERAL 


pains  in  the  limbs  ;  arthritis,  orchitis,  and  enlargement  of  the  spleen  are  common. 
The  early  sjmiptoms  are  obscure  ;  but  pains  in  the  limbs  and  general  debility, 
gastric  derangements,  headache,  bronchitis,  and  continued  fever,  are  the  general 
characteristics  Avhen  the  disease  is  established.  The  diagnosis  would  turn  on 
the  discovery  of  exposure  to  infection,  the  milk  of  goats  that  are  carriers  of  the 
Micrococcus  melitensis  being  the  actual  vehicle  of  infection  :  the  patient's  serum 
shows  the  specific  agglutinating  reaction. 

2.  Chronic  General  Pains  in  the  Limbs  will  often  remain  after  several  of  the 
disorders  mentioned  under  the  former  heading.  Thus,  the  pains  due  to  peripheral 
neuritis  may  become  a  chronic  affection  in  cases  of  chronic  lead  poisoning, 
after  influenza,  or  in  gouty,  diabetic,  or  syphilitic  patients.  Usually  only  one 
or  two  of  the  limbs  will  be  affected  in  these  cases  ;  and  the  diagnosis  will  not 
have  to  be  made  from  the  occurrence  of  the  pains,  but  will  have  become  evident 
from  the  development  of  other  signs  of  disease,  so  that  it  need  not  be  discussed 
at  any  length  here.  In  chronic  lead-poisoning  the  chief  symptoms  may  be 
anaemia,  blue-black  line  on  the  gums,  colic  and  constipation,  wrist-drop,  gout, 
arteriosclerosis  and  high  blood-pressure  ;  post-influenzal  neuritis  will  date 
from  an  attack  of  influenza  or  an  "  influenzal  cold  "  ;  gouty  patients  will  give 
histories  of  attacks  of  acute  arthritic  gout,  and  are  hkely  to  exhibit  tophi  about 
their  joints  or  in  the  ears,  and  to  exhibit  the  signs  of  granular  kidney  ;  diabetic 
patients  will  complain  of  thirst  and  polyuria,  large  appetite,  wasting,  and 
skin- troubles,  and  sugar  will  be  present  in  their  urine. 

In  certain  uncommon  cases  of  tabes  dorsalis  the  name  tabes  dolorosa  has  been 
given,  owing  to  the  severity  and  extent  of  the  pains  that  are  felt.  The  patient 
presents  the  usual  symptoms  of  tabes  ;  in  addition  he  has  frequently  repeated 
lightning  pains  in  the  limbs,  so  severe  as  to  form  the  dominating  element  in  his 
disorder,  at  any  rate  from  the  subjective  point  of  view.  The  diagnosis  will  be 
made  from  the  suddenness  and  shocking  intensity  of  the  pains  on  the  one  hand  ; 
and  on  the  other,  from  the  discovery  of  further  signs  of  tabes — Argyll  Robertson 
pupil,  loss  of  knee-jerk,  ataxia,  sphincter  troubles,  areas  or  zones  of  anaesthesia. 
The  pains  will  have  a  radicular  distribution,  and  the  nerve-trunks  and  muscles 
will  not  be  tender  on  pressure. 

General  pains  in  the  limbs  are  common  in  chronic  rheumatism,  occurring 
particularly  in  consonance  with  changes  in  the  weather.  In  some  instances,  the 
muscles  are  the  chief  seat  of  the  pain  ;  in  others,  the  joints  or  the  fibrous  tissues 
round  them.  In  most  cases,  exercise,  massage,  or  movement  tend  to  diminish 
these  pains,  if  indeed  the  patient  can  be  induced  to  submit  himself  to  the  dis- 
comforts of  motion  or  exertion.  Occurring  in  children,  these  chronic  pains  are 
usually  set  down  as  "  growing  pains  "  ;  but  their  association  with  acute 
rheumatism  is  so  frequent  that  the  patient  should  always  be  examined  for  other 
evidences  of  the  rheumatic  infection  (see  above).  In  adults,  on  the  other  hand, 
chronic  rheumatism  is  less  often  an  inheritance  from  acute  rheumatism,  and  is 
not  so  frequently  combined  with  valvular  disease  of  the  heart  ;  but  it  gives  rise 
to  pseudo-ankylosis  of  the  joints,  inability  to  work,  and  much  impairment  of 
the  general  health. 

Myalgia,  or  the  so-called  "  muscular  rheumatism,"  is  a  common  affection  of 
certain  groups  of  muscles,  and  may  in  some  instances  affect  the  limbs  generally. 
It  is  due  to  chill,  exposure  to  cold  after  sweating,  sitting  in  a  draught,  and  the 
like.  Its  commoner  forms,  such  as  lumbago,  stiff  neck,  pleurodynia,  stiff  back, 
need  only  be  mentioned  here  ;  in  the  rare  cases  where  the  limbs  are  attacked, 
the  diagnosis  of  muscular  rheumatism  will  probably  be  made  faute  de  mieux, 
although  there  is  nothing  to  show  that  the  affection  is  rheumatic,  and  no  proof 
that  it  is  the  muscles  (and  not  their  sensory  nerves,  for  example,)  that  are 
primarily  affected. 


5o8  PAIN     IN     THE     LIMBS,     GENERAL 

There  remains  for  consideration  the  large  class  of  diseases  characterized  by 
chronic  wasting  or  cachexia,  in  which  general  pains  in  the  limbs  are  often  a 
prominent  feature.  There  is  no  doubt  that  these  pains  are  due  to  widely 
different  causes  in  different  instances.  In  some,  they  may  be  due  to  nothing 
more  than  exaggerated  muscular  fatigue  or  overstrain  ;  the  debilitated  patient 
has  but  little  muscle,  and  that  little  is  exhausted  by  exertions  that  would  be 
trifling  for  a  normal  subject,  so  that  the  cachectic  patient  becomes  the  victim 
of  general  pains  by  the  mere  fact  of  being  up  and  about.  In  other  cases,  the 
pains  are  no  doubt  connected  with  peripheral  neuritis,  set  up  by  the  circulation 
of  toxins  in  the  patient's  blood,  though  few  or  none  of  the  other  signs  or  sym- 
ptoms of  neuritis  may  be  detected  on  investigation.  In  others,  again,  the  pains 
seem  to  be  connected  with  the  occurrence  of  fever,  being  lessened  or  absent 
when  the  patient's  temperature  is  normal.  In  the  great  majority  of  cases  these 
pains  are  lessened  by  rest,  or  by  any  line  of  treatment  that  builds  the  patient 
up  and  increases  his  strength.  Either  the  lungs,  the  heart,  the  gastro-intestinal 
system,  or  the  kidneys  may  be  the  organs  primarily  at  fault,  and  bodily  wasting 
and  weakness  will  be  among  the  main  symptoms.  In  cases  where  the  organic 
disease  is  deep-seated  and  out  of  reach,  there  is  danger  lest  the  patient  who  is 
really  seriously  ill,  should  be  suspected  of  nothing  more  than  functional  disease 
and  treated  for  such.  Thus,  patients  with  carcinoma  of  the  stomach  may  be 
treated  for  hysterical  vomiting  or  anorexia  nervosa  ;  the  victim  of  a  carcinoma 
or  aortic  aneurysm  invading  the  spinal  canal  may  receive  the  treatment  usually 
meted  out  to  the  malingerer.  It  is  of  great  importance,  therefore,  that  the 
most  thorough  examination  should  be  made,  and  deep-seated  organic  disease 
of  every  sort  excluded  as  far  as  is  possible,  before  the  diagnosis  of  functional 
disease  be  made  in  a  cachetic  patient.  This  is  all  the  more  necessary  because 
there  is  no  doubt  that  purely  functional  disease  of  long  standing  may  reduce 
nutrition  or  bodily  strength  to  a  very  low  ebb.  A.  J.  Jex-BIake. 

PAIN  IN  THE  NECK.— (See  Sore  Throat  ;   and  Stiff  Neck.) 

PAIN  IN  THE   PELVIS. — In  practice,  pelvic  pain   can  usually  be  classified 

under  four  headings,  namely  :  (i)  Deep-seated  pain  ;  (2)  Superficial  pain  in 
the  skin  ;    (3)   Spasmodic  pain  ;    (4)   Backache  or  sacralgia. 

Deep-seated  Pain  is  aching  in  character,  continuous,  and  may,  of  course, 
be  acute  in  onset,  or  may  be  chronic  in  duration.  It  is,  consequently,  associated 
with  tension  in  the  pelvic  organs,  usually  the  result  of  overfilled  vessels,  or,  in 
other  words,  of  congestion.  If  the  result  of  actual  inflammation,  i.e.,  con- 
gestion due  to  infection,  it  is  acute,  and  very  severe.  It  is  elicited  by  pressure, 
and  thereby  made  worse.  In  its  worst  form  it  is  of  peritoneal  origin  ;  but  it 
may  be  due  to  simple  congestion  of  the  uterus,  tubes,  or  ovaries,  without  infection 
or  evidence  of  actual  inflammation.  The  presence  of  adhesions  between  the 
pelvic  organs  is  an  important  factor  in  the  differential  diagnosis  of  this  type  of 
pain,  making  it  abundantly  clear  that  there  has  been  a  past  peritoneal  inflam- 
mation, and  that  the  tension  in  the  organs  is  the  result  of  the  binding  and 
pressure  of  new  fibrous  tissue.     Thus  it  may  be  caused  by  : — 

Local  peritonitis  due  to  infection,  recent  or  remote,  caused  by  salpingo- 
oophoritis,  infection  after  labour  or  abortion,  ovarian  cyst  with  torsion  of  the 
pedicle,  extra-uterine  gestation,  appendicitis. 

Simple  congestion,  caused  by  retroversion  and  flexion  of  the  uterus,  prolapsed 
ovaries,  sclerosed  ovaries,  hasmorrhagic  corpus  luteum  cyst,  endometritis. 

Superficial  Pain  in  the  Skin — ^This  is  elicited  by  pinching  or  touching 
the  skin  with  the  head  or  point  of  a  pin.  It  is  essentially  a  referred  pain, 
and  may  radiate  very  widely  over  the  abdominal  area,  down  the  groins,  over 


PAIN     IN     THE     PELVIS  509 

the  crest  of  the  ihum,  and  down  the  thighs.  The  area  on  the  skin  in  which 
referred  pain  is  felt  in  connection  with  uterine,  tubal,  or  ovarian  disease,  is  that 
to  which  the  tenth  dorsal  nerve  is  distributed,  according  to  Head  ;  and  the  area 
is  that  which  is  commonly  known  as  the  "  ovarian  region."  It  is  not,  however, 
ovarian  only,  and  it  is  not  even  uterine  and  tubal  only,  but  may  be  affected  also 
by  lesions  of  the  kidney,  ureter,  gall-bladder,  and  some  parts  of  the  intestines. 
Consequently,  referred  pain  in  the  skin  in  this  so-called  ovarian  region  cannot 
be  taken  to  indicate  disease  of  the  generative  organs  at  all,  unless  other  lesions 
can  be  eliminated.  The  region  of  the  tenth  dorsal  segment  is  simply  a  horizontal 
band  spreading  behind  from  the  first  to  third  lumbar  spines,  and  extending 
round  the  body  with  its  upper  level  in  front  at  the  umbilicus.  All  parts  of  the 
region  are  not  necessarily  afEected  equallj-,  but  there  may  be  points  of  maximum 
intensity ;  one,  notably,  is  midway  between  the  umbilicus  and  anterior  superior 
spine.  This  spot,  especially  on  the  left  side,  has  often  been  taken  erroneously  to 
indicate  pain  due  to  ovarian  inflammation.  It  is  interesting  to  note  that 
referred  pain  is  commonly  more  marked  on  the  left  side  of  the  body,  the 
explanation  of  which  is  not  quite  clear.  Referred  pain  in  this  segment  may 
not  be  due  to  any  local  lesion  at  all,  but  may  be  a  marked  manifestation  of 
hysteria  in  its  graver  forms.  When  extreme  hyperaesthesia  of  this  area  on  the 
left  side  is  accompanied  by  anaesthesia  of  the  skin  of  the  legs  and  feet  up  to  the 
level  of  the  knees,  with  brisk  knee-jerks  and  absence  of  the  palate  reflex,  the 
diagnosis  of  hysteria  is  almost  certain. 

Spasmodic  Pain  in  the  pelvis  is  nearly  always  due  to  painful  uterine  contrac- 
tions, when  it  is  of  genital  origin.  The  exception  to  this  is  the  pain,  which  is 
certainly  spasmodic  in  character,  and  which  occurs  in  connection  with  tubal 
gestation,  as  a  rule,  in  the  week  or  two  preceding  tubal  abortion  or  rupture  of  the 
tube.  In  this  case  it  is  supposed  to  be  due  to  contraction  of  the  muscle-coats 
of  the  tube,  but  there  is  no  real  evidence  that  this  is  a  fact.  There  can  be  no 
doubt  that,  even  though  a  part  of  the  pain  is  muscular,  some  of  it  at  least  must 
be  due  to  peritoneal  irritation.  The  only  Avay  to  diagnose  between  this  tubal 
pain  and  that  due  to  uterine  contractions,  will  be  by  a  careful  consideration  of 
the  history  of  the  case,  and  the  finding  of  a  definite  tubal  swelling  by  the 
bimanual  method.  Even  then,  the  diagnosis  is  exceedingly  difficult  and  often 
impossible.  Spasmodic  pain  due  to  uterine  contractions  is  caused  by  :  The  onset 
of  abortion  or  labour ;  deficient  development  of  the  uterine  muscle  in  spasmodic 
dysmenorrhoea  ;  expulsion  of  a  growth  from  the  uterus  such  as  a  fibromyoma  ; 
"  after-pains  "  following  labour  ;   gauze  packing  of  the  uterus  after  operations. 

The  differential  diagnosis  of  these  conditions  is  fortunately  easy  ;  but  a  much 
greater  difficulty  is  sometimes  met  with  when  spasmodic  pain  has  to  be  diagnosed 
on  account  of  causes  which  may  not  be  of  genital  origin  at  all.  The  possible 
extraneous  causes  of  spasmodic  pain  have  already  been  outlined  (see  Dysmexor- 
rhcea),  and  are :  Appendicitis,  intestinal,  renal,  or  hepatic  colic,  leaking 
gastric  ulcer,  ruptured  tubal  gestation,  twisted  ovarian  pedicle,  haemorrhage 
into  a  Graafian  follicle,  rupture  of  an  ovarian  cyst  or  pyosalpinx,  dj'spepsia^ 
and  flatulent  distention  of  the  bowels. 

Backache,  or  Sacralgia,  is  a  very  common  symptom  in  all  classes  of  pelvic 
disorders  ;  and  may  be  present  at  the  same  time  as  deep-seated  pain  and  super- 
ficial skin  tenderness.  It  is,  however,  especially  associated  with  chronic  uterine 
congestion  and  endometritis,  displacements  of  the  uterus,  backward  displace- 
ments, downward  displacements  (prolapse),  and  impacted  uterine  or  ovarian 
tumours.  Sometimes  the  only  lesion  to  be  demonstrated  is  a  chronic  cervical 
catarrh  or  a  cervical  erosion.  It  is  a  very  difficult  pain  to  explain  in  all  cases  ; 
but  it  is  usually  regarded  as  one  referred  to  the  roots  of  the  actual  nerves 
which  supply  the  uterus,  tubes,  and  ovaries.     In  cases  of  impacted  tumours  it  is 


PAIN     IN     THE     PELVIS 


possible  that  the  pain  is  due  to  actual  pressure  on  the  sacral  nerves  at  their  exit 
from  the  bone,  in  which  case  pain  will  also  be  felt  down  the  inner  side  and  backs 
of  the  thighs.  In  cases  of  carcinoma  of  the  cervix,  backache  is  complained  of, 
but  is  always  associated  with  pain  in  the  "  ovarian  regions,"  inguinal  region, 
and  also  radiating  down  the  legs.  It  must  not  be  forgotten  that  this  form  of 
backache  is  not  necessarily  of  genital  origin,  but  may  be  the  result  of  many 
other  lesions.  Thus,  it  may  be  the  result  of  some  irritating  urinary  constituent, 
like  excess  of  urates  and  phosphates  ;  also  it  may  accompany  a  calculus  in  the 
ureter  or  some  lesion  of  the  renal  pelvis.  As  a  rule,  in  renal  cases,  the  pain  is 
situated  rather  higher  up.  Further,  caries  of  the  spine  low  down,  growths  of 
the  spine,  or  of  the  spinal  cord  membranes,  may  give  rise  to  it.  Inflammation 
of  the  sacro-iliac  joint,  rectal  growths,  hsemorrhoids,  and  ulcers,  may  be  its 
originating  cause.  It  is  clear  that  a  correct  diagnosis  in  any  case  cannot  be 
made  without  a  complete  examination  of  all  these  structures,  combined  with 
careful  urinary  analysis.  Thos.  G.  Stevens. 

PAIN  IN  THE  PENIS — is  a  symptom  which  occurs  frequentlj'  in  urinary 
surgery,  not  only  in  association  with  lesions  of  the  penis  or  urethra,  but  also 
as  a  referred  pain  with  disease  of  the  prostate,  bladder,  or  kidney.  The  sym- 
ptom is  one  which  is  common  to  many  diseases,  so  that  in  the  diagnosis  of  any 
case,  due  consideration  must  be  given  to  the  other  symptoms  accompanying 
it,  without  placing  too  much  reliance  on  a  single  symptom  which  may  point 
strongly  to  the  urethra  or  bladder. 

Penile  pain  may  be  present  either  during  or  immediately  after  micturition, 
or  may  be  entirely  independent  of  the  act.  It  may  be  said  generally  that 
if  pain  is  felt  only  during  micturition  there  is  some  inflammatory  lesion  of 
the  urethra  or  prostate ;  whilst  if  it  occurs  immediately  after  the  flow  of  the 
urine,  it  suggests  some  lesion  in  the  urinary  bladder.  On  the  other  hand,  pain 
may  be  present  quite  apart  from  micturition,  due  to  various  diseases  of  the 
penis,  bladder,  ureter,  or  kidney. 

The  term  "  pain,"  too,  is  a  relative  quantity,  varying  with  the  nervous 
susceptibility  of  the  patient,  for  what  is  pain  in  one  may  be  merely  discomfort 
in  another,  so  that  the  patient's  account  may  have  to  be  discounted  to  a  certain 
extent  by  the  clinician. 

I. — Pain  in  the  Penis  experienced  During  Micturition. 


This  may  be  caused  by  : — - 
I.  Diseases  of  the  Urethra — 

Acute  inflammations 

The   passage  of  a  calculus  or 
the  impaction  of  the  latter 

Stricture  of  the  urethra 

Injury  of  the  urethra. 


Diseases  of  the  Prostate- — 

Acute  prostatitis 

Prostatic  abscess 

Prostatic  carcinoma. 
Diseases  of  the  Bladder — 

Acute  cystitis 

Vesical  calculus 

Villous  papilloma 

Pedunculated  carcinoma. 


I.  Diseases  of  the  Urethra. — By  far  the  most  common  cause  of  pain  in  the 
penis  occurring  during  micturition  is  an  acute  inflammation  of  the  urethra, 
usually  gonorrhoeal,  but  occasionally  of  a  septic  origin.  In  the  earliest  stages 
of  an  acute  urethritis,  before  any  marked  urethral  discharge  is  apparent,  there 
is  usually  a  sense  of  smarting  or  tingling  in  the  terminal  urethra,  which  becomes 
more  marked  as  the  discharge  increases,  when  it  is  of  a  burning  or  scalding 
character.      The  occurrence  of  this  pain  during  micturition  within  a  few  days  of 


PAIX     fX     THE     PENIS  311 

sexual  connection  is  frequently  the  earliest  symptom  of  urethral  infection, 
whilst  a  purulent  discharge  from  the  urethra  is  usually  present  when  the  case 
comes  under  observation. 

The  passage  of  a  calculus  through  the  urethra  causes  a  sharp,  cutting  pain 
along  the  urethra,  the  cause  of  which  is  apparent  when  the  calculus  is  voided. 
Occasionally  it  may  happen  that  micturition  occurs  in  these  cases  in  the  dark, 
or  that  urine  is  not  passed  into  a  vessel,  so  that  the  calculus  is  not  actually  seen 
by  the  patient ;  but  if  there  is  a  history  of  previous  renal  descent  of  a  stone 
or  symptoms  pointing  to  vesical  calculus,  the  sharp  urethral  pain  during 
micturition  occurring  upon  one  single  occasion  is  significant  of  the  passage  cf 
a  calculus.  A  stone  may,  however,  pass  on  to  the  urethra  during  micturition 
and  become  arrested  at  some  narrowed  portion  of  the  canal,  usually  at  the 
membranous  portion  or  at  the  distal  end,  when  a  sudden,  sharp  pain  is  felt 
in  the  urethra,  and  at  the  same  time  the  flow  of  urine  is  partially  or  completely 
stopped  before  the  bladder  has  been  emptied,  whilst  further  efforts  fail  to 
re-start  the  stream.  In  these  cases  the  presence  of  a  stone  should  be  suspected, 
and  the  whole  length  of  the  urethra  examined  by  passing  the  finger  along  its 
course,  when  a  stone  may  be  actually  felt,,  or  the  canal  may  be  illuminated  by 
an  endoscope  and  the  calculus  seen. 

Urethral  Stricture  occasionally  causes  pain  in  the  urethra  during  micturition, 
especially  if  the  calibre  is  small,  and  if  there  is  septic  infection  or  ulceration  of 
the  urethral  mucous  membrane  behind  the  stricture.  The  forced  efforts  at 
urination  may  cause  pain  in  the  urethra  during  micturition,  but  as  a  general 
rule  stricture  causes  but  little  pain.  The  gradually  increasing  difficulty  in 
micturition,  the  feeble  stream,  and  the  dribbling  of  urine  from  the  meatus  after 
the  stream  has  terminated,  are  symptoms  pointing  to  stricture  of  the  urethra  ; 
the  diagnosis  will  be  confirmed  readily  by  the  obstruction  offered  to  the  passage 
of  a  full-sized  bougie,  or  better,  by  direct  observation  of  the  urethra  by  means 
of  the  endoscope. 

Injury  of  the  Urethra  may  cause  pain  during  micturition.  The  urethra  may 
be  injured  by  a  faU  on  the  perineum,  by  a  kick  or  blow,  or  by  the  faulty  or 
careless  passage  of  instruments  ;  it  may  also  be  injured  or  lacerated  in  association 
with  a  fracture  of  the  pelvis.  The  urethra  may  be  merely  bruised,  may  be 
lacerated  on  one  aspect,  or  may  be  completely  ruptured.  If  the  urethra  be 
injured,  there  is  usually  an  appearance  of  blood  at  the  external  urinary  meatus, 
together  with  a  contusion  in  the  perineum  or  along  the  course  of  the  urethra, 
if  the  laceration  is  caused  by  direct  injury.  Any  attempt  at  micturition  causes 
pain  in  the  penis,  whilst  urine  may  or  may  not  be  expelled  from  the  meatus, 
depending  upon  the  extent  of  the  injury,  or  may  be  extra vasated  into  the  perineal 
or  scrotal  tissues.  As  a  rule,  no  difficulty  will  be  experienced  in  the  diagnosis, 
but  in  any  suspected  case  the  greatest  care  should  be  exercised  in  passing  an 
instrument  into  the  urethra. 

2.  Diseases  of  the  Prostate. — Any  acute  inflammation  of  the  prostate  causes 
pain  in  the  urethra  during  micturition.  Thus  acute  prostatitis  and  prostatic 
abscess  both  give  rise  to  pain  during  micturition,  in  addition  to  increased 
frequency  and  difficulty  during  the  act.  Both  are  usually  sequelse  of  an  acute 
urethritis,  and  whereas  an  acute  prostatitis  is  accompanied  by  a  temperature 
raised  to  100°  F.  or  101°  F.,  a  prostatic  abscess  causes  the  usual  rise  and  fall 
in  temperature  common  to  septic  processes.  The  diagnosis  of  the  two  conditions 
is  readily  made  on  a  careful  rectal  examination,  when  the  acutely  inflamed  gland 
presents  a  much  enlarged,  smooth-surfaced  prominence  in  the  rectum ;  whilst 
if  an  abscess  be  present,  a  softer  area  in  the  inflamed  gland  can  usually  be 
detected. 

Adenomatous  enlargement  of  the  prostate  gives  rise  to  no  penile  pain  during 


PA  IX     IX     THE    PEXIS 


micturition ;  neither  does  the  prostate  containing  tuberculous  deposits,  but  pain 
in  the  penis  is  occasionally  present  during  micturition  in  cases  of  prostatic 
carcinoma,  owing  to  the  direct  infiltration  of  the  urethral  mucous  membrane. 
Prostatic  carcinoma  is  by  no  means  uncommon,  and  whilst  in  its  general 
s^^nptoms  it  resembles  those  of  prostatic  adenoma,  there  is  a  marked  difference 
found  on  digital  examination  of  the  gland  per  rectum.  The  carcinomatous 
gland  presents  rounded  areas  of  densely  infiltrated  tissue,  in  contradistinction 
to  the  elastic,  uniform  feel  of  the  adenomatous  variety- ;  the  whole  gland  is 
fixed  and  immovable,  and  in  advanced  stages  distinct  infiltration  of  the  lateral 
pel^'ic  h-mphatics  may  be  felt  extending  from  the  lateral  aspects  of  the  affected 
organ. 

Care  must  be  taken  not  to  mistake  the  hard  nodules  felt  in  a  prostate  containing 
calculi  for  carcinoma.  With  calculous  disease,  the  gland  is  not  fixed  and  is  only 
shghtlv  enlarged,  whilst  on  gentle  pressure  -svith  the  examining  finger  the  calcuH 
mav  be  felt  to  grate  upon  each  other.  During  the  passage  of  a  catheter  through 
the  prostatic  urethra,  distinct  grating  may  be  felt  if  any  calculus  has  ulcerated 
the  urethral  wall. 

3.  Diseases  of  the  Bladder  may  cause  penile  pain  during  micturition  under  cer- 
tain circumstances,  although  it  is  much  more  common  to  find  that  pain  in  vesical 
disease  follows  the  completion  of  micturition.  In  acute  cystitis,  penile  pain  is 
present  throughout  micturition,  due  to  the  intense  congestion  of  the  vesical 
mucous  membrane  of  the  trigone  and  around  the  internal  urethral  orifice.  The 
other  s}Tnptoms  of  acute  cystitis,  namely  suprapubic  pain,  pATrexia,  increased 
frequency  of  micturition,  and  the  presence  of  pus  and  blood  in  an  acid  urine, 
are  sufiicient  for  the  diagnosis. 

Pain  during  micturition  in  other  vesical  lesions  is  caused  whenever  there  is 
any  sudden  obstruction  to  the  normal  flow  of  urine  by  the  implantation  of  some 
body  against  the  internal  urethral  orifice.  This  may  occur  with  a  small  calculus 
or  with  a  pedunculated  tumour,  whether  simple  or  maUgnant,  when  during 
micturition  the  flow  is  suddenly  arrested,  accompanied  by  a  shooting  pain  in 
the  urethra,  whilst  after  an  inter\-al  of  a  few  seconds  the  stream  may  be  re- 
estabhshed.  With  vesical  calculus,  the  urine  may  be  normal  or  may  contain 
pus  and  blood  if  the  bladder  has  become  infected  ;  there  is  penile  pain  after 
micturition,  and  the  stone  may  be  felt  with  a  sound.  With  a  simple  villous 
papilloma  there  is  no  pain  unless  part  of  the  fimbriated  portion  of  the  tumour 
engage  in  the  urethral  orifice  during  micturition,  but  there  are  usually  recurrent 
attacks  of  profuse  haematuria,  whilst  in  a  villous-covered  carcinoma  there  is 
increased  frequency  of  micturition,  with  pain  following  the  act,  more  or  less 
constant  haematuria,  and  usually  p^niria.  Upon  rectal  or  vaginal  examination, 
the  base  of  the  bladder  may  be  felt  to  be  infiltrated,  but  b}-  far  the  most 
valuable  means  of  diagnosis  between  the  three  conditions  is  cystoscopy', 
when  a  calculus  or  viUous  tumour  is  readil)"  seen,  whilst  a  pedunculated 
carcinoma  appears  as  a  dark  red  tumour  covered  with  stunted  processes. 
(See  Plate   VI j. 

II. — Penile  Paix  followixg  Micturition. 

This  s\-inptom.  is  common  to  many  lesions  of  the  urinary'  bladder,  more 
especially  those  in  which  there  is  any  ulceration  or  infiltration  of  the  basal  areas. 
The  particular  pain  felt  by  the  patient  is  described  as  a  sharp  pricking  or  tingling 
sensation  at  the  terminal  part  of  the  penis  on  the  cessation  of  micturition, 
lasting  some  minutes  and  causing  a  desire  to  squeeze  the  glans.  It  has  often 
been  described  as  t^^-pical  of  vesical  calculus,  but  this  is  very*  far  from  being  the 
case,  and  it  rather  points  to  some  affection  causing  changes  in  the  trigonal 
portion  of  the  bladder. 


PAIN     IN     THE     PENIS  513 


The  common  causes  of  pain  in  the  penis  following  upon  micturition  are  :- 


Vesical — 

Calculus 

Tuberculosis 

Tumour^ — carcinoma 
papilloma 

Acute  cystitis 

Bilharzia. 
Ureteric — 

Calculus  in  lower  end 

Descending  ureteritis 

Descendin9  tuberculosis. 


Prostatic — 

Acute  inflammation 

Abscess 

Calculus. 
Rectal  : — 

Carcinoma. 
Anal  :■ — • 

Fissure 

Inflamed   haemorrhoids. 


I.  In  Diseases  of  the  Bladder. 

Calculus. — If  a  calculus  is  present  in  the  bladder,  unless  it  is  trapped  in  the 
pouch  behind  an  enlarged  prostate,  it  causes  pain  in  the  glans  penis  after 
micturition.  A  calculus  may  exist  without  causing  cystitis,  although  commonly 
there  is  some  degree  of  pyuria  when  the  case  is  first  seen.  There  is  increased 
frequency  of  micturition  during  active  exercise  or  during  the  jolting  of  travelling, 
but  not  during  complete  rest  unless  cystitis  is  marked.  The  terminal  drops  of 
urine  during  micturition  are  often  tinged  with  blood,  and  on  some  occasions 
there  may  have  been  a  sudden  stoppage  of  the  stream  during  micturition.  In 
some  cases  there  is  a  history  of  the  descent  of  a  stone  from  the  kidney  without 
the  subsequent  appearance  of  a  calculus  in  the  urine.  Patients  subject  to 
vesical  stone  have  usually  reached  the  later  part  of  life,  and  although  the 
symptoms  are  as  a  rule  sufficiently  marked  to  render  the  diagnosis  easy,  some- 
times they  may  be  so  few  that  vesical  calculus  is  quite  unexpected,  or  the 
symptoms  are  so  like  those  caused  by  other  lesions  of  the  bladder,  that  error 
is  easy.  In  such  a  case  it  is  advisable  to  examine  the  interior  of  the  bladder 
with  a  cystoscope  rather  than  by  the  usual  vesical  sound  ;  with  a  sound  a  small 
calculus,  or  one  contained  in  a  vesical  pouch,  may  be  missed,  whilst  with  a 
cystoscope  it  is  readily  seen,  its  approximate  size  determined,  and  any  other 
condition  of  the  bladder  accompanying  or  simulating  calculus  may  be  diagnosed 
with  certainty.     (See  Plates  V,  VI.) 

Vesical  tuberculosis  may  be  a  primary  affection,  but  is  more  frequently  second- 
ary to  tuberculous  disease  in  some  other  part  of  the  genito-urinary  tract.  It 
causes  marked  penile  pain  after  micturition,  together  with  pyuria  and  a  tinge 
of  blood  in  the  terminal  drops  of  urine  ;  the  frequency  of  micturition  is  increased 
during  both  day  and  night,  and  is  uninfluenced  by  rest,  thus  differing  from  the 
increased  frequency  of  calculous  disease.  Vesical  tuberculosis  usually  occurs 
in  young  adults,  but  it  must  be  distinguished  carefully  from  other  vesical 
infections,  and  more  particularly  from  renal  tuberculosis,  in  which  symptoms 
referable  to  the  bladder  are  commonly  present  before  the  bladder  is  attacked  by 
disease.  In  a  j^oung  patient  in  whom  increased  frequency  of  micturition,  pyuria, 
and  penile  pain  are  present,  a  search  should  be  made  for  any  tuberculous  focus, 
especially  in  the  testes,  prostate,  and  seminal  vesicles,  or  for  marked  thickening 
of  the  terminal  ureter  as  felt  per  rectum,  whilst  a  careful  search  should  be 
made  for  the  tubercle  bacillus  in  the  urine.  A  cystoscopic  examination  may  be 
necessarj'  to  determine  the  extent  of  the  disease  {Plate  V,  Fig.  E),  but,  speaking 
generally,  the  less  instrumentation  that  is  carried  out  in  these  cases  the  better. 

Vesical    Tumours.  —  Carcinoma    of   the  bladder   occurs  in   two    forms  :   the 

infiltrating  epithelioma  and  the  villus-covered  carcinoma.     Either  form  most 

commonly   begins   in   the   basal  portion  of  the  bladder,  the  muscular  planes 

of  which  become  infiltrated.     For  this  reason,  the  contraction  of  the  bladder 

D  33 


514  PAIN     IN     THE     PENIS 

wall  during  micturition  causes  pain  which  is  referred  to  the  terminal  portion  of 
the  urethra.  Both  forms  occur  in  elderly  patients,  and  give  rise  to  increased 
frequency  of  micturition  during  both  day  and  night,  and  to  hsematuria.  They 
also  often  give  rise  to  renal  pain  when  the  infiltration  has  extended  to  the 
ureteric  orifice  in  the  bladder.  The  base  of  the  bladder  may  be  found  per  rectum 
to  be  infiltrated,  or  enlarged  glands  may  be  felt  in  the  lateral  pelvic  space,  and 
a  cystoscopic  examination  will  usually  clear  up  the  diagnosis  {Plate  VI,  Figs. 
F,  G). 

Whereas  the  carcinomatous  growths  of  the  bladder  give  rise  to  penile  pain 
after  micturition  from  the  direct  infiltration  of  the  vesical  walls,  the  peduncu- 
lated villus-covered  carcinoma  and  the  simple  villous  papilloma  may  give  rise 
to  sharp  penile  pain  during  micturition,  from  the  blocking  of  the  internal 
urethral  orifice  with  a  process  of  growth.  The  occurrence  of  this,  together  with 
attacks  of  profuse  haematuria,  are  evidence  of  a  pedunculated  growth.  On 
cystoscopic  examination,  the  carcinomatous  pedunculated  tumour  is  seen  to  be 
covered  by  blunt,  stunted  processes  ;  it  is  often  multiple,  whereas  the  innocent 
villous  papilloma  is  single  and  presents  much  more  delicate  fimbriae. 

Acute  cystitis  causes  tingling  pain  in  the  penis  after  micturition  from  the 
inflammatory  infiltration  of  the  trigonal  area.  The  mode  of  onset,  the  character 
of  the  pain,  and  other  symptoms  of  cystitis  will  point  to  the  cause  of  the  pain. 

Bilhayzia  hcsmatobia  gives  rise  to  clinical  symptoms  very  similar  to  that  of 
vesical  tuberculosis.  The  history  of  residence  in  an  infected  district,  the  micro- 
scopical examination  of  the  urine  for  ova  (see  Fig.  13,  p.  93),  and  the  typical 
cystoscopic  appearance  of  the  bladder  (see  Plate  VI,  Fig.  K)  will  render  the 
diagnosis  apparent. 

2.  Ureteric  lesions  not  infrequently  produce  pain  in  the  glans  penis  after 
micturition,  and  may  cause  considerable  difficulty  in  the  diagnosis  from  vesical 
disease. 

When  a  calculus  becomes  impacted  in  the  narrowed  terniinal  or  intramural 
portion  of  the  ureter,  symptoms  are  produced  almost  exactly  similar  to  those 
of  vesical  calculus  or  tuberculosis,  namely,  increased  frequency  of  micturition, 
pain  in  the  glans  penis  after  micturition,  and  a  small  amount  of  pus  and  blood  in 
the  urine.  Intimate  knowledge  of  the  history  of  the  illness  will  often  be  of  value 
in  these  cases  ;  the  first  attack  of  pain  is  usually  described  as  being  sudden, 
and  felt  in  the  renal  angle  posteriorly,  passing  forward  above  the  iliac  crest  and 
spine,  and  finally  becoming  localized  at  the  situation  of  the  external  abdominal 
ring.  The  calculus  may  become  impacted  in  the  terminal  inch  of  the  ureter, 
when,  in  addition  to  this  pain,  increased  frequency  of  micturition  and  penile 
pain  are  added.  In  a  recent  case  under  the  author's  car,e,  in  which  a  small 
oxalate  calculus  was  impacted  in  the  terminal  part  of  one  ureter,  there  were 
frequent  attacks  of  fairly  profuse  haematuria,  suggesting  a  villous  papilloma, 
but  this  is  probably  infrequent.  With  ureteric  calculus  there  is  usually  pain 
in  the  kidney  of  the  affected  side  from  the  dilatation  of  the  pelvis  of  the  latter, 
due  to  the  increased  renal  tension. 

The  diagnosis  of  these  cases  is  not  so  difficult  if  a  careful  enquiry  is  made 
into  the  history  and  symptoms,  and  so  long  as  it  is  remembared  that  increased 
frequency  of  micturition  and  penile  pain  may  be  caused  by  ureteric  impaction  of 
a  calculus.  A  good  skiagraphic  examination  of  the  pelvic  areas  may  show  the 
shadow  of  a  stone,  whilst  the  latter  may  be  felt  occasionally  as  a  small,  painful 
nodule  above  the  seminal  vesicles  upon  examination  per  rectum.  A  cj^stoscopic 
examination  also  affords  valuable  information,  not  only  in  excluding  vesical 
lesions,  but  by  giving  a  distinct  indication  of  ureteric  calculus  by  the  marked 
congestion  and  dilatation  of  the  blood-vessels  in  the  immediate  vicinity  of  the 
ureteric  orifice.     A  small  bougie  passed  into  the  ureter  may  meet  with  obstruction 


PAIN     IN     THE     PENIS  515 

in  its  passage,  whilst  a  wax-tipped  bougie  may  be  grooved  or  indented  by  the 
stone. 

Ureteritis  descending  from  infection  of  the  renal  pelvis  may  give  rise  to  slight 
penile  pain  and  to  increased  frequency  of  micturition.  This  is  most  commonly 
seen  in  the  tuberculous  form,  but  is  present  in  a  less  marked  degree  with  infection 
by  other  organisms,  of  which  the  most  common  are  the  Bacillus  coli  communis 
and  the  staphylococcus.  When  the  infection  has  reached  the  ureter,  the  symptom 
may  be  present  before  there  is  any  visible  infection  of  the  vesical  mucous  mem- 
brane, and  in  this  way  rather  point  to  a  diagnosis  of  vesical  disease.  In  the 
non- tuberculous  form,  the  ureter  may  be  felt  per  rectum  to  be  slightly  thickened, 
but  the  cvstoscopic  appearance  of  the  inflamed  ureteric  orifice  is  quite  distinctive 
{Plate  V,  Fig.  C).  In  descending  tuberculosis  from  the  kidney,  the  ureter  may 
be  felt  as  a  firm,  infiltrated  cord  on  the  bladder  base,  the  penile  pain  and  increased 
frequency  of  micturition  are  more  marked,  the  kidney  may  be  felt  enlarged 
and  tender,  and  tubercle  bacilli  will  be  found  in  the  urine.  Apart  from  this, 
typical  changes  in  the  ureteric  orifice  are  seen  on  cystoscopic  examination,  the 
orifice  being  pulled  up  or  retracted  or  horse-shoe  shape,  and  usually  occupying 
a  position  slightly  above  and  outside  the  situation  of  the  normal  orifice,  due  to 
the  actual  shortening  of  the  duct  by  infiltration  of  the  submucous  coats  {Plate  V, 
Fig.  D). 

3.  Diseases  of  the  Prostate  often  cause  pain  in  the  penis  immediately  following 
micturition.  This  is  most  commonly  seen  in  the  acute  inflammation  or  abscess 
in  the  gland  as  a  sequela  of  an  acute  gonorrhoeal  or  septic  urethritis.  In  either 
case  there  is  penile  pain,  sometimes  associated  with  erection,  but  little  difficulty 
will  ■  be  experienced  in  the  diagnosis  on  due  consideration  of  the  symptoms 
and  upon  rectal  examination. 

Prostatic  calculi  are  not  uncommon,  and  there  may  be  a  single  calculus 
or  a  nest  of  them  in  the  prostate.  They  tend  to  ulcerate  into  the  urethra, 
so  that  smaU  calculi  may  be  passed  in  the  urinary  stream,  or  some  may 
pass  back  along  the  dilated  prostatic  urethra  into  the  bladder.  If  a  calculus 
projects  from  the  prostate  into  the  urethra,  it  causes  pain  in  the  penis  after 
micturition.  A  diagnosis  of  prostatic  calculus  is  often  made  by  the  grating 
sensation  imparted  to  a  catheter  in  traversing  the  prostatic  urethra,  whilst  on 
rectal  examination  the  calculus  may  be  felt  as  an  isolated,  hard  nodule  in  the 
gland,  or,  if  more  than  one  is  present,  by  the  crepitation  of  one  upon  another 
on  digital  pressure  in  the  rectum. 

4,  5.  Diseases  of  the  Rectum  and  Anus  may  occasionally  give  rise  to  penile  pain 
following  micturition,  apart  from  any  infection  of  the  bladder  or  prostate.  Thus, 
a  carcinoma  in  the  anal  canal,  a  rectal  fissure,  or  an  inflamed  haemorrhoid  may 
occasionally  cause  pain  in  the  penis,  but  in  each  the  local  symptoms  of  the 
trouble  wiU  be  the  more  marked,  and  little  difficulty  will  be  found  in  the 
diagnosis  if  a  local  examination  is  made  with  care. 

III. — Pain  Apart  from  Micturition. 

Under  the  above  divisions  the  symptom  penile  pain  has  been  considered 
in  relation  to  the  act  of  micturition,  and  it  remains  to  consider  some  condi- 
tions giving  rise  to  pain  in  the  penis  apart  from  urination.  These  include 
certain  local  lesions  of  the  penis  and  urethra,  and  also  the  pains  referred 
from  disease  elsewhere.  Although  a  local  lesion  may  cause  little  more  than 
discomfort  in  many  patients,  in  some  it  is  described  as  pain,  the  degree  of  which 
depends  upon  the  nervous  susceptibility  of  the  patient.  Thus,  penile  pain  mav 
be  present  with  acute  urethritis,  with  balanitis  in  association  with  phimosis, 
with  paraphimosis,  or  with  the  lymphangitis  of  the  organ  due  to  a  septic  sore  or 
abrasion  of  the  skin  or  mucous  membrane.     In  some  instances  herpes  of  the 


5i6 


PAIN     IN     THE     PENIS 


prepuce  or  penile  skin  causes  distinct  pain.  Any  infiltration  of  the  cavernous 
tissue  of  the  penis  causes  pain  during  erection  of  the  organ  ;  thus  during  an 
attack  of  acute  urethritis,  the  common  symptom  known  as  chordee  arises  from 
this  cause,  whilst  in  a  chronic  form,  cavernitis  may  be  due  to  infiltration  in 
association  with  tertiarj^  syphilis  or  to  gouty  diathesis,  so  that  erection  of  the 
organ  is  only  partial  or  confined  to  the  proximal  part,  and  causes  pain.  Another 
condition  causing  the  same  condition  arises  from  the  organization  of  a  hcsniatoma 
in  the  cavernous  tissues  of  the  penis  following  upon  a  local  injury',  either  from 
external  violence  or  during  forcible  attempts  at  coitus. 

Epithelioma  of  the  penis  occasionally  gives  rise  to  pain  in  the  organ. 

Pain  maj'  be  felt  in  the  penis  in  some  cases  of  renal  colic,  in  which  case  it  is 
classed  as  a  referred  pain.  Thus,  in  the  acute  colic  accompanying  the  passage 
of  a  calculus,  blood-clot,  or  debris  of  caseous  material,  aching  pain  ma}^  be  felt 
in  the  penis  quite  apart  from  the  increased  desire  to  pass  urine.  Penile  pain 
is,  however,  only  a  minor  detail  in  the  presence  of  the  severe  pain  in  the  loin,  and 
is  often  only  lightly  alluded  to.  R.  H.  Jocelyn  Swan. 

PAIN  IN  THE  PERINEUM. — Pain  in  the  perineum  is  a  symptom  which  is 
often  mentioned  by  patients  in  giving  their  history?  of  some  affection  of  the 
genito-urinary  apparatus  or  of  other  organs,  but  usualh^  onl}^  as  a  dull  aching 
pain,  of  which  little  notice  is  taken,  as  it  is  generally  of  miner  consequence  in 
comparison  with  other  more  striking  symptoms.  The  complaint  of  perineal  pain 
per  se  does  not  convey  much  information  to  the  clinician,  and  it  is  practically 
never  present  as  the  only  symptom  in  a  case. 

Aching  in  the  perineum  is  frequently  present  in  diseases  of  the  following 
organs  : — • 


Prostate — 

Acute  or  subacute  inflammation 

Abscess 

Tuberculosis 

Calculus 

Adenomatous  enlargement 

Carcinoma. 
Seminal  Vesicles — 

Acute  inflammation 

Tuberculosis. 
Urinary  Bladder — 

Cj^stitis 

Tuberculosis 

Calculus 

Carcinoma. 
Urethra — 

Traumatism  and  rupture 

Stricture  with    extravasation  or 
urethral  abscess 

Fistula 

Calculus    impacted     in    bulbous 


Testicle — 

Congenital     misplacement     in 
perineum. 
Anal  Area — • 

Haemorrhoids 

Fissure 

Boil 

Carbuncle 

Ulcer 

Carcinoma. 
Vagina — 

Acute  inflammation 

Inflammation     or     abscess     of 
Bartholin's  glands 

Cj^stocele 

Epithelioma. 
Cutaneous  Diseases — 

Intertrigo 

Eczema,  gouty  and  diabetic 

Condylomata. 


portion.  i 

From  the  foregoing  list  it  will  be  seen  that  aching  in  the  perineum  occuis' 

with    numerous    different    lesions,  but    other    sj-mptoms  are   in   almost  every 

case  more  marked.     These  have  already  been  discussed  elsewhere,  and  to  them 

reference  should  be  made.  R.  H.  Jocelyn  Swan. 

PAIN  IN  THE  SHOULDER.— (See  Pain  in  the  Extremity,  Upper.) 


PAIN     IN     THE     TESTICLE  517 


PAIN  IN  THE  SPINAL  REGION,  CERVICAL.— (Sec  Pain  ix  the  Back.) 

PAIN  IN  THE  SPINAL  REGION,  COCCYGEAL.— (See  Pain  in  the  Back.) 

PAIN  IN  THE  SPINAL  REGION,  DORSAL.— (See  Pain  in  the  Back.) 

PAIN  IN  THE  SPINAL  REGION,  LUMBAR. — (See  Pain  in  the  Back.) 

PAIN  IN  THE  SPINAL  REGION,  SACRAL.— (See  Pain  in  the  Back.) 

PAIN  IN  THE  STERNAL  REGION.— (See  Pain  in  the  Chest.) 

PAIN  IN  THE  TESTICLE. — Pain  of  a  varying  degree  may  be  present  in 
the  testicle  in  many  conditions,  and  it  is  well  for  the  consideration  of  this 
symptom  to  discuss  it  under  separate  headings  into  which  tlie  various  causes 
fall,    namely  : — 

{A)   Diseases   of   the  body  of  the  testis  or  epididymis. 

(B)  Affections  of  the  coverings  of  the  testicle. 

(C)  Affections  of  the  spermatic  cord. 

(D)  A  retained  or  misplaced  testicle. 

{E)  Pain  from  lesions  remote  from  the  testis. 

A. — Diseases  of  the  Body  of  the  Testis  or  Epididymis. 

I.  Inflammatory  Lesions. — Inflammation  may  attack  the  testis  proper,  or, 
as  is  more  common,  it  may  begin  in  the  epididymis  ;  it  rarely  remains  confined 
to  one  part  of  the  organ,  however,  for  the  process  tends  to  spread  rapidly  from 
one  part  to  the  other,  so  that  the  whole  organ  is  involved  and  the  result  termed 
an  "  epididymo-orchitis."  An  inflammatory  affection  of  the  testicle  may  be 
acute,  subacute,  or  chronic,  the  latter  being  the  terminal  result  of  the  former. 

An  acute  epididymo-orchitis  arises  most  commonly  by  the  direct  infection  of 
the  organ  from  the  urethra  via  the  vas  deferens.  When  any  inflammation  has 
reached  the  prostatic  portion  of  the  urethra,  the  orifices  of  the  vasa  deferentia 
may  become  infected,  and  inflammation  spreads  rapidly  along  the  duct  to  the 
epididymis  and  testis.  Whilst  formerly  the  occurrence  of  an  acute  inflammatory 
condition  of  the  testis,  following  upon  some  form  of  urethritis,  was  looked  upon 
as  "  metastatic,"  it  has  been  shown  that  this  view  is  no  longer  tenable,  and  that 
we  must  look  upon  it  as  a  direct  spread  of  infection  via  the  vas  deferens. 

Causes  of  Acute  Epididymo-orchitis  : — 
Causes  of  urethral  origin  : — 


Gonorrhoeal  urethritis 
Septic  urethritis 
Passage  of  catheters 
Urethral  instrumentation 
Ulceration  behind  a  stricture 


Ulceration  about  an  impacted 
calculus  or  a  prostatic  calculus 

Injections  into  the  posterior 
urethra. 


General  causes  : — 

Fevers — Parotitis  (mumps)  ,  Influenza 

Enterica  1         Gout  and  rheumatism. 

Scarlet  fever 
Traumatism 

Acute  epididymo-orchitis  begins  as  a  painful  thickening  of  the  epididymis 
associated  with  febrile  symptoms.  Before  any  actual  pain  is  noticed  in  the 
testis,  there  is  often  a  sense  of  discomfort  and  weight  over  the  external  abdominal 
ring  and  inguinal  canal  due  to  the  inflammatory  piocess  extending  along  the 
vas  deferens.     The  swelling  of  the  epididymis  increases,  and  with  it  the  tubules 


5i8  PAIN     IN     THE     TESTICLE 

of  the  testis  proper  become  infected,  causing  swelling  of  its  body  and  increase 
of  pain.  The  whole  organ  thus  becomes  enlarged,  and  it  is  often  exquisitely 
tender,  the  touch  of  the  clothes  or  the  most  gentle  examination  causing  pain. 
The  swollen  gland  is  often  flattened  on  the  outer  and  posterior  aspect  from 
pressure  against  the  adductor  muscles  of  the  thigh  ;  the  vas  deferens  and  tissues 
of  the  spermatic  cord  are  thickened. 

By  far  the  most  common  cause  of  an  acute  epididj-mo-orchitis  is  an  acute 
gonorrhoeal  urethritis.  During  the  third  week  of  the  disease  the  prostatic  portion 
of  the  canal  frequently  becomes  infected,  when  the  orifices  of  the  ejaculatory  ducts 
may  share  in  the  inflammation,  and  infection  be  conveyed  by  the  vas  deferens 
to  the  testicle.  Similarly,  but  less  frequentl}',  infection  may  arise  from  a  septic 
posterior  urethritis,  contracted  during  connection  with  a  woman  the  subject  of  a 
vaginal  leucorrhoea.  The  gonorrhoeal  form  of  acute  epididA^mo-orchitis  usually 
resolves  slowty,  and  shows  very  little  liability  to  suppurate,  whereas  the 
inflammation  resulting  from  a  staphylococcal  or  a  streptococcal  infection  may 
break  down  into  a  testicular  abscess. 

Acute  epididymo-orchitis  may  also  arise  from  septic  processes  in  the  urethra 
following  upon  the  passage  of  catheters,  of  instruments  for  vesical  operations, 
such  as  lithotrity,  from  ulceration  behind  a  urethral  stricture  or  about  a  calcuhis 
in  prostatic  urethra,  and  occasionally  after  the  instillation  of  strong  solutions 
into  the  posterior  urethra  in  the  treatment  of  a  chronic  urethritis.  In  an}-  case 
the  onset  of  pain  and  rapid  swelling  of  the  testis  should  always  lead  to  the 
suspicion  of  urethral  infection,  and  attention  should  be  directed  to  the  urethra 
with  that  in  view.  Bacteriological  examination  of  any  urethral  discharge  is 
essential  (see  Discharge,  Urethral). 

Acute  epididymo-orchitis  occasionally  arises  without  any  preceding  urethral, 
infection,  and  uncommonly  occurs  as  a  complication  of  acute  specific  parotitis 
(mumps),  enter ica,  scarlet  fever,  or  influenza.  The  testicle  becomes  painful,  and 
enlarges  rapidly  in  the  same  manner  as  in  acute  inflammation  from  urethral 
infection,  and  under  appropriate  treatment  gradually  resolves.  Less  frequently 
testicular  inflammation  ma}^  occur  with  gout  or  acute  rheumatism,  or  after  a 
direct  injury  to  the  organ,  such  as  a  blow  or  squeeze. 

The  pain  in  an  acute  inflammation  is  generally  of  an  aching  character  at  first, 
felt  not  only  in  the  testis,  but  at  the  external  abdominal  ring,  and  often  as  a 
heavy  dragging  pain  in  the  loin  of  the  aft'ected  side.  As  the  testis  enlarges,  the 
local  pain  becomes  more  severe,  so  that  the  swollen  gland  is  exquisitely  tender 
to  pressure  or  to  the  touch.  After  a  few  days  the  pain  subsides  to  a  large  extent, 
but  remains  as  a  dull  ache  until  the  swelling  becomes  greatly  reduced,  and  usually 
disappears  some  time  before  the  organ  returns  to  the  normal  size.  In  a  few  cases 
in  which  a  fibrous  scar  remains  in  the  epididymis,  pain  may  remain  and  cause 
some  difficulty  in  the  diagnosis  from  a  commencing  tuberculous  lesion,  but  the 
earlier  history  of  acute  inflammation  will  help  in  forming  an  opinion.  In  other 
cases  the  persistence  of  the  pain  and  swelling  may  indicate  the  formation  of  an 
abscess  in  the  testicle,  when,  after  decrease  at  first,  the  swelling  increases,  the 
skin  covering  it  becomes  reddened,  and  a  soft  area  becomes  evident  to  one  or 
other  side  of  the  organ. 

2.  Tuberculosis  of  the  Testicle  is  comparatively  common,  occurring  as  a 
primary  disease  or  secondary  to  tuberculous  disease  of  the  kidney,  bladder,  or 
prostate.  It  begins  as  a  localized  deposit  in  almost  all  cases,  causing  a  rounded, 
firm  nodule  in  the  epididymis.  It  frequently  arises  in  the  upper  pole  of 
the  epididymis,  whereas  the  inflammatory  affections  secondary  to  urethral 
infection  begin  in  the  lower  pole.  This  nodule  may  remain  unaltered  for  many 
months,  or  may  enlarge,  soften,  become  adherent  to  the  skin  and  coverings  ol 
the  testicle,  or  actuall}^  ulcerate  through  them   to   form  a  discharging  fistula 


PAIN     IN     THE     TESTICLE  519 


in  the  scrotum.  The  small  commencing  nodule  in  the  epididymis  is  usually 
painless  at  hrst  and  may  be  found  by  accident,  but  later,  as  it  gradually 
enlarges,  it  causes  an  aching  pain  in  the  organ.  Other  nodules  may  be  formed 
in  the  epididymis,  or  the  body  of  the  testis  may  become  involved,  whilst 
commonly  small  shot-like  thickenings  may  be  felt  in  the  course  of  the  vas 
deferens.  In  the  most  advanced  stages,  nodules  may  be  felt  upon  rectal  examina- 
tion in  the  seminal  vesicles  or  prostate,  or  the  epididymis  of  the  other  side. 

Tuberculous  disease  of  the  testicle  usually  presents  little  difficulty  in  the  dia- 
gnosis. In  an  early  case  the  occurrence  of  one  or  more  nodules  in  the  epididymis, 
which  are  painful  on  pressure  and  which  have  not  resulted  from  a  preceding 
acute  epididymo-orchitis,  should  always  suggest  a  tuberculous  focus,  and  a 
careful  search  should  be  made  for  any  other  tuberculous  lesion  in  the  body. 
Should  none  be  found,  the  estimation  of  the  opsonic  index  of  the  blood  to  tubercle, 
or  one  of  the  several  cHnical  tests  for  tubercle,  such  as  von  Pirquet's  tuberculin 
skin  reaction,  may  clear  up  the  diagnosis.  In  later  stages  the  diagnosis  i.<^ 
less  difficult  ;  the  gradual  enlargement  of  the  nodules,  their  craggy  or  bossy 
feel,  the  infection  of  the  vas  or  other  genito-urinary  organs  with  tuberculosis, 
and  above  all,  the  tendency  of  the  focus  in  the  epididymis  to  soften  and  to  become 
adherent  to  the  scrotal  coverings,  are  points  to  be  looked  for  ;  whilst  if  it  should 
have  led  to  the  formation  of  a  fistula,  tubercle  bacilli  may  be  detected  in  the 
discharge. 

3.  Syphilitic  disease  of  the  Testis  causes  very  little  pain  in  the  organ,  but  there 
is  often  a  sense  of  dragging  or  heaviness,  and  for  this  reason  it  must  be  considered. 

Syphilis  may  attack  the  testicle  in  several  different  ways,  producing  : — 


In  Congenital  Syphilis 
Interstitial  orchitis 
Gummatous  orchitis. 


In  Acquired  Syphilis  : — 
Diffuse  interstitial  orchitis 
Gummatous  orchitis 
Epididymitis. 

The  outstanding  feature  of  syphilitic  disease  of  the  testicle  is  that  it  affects 
the  body  of  the  testis  rather  than  the  epididymis,  thus  differing  in  a  marked 
degree  from  tuberculous  disease.  In  the  interstitial  form  there  is  thickening  of 
the  intertubular  connective  tissue,  with  an  infiltration  of  spindle  cells,  which, 
forming  young  connective  tissue,  yield  fibrous  tissue  when  untreated.  The 
subsequent  contraction  of  this  fibrous  tissue  may  cause  atrophy  of  the  testis. 
The  testis  may,  on  section,  show  small  gummata  in  addition  to  the  diffuse 
orchitis,  or  if  the  inflammation  is  more  localized,  gummata  may  be  the  main 
feature,  these  varying  in  size  from  that  of  a  pea  to  that  of  a  walnut,  or  larger. 
The  epididymis  is  but  rarely  affected,  but  cases  are  on  record  of  a  nodular 
swelling  in  the  epididymis  during  the  secondary  stage  of  syphilis,  which 
disappeared  rapidly  under  antisyphilitic  treatment. 

In  congenital  syphilis,  both  the  interstitial  and  gummatous  forms  exist  ; 
they  usually  occur  in  childhood  or  in  young  adult  life,  and  in  many  cases  the 
affection  is  bilateral.  Sj^philitic  inflammation  of  the  testicle  may  be  accompanied 
in  either  the  acquired  or  the  congenital  form  by  a  vaginal  hydrocele. 

There  is  a  sense  of  weight  in  the  scrotum  rather  than  pain,  and  often  an  aching 
or  dragging  feeling  in  the  inguinal  or  lumbar  region.  On  palpation,  the  bod}^ 
of  the  testis  feels  enlarged  and  nodular  with  the  gummatous  deposits,  but 
the  epididymis  can  usually  be  distinguished  from  the  testis  and  be  found  to  be 
unaffected.     The  tissues  of  the  cord  remain  unthickened. 

The  diagnosis  of  syphilitic  disease  of  the  testis  is  usually  simple.  There  may 
or  may  not  be  a  history  of  syphilis,  but  other  signs  of  the  disease  should  be 
looked  for — thus,  in  the  acquired  form,  any  scar  of  pievious  ulceration  or 
periosteal  thickening,   or  in  the    congenital  variety,  signs   in   the   teeth,  eyes. 


520  PAIN     IN     THE     TESTICLE 

or  ears.  If  any  doubt  remains,  a  positive  Wassermann  reaction  of  the  blood,, 
or  the  behaviour  of  the  sweUing  when  treated  with  large  doses  of  potassium 
iodide  and  mercury,  should  be  noted. 

Syphilitic  disease  is  distinguished  from  tubemilous  disease  of  the  testis  by  the 
fact  that  the  epididymis  is  usually  free  from  infection;  that  the  cord,  prostate, 
and  vesicles  remain  normal ;  and  by  the  comparative  absence  of  pain  in  the 
testicle  upon  pressure  being  made  upon  it.  Tuberculous  deposits  tend  to  soften 
and  to  involve  the  scrotal  coverings  in  spite  of  treatment.  From  chronic  orchitis 
it  is  differentiated  by  the  history  of  traumatism  and  by  the  absence  of  the 
history  or  signs  of  syphilis.  Syphilis  also  tends  to  attack  both  testes.  From 
malignant  tumours  of  the  testis  it  is  distinguished  by  the  history  of  syphilis,  the 
tendency  of  syphilitic  disease  to  be  bilateral,  the  slow  enlargement,  and  a 
positive  Wassermann  reaction.  In  malignant  disease,  the  increase  in  the  size  of 
the  testicle  is  more  rapid,  whilst  the  tumour  often  shows  areas  of  varying 
consistence  ;    the  cord  is  often  enlarged  in  malignant  cases. 

4.  Malignant  Tumours  of  the  Testis  may  give  rise  to  pain  in  the  organ,  but  as 
a  rule  pain  is  only  experienced  in  the  later  stages  of  the  disease.  Both  carcinoma 
and  sarcoma  may  arise  in  the  testis,  but  embryoma  is  more  common,  exhibiting 
both  epithelial  structures  and  a  combination  of  several  forms  of  connective- 
tissue  type — cartilaginous,  myxomatous,  etc.  Clinically,  without  microscopical 
examination,  a  soft  carcinoma  and  a  sarcoma  can  rarely  be  differentiated,  and 
as  their  symptoms  and  history  are  so  similar,  they  may  for  convenience  be 
considered  together.  A  testicle  that  is  the  seat  of  a  malignant  growth  enlarges 
rapidly,  but  as  pain  is  at  first  absent,  there  may  be  nothing  to  arouse  the  patient's 
suspicions.  As  long  as  the  tunica  albuginea  remains  intact,  the  swelling  retains 
the  shape  of  the  testis,  but  when  perforation  of  the  fibrous  covering  takes  place, 
nodular  projections  appear  and  render  the  surface  of  the  tumour  irregular. 
These  projections  are  softer  than  the  remainder  of  the  growth,  and  they  form  a 
valuable  point  in  the  diagnosis.  In  a  rapidly  growing  sarcoma  or  carcinoma  of 
the  testis,  the  mass  may  be  so  soft  as  to  appear  to  be  a  fluid  collection  in  the 
tunica  vaginalis.  Generally,  however,  although  a  growth  may  be  accompanied 
by  a  small  amount  of  fluid  in  the  tunica  vaginalis,  the  more  solid  mass  can  be 
felt  through  the  fluid  on  careful  examination  ;  this  fluid  is  often  bloodstained. 
The  epididymis  may  become  incorporated  in  the  growth,  so  that  it  cannot  be 
distinguished,  and  the  tissues  of  the  cord  become  thickened.  The  coverings 
of  the  testis  become  stretched  over  the  tumour ;  the  mass  does  not  become 
adherent  to  the  scrotal  skin  until  late  in  the  disease.  In  both  carcinoma  and 
sarcoma,  the  iliac  and  lumbar  glands  become  enlarged,  and  may  be  felt  in  a 
thin  subject  at  the  brim  of  the  pelvis,  and  pain  due  to  the  pressure  of  these 
glands  upon  nerve  structures  may  become  marked.  The  inguinal  glands  are 
usually  not  enlarged  unless  the  scrotal  skin  is  affected. 

The  diagnosis  of  malignant  disease  of  the  testis  may  be  quite  easy  in  the  case 
of  rapidly  growing  tumours,  but  in  others,  especially  in  the  early  stages,  it 
may  present  great  difficulty. 

Between  sarcoma  and  carcinoma  it  may  be  clinically  impossible  to  distinguish. 
In  quite  early  life  the  tumour  is  more  likely  to  be  a  sarcoma  ;  the  cord  is  thickened 
earlier  in  carcinoma,  but  with  rapidly  growing  tumours  it  may  be  quite 
impossible  to  say  whether  it  is  a  sarcoma,  carcinoma,  or  embryoma  until  a  piece 
is  examined  under  a  microscope. 

Orchitis  m.ay  be  confused  with  the  more  slowly-growing  forms  of  sarcoma. 
In  both  the  swelling  may  have  followed  an  injury,  and  in  both  there  may 
be  a  syphilitic  history.  Orchitis  is,  however,  more  chronic,  it  retains  more 
the  oval  shape  of  the  testis,  and  does  not  present  the  rounded,  slightly  raised 
bosses  which  are  commonly  present  in  a  sarcomatous  testis.     In  orchitis  the 


■PAIN     IN     THE     TESTICLE  521 

cpididyiDiis  is  usually  distinguished  more  easily,  and  the  cord  is  not  so 
thickened  as  with  a  growth.  Finally,  the  result  of  treatment  with  strapping 
and  with  mercury  and  iodide  will  often  show  the  disease  to  be  of  a  non- 
malignant  nature. 

Chronic  torsion  of  the  testicle  is  not  very  uncommon  amongst  habitual  horse- 
riders,  and  sometimes,  if  there  is  no  clear  history  as  to  the  relationship  between 
the  swelling  and  a  saddle  injury,  the  nature  of  the  painful  tumour  may  be  so 
uncertain  that  operation  and  histological  examination  are  resorted  to. 

Tuberculous  disease  is  usually  diagnosed  easily  from  malignant  disease  by  the 
tendency  of  tubercle  to  attack  the  epididymis,  to  caseate,  suppurate,  and  to 
become  adherent  to  the  scrotal  skin  comparatively  early.  Tuberculosis  occasion- 
ally attacks  the  body  of  the  testicle  first,  however,  forming  an  oval,  smooth 
tumour  of  the  organ  ;  the  epididymis  and  vas  deferens  may  be  unaffected  for 
a  time,  and  if  no  deposit  is  found  in  the  prostate  or  vesicles,  the  differential 
diagnosis  between  tubercle  and  growth  may  be  far  from  easy.  These  cases  are 
very  rare,  so  that  the  difficulty  will  seldom  arise. 

HcBmatocele. — The  diagnosis  between  a  ha3matocele  and  a  malignant  tumour  of 
the  testis  may  present  considerable  difficult^^  In  both  the  swelling  may  date 
from  an  injury,  whilst  the  indistinct  fluctuation  obtained  in  the  soft  areas  of  a 
growth,  accompanied  sometimes  by  some  fluid  in  the  tunica  vaginalis,  may  give 
the  appearance  of  hsematocele.  The  latter  feels  heavy  to  the  hand,  but  is 
usually  softer  in  its  whole  mass  and  more  regular  than  a  growth.  Care  must 
be  taken  not  to  place  too  much  reliance  upon  the  withdrawal  of  a  few  drops  of 
blood  from  the  tumour  by  means  of  a  trocar  and  cannula,  a  result  which  may 
happen  equally  with  growth  or  haematocele.  A  hsematocele  may  cease  to  enlarge, 
or  even  diminish  in  size,  whereas,  in  growth,  increase  in  size  is  progressive.  The 
cord  remains  unaffected  with  h3ematocele  and  testicular  sensation  is  more  likely 
to  be  lost  in  growth.  If  any  doubt  exist,  it  is  advisable  to  make  an  exploratory 
incision  rather  than  a  puncture,  when,  if  necessary,  a  radical  operation  can  be 
proceeded  with. 

Hydrocele. — A  hydrocele  of  very  long  standing,  an  irregular,  nodular  surface, 
and  the  absence  of  translucency  due  to  the  thickened  tunica  vaginalis  and  the 
thick  contents  of  the  sac,  may  simulate  a  new  growth,  but  the  long  history  of 
the  case,  and  the  absence  of  progressive  increase  in  size  of  the  swelling,  will 
prevent  a  mistake  of  this  kind. 

5.  Cysts  of  the  Testis  occur  most  frequently  in  connection  with  the  epididymis, 
very  rarely  with  the  body  of  the  testis.  These  cysts  are  quite  different  from 
hydrocele  of  the  tunica  vaginalis,  and  are  often  spoken  of  as  encysted 
hydrocele  of  the  epididymis  or  testis,  or  as  a  spermatocele,  although  all  do 
not  contain  spermatozoa.  They  cause  a  swelling  of  varying  degree  in  the 
scrotum,  and  usually  an  aching  in  the  testicle,  groin,  or  lumbar  region. 
They  may  arise  as  retention  cysts  of  the  tubules  of  the  epididj'^mis  or  from 
one  of  the  foetal  remains  which  occur  about  the  globus  major  of  the 
epididymis,  namely,  the  organ  of  Giraldes,  the  hydatid  of  Morgagni,  or  the  vas 
aberrans  of  Haller. 

These  cysts  are  usually  placed  above  and  to  the  outer  side  of  the  testis, 
occasionally  behind  it.  They  move  with  the  organ,  and  can  usually  be  dis- 
tinguished from  the  latter  by  the  test  of  translucency.  Their  increase  in  size  is 
very  slow,  but  they  may  cause  aching  pain  in  the  testicle  by  pressure  upon,  or 
stretching  of,  the  tissues  of  the  epididymis.  They  can  be  distinguished  from 
hydrocele  of  the  tunica  vaginalis  by  the  relative  position  of  the  swelling  to  the 
testicle,  and  by  the  fact  that  the  fluid  contained  in  them  is  colourless  or  slightly 
opalescent  from  the  contained  spermatozoa,  in  distinction  to  the  straw-coloured 
fluid  of  a  vaginal  hydrocele. 


PAIN     IN     THE     TESTICLE 


B. — Affections  of  the  Coverings   of  the  Testis  causing  Pain 
IN  THE   Organ. 

The  only  comnion  lesions  of  the  coverings  of  the  testis  are  hydrocele  and 
hesmatocele  ;  new  growths  of  the  testicular  tunics  are  so  rare  as  to  render  them 
surgical  curiosities. 

Hydrocele  may  occur  occasionally  as  an  acute  affection  accompanying  an 
acute  epididymo-orchitis,  injury  to  the  scrotum,  or  in  the  course  of  acute 
specific  fevers  such  as  small-pox,  rheumatism,  or  mumps.  Recently  acute 
hydrocele  has  been  described  in  conjunction  with  acute  lesions  of  other  serous 
membranes — multiple  serositis  or  polyorrhymenitis.  The  more  usual  form  of 
hydrocele  is  the  chronic  variety,  which  may  be  due  to  some  disease  of  the  testicle,. 
but  for  which,  in  the  majority  of  cases,  no  ascertainable  cause  can  be  found. 

A  hydrocele  may  cause  some  aching  in  the  testicle,  but  more  frequently  it 
causes  a  dragging  sensation  in  the  loin  from  the  mechanical  effect  of  its  weight. 
It  forms  a  swelling  on  one  side  of  the  scrotum,  oval  in  shape,  with  smooth 
uniform  surface  ;  it  gives  a  distinct  sense  of  fluctuation.  The  swelling  is. 
distinctly  limited  above  from  the  cord  or  external  abdominal  ring,  and  gives  nO' 
sense  of  impulse  on  coughing  ;  with  a  good  light  it  can  be  found  in  most  cases  to 
be  translucent,  the  testicle  usually  occupying  a  posterior  and  low  position  in  the 
swelling. 

The  diagnosis  of  hydrocele  is  usually  easy,  but  occasionally,  when  in  old- 
standing  cases  the  walls  are  much  thickened,  difficulty  may  be  experienced. 
A  hydrocele  must  be  diagnosed  from  (i)  A  scrotal  hernia,  (2)  Heematocele, 
(3)  New  growth,  and  (4)   An  encysted  hydrocele  of  the  testis. 

1.  Scrotal  Hernia. — Usually  a  hernia  gives  an  impulse  on  coughing,  can 
be  reduced  into  the  abdomen  with  a  sudden  slip  or  gurgle,  and  varies  in 
size  with  the  position  of  the  patient.  A  hernia  comes  down  frora  above  and 
descends  into  the  scrotum.  In  a  large  irreducible  hernia,  some  part  of  it  is 
usually  resonant  from  the  contained  intestine,  the  swelling  is  not  limited  above, 
and  the  testis  can  be  distinguished  at  the  bottom  of  the  scrotum.  A  hydrocele 
is  distinctly  limited  above,  and  the  spermatic  cord  can  be  distinguished  easily ; 
it  gives  no  impulse,  and  is  translucent.  The  testis  in  a  hydrocele  cannot  usually 
be  distinguished  in  the  scrotum  as  in  a  hernia. 

Difficulty  may  arise  between  the  two  conditions  when  the  hydrocele  extends 
along  the  inguinal  canal,  and  thus  gives  an  impulse  on  coughing,  or  if  the  trans- 
lucency  is  lost  owing  to  the  thickness  of  the  walls  or  contents  of  the  sac. 
A  scrotal  hernia  in  an  infant  may  be  translucent. 

2.  HcBmatocele  is  distinguished  from  hydrocele  by  the  absence  of  translucenc3\ 
the  greater  weight,  and  the  suddenness  of  the  onset,  usually  after  an  injury  or 
puncture.  If  any  doubt  exist,  an  incision  may  be  made  into  the  swelling, 
permission  being  obtained  to  proceed  to  any  form  of  cure  that  may  be  found 
desirable. 

3.  New  Growths  of  the  Testis. — A  hydrocele  is  of  much  slower  rate  of  increase 
in  size,  of  smooth  surface  and  uniform  consistence,  and  is  translucent. 

4.  Encysted  Hydrocele  of  the  Testis  (see  above). 

Haematocele  may  occur  as  the  result  of  tapping  a  hydrocele,  from  puncture 
of  a  vein  in  the  sac  or  of  the  testicle,  or  by  the  occurrence  of  bleeding  into  a 
hydrocele.  It  may  occur  quite  independently  of  a  hydrocele,  usually  after 
direct  injury.  As  a  rule  there  is  a  rapid  onset  of  swelling  in  the  scrotum  following 
the  injury,  with  ecchymosis  of  the  scrotal  skin  ;  the  resulting  tumour  resembles 
a  hydrocele  in  its  clinical  symptoms,  save  that  it  is  not  translucent.  In  other 
cases  the  swelling  arises  more  slowly,  when  a  pyriform  or  oval  swelling  is  present 
in  one  side  of  the  scrotum  covered  by  normal  skin  ;    the  surface  of  the  swelling  is 


PAIN     IN     THE     TESTICLE  525 

smooth,  and  gives  a  sense  of  fluctuation  and  elasticity.    There  is  no  translucency, 
and,  on  tapping,  dark  blood-stained  fluid  is  withdrawn. 

The  diagnosis  in  the  less  acute  cases  often  presents  a  difficulty,  especially  with 
regard  to  malignant  disease  of  the  testicle  (see  above).  From  hydrocele  it  is 
distinguished  by  the  absence  of  translucency  ;  from  hernia  by  the  same  points, 
except  translucency,  mentioned  above  in  the  diagnosis  between  hydrocele  and 
hernia. 

C. — Affections    of   the    Spermatic    Cord    causing   Testicular    Pain. 

An  inflammatory  affection  of  the  cord  secondary  to  urethral  infection  is  not 
uncommon,  but  rarely  exists  without  a  similar  inflammatory  affection  of  the 
epididymis.  Similarly,  tuberculous  infection  of  the  cord  is  practically  never 
present  without  corresponding  infection  of  the  testis  or  epididymis.  New 
growths  of  the  cord,  lipomata,  myxolipomata,  and  sarcomata  or  hydroceles  of 
the  cord,  cause  no  pain  in  the  testis. 

A  varicocele,  especially  if  large,  in  a  pendulous  scrotum,  is  a  frequent  cause  of 
a  dull,  aching  pain  in  the  testicle.  The  characteristic  feel  of  the  enlarged  veins 
of  the  cord  in  the  erect  position,  and  the  slight  impulse  on  coughing,  will  readily 
point  to  the  correct  diagnosis. 

D. — The    Retained    or   ]Misplaced    Testis. 

This,  in  its  various  situations,  may  give  rise  to  pain,  and  may  cause  some 
difficulty  in  the  diagnosis  of  the  condition  present.  A  testis  may  be  arrested  in 
its  descent  at  the  external  abdominal  ring  in  the  inguinal  canal,  may  remain 
inside  the  abdomen,  or  may  pass  (i)  into  the  perineum  after  traversing  the 
inguinal  canal,  (2)  to  the  upper  part  of  the  thigh  vicl  the  crural  ring,  or  (3)  to 
the  root  of  the  penis  in  front  of  the  pubes. 

In  the  various  situations  in  which  an  undescended  or  ectopic  testicle  is  placed^ 
it  may  be  attacked  by  the  several  diseases  which  affect  the  normally  placed 
organ,  and  thus  give  rise  to  pain  ;  but  in  addition,  owing  to  the  effect  of  constant 
muscular  strains  and  the  comparative  immobility  of  the  organ,  it  is  particularly 
liable  to  recurrent  attacks  of  traumatic  inflammation,  especially  when  the  testis 
is  retained  in  the  inguinal  canal  :  in  the  intra-abdominal  position  it  remains 
protected  from  muscular  injury,  whilst  ectopic  testicles  have  a  greater  range  of 
mobility  than  has  one  that  is  retained  in  the  inguinal  canal.  The  inflammation 
of  an  undescended  testicle  may  be  so  acute  as  to  lead  to  gangrene  of  the  organ, 
with  or  without  torsion  of  the  cord. 

The  pain  may  be  first  complained  of  when  the  testes  begin  to  swell  at  puberty, 
at  which  time  an  undescended  right  testicle  may  produce  symptoms  easily 
inistakeable  for  appendicitis. 

The  diagnosis  of  undescended  testicle  rests  upon  the  following  points  :  the  fact 
that  one  side  of  the  scrotum  is  empty,  the  outline  and  situation  of  a  swelling  in 
the  inguinal  canal  or  elsewhere,  the  testiculai  sensation  upon  pressure,  and  the 
recurrent  attacks  of  pain.  An  undescended  testicle  may  give  rise  to  acute 
pain  from  inflammatory  lesions  or  from  acute  torsion  of  the  organ,  and  may, 
if  placed  in  the  inguinal  canal,  give  rise  to  symptoms  suggestive  of  a 
strangulated  hernia.  It  must  be  remembered  also  that  a  partially  descended 
testicle  is  often  accompanied  by  an  inguinal  hernia.  It  is  also  stated  that  the 
misplaced  testis  is  prone  to  become  the  seat  of  malignant  disease. 

E. — Testicular   Pain   from   Lesions   other   than   in   the   Testicle. 

It  is  necessary  to  mention  this  class  of  case,  in  which  complaint  is  made  of 
testicular  pain,  when  on  clinical  examination  the  testis  is  found  to  be  normal. 
After  an  acute  inflammation  of  the  organ,  even  when  no  palpable  nodule  remains. 


524  PA  IX     IX     THE     UMBILICAL     REGION 

the  resulting  cicatrization  ma}^  cause  an  aching  in  the  organ,  especially  after 
sexual  excitement  or  prolonged  desire.  Apart  from  former  testicular  disease, 
pain  may  be  felt  in  the  organ  if  a  calculus  be  present  in  the  pelvis  of  the  kidney 
or  upper  ureter,  with  a  marked  degree  of  oxaluria,  or  from  stimulation  of  the 
peripheral  nerves  by  carcinoma  of  the  bodies  of  the  lumbar  vertebrcB  or  the  pressure 
of  an  aneurysm  in  this  situation.  R.  Jj.  Jocelyn  Szvan. 

PAIN  IN  THE  THIGH.— (See  Pain  ix  the  Extremity,  Lower.) 

PAIN  IN  THE  THROAT.— (See  Sore  Throat.) 

PAIN    IN    THE    UMBILICAL    REGION.— 

Pain  associated  with  External  Swelling. — This  may  be  due  to  the  following 
causes : — 

Umbilical  Hernia. — This  is  common  in  youno  infants,  and  also  in  fat,  middle- 
aged  people,  particularly  women  who  have  borne  children.  Attention  is  often 
first  called  to  the  protrusion  by  the  presence  of  pain.  In  the  early  stages,  while 
the  hernia  is  j^et  small,  it  may  easily  be  overlooked,  especially  if  the  patient  is 
obese.  The  sweUing  is  usually  globular  in  shape,  has  an  impulse  on  coughing, 
and  may  or  may  not  be  reducible.  In  a  verj-  large  proportion  of  cases  the  hernia 
is  irreducible,  and  it  nearly  always  contains  omentum. 

Sebaceous  Cyst. — This  is  found  not  uncommonly  at  the  umbilicus.  It  presents 
itself  as  a  smaU  spherical  swelling,  which  might  be  mistaken  for  a  small 
irreducible  umbilical  hernia.  There  is,  however,  no  direct  impulse  on  coughing, 
and  the  swelling  is  attached  to  the  skin.  There  is  generally  but  little  pain  unless 
the  cj-st  has  become  injured  or  inflamed. 

Xew  Growth. —  Occasionally  the  umbilicus  is  the  seat  of  a  small  secondary 
nodule  of  growth  which  has  been  brought  by  the  vessels  in  the  round  ligament 
from  the  neighbourhood  of  the  liver.  It  may  furnish  a  clue  in  making  the 
diagnosis  of  an  obscure  abdominal  ailment. 

Eczema  Intertrigo. — Ver\-  obese  people  of  uncleanly  habits  may  suffer  from 
this  trouble  at  the  umbihcus. 

Divarication  of  the  Recti  Muscles. — A  patient  lying  in  the  recumbent  posi- 
tion may  show  no  evidence  of  this  condition.  Diffuse  pain  is  complained  of 
about  the  umbilicus,  and  the  divarication  is  at  once  made  evident  if  the  patient 
is  asked  to  lift  the  head. 

Pain  associated  with  Internal  Swelling. 

Tuberculous  peritonitis  with,  formation  of  a  localized  abscess  is  the  commonest 
cause  of  pain  and  a  swelhng  situated  inside  the  abdomen  at  the  umbihcus.  The 
patient  is  usually  a  child,  and  presents  well-marked  signs  of  chronic  abdominal 
disease. 

Carcinoma  of  the  Pylorus  or  Carcinoma  of  the  Colon  maj'  present  as  an  umbilical 
tumour,  especialty  if  it  has  become  fixed  by  adhesions,  but  it  can  usually  be 
diagnosed  without  difficult\-  on  account  of  the  special  s%'mptoms  arising  in 
each  case. 

Pain  without  Swelling  or  other  Localizing  Symptoms. 

The  causes  of  umbilical  pain  are  so  numerous  and  varied,  that  in  order  to 
mention  all  it  would  be  necessar}"  to  enumerate  nearh-  all  abdominal  complaints. 
This  cannot  be  done  here,  but  an  indication  wiU  be  gi\"en  of  possible  causes 
in  patients  in  whom  no  trace  of  abdominal  disease  can  be  found,  and  who  still 
complain  of  pain  at  or  about  the  umbilicus. 

Tabes  Dorsalis. — The  only  complaint  of  the  patient  ma}'  be  of  abdominal 
pain,  often  referred  to  the  region  of  the  umbilicus.  The  typical  gastric  crises 
may  be  replaced  b}^  a  much  more  difiuse  pain,  and  more  than  one  person  has 


PALPITATION  525 


been  operated  on,  and  a  gastro-enterostomy  performed,  under  a  mistaken  dia- 
gnosis. A  systematic  examination  of  the  knee-jerks,  pupil-reflexes,  etc.,  should 
be  made  in  all  cases. 

Lead  Poisoning. — Severe  attacks  of  cramp-like  abdominal  pains  referred  tO' 
the  umbilicus  may  be  the  chief,  or  even  the  only,  symptom  of  plumbism.  The 
patient's  occupation  may  suggest  the  diagnosis  ;  a  blue  line  may  be  found  upon 
the  gums  ;  lead  may  be  discovered  in  the  urine  after  evaporation  of  a  bulk  to 
dryness. 

Tumour  of  the  Spinal  Column  or  Cord,  Spinal  Caries,  and  Compression 
Myelitis. — Though  a  less  common  source  of  error,  these  must  be  borne  in  mind. 
Owing  to  its  situation,  a  growth  in  the  spine  may  be  very  hard  to  locate  ;  a 
skiagram  may  be  of  service. 

Phthisis. — In  this  disease  gastric  pains  are  a  common  symptom,  and  the  pains 
may  even  be  referred  to  the  umbilicus.  George  E.  Gask. 

PAIN  IN  THE  WRIST. — (See  Joints,  Affections  of  the.) 

PAIN,  PRECORDIAL.^(See  Pain  in  the  Chest.) 

PAINFUL  COITUS.— (See  Dyspareunia.) 

PAINFUL  MICTURITION. — (See  Micturition,  Abnormalities  of.) 

PAINFUL  SWALLOWING.— (See  Dysphagia.) 

PALLOR. — (See  An.emia.) 

PALPITATION  signifies  the  sensation  experienced  by  a  person  who  is  con- 
scious of  his  heart  beats.  It  is  not  necessarily  associated  with  pain.  It  may 
be  due  to  manv  different  causes,  of  which  the  following  are  the  chief  : — 


Aortic  stenosis 

Aortic  regurgitation 

Aortic  stenosis  and  regurgitation. 


1.  Valvular  Heart  Disease,  especially 

Mitral  stenosis 

Mitral  regurgitation 

Mitral  stenosis  and  regurgitation 

2.  Heart  affections  associated  with  very  High  Blood-pressure  : — 

Arteriosclerosis  |  Granular  kidney. 

3.  Myocardial  affections  : — 

Fatty  heart  1         Pericarditis 

Fibroid  heart  Adherent  pericardium 

Cloudy  swelling  '  Senile  changes  with  atheroma. 

4.  Lung  affections  leading  to  Failure  of  the  right  side  of  the  Heart:— 

Chronic  bronchitis  I  Fibroid  lung 

Emphysema  |         Large  pleural  or  pleuritic  effusions. 

5.  The  Effect  upon  the  Heart  of  certain  Drugs,  etc.  :— 


Tobacco 

Tea 

Coffee 


Alcohol 

Absinthe 

Morphia 


Cocaine 
Digitalis 
Thyroid  extract. 


6.  Heredity,  Nervousness,  and  Allied  Causes 


Fright  or  other  emotion  Neurasthenia 

Graves'  disease   (exophthalmic  Hysteria 

goitre)  Locomotor  ataxia 

Paroxysmal  tachycardia  Epilepsy. 

Anaemia  from  whatever  cause,  but  particularly 
Chlorosis  I  Pernicious  anaemia. 


526  PALPITATION 


8.  Mechanical  Interference  with  the  Heart  by  : — 


Mediastinal  new  growth 
Chronic  mediastinal  fibrosis 
Thoracic  aneurysm  of  large  size 
Tympanites 


Ascites 
Pregnane}' 

Ovarian  cyst  or  other  large  intra- 
abdominal tumour. 

9.   Dyspepsia :    especially  that  which  is  associated  with  flatulence  and  with 
stoutness  from  lack  of  exercise. 

The  majority  of  patients  who  complain  of  palpitation  jump  to  the  conclusion 
that  they  have  something  the  matter  with  the  heart  and^  although  the  above 
list  is  a  long  one,  the  diagnosis  resolves  itself  in  all  but  a  few  cases  into  deciding 
whether  the  palpitations  are  cardiac  or  gastric  in  origin.  A  routine  examination 
of  the  various  systems  will  very  often  indicate  the  correct  diagnosis  at  once. 

Valvular  heart  disease  will  be  indicated  by  the  history  of  rheumatic  fever, 
scarlet  fever,  chorea,  syphilis,  or  the  like,  and  by  the  alteration  in  the  size  of 
the  heart,  together  with  the  various  bruits.  Mitral  stenosis  is  sometimes  more 
difficult  than  the  others  to  diagnose  on  account  of  the  possible  absence  of  a  bruit 
or  of  enlargement  of  the  left  ventricle,  but  it  may  be  suggested  by  the  patient's 
malar  flush,  by  the  history  of  acute  rheumatism,  and  by  the  loud,  sharp, 
slapping  character  of  the  first  sound  at  the  impulse.  Aortic  regurgitation  is 
sometimes  present  without  a  bruit,  but  it  can  generally  be  detected  in  these 
cases  by  the  typical  collapsing  character  of  the  pulse  ;  if  there  is  still  doubt, 
and  the  patient  is  able  to  take  exercise,  it  is  frequently  possible  to  bring  out  an 
aortic  regurgitant  bruit  by  asking  him  to  take  a  few  steps  briskly. 

High  blood-pressure  conditions  are  best  detected  by  means  of  a  sphygmo- 
manometer ;  the  diagnosis  will  be  confirmed  by  the  big  heart,  the  albuminuria 
with  tube  casts,  and  perhaps  by  retinitis  (p.  18). 

Of  the  myocardial  affections,  pericarditis  and  cloudy  swelling  are  both  acute 
conditions,  often  associated  with  fever  and  with  sufficient  general  illness  to 
confine  the  patient  to  bed,  so  that  the  palpitations  are  a  minor  part  of  the 
malady.  The  diagnosis  of  fatty  or  fibroid  heart  and  of  adherent  pericar- 
dium are  discussed  on  pp.  241,  242.  Palpitations  due  to  heart-muscle  affection 
are  sometimes  most  difficult  to  distinguish  from  similar  palpitations  due  to 
dyspepsia.  This  applies  particularly  to  fatty  changes  in  the  heart.  Not  a 
few  middle-aged  persons  suffer  from  palpitations  which,  by  some  observers, 
will  be  attributed  to  gastric  trouble,  whilst  by  others  both  the  palpitations  and 
the  dyspepsia  will  be  attributed  to  fatty  heart  ;  nor  can  the  diagnosis  be  made 
by  watching  the  effect  of  slight  exercises  upon  the  pulse-beat,  for  in  typical 
dyspeptic  persons  without  fatty  heart,  the  general  condition  is  usually 
sufficiently  lacking  in  tone  for  the  pulse-rate  to  be  readily  increased  by  exercise. 
If  material  benefit  results  from  the  giving  of  digitalis,  from  the  adoption  of 
Schott's  Nauheim  treatment  or  some  modification  of  the  latter,  the  argument 
will  be  in  favour  of  some  mj^ocardial  degeneration;  but  in  many  instances  of 
flatulence  and  palpitation  the  diagnosis  between  fatty  heart  and  mere  dyspepsia 
will  remain  largely  a  matter  of  opinion. 

Lung  affections  causing  strain  of  the  right  ventricle,  and  thus  leading  to 
palpitations,  are  detected  as  a  rule  by  physical  examination,  but  here  again  there 
may  be  so  much  difficulty  in  interpreting  the  physical  signs,  that  when  a  stout, 
middle-aged  person,  with  obvious  emphysema,  and  with  wheezing  and  shortness 
of  breath  on  exertion,  complains  of  dyspeptic  symptoms  and  also  of  palpitations, 
it  may  be  very  difficult  indeed,  except  by  watching  the  effect  of  different  lines 
of  treatment,  to  say  whether  the  actual  cause  of  the  palpitations  is  emphysema 
with  secondary  dilatation  of  the  heart,  or  dyspepsia  with  reflex  palpitations,  or 
the  result  of  fatty  changes  in  the  heart  muscle  of  a  dyspeptic  person  of  sedentary 
occupation  who  is  both  stout  and  emphysematous. 


PALPITATION  527 


Tobacco  is  a  very  important  cause  for  palpitations  in  a  patient  who  may  seem 
to  be  perfectly  healthy  :  the  degree  to  which  different  individuals  can  smoke 
tobacco  with  impunity  varies  enormously,  and  whereas  some  may  smoke  from 
morning  to  night  and  develop  no  untoward  symptoms  at  all,  others  develop 
some  ill  effects  from  what  are  relatively  quite  small  quantities.  Cigarettes 
seem  to  be  the  greatest  offenders  in  this  respect,  particularly  cheap  cigarettes 
sold  in  packets  of  considerable  numbers  for  a  penny.  In  bad  cases  the  heart 
becomes  absolutely  irregular  ;  in  all  cases  of  the  kind  any  extra  exertion,  such 
as  trotting  a  hundred  yards,  causes  a  rise  in  the  pulse-rate  out  of  all  proportion 
to  what  it  should  ;  the  pulse  may  rise,  for  instance,  from  70  to  150  or  160  per 
minute  as  the  result  of  slight  exertion  which  in  an  ordinary  individual  would 
only  increase  it  to  gcj  or  100.  These  patients  may  have  palpitations  at  any  time 
■of  the  day  or  night,  but  particularly  when  they  first  get  into  bed,  when  violent 
thumpings  may  cause  them  considerable  alarm.  Similar  thumpings  of  the 
heart,  closely  allied  to  but  hardly  identical  with  palpitations,  are  complained 
of  by  elderly  men,  particularly  those  of  the  gouty  habit,  probably  with  atheroma- 
tous degeneration  of  their  coronary  arteries.  Another  condition  in  which  the 
heart  may  produce  similar  symptoms  is  epilepsy,  in  which  disease,  quite  apart 
from  the  major  attacks,  there  are  innumerable  accessory  sjonptoms  of  which 
cardiac  thumpings  in  bed  at  night  are  one.  In  that  particular  variet^^  of 
epileptic  convulsions  which  is  associated  with  a  sudden  halving  of  the  pulse- 
rate  and  coma — sometimes  spoken  of  as  Stokes- Adams  syndrome — palpitations 
may  also  be  a  prominent  symptom.  Tea,  coffee,  alcohol,  and  absinthe,  as 
causes  of  cardiac  irregularity  and  consequent  palpitations,  can  be  diagnosed 
best  by  the  history  and  by  the  effects  of  stopping  the  drugs  in  question.  Morphia 
and  cocaine,  if  taken  over  periods  sufficiently  long  to  lead  to  palpitations,  will 
generally  be  indicated  by  the  presence  of  multiple  prick-marks  upon  the  body 
or  limbs.  The  palpitations  and  other  cardiac  symptoms  are  worse,  not  while 
the  drug  is  being  taken,  but  when  it  is  being  intermitted.  Digitalis  and  thyroid 
extract  will  be  recognized  as  the  cause  at  once  if  they  are  being  prescribed  b}^ 
the  medical  attendant. 

When  palpitations  are  due  to  nervousness,  fright,  or  other  emotion,  they  are 
transient  and  not  difficult  to  diagnose  ;  if  they  keep  on  recurring  from  apparently 
trivial  causes  in  a  person  who  has  not  hitherto  been  nervous,  it  is  important 
to  bear  in  mind  the  possibility  of  Graves'  disease,  for  although  exophthalmos 
and  enlargement  of  the  thyroid  gland  are  important  symptoms  of  this  disease, 
it  is  not  at  all  uncommon  for  them  to  be  absent,  especially  in  the  early  stages, 
and  for  the  only  sign  of  the  malady  to  be  undue  nervousness  of  the  patient 
with  a  tendency  to  tachycardia  and  palpitations.  Any  condition  in  which  the 
nervous  system  seems  to  be  lacking  in  force  or  in  control  is  liable  to  be"  termed 
neurasthenia  nowadays,  and  if  neurasthenia,  be  defined  in  this  broad  sense,  then 
■one  variety  of  it  has  palpitations  for  a  chief  symptom  :  the  making  of  a 
diagnosis  of  neurasthenia,  in  such  cases,  how"ever,  is  equivalent  to  saying  that 
the  palpitations  are  of  purely  nervous  origin,  so  that  all  one  has  really  done 
ds  to  exclude  organic  changes.  The  same  applies  to  hysteria,  though  it  should 
be  borne  in  mind  that  modern  authorities  distinguish  between  hysteria  and 
neiivosis,  confining  the  word  hysteria  to  those  cases  in  which  the  symptoms 
are  directly  controllable  by  suggestion.  Locomotor  ataxia  may  give  rise  to 
symptoms  referable  to  almost  any  of  the  viscera,  and  there  seems  no  reason 
why  cardiac  crises  should  not  occur  as  much  as  laryngeal,  gastric  or  intestinal  ; 
they  are,  however,  rare,  and  when  cardiac  symptoms  develop  in  a  patient 
suffering  from  locomotor  ataxia,  syphilitic  affection  of  the  heart  would  be  a 
safer  diagnosis  than  would  cardiac  crises.  The  relation  of  epilepsy  to  palpita- 
tions has  been  mentioned  above. 


528  PALPITATION 


Ancsmia,  when  it  produces  palpitations,  is  usually  obvious  from  the  patient's 
appearance,  and  it  can  be  confirmed  by  blood  examination.  As  a  rule, 
palpitations  in  anaemic  patients  are  entirely  absent  while  the  patient  is  at  rest 
in  bed,  occurring  mainly  when  she  exerts  herself  and  causes  temporary  dilatation 
of  the  anaemic  heart.     The  palpitations  disappear  when  the  anaemia  is  cured. 

Palpitations  due  to  mechanical  interference  with  the  heart,  by  masses  or  fluid 
or  wind  displacing  it,  can  generally  be  relegated  to  their  correct  cause  as  the 
result  of  physical  examination  of  the  chest  and  abdomen  ;  mediastinal  new 
growth,  tympanites,  ovarian  cyst  of  large  size,  and  the  other  conditions  referred 
to  above,  generally  make  their  presence  obvious  before  they  are  of  sufficient 
size  to  produce  palpitations,  and  they  will  have  been  diagnosed  upon  other 
grounds.  Herbert  French. 

PAPULES  — or  pimples — belong  to  the  group  of  elementary  or  primary 
(as  distinct  from  secondary)  lesions  of  the  skin.  In  the  diagnosis  of  derma- 
toses they  hold  a  most  important  place,  so  varied  are  they,  and  so  numerous 
the  affections  in  which  they  occur.  They  may  be  defined  as  solid,  circum- 
scribed elevations  of  the  skin,  not  larger  than  a  pea.  Similar  formations 
exceeding  that  size  are  classed  as  tubercles — not,  of  course,  to  be  confused  with 
the  characteristic  lesion  of  tuberculosis — or  as  tumours.  They  do  not  persist 
indefinitely,  but,  unless  they  are  transitional,  undergo  spontaneous  resolution^ 
as  tubercles  do  not ;  nor  do  they  cicatrize — as  tubercles  do.  From  Vesicles 
[q.v.)  they  are  distinguished  by  their  solidity  ;  if  a  papule  is  punctured,  nothing 
but  blood  exudes.  But  in  many  instances  papules,  especially  those  of  an 
inflammatory  kind,  are  transitional  lesions,  passing  into  (a)  vesicles,  [b)  pustules^ 
(c)  scales,  or  [d]  breaking  down  into  ulcers,  (e)  undergoing  hypertrophy,  as  warts, 
or  ( / )  atrophying.  If  the  transformation  into  pustules  or  vesicles  is  only 
partial,  the  lesions  are  described  as  papulo-pustules  or  papulo-vesicles,  and  if 
this  is  characteristic  of  the  greater  number  of  the  lesions,  the  eruption  is  said 
to  be  papulo-vesicular  (or  vesiculo-papular)  or  papulo-pustular.  If  the  lesions, 
originating  as  erythematous  macules,  do  not  take  on  the  full  character  of 
papules,  they  are  said  to  be  maculo-papular  or  erythemato-papular. 

In  size,  papules  may  vary  from  a  pin's  head,  as  in  lichen  scrofulosorum,  to  a 
pea,  as  in  lichen  ruber  planus.  The  most  typical  shape  is  that  of  the  papule  of 
lichen  planus,  flattened  and  with  an  irregular  base  ;  but  they  may  be  rounded 
or  oval,  as  in  prurigo,  or  cone-shaped,  as  in  pityriasis  rubra  pilaris  ;  or  triangular, 
or  umbilicated  as  in  lichen  planus.  In  colour,  they  may  be  pink  or  rose-coloured, 
as  in  the  inflammatory  papules  of  urticaria  papulosa,  violet  or  purplish  as  in 
lichen  planus,  bright  red  as  in  eczema,  dark  or  coppery  as  in  syphilis,  yellow 
as  in  xanthoma,  whitish  as  in  milium,  almost  black,  as  in  infiltrations  sometimes 
met  with  in  sarcoma,  or  simply  skin-coloured,  as  in  prurigo  or  verruca  plana. 
They  may  be  discrete,  as  in  prurigo,  or  may  occur  in  patches,  as  in  lichen 
scrofulosorum  ;  sometimes  they  form  round  a  hair  follicle,  as  in  eczema 
folliculorum  and  pitj^riasis  rubra  pilaris  ;  they  are  also  met  with  in  connection  ' 
with  the  sebaceous  glands,  the  sweat-glands,  or  the  papillae.  They  may  be 
inflammatory,  as  in  eczema,  or  non-inflammatory  as  in  severe  goose-skin,  or 
when  they  are  the  result  of  retained  secretion,  as  in  acne,  or  of  excessive  corni- 
fication  round  the  mouths  of  hair-follicles.  Usually,  inflammatory  papules 
give  rise  to  itching  ;  with  the  non-inflammatory  kind  there  are  seldom  marked 
subjective   symptoms. 

Papules  may  occur  in  the  epidermis,  as  in  verruca  plana,  or  in  the  derma, 
when  they  may  be  oedematous,  as  in  urticaria,  or  infiltrated,  as  in  lichen  scrofulo- 
sorum ;  or  they  may  affect  both  structures,  as  in  lichen  planus  and  the  strophulus 
papule    of    acute  prurigo.      The  epidermic  papule  may  be  recognized  by  its 


PAPULES  529 

soliditv,  its  hardness  and  dryness,  and  its  superficial  elevation  ;  the  oedematous 
dermic  papule  by  its  pinkish  colour  and  its  momentary  yielding  to  pressure  ; 
the  infiltrated  dermic  papule  by  its  redness,  induration,  and  elasticity  ;  the 
epidermo-dermic  papule  by  its  union  of  some  of  the  characters  of  the  other 
varieties. 

One  of  the  most  famihar  examples  of  the  papule  is  that  met  with  in  papular 
eczema.  The  small  papule  which  occurs  in  this  affection  is  usually  conical  in 
shape,  with  a  rounded  base  ;  and  is  bright  red  in  colour.  Owing  to  rupture 
bv  scratching,  the  papules  are  covered  with  a  tiny  dome  of  blood-crust.  In 
papular  eczema  there  is  usually  intense  itching.  Eczema  of  this  type  may 
resemble  lichen  ruber  planus,  but  in  that  affection  the  papule,  as  a  rule,  is  flat 
or  umbihcated,  with  an  irregular  base,  is  dark-red  or  violaceous  in  colour,  and 
has  a  ghstening  surface  ;  nor  is  there  ever  any  discharge  or  crust-formation. 
The  papules  of  hchen  planus,  again,  are  not  transitional,  and  they  leave  behind 
them  brownish  or  black  stains,  while  those  of  eczema  frequently  pass  into 
vesicles  and  seldom  produce  discoloration.  Confusion  between  the  plaques 
of  lichen  planus  and  those  of  scaly  eczema  may  be  ob\iated  by  attention 
to  the  differences  in  colour  and  in  definition  ;  in  the  former  affection  the 
plaques  are  generally  dark  red  or  purpUsh,  and  are  sharply  defined  ;  in  the 
latter,  they  are  bright  red  and  are  not  clearly  marked  oft'  from  the  surrounding 
skin.  Moreover,  under  the  lens,  a  minute  vesicle  can  often  be  seen  on  the  top 
of  each  papule  in  eczema  papulatum,  which  is  not  the  case  in  lichen  planus. 
Yet  another  point  of  distinction  between  the  two  conditions  is,  that  in  Hchen 
planus,  characteristic  discrete  papules  can  usually  be  found  at  the  margin  of 
the  patches.  This  feature  serves,  too,  to  differentiate  hchen  planus,  in  its  turn, 
from  generalized  psoriasis,  which  is  marked  also  by  more  scahness  and  less 
thickening. 

Lichen  scrofulosorum  is  a  papular  dermatosis  which  chnically  bears  some 
resemblance  to  hchen  planus,  but  it  has  no  right  to  the  designation  hchen, 
and  belongs  rather  to  the  tuberculides.  The  papules  are  seldom  larger  than 
a  pin's  head,  are  usuall}^  flatfish  but  occasionally  conical,  very  shghtly  resis- 
tant, sometimes  smooth  and  shiny  but  more  usually  covered  with  a  tiny  scale 
which  is  but  shghtly  adherent  ;  occasionally  the  summit  is  occupied  by  a 
pustule  instead  of  by  a  scale.  The  prevaihng  colour  is  red,  but  it  varies  from 
a  pale  yellow  through  red  to  violet.  At  first  the  lesions  are  disposed  in  groups, 
forming  patches  of  various  sizes.  Others  are  arranged  in  arcs  of  circles,  which 
are  usually  seen  about  the  orifices  of  the  sebaceous  glands.  The  eruption  shows 
a  distinct  predilection  for  the  trunk — the  lower  part,  and  the  back  of  the 
abdomen  ;  but  it  occasionally  extends  to  the  beginnings  of  the  limbs  and  may 
invade  the  face.  If  the  affection  becomes  generalized  by  the  spread  and 
coalescence  of  the  scattered  groups  of  papules,  the  whole  skin  is  covered  with 
thin  scales  and  is  of  a  dirty  reddish-brown  hue.  Itching  is  absent,  or  is  so  shght 
as  to  be  negligible  as  a  symptom.  The  eruption  begins  insidiously  and  may  last 
for  several  months  ;  and,  having  disappeared,  leaving  behind  it  no  trace,  it  may 
reappear  again  and  again  over  a  period  of  several  years.  In  the  great  majoritv'  ^ 
of  cases,  the  disease  is  associated  with  some  form  of  tuberculosis — with  phthisis, 
or  necrosis  of  bone,  or  scrofuloiis  ulceration  of  the  skin  ;  but  much  more  commonly 
with  enlarged  glands,  submaxillary,  cervical,  or  axillary.  Its  usual  subjects 
are  children  and  adolescents  ;  it  is  uncommon  after  the  age  of  twenty.  The 
characters  of  the  papules — their  homogeneity,  their  flattish  shape,  their  arrange- 
ment in  groups,  their  painlessness,  their  situation  on  the  trunk — with  the  absence 
of  itching,  and  the  youth  of  the  patient,  are  generally  sufficient  to  determine 
the  nature  of  the  affection.  In  papular  eczema,  as  we  have  seen,  the  papules 
are  not  limited  to  the  trunk,  are  bright  red,  and  there  is  troublesome  itching  ; 
D  34 


530  PAPULES 

moreover,  in  many  cases  there  are  vesicular  or  papulo-vesicular  lesions  as  well 
as  papules.  From  miliary  papular  syphilides,  lichen  scrofulosorum  can  be 
distinguished  by  the  absence  of  any  other  sign  of  syphilitic  affection,  and  bv 
the  usualh'  restricted  distribution  of  the  lesions. 

In  keratosis  pilaris,  or  xerodermia,  the  papules  do  not  form  groups  or  patches 
as  in  lichen  scrofulosorum,  and  usually  they  appear  on  the  limbs,  most  frequently 
the  thighs  ;  they  consist  of  projecting  hair-follicles,  which  convej'  to  the  hand 
the  sensation  of  a  nutmeg-grater.  This  affection  has,  in  turn,  to  be  distinguished 
from  goose-flesh,  in  which  the  elevations,  besides  being  evanescent,  are  not 
rough  or  scaly.  Keratosis  pilaris  is  one  form  of  ichthyosis  ;  another  form, 
sometimes  met  with  in  association  with  xerodermia,  but  more  often  alone,  is 
ichthyosis  hystrix,  in  which  the  lesions  consist  of  small  papillar}-  papules  with 
horn}-  tops,  which  stud  the  skin  as  with  minute  nail-heads,  and  sometimes  develop 
into  large  warty  masses.  The  condition,  dating  back  to  infanc}',  or  at  least  to 
early  childhood,  is  easy  of  identification. 

The  same  may  be  said  of  the  ordinary  wart  [verruca  vulgaris).  The  small 
fiat  wart  [verruca  plana  juvenilis)  may  sometimes  suggest  Uchen  planus,  but  it 
is  smaller  than  the  papule  of  that  affection,  it  has  not  the  dark  colour,  it  gives 
rise  to  no  itching,  nor  is  there  any  tendency  for  the  growths  to  run  together 
into  rough,  scaly,  infiltrated  patches. 

In  pityriasis  rubra  pilaris,  papules  form  at  the  orifices  of  the  hair-follicles, 
usually  following  in  the  wake  of  an  eruption  of  scaly  patches,  or  of  a  dry 
eruption  covered  with  eczematous-looking  crusts.  The  papules,  when  fhey 
appear,  are  seen  to  be  small,  red,  and  dry,  harsh  to  the  touch,  more  or  less 
conical  in  form,  and  the  centre  of  each  is  pierced  b}^  a  single  atrophied  hair, 
which  is  surrounded  by  a  sheath  that  penetrates  into  the  folhcle.  The  surface 
of  the  integument,  thus  roughened,  has  been  likened  by  Besnier  to  the  skin  of 
a  newly-plucked  fowl.  At  first  the  papules  are  discrete,  but  later  they  tend  to 
run  together  into  patches  which  present  the  aspect  of  pale  j'ellowish-red  areas 
covered  with  papery  scales,  or  with  small  adherent  ones  resembling  mica.  They 
mostly  affect  the  limbs,  especially  the  surfaces  where  hair  is  most  abundant  ; 
if  they  encroach  upon  the  trunk  the}^  are  usually  found  at  the  waist  and  the 
lower  part  of  the  abdomen.  Itching  is  sometimes  absent,  and  when  present 
is  always  insignificant.  When  the  patches  are  covered  with  mica-like  scales 
and  are  met  with  in  the  situations  most  common  to  psoriasis — the  tips  of  the 
elbows,  fronts  of  the  knees,  and  the  extensor  surfaces  of  the  hmbs — there  is 
some  danger  of  confusion  with  that  disease  ;  but  at  the  edge  of  each  patch,  the 
characteristic  conical  papule  with  its  single  hair,  plugging  the  mouth  of  a  follicle, 
is  always  to  be  seen.  The  best  place  to  look  for  the  papule  is  on  the  backs  of 
the  fingers.  In  psoriasis,  again,  the  lesions  grow  by  peripheral  extension  instead 
of  by  the  accretion  of  new  papules.  The  fact  that  the  general  health  is  not » 
affected  suffices  to  mark  off  pityriasis  rubra  pilaris  from  other  forms  of  exfoliative 
dermatitis,  in  which  also  there  is  rarely  any  appreciable  thickening  of  the  skin, 
while  the  colour  is  redder  than  in  pityriasis  and  the  scahness  more  marked. 
From  lichen  ruber  planus,  pityriasis  rubra  pilaris  is  distinguished  by  the  absence 
of  itching  and  of  impaired  nutrition,  and  by  its  irresponsiveness  to  arsenic. 
In  lichen  planus,  too,  the  papules  are  flattened,  and  often  umbihcated. 

In  acne  vulgaris,  the  papule  forms  the  primary  lesion.  If  the  obstruction  is 
at  the  mouth  of  the  sebaceous  gland-duct,  the  plug  appears  on  the  surface  as 
a  small  black  point — the  comedo  ;  if  it  is  in  the  gland  itself,  the  obstructing 
material  is  seen  as  a  tinj^  whitish  mass  in  the  substance  of  the  skin — the  milium. 
The  lesion  may  not  develop  beyond  this  stage,  but  usualh^  it  grows  into  a 
reddish  papule  about  the  size  of  a  pea,  and  in  many  cases  the  papule  passes 
into  a  pustule.     Acne  can  usually  be  recognized   by  the  distribution  of    the 


PAPULES  531 

lesions — on  the  face,  especially  the  cheeks,  nose,  forehead  and  chin,  and  less 
frequently  the  back  of  the  neck,  the  back  between  the  shoulders,  and  the  chest — 
their  discrete  character,  the  presence  of  comedones  or  of  milia,  and  the  patient's 
age,  for  the  affection  is  essentiall}^  one  of  puberty.  Usualh',  too,  the  several 
stages  through  which  the  lesions  pass  are  present  at  the  same  time — the  comedo 
or  milium,  the  papule,  the  pustule.  Rosacea  differs  from  acne  in  that  it  chiefly 
affects  the  flush  area  of  the  face,  is  marked  bj^  much  congestion,  and  is  most 
common  in  middle  hfe.      (See  also  Pustules.) 

In  erythema  multiforme,  papules,  tubercles,  vesicles,  bullae,  nodules,  macules 
may  all  be  present  at  the  same  time.  Any  one  of  these  lesions  may  be  predomin- 
ant in  a  particular  case  or  at  a  given  time  ;  but  the  type  of  eruption  most 
frequently  met  with  is  that  which  consists  wholly  or  predominantly  of  papules 
— srythema  papiilatum.  This,  too,  is  usually  the  first  stage  of  the  eruption  in 
cases  which  go  on  to  other  types.  The  papules  are  generally,  at  the  beginning, 
no  larger  than  a  pin's  head,  bright  red  in  colour,  and  fiattish,  sometimes 
umbilicated.  If  closely  grouped  together  they  may  coalesce  and  form  raised 
patches  as  large  as  a  threepenny  or  a  sixpenny  piece  ;  each  patch  has  a  sharply 
defined  border,  and  is  surrounded  by  an  areola  of  congested  skin  ;  the  tint 
in  the  centre  soon  deepens  to  violet,  and  afterwards  to  purple.  The  favourite 
sites  are  the  dorsal  surfaces  of  the  hands  and  forearms  ;  sometimes,  too,  the 
legs,  feet  and  the  face  are  involved.  Papular  erythema  multiforme  is,  as  a 
rule,  easy  of  recognition.  Urticaria  of  the  papular  variety — the  strophulus  or 
prurigo  simplex  aigu  of  French  dermatologists — in  which  the  wheals  are  no 
larger  than  a  lentil,  and  leave  papules  when  they  subside,  occasionally  offers 
some  resemblance  to  it  ;  but  the  two  affections  differ  in  that  the  lesions  of 
erythema  papulatum  are  much  more  persistent,  are  not  white  in  the  centre, 
do  not  give  rise  to  itching,  but  do  leave  stains.  One  of  the  most  marked  of 
these  differences  is  that  which  concerns  itching,  for  in  papular  urticaria  this 
symptom,  though  variable,  is  frequently  most  severe.  In  urticaria,  too,  it  is 
chiefly  the  covered  portions  of  the  body,  and  especially  the  lower  lumbar  region, 
that  are  attacked,  and  the  affection  is  mostly  met  with  in  children. 

Papules  like  those  of  urticaria  papulosa  are  often  met  with  in  prurigo,  both 
in  prurigo  ferox  of  Hebra,  the  severe  form  of  the  affection,  and  in  prurigo  mitis, 
the  mild  and  ordinary  form.  The  characteristic  lesion  is  an  eruption  of  discrete, 
firm,  very  slightly  raised  papules,  more  or  less  hemispherical  in  shape,  with  a 
roundish,  sometimes  oval  contour,  and  a  glistening  surface.  At  first,  the  papule 
is  of  the  same  colour  as  the  skin,  but  afterwards  it  becomes  red,  yellowish,  or 
brownish,  increases  in  size,  and  is  frequently  covered  by  a  blood-crust.  In 
structure,  according  to  Darier,  it  is  a  localized  acanthosis.  Most  abundant  on 
the  extensor  surfaces  of  the  Hmbs,  and  rarely  seen  on  the  flexor  aspects,  or  on 
the  face,  the  papules  occur  not  infrequently  on  the  chest,  the  lower  part  of  the 
abdomen,  the  sacral  region,  and  the  buttocks.  The  itching  is  intense,  and 
mixed  with  the  secondary  changes  produced  by  scratching,  there  may  be  found 
others  not  unhke  those  of  eczema.  Pustules  and  sores  are  common,  often 
accompanied  by  great  enlargement  of  the  axillary  and  femoral  glands.  In 
prurigo  ferox,  the  papules  are  much  larger  and  more  numerous,  and  in  parts 
the  skin  feels  to  the  touch  hke  very  coarse  brown  paper  or  a  nutmeg-grater. 
The  changes  secondary  to  the  inflammatory  process  in  prurigo  are  summed  up 
by  French  dermatologists  in  the  term  lichenisation  or  lichenification.  The  skin 
is  thickened  and  rugose,  and  owes  its  pecuhar  aspect  to  an  exaggeration  of  the 
fine  striae  of  the  normal  integument,  so  that  it  becomes  quadrillated  into  a 
network  of  which  the  meshes  are  square,  lozenge-shaped,  or  polygonal,  with  a 
flat  surface  which  often,  as  Darier  says,  presents  the  aspect  of  glossy..and  brilliant 
facets,  as  of  a  mosaic.     Sometimes  it  is  covered  with  fine  scales.     The  skin  is, 


532  PAPULES 

of  course,  less  supple  than  normal  skin,  and  though  in  colour  it  may  undergo 
no  change,  it  is  more  often  gre^dsh  or  brownish.  The  condition  has  to  be 
distinguished  from  the  lichenization  met  with  in  other  dermatoses.  In 
eczema  and  psoriasis,  the  thickened  and  rugose  skin  is  red,  it  has  no 
glistening  facets,  and  the  margins  are  clearly  defined.  In  lichen  planus  the 
plaques  are  formed  by  confluent  papules  and  are  surrounded  by  characteristic 
papules. 

Apart  from  these  secondary  characters  of  prurigo,  the  diagnosis  is  made  by 
excluding  other  itching  affections,  such  as  scabies  and  pediculosis,  on  account 
of  the  absence  of  the  lesions  characteristic  of  those  conditions,  and  by  the 
positive  characters — the  origin  of  the  affection  in  infancy,  and  its  persistence, 
the  poor  general  health,  the  preference  the  papular  eruption  shows  for  the 
extensor  surfaces  of  the  limbs,  the  freedom  of  the  bends  of  the  joints,  and  the 
glandular  enlargement,  especially  in  the  inguinal  region. 

In  syphilis,  papules  are  frequently  met  with  in  association  with  macules,  but 
they  may  occur  independently.  They  may  be  divided  into  two  main  classes  : 
(i)  Miliary  papular,  and  (2)  Flat  papular  syphiloderms. 

I.  Miliary,  or  follicular,  papular  syphilides  are  the  result  of  infiltration  around 
and  beneath  the  pilo-sebaceous  follicles  ;  they  are  rough  to  the  touch,  and  feel 
like  small  shot  ;  they  vary  in  size,  from  a  pin-head  upward,  and  may  be  either 
acuminate  or  rounded.  The  sites  of  election  are  the  trunk,  back,  shoulders, 
and  loins,  but  the  limbs  may  be  invaded,  and  also  the  face.  Very  frequently 
the  lesions  appear  in  groups  which  run  into  each  other  ;  and  they  are  sometimes 
disposed  in  rings.  The  characteristic  colour  is  that  of  raw  ham,  but  at  first 
they  may  be  pink  or  red.  Involution  proceeds  slowly,  the  stain  left  behind  is 
long  in  dying  away,  and  is  sometimes  succeeded  by  a  shallow  depression  which 
may  last  for  years.  There  is  often  a  slight  scale  on  the  surface  of  the  papule, 
and  not  seldom  a  tiny  vesico-pustule  or  pustule  may  be  detected  on  the  summit. 
Sometimes  there  is  overgrowth  of  the  papillse  ;  and  if  the  lesion  is  situated  in 
a  moist  part,  the  warty  growth  is  covered  with  sodden  white  epithelium,  when 
the  lesion  is  known  as  a  moist  papule,  or  mucous  papule.  A  more  marked 
degree  of  hypertrophy  transforms  the  moist  papule  into  a  mucous  tubercle  or 
condyloma,  distinguishable  from  a  wart  in  that  the  overgrown  papillae  are 
welded  into  a  coherent  mass  by  swelling  of  the  intervening  tissue,  while  in  the 
wart  they  are  free. 

Flat  or  lenticular  papular  syphilides  vary  in  size  from  a  pin-head  to  a  bean, 
and  the  small  or  the  large  lesions  may  predominate  in  a  given  case.  They  may 
develop  directly  out  of  macular  syphilides.  In  contour  they  are  almost 
perfectly  round,  with  a  flattened  top,  are  but  slightly  elevated,  and  in  colpur 
usually  brownish-red.  The  whole  body  is  affected  pretty  impartially  ;  there 
is  little  tendency  to  agmination  ;  sometimes  the  lesions  form  a  kind  of  circlet 
on  the  brow  round  the  margin  of  the  hair  (the  corona  veneris).  In  some  cases, 
ring-like  patches  (the  circinate  or  annular  syphiloderm)  appear  on  the  chin, 
around  the  lips  or  nostrils,  or  sometimes  on  the  vulva  ;  they  are  made  up  of 
small  yellowish-red  papules,  with  fine  scales  ;  elsewhere  the  papules,  in  the 
same  case,  are  of  the  ordinary  kind.  In  other  instances,  the  flat  lenticular 
papules  of  this  group  become  seborrhoeic  ;  these  are  characterized  by  their 
obduracy  to  treatment.  When  there  is  marked  scale-formation,  the  papules 
being  covered  with  a  dry,  dirty-grey  scale,  they  are  styled  papulo-squamous. 
Favourite  situations  for  papulo-squamous  syphiloderms  are  the  palms  and  the 
soles,  where  they  may  be  mixed  with  maculo-papular  and  papulo-tubercular 
lesions.  Syphilides  in  these  sites  are  often  rounded  or  irregular  in  shape, 
have  but  slight  elevation,  are  at  first  brownish-yellow  or  brownish-red, 
but    presently   become   of   a   dirty    grey,    and    on    the    disappearance    of    the 


PA  RAL  YSIS ,     FA  CIA  L  533 

scales  are  seen  to  have  the  characteristic  colour  of  raw  ham.  When  the  scales 
are  more  abundant  than  usual,  they  form  the  syphilides  cornees  of  French 
dermatologists. 

The  small  papular  syphilides  may  in  some  cases  be  difficult  to  distinguish 
from  a  widely  ditfused  lichen  ruber  planus  ;  but  in  this  affection  the  rash  is 
uniform,  the  papules  generally  have  a  linear  arrangement,  and  there  is  usually 
severe  itching.  The  papules  of  syphihs  are  most  hkely  to  be  confused  with 
psoriasis — the  squamous  papules  with  the  ordinary  form  of  psoriasis,  the  papules 
in  rings  with  annular  psoriasis.  Attention  must  be  paid  to  the  polymorphism 
of  the  S}-phihtic  eruption,  the  coppery  colour,  the  enlarged  glands,  the  sore 
throat  or  tongue,  and  the  distribution  of  the  lesions,  no  such  partiahty  for  the 
elbows  and  knees  being  shown  as  is  observed  in  psoriasis,  and  the  papular 
s\-philide  having  a  preference  for  the  flexor  surfaces  of  the  hmbs,  while  psoriasis 
affects  rather  the  extensor  aspects.  The  syphilitic  scales,  too,  are  thin  and 
dirty  white,  while  those  of  psoriasis  are  heaped  up  in  layers  and  have  a  silvery 
sheen.  In  psoriasis,  the  subject  will  usually  have  a  history  of  previous  attacks 
to  relate  ;  and  often  the  affection  can  be  traced  back  to  early  hfe,  whereas  in 
s\'philis  a  particular  lesion  is  seldom  repeated.  The  palmar  and  plantar 
syphiloderms  described  above,  which  occur  symmetrically  as  secondary  and 
unilaterally  as  tertiary  lesions,  may  be  confused  with  the  dry  chronic  eczema 
of  those  regions  ;  but  in  eczema  there  are  heat  and  itching,  and  usually'',  in  the 
case  of  the  palms,  the  fingers  also  are  involved,  and  at  some  point  or  other 
the  process  is  seen  to  have  a  catarrhal  character.  Palmar  syphiHdes  may  be 
distinguished  from  eczema  seborrhoeicum  by  the  fact  that  in  the  latter  there 
are  coincident  lesions  in  the  common  situations — the  scalp  and  eyebrows,  the 
neighbourhood  of  the  beard,  the  naso-labial  folds,  the  sternal  and  inter- 
scapular regions  ;  nor  do  they  usually  assume  the  form  of  crescents  or  segments. 
Whenever  the  diagnosis  is  doubtful,  recourse  may  be  had  to  Wassermann's 
serum  test.  Malcolm  Morris. 

PAR.ffi3THESIA. — (See  Sexsation,  Abnormalities  of.) 
PARALYSIS,  CROSSED.— (See  Hemiplegia.) 

PARALYSIS,  FACIAL. — This  term  is  commonly  applied  to  a  condition  of 
complete  or  partial  paralysis  of  the  muscles  supplied  by  the  7th  cranial  nerve. 
One  or  both  sides  of  the  face  may  be  involved,  the  unilateral  being  more  common 
than  the  bilateral  affection.  It  is  in  some  cases  the  result  of  a  morbid  process 
hmited  to  the  7th  nerve,  when  it  is  known  under  the  name  of  Bell's  palsy  ; 
in  other  instances  it  constitutes  one  of  the  diagnostic  signs  of  a  more  com- 
plex, and  perhaps  more  remote,  disease. 

In  complete  unilateral  facial  palsy,  whatever  its  origin,  the  asymmetry  of 
the  face  may  be  so  marked  that  the  diagnosis  can  be  made  at  sight.  On  the 
other  hand,  less  severe  facial  weakness  may  be  overlooked  unless  the  means 
for  its  detection  are  borne  in  mind  and  employed.  It  will  be  well,  therefore, 
to  recall  briefly  the  evidences  of  facial  palsy  before  proceeding  to  point  out  the 
particular  features  which  characterize  its  various  forms. 

Even  with  the  face  at  rest,  there  are  certain  appearances  on  the  affected  side 
which  attract  the  attention  of  the  careful  observer.  The  natural  lines  and 
\\Tinkles  are  less  marked,  and,  with  the  obliteration  of  the  naso-labial  fold,  the 
cheek  has  a  somewhat  flattened  or,  in  old  persons,  bagg^'  aspect.  If  the  patient 
is  unconscious  or  asleep,  the  flabbiness  of  the  tissues  may  be  emphasized  by  the 
flapping  of  the  cheek  with  respiration,  especially  if  breathing  is  laboured  or 
stertorous.  The  palpebral  fissure  is  wider  than  its  fellow,  and  the  corner  of  the 
mouth  may  tend  to  droop. 


534 


PARALYSIS,     FACIAL 


When  the  facial  muscles  are  thrown  into  action  by  attempts  to  raise  the 
eyebrows,  to  close  the  eyelids,  or  to  expose  the  teeth  {Fig.  136),  the  difference 
between  the  two  sides  is  rendered  more  obvious,  the  movements  on  the  paretic 
half  of  the  face  being  carried  out  with  less  power  and  more  slowly  than  those  of 
the  healthy  half.  The  ability  to  whistle  or  to  move  one  nostril  may  also  be 
impaired,  and  even  with  shght  degrees  of  paresis,  a  person  who  has  previously 
been  able  to  close  the  eye  of  the  affected  side,  the  other  eye  remaining  open, 
is  no  longer  able  to  perform  the  feat.  The  same  difficulty  is  experienced  in 
making  movements  of  the  ear,  by  patients  who  have  formerly  possessed  that 
accomplishment. 

Having  estabhshed  the  presence  of  some  facial  weakness,  it  is  necessary,  in 
order  to  take  full  advantage  of  its  diagnostic  value,  to  make  certain  careful 
observations  with  a  view  to  determining  the  site  of  the  lesion  which  is  responsible 

for  the  defect.  Thus,  facial  paralysis  may  be 
brought  about  by  :  (i)  A  lesion  anywhere  in 
the  com-se  of  the  pyramidal  fibres  passing 
from  the  lower  end  of  the  precentral  g}Tus  in 
one  cerebral  hemisphere  to  the  facial  nucleus 
on  the  opposite  side  of  the  pons  Varolii 
{supranuclear  paralysis)  ;  (2)  A  lesion  involv- 
ing the  facial  nucleus  itself  {nuclear  paralysis)  ; 
and  (3)  A  lesion  of  the  7th  nerve  between  its 
origin  in  the  nucleus  and  the  point  where  it 
divides  in  order  to  supply  the  various  facial 
muscles  {peripheral  paralysis). 

I.  Supranuclear  Paralysis. — Owing  to  the 
fact  that  the  fibres  of  the  pyramidal  tract 
concerned  with  facial  movements  cross  the 
mid-line  of  the  brain-stem  only  a  very  short 
distance  above  the  7th  nucleus,  the  facial 
paralysis  is  on  the  side  opposite  to  the  lesion. 
Occasionally  these  fibres  are  alone  involved  ; 
more  often  those  destined  to  the  correspond- 
ing arm  and  leg  suffer  as  well,  in  which  case 
the  facial  palsy  forms  part  of  a  hemiplegia. 
In  this  type  of  paralysis  the  difference  between  the  two  sides  is  not  nearly  so 
marked  in  the  upper  as  in  the  lower  half  of  the  face.  For  instance,  the  patient 
is  able  to  elevate  both  eyebrows  and  to  close  both  eyes,  although  it  will  be 
found,  on  testing,  that  he-  is  not  able  to  resist  an  attempt  on  the  part  of  the 
observer  to  open  the  eye  of  the  affected  side  with  the  same  degree  of  success 
as  attends  his  efforts  on  the  healthy  side.     {Figs.  137,  138,  139.) 

In  the  attempt  to  expose  the  teeth,  the  facial  asymmetry  is  more  striking,  the 
lip  remaining  immobile  or  retracting  slowly  and  feebly  on  the  paretic  side.  In  this 
way  the  contrast  between  the  depth  of  the  naso-labial  folds  on  the  two  sides  is 
clearly  emphasized. 

Notwithstanding  the  impairment  of  voluntary  movement  on  one  side,  the  face 
may  present  perfect  symmetry  when  it  responds  automatically  to  emotional  or 
reflex  impulses.  In  laughing  or  crying,  the  lines  and  wrinkles  are  equally 
developed,  while  protective  closure  of  the  eyelids  is  accomplished  as  well  on  one 
side  as  the  other  in  response  to  any  threatened  violence  to  the  eyes.  The  preser- 
vation of  these  automatic  movements  depends  on  the  integrity  of  a  facial  reflex 
centre  in  the  mid-brain.  When  this  centre  is  involved  at  the  same  time  as  the 
fibres  of  the  pyramidal  system,  the  emotional  movements  are  lost  or  impaired 
along  with  those  of  voluntary  origin. 


/^/^.  136. — Paralysis  of  the  right  side 

of  the  face,  the  patient  attempting  to 

show  her  teeth.     Note  that  the  right 

palpebral  fissure  is  wider  than   the  left. 

I'/ioia  by  Di:  S.  A.  K.   Wilson. 


PARALYSIS,     FACIAL 


535 


The  corneal  reflex  can  generally  be  elicited  in  this  form  of  facial  paralysis, 
provided  there  is  no  coexistent  diminution  of  sensibility  within  the  area  supplied 
by  the  trigeminal  nerve  of  the  same  side.     In  sharp  contradistinction  to  what 


F/^.  137. — Post-paralytic  contracture 
of  the  left  side  of  the  face.  At  a  first 
glance  the  appearance  suggests  that  the 
right  side  is  the  seat  of  paralj-sis. 


J^ig:  138. — Post-paralytic  contracture. 
The  same  patient  closing  her  ej-es  and 
showing  the  over-action  of  all  the  facial 
muscles  on  the  affected  side. 


obtains  in  the  nuclear  or  peripheral  tj^pes  of,  palsy,  the  nutrition  and  electrical 
excitability  of  the  facial  muscles  undergo  no  alteration  when  the  lesion  is  situated 
above  the  nucleus. 

Bilateral   supranuclear    paralysis,  such  as  is  seen  in  cases  of  cerebral  diplegia 


1 

tPI^^^^I^^H^^H^ 

i 

I  i 

4 

■K  ^  A 

n 

f^^^^k-^*-^  ^1 

^H 

1 

/^i^.  139.  —  Post-paralytic  contrac- 
ture. The  same  patient  smiling,  with 
an  involuntary  wink. 

P/iotos  by  Dr.   S.  A.  K.  Wilson. 


Fig:  140. — Bilateral  facial  palsj-. 
The  photograph  shows  absence  of  all 
lines  and  sagging  of  both  corners  of 
the  mouth. 

Photo  hy  Dr.  S.  A.   K.   Wilson. 


and  pseudo-bulbar  paralysis,  is  characterized  by  a  general  impairment  of  the 
natural  movements,  and  tends  to  the  production  of  a  stiff,  expressionless 
physiognomy    {Fig.    140).     With   the   consequent    defective    inhibition    of    the 


536  PARALYSIS,     FACIAL 

reflex  centre,  emotional  movements  are  often  uncontrolled,  and  with  little 
provocation  the  patient  betrays  in  his  face  degrees  of  mirth  or  distress  which 
he  is  very  far  from  feeling.  This  condition  can  be  distinguished  from  true 
bulbar  palsy  b}^  the  preservation  of  the  nutrition  and  the  normal  electrical 
excitability  of  the  muscles,  and  by  the  absence  of  accompanying  atrophic 
paralysis  of  the  tongue,  masseters,  etc. 

Reference  must  be  made  to  the  occurrence  of  cases,  the  result  of  mid-brain 
lesions,  in  which  the  emotional  movements  are  lost  and  the  voluntary  movements 
are  preserved  on  one  side  of  the  face.  Asymmetry  is  then  onlj'  noticeable  when 
the  patient  smiles  or  cries. 

Finally,  it  must  not  be  forgotten  that  in  long-standing  cases  of  infantile  hemi- 
plegia, facial  weakness  may  be  associated  with  spontaneous  athetoid  movements 
similar  to  those  observed  in  the  arm  and  leg. 

2.  Nuclear  Paralysis. — Lesions  of  the  facial  nucleus  may  be  slight  or  severe, 
and  the  resulting  facial  paralj^sis  may  consequently  be  partial  or  complete.  As  a 
rule,  all  the  muscles  supplied  by  the  nerve  are  more  or  less  equally  affected,  and 
the  impairment  of  movements  obtains  whether  they  are  voluntary,  emotional, 
or  reflex  in  origin.  In  cases  of  complete  nuclear  palsy,  certain  additional  effects 
are  produced.  The  inability  to  close  the  eye,  and  the  drooping  of  the  lower  lid, 
lead  to  imperfect  protection  of  the  eyeball,  and  to  the  overflow  of  tears  on  to  the 
cheek  (epiphora).  Conjunctivitis  and  blepharitis  may  result.  Paralysis  of  the 
lip  muscles  allows  of  saliva  escaping  from  the  corner  of  the  mouth,  and  may 
interfere  materially  with  the  articulation  of  labial  consonants.  Paralysis  of 
the  stapedius  muscle  disorganizes  the  control  of  tympanic  tension,  so  that  the 
patient  suffers  from  excessive  sensitiveness  to  deep  tones  (hyperacusis)  and 
perhaps  from  tinnitus. 

Unlike  supranuclear  paralysis,  the  nuclear  forna  is  accompanied  by  atrophy 
and  alteration  in  the  electric  excitability  of  the  facial  muscles.  In  slow  de- 
generative (usually  bilateral)  processes  affecting  the  facial  nucleus,  the  electrical 
response  shows  a  quantitative  modification  ;  in  acute  destructive  (usually 
unilateral)  lesions  of  the  nucleus,  the  facial  paralysis  is  followed  rapidly  by  the 
reaction  of  degeneration. 

Owing  to  the  situation  of  the  facial  nucleus  in  the  pons,  unilateral  nuclear  palsy 
may  be  associated  with  paralysis  of  the  external  rectus  muscle  of  the  same  side 
and  paralysis  of  the  opposite  arm  and  leg  ("  crossed  "  paralysis). 

3.  Peripheral  Paralysis. — The  clinical  picture  of  a  peripheral  facial  paralysis 
resembles  in  its  most  important  details  that  which  has  aheady  been  described 
under  the  heading  of  nuclear  paralysis.  All  the  muscles  supplied  by  the  nerve 
are  affected  in  more  or  less  equal  degree,  and  the  palsy  is  associated,  within  a 
short  time  of  its  onset,  with  atrophy  and  alterations  in  electrical  excitability  of 
the  muscles  concerned.  The  diagnosis  between  the  two  types  depends  chiefly 
upon  the  presence  of  additional  symptoms  resulting  from  interference  with  the 
function  of  neighbouring  tissues,  and  this  varies  again  with  the  exact  site  of  the 
lesion  in  the  peripheral  course  of  the  nerve. 

A  lesion  affecting  the  fibres  within  the  pons  is  likely  to  produce,  in  addition 
to  the  facial  paralysis,  external  rectus  palsy,  together  with  other  symptoms  in 
proportion  to  the  extent  of  the  destructive  process. 

A  lesion  between  the  surface  of  the  pons  and  the  internal  auditory  meatus 
will  probably  interfere  with  the  vestibular  and  cochlear  parts  of  the  8th  nerve, 
and  so  give  rise  to  vertigo  and  impairment  of  hearing. 

At  the  level  of  the  geniculate  ganglion,  the  chorda  tympani  is  unhkely  to 
escape,  and  the  taste  fibres  coming  from  the  anterior  two-thirds  of  the  tongue 
lose  their  function.  At  the  same  time,  irritation  of  the  ganglion  may  provoke  an 
herpetic  eruption  on  the  auricle  and  around  the  external  auditory  meatus. 


PARALYSIS,     LARYNGEAL 


In  the  upper  part  of  the  Fallopian  canal  a  lesion  produces  complete  facial 
paralysis  and  loss  of  taste  on  the  anterior  part  of  the  tongue  ;  in  the  lower  part 
of  the  canal  the  resulting  symptoms  are  the  same,  with  the  exception  that 
paralysis  of  the  stapedius,  with  its  consequent  hyperacusis,  does  not  occur. 
The  nerve  to  the  stapedius  leaves  the  facial  nerve  between  these  two  points. 
Involvement  of  the  chorda  tympani  may  also  cause  deficiency  in  the  salivary 
secretion  of  the  submaxillary  and  sublingual  glands  of  the  same  side. 

At  the  stylomastoid  foramen,  the  effects  of  a  lesion  are  limited  to  the  facial 
nerves,  the  taste  fibres  being  no  longer  in  close  apposition  to  the  latter. 

From  the  above  data,  the  site  of  any  lesion  causing  peripheral  facial  palsy  can 
be  determined  approximately,  and  it  is  only  necessary  to  add  that  the  term 
Bell's  palsy    is   generally  limited   to   cases  in 
which  the  exciting  cause,  probably  an  acute 
inflammatory  process,  operates  at  some  point 
within  or  just  below  the  Fallopian  canal. 

From  the  diagnostic  standpoint  it  is 
important  to  remember,  that  a  condition 
which  often  results  from  a  long-standing 
Bell's  palsy  may  produce  a  facial  as3-mmetry 
capable  of  erroneous  interpretation,  unless 
the  observer  is  familiar  with  it.  This  is  the 
so-called  post  -  paralytic  contracture,  which 
emphasizes  the  folds  and  lines  on  the  affected 
side  in  such  a  way  that  the  opposite  side  of 
the  face  may  appear  at  first  sight  to  be  the 
weaker.  It  will  be  noticed,  however,  that 
an  attempt  to  close  the  eye  is  imperfectly 
carried  out,  and  that  the  angle  of  the  mouth 
is  strongly,  although  involuntarily,  retracted 
at  the  same  time.  Similarly,  on  asking  the 
patient  to  show  his  teeth,  he  can  only  do  so 
slowly  and  with  effort,  while  the  eye  is  almost 
closed  on  the  same  side  by  a  powerful  associated  contraction  of  the  orbicularis 
palpebrjE.  The  only  complaint  of  a  girl  suffering  from  a  sHght  degree  of  this 
contracture,  was  to  the  effect  that  she  was  unable  to  smile  without  at  the  same 
time  giving  the  impression  that  she  was  winking. 

Hysterical  facial  spasm  is  another  condition  which  may  suggest  weakness  of 
the  opposite  side  of  the  face,  but  the  nature  of  the  defect  will  be  made  obvious 
when  the  whole  face  is  put  into  action. 

Facial  hemiatrophy  often  simulates  facial  paralysis  {Fig.  141)  ;  it  may  be 
differentiated  by  the  fact  that  not  only  the  muscles,  but  all  the  tissues  of  the 


Fig^.  141. — Hemiatrophy  of  the  left 
side  cjf  the  face  in  an  early  stage.  This 
condition  is  sometimes  mistaken  for 
facial  palsy. 


face  on  the  affected  side,  undergo  atrophic  changes. 


E.  Farqiihar  Buzzard. 


PARALYSIS,  LARYNGEAL. — Laryngeal  paralysis  is  to  be  distinguished 
from  interference  with  the  vocal  cords  by  inflammatory  or  ulcerative  lesions, 
fixation  of  the  ar\-tenoid  joints,  and  other  affections  which  mechanically  prevent 
free  movements  of  the  cords.  The  distinction  can  scarcely  be  made  without 
careful  examination  of  the  parts  with  the  laryngoscope. 

In  some  cases,  especially  when  bilateral  abductor  paralysis  comes  on  suddenly, 
the  symptoms  may  be  urgent  and  extreme  ;  in  others,  there  may  be  no  definite 
symptoms  at  all,  particularly  if  there  is  but  partial  paralj'sis  of  one  vocal  cord, 
the  other  being  freely  movable  and  able  to  cross  the  middle  line  so  as  to  meet 
its  fellow  for  purposes  of  speech  or  coughing.  In  most  cases  the  symptoms 
which  point  to  the  presence  of  paresis  or  paralysis  of  a  vocal  cord  are  a  definite 


538  PARALYSIS,     LARYNGEAL 


change  in  the  character  of  the  patient's  voice,  as  noticed  by  himself  and  his 
friends,  and  a  greater  difficulty  in  coughing  effectually  when  need  arises, 
the  act  of  coughing  being  sometimes  associated  with  a  peculiar  sound  described 
by  the  terms  "  brassy  cough  "  or  "  bovine  cough."  For  purposes  of  differential 
diagnosis  laryngeal  paralysis  may  be  divided  into  three  main  groups,  namely  : 
(i)   Functional  ;    (2)    Unilateral  organic  ;    (3)   Bilateral  organic. 

1.  Functional  Paralysis  of  the  Vocal  Cords  has  for  its  main  symptom  aphonia 
without  pain  or  discomfort,  the  patient  nearly  always  being  a  young  woman, 
or  a  girl  over  the  age  of  puberty,  who  complains  that  she  has  almost  suddenlj^ 
become  quite  unable  to  speak  otherwise  than  in  a  hoarse  whisper.  There  may 
or  may  not  have  been  other  functional  nerve  symptoms,  the  commonest  being 
perhaps  difficulty  in  swallowing  owing  to  globus  hystericus.  This  form  of  loss 
of  speech  is  due  to  functional  adductor  paralysis  during  vocalization;  but  when 
the  patient  is  asked  to  cough  she  does  so  with  perfect  ease,  and  thus  demonstrates 
that  the  adductor  paralysis  is  not  real,  for  one  cannot  cough  properly  without 
adducting  the  vocal  cords.  If  the  larynx  is  examined  with  the  laryngoscope 
the  cords  will  be  seen  to  move  perfectly  well  both  with  respiration  and  when  the 
patient  retches,  though  they  may  remain  in  the  abductor  position  if  the  patient 
is  asked  to  make  any  particular  voice  sound.  The  condition  always  gets  well, 
and  it  may  pass  off  almost  instantaneously  as  the  result  of  local  electrical  applica- 
tion or  of  treatment  by  suggestion. 

2.  Unilateral  Organic  Affection  of  a  Vocal  Cord  is  obvious  on  laryngoscopic 
examination  ;  it  may,  however,  be  due  to  more  than  one  cause.  It  is  nearly 
always  the  result  of  interference  with  the  corresponding  recurrent  laryngeal 
nerve,  and  owing  to  anatomical  differences  between  the  two,  the  left  is  more 
commonly  affected  than  the  right.  It  may  be  paralyzed  by  pressure  from,  or 
infiltration  by,  an  intra-thoracic  aortic  aneurysm  ;  a  mediastinal  new  growth  ; 
secondary  deposits  in  the  deep  cervical  or  mediastinal  lymphatic  glands,  for 
instance  in  a  case  of  squamous-celled  carcinoma  of  the  oesophagus  ;  lymph- 
adenoma  ;  gumma  ;  or  mediastinal  fibrosis,  particularly,  though  not  very  com- 
monly, in  association  with  syphilis,  or  with  fibrotic  phthisis  affecting  the  upper 
part  of  the  left  lung.  The  differential  diagnosis  between  these  various  condi- 
tions will  be  found  discussed  elsewhere  ;  ;v-ray  examination  of  the  thorax  may  be 
helpful.  In  the  absence  of  special  indications,  paralysis  of  the  left  vocal  cord 
due  to  interference  with  the  left  recurrent  laryngeal  nerve  in  a  man  of  about 
forty-five  years  of  age  is  always  suggestive  of  an  aneurysm  of  the  distal  portion 
of  the  arch  of  the  aorta,  particularly  if  the  patient  has  had  syphilis,  has  not  been 
an  abstainer,  and  has  undergone  strenuous  physical  exertion. 

3.  Bilateral  Affections  of  the  Vocal  Cords  are  seldom  due  to  thoracic  aneurysm, 
but  any  of  the  other  diseases  mentioned  in  the  preceding  paragraph  may  extend 
far  enough  up  into  the  root  of  the  neck  on  the  right  side  to  reach  and  involve 
the  right  recurrent  laryngeal  nerve  as  it  passes  beneath  the  right  subclavian 
artery,  as  well  as  the  left  recurrent  laryngeal  nerve  as  it  turns  round  the  arch  of 
the  aorta  to  the  left  of  the  left  subclavian  artery.  Careful  examination  of  the 
chest  for  evidence  of  new  growth  or  of  syphilitic  or  tuberculous  fibrosis  is 
necessary,  therefore,  before  one  is  in  a  position  to  diagnose  the  more  common 
cause  for  bilateral  paralysis  of  the  vocal  cords,  namely  degeneration  of  the  nerve 
cells  in  the  vagus  centres  in  the  medulla  oblongata.  It  should  also  be  remembered 
that  some  enlargements  of  the  thyroid  gland,  particularly  those  of  a  malignant  type, 
and  also  secondary  deposits  in  the  deep  cervical  lymphatic  glands,  or  even  extensive 
infiltration  of  the  latter  by  tuberculous  processes,  may  involve  both  recurrent 
laryngeal  nerves  as  they  lie  on  either  side  in  the  sulcus  between  the  trachea  and 
oesophagus,  and  thus  cause  bilateral  paralysis  of  the  vocal  cords.  When  the 
paralysis  is  due  to  central  degeneration  in  the  vagal  nuclei  there  is  generally 


PARALYSIS     OF     ONE     LOWER     EXTREMITY  539 

abductor  before  combined  abductor  and  adductor  paralysis  ;  in  cases  in  which 
the  affection  is  symmetrical  from  the  beginning  the  bilateral  adductor  spasm  may 
result  in  acute  dyspnoea  simulating  acute  suffocative  oedema  of  the  larynx  and 
requiring  immediate  tracheotomy.  More  often,  fortunately,  one  vocal  cord 
passes  through  the  stage  of  abductor  paralysis  into  that  of  complete  paralysis 
before  the  other  is  affected,  so  that  the  dangerous  condition  of  simultaneous 
abductor  paralysis  of  both  vocal  cords  is  avoided.  The  diagnosis  depends  upon 
the  alteration  in,  or  the  loss  of,  voice,  together  with  the  inability  to  cough  effi- 
ciently, except  with  the  sound  which  simulates  the  coughing  of  a  cow  (bovine 
cough)  ;  upon  observation  of  the  bilateral  paresis  of  the  cords  with  the  laryngo- 
scope ;  upon  the  exclusion  of  gross  lesions  within  the  thorax,  or  in  the  neck  ; 
and  upon  the  co-existence  of  other  indications  of  changes  in  the  central  nervous 
system.  These  in  younger  people  are  generally  the  result  of  syphilis,  often  taking 
the  form  of  strabismus,  or  of  locomotor  ataxy,  or  general  paralysis  of  the  insane  ; 
whilst  in  older  people  there  may  be  vascular  degeneration  associated  with  evidence 
of  cerebral  softening  with  or  without  albuminuria,  glycosuria,  thickened  arteries, 
an  enlarged  heart,  and  a  high  blood-pressure.  Only  in  very  rare  cases  is  the 
symptom  due  to  hcemorrhage  or  neoplasm  in  the  medulla  oblongata,  for  with 
either  of  these  lesions  the  patient  does  not  usually  survive  to  show  signs  of  the 
laryngeal  paralysis.  Herbert  French. 

PARALYSIS,  OCULAR. — (See  Strabismus  ;   and  Pupil,  Abnormalities  of.) 

PARALYSIS  OF  BOTH  LEGS.— (See  Paraplegia.) 

PARALYSIS  OF  ONE  EXTREMITY  (LOWER).  — The  diagnosis  of  those 
morbid  conditions  in  which  paralysis  of  both  legs  occurs  is  dealt  with  under 
Paraplegia  ;  the  present  article  only  refers  to  cases  in  which  paralj^sis 
of  one  leg  is  complained  of.  It  is,  however,  a  common  experience  for  the 
clinician  to  find  signs  pointing  to  a  bilateral  affection  when  the  patient  is 
only  aware  of  disability  affecting  one  lower  extremity.  A  notable  and  cominon 
example  of  this  is  afforded  by  many  cases  of  disseminated  sclerosis.  The  patient 
complains  of  weakness  in  one  leg,  and  the  physician  finds  exaggeration  of  both 
knee-jerks  as  well  as  extensor  plantar  responses  on  both  sides,  and  is  led  to  the 
conclusion  that  both  pyramidal  tracts  are  affected,  although  one  may  be  damaged 
more  severely  than  the  other. 

The  various  types  of  crural  monoplegia  may  be  divided  roughly  into  two 
classes,  one  of  which  includes  those  cases  without  muscular  atrophy,  and  the 
other  those  which  present  greater  or  less  degrees  of  muscular  wasting. 

Paralysis  of  One  Leg  without  Muscular  Atrophy — The  cases  in  this  class  may  be 
sub-divided  into  two  groups, the  first  comprising  those  in  which  the  pyramidal  tract 
is  affected,  and  the  second  those  in  which  there  is  no  evidence  of  pyramidal  affection. 

Spastic  paralysis  of  one  leg  may  result  from  a  lesion  of  the  pyramidal  tract 
in  any  part  of  its  course,  but  for  anatomical  reasons  it  is  more  likely  that  the 
paralysis  will  be  confined  to  one  side  when  a  lesion  affects  the  opposite  cerebral 
hemisphere  above  the  pons,  that  is  to  say,  above  the  level  at  which  the  two 
pyramidal  tracts  run  in  close  proximity.  Spastic  paralysis  of  one  leg  may, 
however,  result  from  a  lesion  at  any  level,  and  the  diagnosis  of  the  level  must 
be  made  from  a  consideration  of  other  symptoms.  In  all  cases  the  condition  of 
the  leg  is  qualitatively,  if  not  quantitatively,  the  same.  A  spastic  leg  is  charac- 
terized by  a  certain  amount  of  weakness,  a  certain  amount  of  rigidity,  by  an 
exaggeration  of  the  knee-  and  ankle- jerks,  and  by  the  presence  of  the  extensor 
type  of  plantar  response.  It  is  useful  to  remember  that  the  weakness  in  a  spastic 
leg  does  not  affect  all  the  movements  to  the  same  extent.  If  the  movements 
at  the  various  joints  are  tested  against  the  observer's  resistance,  it  will  generally 


540 


PARALYSIS     OF     ONE     LOWER     EXTREMITY 


be  found  that  dorsifiexion  of  the  ankle  and  flexion  of  the  knee  are  more  profoundly 
affected  than  other  movements.  It  is  for  this  reason  that  the  patient  tends 
to  drag  his  toes  more  on  the  affected  side  than  on  the  other,  and  evidence  of 
this  is  often  forthcoming  in  the  fact  that  he  tends  to  wear  away  the  toes  of  his 
boot.  The  muscles  of  a  spastic  leg  show  no  localized  wasting,  and  present  no 
alteration  from  the  normal  in  their  response  to  electrical  stimulation. 

In  the  attempt  to  diagnose  the  level  of  the  lesion  which  gives  rise  to  spastic 
paralysis  of  one  leg,  certain  considerations  are  of  particular  importance.  If 
the  lesion  is  situated  immediately  above  the  lumbar  enlargement  of  the  cord, 
the  abdominal  reflexes  can  be  obtained.  If  the  lesion  is  situated  at  the  level 
of  the  loth  dorsal  segment,  the  lower  abdominal  reflex  on  that  side  will  be  absent, 
while  the  epigastric  reflex  remains  intact.  A  lesion  of  any  of  the  upper  dorsal 
segments  causes  abolition  of  all  abdominal  reflexes  on  the  corresponding  side. 
A  lesion  above  the  cervical  enlargement  will  lead  probably  to  some,  even  if 
slight,  weakness  in  the  corresponding  upper  extremity,  in  which  the  tendon- 
jerks  will  be  found  exaggerated.  In  the  same  way,  a  lesion  of  the  higher  part  of 
the  pons  or  of  any  level  between  the  pons  and  the  cerebral  cortex  will  produce 
some  asymmetry  in  the  facial  movements  as  well  as  weakness  in  the  arm  and  leg. 

Disseminated  sclerosis  has  been  mentioned  already  as  a  disease  in  which 
spastic  paralysis  of  one  leg  may  result  from  a  lesion  situated  in  the  spinal  cord. 
In  all  probability  evidence  of  other  patches  of  disease  will  be  discovered  in  such 
cases  if  a  careful  examination  is  made.  Some  intention  tremor  in  one  or  both 
hands,  nystagmus,  diplopia,  optic  atrophy,  and  sphincter  troubles  are  among 
the  signs  which  may  be  forthcoming.  Less  commonly,  a  one-sided  affection  of 
the  spinal  cord  above  the  lumbo-sacral  enlargement  is  due  either  to  some  intra- 
medullary disease,  such  as  a  patch  of  myelitis,  a  gumma,  or  a  new  growth.  When 
this  occurs  there  may  arise  a  symptom-complex  to  which  the  term  Brown- 
Sequard  paralysis  is  applied.  In  this  condition  there  is  spastic  paralysis  of  the 
leg  on  the  same  side  as  the  lesion,  together  with  loss  of  sensibility,  especially 
of  thermal  and  painful  sensibility,  in  the  opposite  leg.  The  physical  signs  in 
Brown- Sequard  paralysis  are  represented  in  greater  detail  in  the  accompanjdng 
diagram :  — 

Zone  of  HvperfEsthesia 


J        1       f  Atrophic  Paralysis 

vff    U     '  Painful  and  Thermal  Loss 

£.necis     (^  j^^gg  ^^  ^jj  Rgflexes 


Not 


Spastic  Paralysis 

(  Loss  of  sense  of  passive  posi- 
tion and  movement 


„    ons  an    ( j^^^^  ^^  tactile  discrimination 
> 

}  Diminished  skin  reflexes 

i 

3  Increased  tendon  reflexes 

i  Ankle -clonus 

Extensor  plantar  reflex 

Fi£:  742. — Diagrammatic  representation  of  the  results  of  a  one-sided  lesion  of  the  spinal  cord- 
Brown-.Sequard  Paralysis. 


No  Local  Effects 


(4  to  6  normal  segmental  areas) 

No  paralysis 

Loss  of  sensibility  to  painful  and  thermal 

stimuli 
Loss  of  tactile  and  pressure   I  uncommon 

sensibility  and  localization  > 

Normal  skin  reflexes 
Normal  tendon  reflexes 
No  clonus 
Flexor  plantar  reflex 


PARALYSIS     OF     ONE     LOWER     EXTREMITY  541 

Hysterical  paralysis  of  one  leg  usually  does  not  afford  much  difficulty  in  dia- 
gnosis. The  affected  limb  may  be  either  rigid  or  flaccid  ;  in  either  case  there  is 
no  true  muscular  atrophy  and  no  alteration  in  the  muscular  response  to  electrical 
stimulation.  The  condition  of  the  reflexes  provides  the  most  important  informa- 
tion. In  the  hysterical  form  of  paralysis  the  knee-  and  ankle- jerks  may  be 
exaggerated,  but  they  are  never  lost.  A  true  ankle-clonus  is  never  obtained, 
and  the  plantar  reflex  is  either  absent  or  of  the  flexor  type.  As  a  general  rule 
the  tendon  reflexes  in  the  opposite  unaffected  limb  will  be  found  to  be  equally 
brisk.  In  contradistinction  to  spastic  paralysis  resulting  from  a  pyramidal 
lesion,  in  which  it  has  already  been  pointed  out  that  dorsiflexion  of  the  ankle 
and  flexion  of  the  knee  are  the  movements  most  profoundly  affected,  the  move- 
ments of  the  leg  in  a  case  of  hysterical  paralysis  are  found  to  be  more  or  less 
equally  deficient  at  all  joints  and  in  all  directions.  Certain  attitudes  and  certain 
types  of  gait  are  almost  characteristic  of  hysterical  paralysis  of  one  leg.  In 
one  form  the  whole  leg  is  kept  rigidly  extended,  and  the  foot  strongly  inverted, 
so  that  the  patient  walks  on  the  outer  plantar  edge  with  a  stiff  leg.  In  another 
form,  the  leg  is  flaccid  and  is  dragged  behind  the  opposite  limb  with  the  toes 
scraping  the  floor.  In  some  cases,  examination  of  the  Umb  when  the  patient  is 
at  rest  in  bed  reveals  little  or  no  paralysis,  but  in  the  attempt  to  stand  or  walk 
the  limb  appears  to  be  quite  useless.  Hysterical  paralj^sis  of  a  leg  may  of  course 
be  associated  with  similar  palsies  of  the  opposite  leg,  or  of  the  arm  on  the  same 
side  (hysterical  paraplegia,  hysterical  hemiplegia).  More  otten  than  not  a  leg- 
which  is  the  seat  of  hysterical  paralysis  also  presents  complete  insensibihty  to 
all  forms  of  stimulation,  and  the  upper  limit  of  such  anaesthesia  may  correspond 
with  the  line  of  the  groin  or  the  level  of  the  umbilicus. 

In  the  early  stages  of  paralysis  agitans  a  patient  may  complain  of  loss  of  power 
in  one  leg,  and  the  diagnosis  of  this  condition  may  present  considerable  difficulty 
if  the  characteristic  tremor  of  this  disease  has  not  made  its  appearance.  An 
examination  of  the  limb  may  show  little  that  is  abnormal.  Some  sHght  paresis 
and  some  slight  stiffness  in  response  to  passive  movements  may  be  detected, 
but  no  alteration  in  the  character  of  the  reflexes  will  be  observed.  The  diagnosis 
must  depend  more  upon  the  general  aspect  and  the  attitude  and  gait  of  the 
patient.  Some  loss  of  facial  expression,  the  general  slowness  of  his  movements, 
and  the  tendency  to  shuffle  with  the  affected  leg,  are  points  which  may  lead  the 
observer  to  form  a  correct  opinion. 

Paralysis  of  One  Leg  with  Muscular  Atrophy. — In  any  case  which  presents 
tlie  signs  of  atrophic  palsy  of  one  leg,  the  first  essential  point  for  making  a 
diagnosis  is  to  ascertain  the  exact  distribution  of  the  atrophied  muscles,  and  to 
review  this  distribution  in  the  light  of  what  we  know  with  regard  to  the  central 
and  peripheral  innervation  of  the  muscles  of  the  lower  hmb.  The  reader's 
memory  on  this  point  can  be  refreshed  by  reference  to  the  table  on  p.  542. 

Single  nerve  palsies  in  the  lower  extremity  are  not  so  common  as  similar 
affections  in  the  upper  extremity,  but  they  may  occur,  especially  as  the  result 
of  injury.  Isolated  paralysis  of  the  anterior  crural  nerve  and  of  the  obturator 
nerve  are  quite  uncommon,  and  when  they  do  occur  are  generally  the  result  of 
compression  of  the  nerve  within  the  abdominal  cavity,  either  by  growths  or 
during  the  act  of  parturition.  In  affections  of  the  anterior  crural  nerve,  the 
movements  of  flexion  of  the  thigh  on  the  trunk  and  extension  of  the  leg  upon  the 
thigh  may  both  be  impaired  or  lost.  Wasting  of  the  anterior  thigh  muscles, 
and  diminution  or  loss  of  the  knee-jerk,  are  other  obvious  signs  of  this  condition. 
When  the  obturator  nerve  is  injured,  the  patient  can  flex  his  hip  but  cannot 
adduct  the  thigh,  and  so,  when  sitting,  he  can  raise  his  knee  but  cannot  throw  it 
across  the  other  leg.  He  can  walk  about  with  no  obvious  disturbance  of  gait,  but 
he  cannot  rotate  the  thigh  either  outwards  or  inwards,  with  any  degree  of  force. 


542 


PARALYSIS     OF     ONE    LOWER     EXTREMITY 


Table  showing  the  Muscles  to  which  the  various  Nerves  of  the  Lumbar  and 
Sacral    Plexuses  are  distributed. 

Nerve.  Muscle. 


Obturator 

(L.   2,   3,   4) 


Anterior  crural 
(L.   2,   3,   4) 

Sciatic  nerve 

(L.  4,   5,  S.   I,   2, 


External  popliteal 

(L.  4,   5,  S.   I,   2) 


Internal  popliteal 
(L.  4,  5,  S.   I, 


Internal  plantar 


External  plantar 


Nerve  of  the  quadratus  femoris 
(L.  5,  S.   I) 

Nerve  of  the  obturator  internus 
(L.  5,  S.   I,   2) 

Nerve  of  the  pyriformis 

Superior  gluteal  nerve 
(L.  4,  5,  S.   I,   2) 

Inferior  gluteal  nerve 
(L.  5,  S.   I,  2) 


Adductor  longus 
I  Gracilis 

-  Adductor  brevis 
I  Obturator  externus 
■  Adductor  magnus 
riliacus 
J  Pectineus 
j  Sartorius 

I  Quadriceps  extensor 
i  Semitendinosus 
\  Biceps 

1^  Semimembranosus 
/Tibialis  anticus 

Extensor  proprius  hallucis 
I  Extensor  longus  digitorum 
-<i  Peroneus  tertius 
I  Extensor  brevis  digitorum 

Peroneus  longus 
\  Peroneus  brevis 
'  Gastrocnemius 

Plantaris 

Soleus 
-  Popliteus 

Tibialis  posticus 

Flexor  longus  digitorum 
\  Flexor  longus  hallucis 
I  Flexor  brevis  hallucis 
J  Abductor  hallucis 
j  Flexor  brevis  digitorum 
list  lumbrical 
/  Accessorius 
■    Abductor  minimi  digiti 
I  Flexor  brevis  minimi  digiti 

Interossei 

Adductor  obliquus  hallucis 

Adductor  transversus  hallucis 

Outer  3  lumbricals 

f  Quadratus  femoris 
t  Gemellus  inferior 

/Obturator  internus 
t  Gemellus  superior 

Pyriformis 

r  Gluteus  medius 
-!  Gluteus  minimus 
iTensor  vaginae  femoris 

Gluteus  maximus 


Paralysis  of  the  main  trunk  of  the  sciatic  nerve,  which  would  include  paralysis 
of  all  the  muscles  supplied  by  the  internal  and  external  popliteal  nerves  as  well, 
points  to  some  form  of  disease  or  injury  affecting  the  pelvis.  It  may  be  brought 
about  by  a  fracture  of  the  pelvis  or  of  the  upper  end  of  the  femur,  or  by  injuries 
to  the  hip  joint ;  on  the  other  hand,  the  sciatic  nerve  may  be  compressed  by 
tumours  or  inflammatory  masses  within  the  pelvis.  The  result  of  such  an 
extensive  palsy  has  a  considerable  effect  on  the  patient's  gait,  as  he  is  unable 
to  flex  the  knee,  and  consequently  has  to  use  the  leg  as  a  stiff,  extended  support. 
Moreover,  the  disability  is  increased  by  the  complete  absence  of  all  movements 
at  the  ankle  joint.     The  sensory  loss  in  such  a  condition  includes  the  outer  side 


PARALYSIS     OF     ONE     LOWER     EXTREMITY  543 

of  the  leg  and  the  whole  of  the  foot,  except  a  small  area  on  its  inner  and  upper 
aspect. 

Palsy  of  the  external  popliteal  nerve  is  certain!}-  the  most  common  isolated 
nerve  palsy  in  the  lower  extremity.  Not  only  is  it  particularly  exposed  to 
injury  in  its  course  through  the  popliteal  space,  and  as  it  winds  round  the  fibula, 
but  a  primary  neuritis  of  it  is  by  no  means  uncommon,  especially  in  cases  of 
diabetes  mellitus  and  lead  poisoning.  Isolated  paralysis  of  the  external  popliteal 
nerve  has  been  observed  frequently  in  cases  of  tabes  dorsalis.  The  most  obvious 
result  of  this  form  of  paralysis  is  the  dropped  foot  to  which  it  gives  rise,  and  the 
high-stepping  gait,  which  is  necessary  if  the  patient  is  to  clear  the  ground  with 
his  toes. 

Injury  to  the  internal  popliteal  nerve  is  very  much  less  common,  but  of  course 
it  ma}''  be  involved  by  tumours  or  the  products  of  inflammation  in  the  upper  part 
of  the  leg.  Paralysis  of  the  calf  muscles  is  the  chief  consequence,  preventing 
the  patient  from  extending  his  foot  and  standing  on  tip-toe,  or  from  making 
any  kind  of  springing  movement  in  the  attempt  to  walk  or  run.  The  paralysis 
of  the  interossei  and  the  unopposed  contraction  of  the  long  extensors  may  lead 
to  the  production  of  Claw- foot  {q-v.). 

Table  showing  the  Muscles  Innervated  by  the  different  Roots  of  the 
Lumbar  and   Sacral   Plexuses.* 

L.  I,  2.  Iliopsoas.  Quadratus  lumbormn.  Sartorius.  Cremaster.  Quadri- 
ceps. 

L.  3.  Quadriceps.  Sartorius.  Quadratus  lumborum.  Adductores  femoris. 
Obturator  externus. 

L.  4.  Adductores  femoris.  Quadriceps.  Sartorius.  Tensor  fascia? 
femoris.  Tibialis  anticus.  Extensor  communis.  Extensor 
hallucis. 

L.  5.  Tibialis  anticus.  Extensor  communis  digitorum.  Extensor  hallucis. 
Peronei.  Abductprs  and  external  rotators  of  the  hip. 
Gastrocnemii.       Long  flexors  of  the  toes.     Hamstrings.      Glutei. 

S.  I.  Gastrocnemii.  Hamstrings.  Long  flexors  of  the  toes.  Peronei.  Ab- 
ductors and  external  rotators  of  the  hip.     Glutei. 

S.  2.  Glutei.  Intrinsic  muscles  of  the  foot.  Gastrocnemii.  Hamstrings. 
Long  flexors  of  the  toes. 

S.  3,  5.   The  musculature  of  the  perineum  connected  with  defcecation,  micturition, 
etc. 
~  The  muscles  which  afford  the  most  useful  landmarks  are  printed  in  italics. 

In  addition  to  these  peripheral  nerve  palsies  of  the  lower  limb,  we  have  to 
take  into  consideration  those  forms  of  paralysis  which  are  due  to  lesions  of  the 
roots  leaving  the  lumbo-sacral  region  of  the  cord,  and  other  forms  resulting 
from  disease  of  that  part  of  the  spinal  cord  itself  (see  table  above)  :  atrophic 
palsy  of  one  leg  is  not  commonly  the  result  of  spinal  caries,  although  this  may 
occur  when  the  caries  affects  the  lower  lumbar  or  sacral  region.  On  the  other 
hand,  paralysis  of  one  leg,  generally  associated  mth  acute  pain  of  root  distri- 
bution, is  not  a  very  rare  early  symptom  of  malignant  disease  of  the  lower  part 
of  the  vertebral  column.  In  the  absence  of  any  obvious  deformity,  the  diagnosis 
in  such  cases  is  often  difficult,  and  much  may  depend  on  the  use  of  skiagraphy. 
In  some  cases  a  good  deal  may  be  learnt  from  observing  loss  of  the  natural 
spinal  lumbar  curve,  and  from  a  suggestion  of  shortening  in  the  stature  of  the 
patient,  and  particularly  by  noticing  the  diminished  interval  between  the  lower 
ribs  and  the  iliac  crests.  These  are  signs  of  collapse  on  the  part  of  the  softened 
vertebrae,  and  constitute  a  condition  to  which  the  name  "  entassement  "  is 
sometimes  apphed. 

Syphilitic  meningitis,  involving  the  roots  of  the  lumbo-sacral  cord,  is  another 
not  very  uncommon  source  of  crural  monoplegia.     The  diagnosis  depends  upon 


544 


PARALYSIS     OF     ONE    LOWER     EXTREMITY 


the  history  of  syphihs,  a  positive  Wassermaiin  serum  reaction,  the  results  of  an 
examination  of  the  cerebrospinal  fluid,  and  the  fact  that  both  the  motor  palsy 
and  the  sensory  loss  follow  a  root  distribution. 

Probably  more  common  than  any  other  cause  for  atrophic  paralysis  of  one 
leg  is  the  disease  known  as  acute  poliomyelitis.  The  history  of  an  acute  onset 
with  constitutional  disturbances  of  more  or  less  severity,  and  the  absence  of  any 
sensory  loss  or  of  any  permanent  affection  of  the  sphincters,  are  important  points 
in  the  diagnosis.  It  is  well  to  remember,  too,  that  the  paralysis  in  these  cases 
is  generally  more  widespread  during  the  early  days  of  the  disease  than  the 
permanent  results  suggest.     Consequently,  it  is  not  unusual  to  hear  that,  in  a 


i^Vj,'.  143.— Diagram  to  illustrate  the  lumbo-sacral  plexus  and  its  branches  (a/U?-  Kochcr). 

case  where  there  is  permanent  atrophic  palsy  of  one  leg  {infantile  paralysis), 
the  onset  of  the  trouble  was  characterized  by  a  paraplegia  or  palsy  of  both  legs. 
Tumours  of  the  spinal  cord  and  syringomyelia  are  very  much  rarer  causes  of 
this  paralysis  of  the  lower  extremity,  although  the  possibility  of  their  occurrence 
may  sometimes  need  to  be  taken  into  consideration.  Various  forms  of  pro- 
gressive muscular  atrophy,  either  of  spinal  or  primary  muscular  origin,  are  more 
important  causes  of  Paraplegia  {q.v.)  than  of  unilateral  paralysis.  As  a  general 
rule  they  are  symmetrical,  or  approximately  symmetrical,  in  their  onset  and 
progress,  but  every  now  and  then  one  may  meet  with  cases  in  their  earUest 
stage,  when  the  complaint  of  the  patient  is  referred  to  one  limb  only.  A  good 
example  of  such  an  occurrence  is  afforded  by  the  case  of  a  lad  who  was  brought 
to  me  on  account  of  some  weakness   in   one  foot  which   had   appeared  quite 


PARALYSIS     OF     THE     UPPER     EXTREMITY  545 

insidiously  and  was  tending  to  progress.  Examination  of  the  affected  limb 
showed  atrophic  palsy  of  the  long  extensors  of  the  toes  and  of  the  peroneal 
muscles.  The  diagnosis  of  peroneal  muscular  atrophy  was  confirmed  by  the 
appearance  of  similar  physical  signs  in  the  other  leg  some  months  later.  In 
addition  to  their  earh'  symmetrical  distribution,  these  progressive  degenerative 
diseases  can  be  distinguished  from  gross  diseases  of  the  spinal  cord  and  its 
env'elopments  by  the  absence  of  pain  in  the  course  of  their  evolution. 

E.   Farquhar  Buzzard. 

PARALYSIS  OF  THE  EXTREMITY  (UPPER).— This  title,  if  interpreted 
strictly,  would  refer  only  to  those  conditions  under  which  the  power  to  move 
the  whole  or  any  part  of  the  upper  limb  is  completely  lost.  The  word 
"  paralysis,"  however,  has  come,  by  general  use,  to  include  less  complete  palsies, 
and,  in  fact,  to  embrace  all  varieties  of  impaired  voluntary  movement.  It  is 
in  this  sense  that  the  word  will  be  used  for  the  purpose  of  this  article.  No  other 
interpretation  would  be  of  value  in  discussing  diagnosis,  because  the  latter  nearly 
always  depends,  not  upon  the  degree  of  paralysis,  but  upon  its  nature,  distribu- 
tion, and  associated  phenomena.  ^Moreover,  it  is  often  the  case  that  accurate 
diagnosis  is  most  difficult,  although  perhaps  more  important  from  the  point  of 
view  of  successful  treatment,  when  the  limitation  of  voluntary  movement  is 
only  of  slight  degree. 

Before  entering  upon  a  discussion  of  the  various  forms  of  paralysis  met  with 
in  the  upper  extremity,  some  reference  must  be  made  to  a  few  practical  points 
which  are  important  in  the  proper  investigation  of  cases  complaining  of  inability 
to  use  an  arm. 

The  medical  man  must  not  be  satisfied  with  the  patient's  statenrent  that  he 
has  lost  power  or  that  he  is  weak  in  his  limbs.  Tests  must  be  employed  in  order 
to  ascertain  whether  this  is  really  the  case.  The  movements  at  each  joint, 
of  flexion,  extension,  pronation,  supination,  must  be  investigated,  and  if 
necessary  their  power  measured  against  the  observer's  resistance.  It  may  be 
found  that  the  grasp  is  powerful  in  a  patient  who  is  unable  to  use  his  hand  on 
account  of  loss  of  control  over  the  finger  movements.  In  such  a  case  there  is 
not  parah^sis,  but  inco -ordination  or  ataxy  (see  Ataxy).  Similarly,  there  is 
certain  to  be  difficulty  in  carrying  out  delicate  movements  if  there  is  loss  of 
cutaneous  sensibility.  Without  tactile  sense  it  is  impossible  to  handle  a  pen 
in  a  proper  manner.  Sometimes  a  patient  will  complain  of  loss  of  power,  when 
investigation  shows  that  the  ability  to  execute  movements  is  inhibited  by  the 
pain  in  a  muscle  or  joint  evoked  by  the  attempt.  In  other  instances,  mechanical 
limitation  of  movement  by  arthritic  changes,  without  pain,  may  lead  the  patient 
to  believe  that  there  is  loss  of  power.  He  finds  he  cannot  lift  his  arm,  and 
ascribes  the  disability  to  paralysis  instead  of  to  ankylosis  of  the  shoulder  joint. 
On  the  other  hand,  it  must  be  remembered  that  pain  and  loss  of  power  may  be 
associated  in  some  forms  of  neuritis.  If  the  patient  says,  "  My  arm  is  so  painful 
that  I  cannot  lift  it,"  examination  must  be  directed  to  ascertain  whether  the 
inabilit}^  is  due  only  to  painful  inhibition  or  to  real  paralysis  in  addition. 

Stress  must  be  laid  upon  the  necessity  for  obtaining  a  careful  history,  and 
especially  an  accurate  account  of  the  duration  of  the  trouble,  whether  its  onset 
was  sudden,  rapid,  or  slow  and  progressive,  and  whether  the  loss  of  power  was 
accompanied  or  preceded  by  pain,  numbness,  or  tingling.  The  family  and 
previous  history  must  not  be  neglected.  In  examining  the  paralj^zed  arm,  care 
should  be  taken  that  the  whole  of  both  upper  limbs,  as  well  as  the  neck,  upper 
part  of  thorax,  and  shoulders  are  stripped,  so  as  to  be  inspected  easily  and  the 
two  sides  compared.  It  will  also  be  necessary,  in  the  large  majority  of  instances, 
to  investigate  the  functions  of  the  cranial  nerves  and  the  reflexes,  etc.,  of  the 
trunk  and  lower  extremities.  This  is  often  imperative  even  when  no  complaint 
D  35 


546  PARALYSIS     OF     THE     UPPER     EXTREMITY 

is  made  of  loss  of  power  or  other  symptoms  in  any  part  of  the  body  except  one 
upper  limb.  The  importance  of  this  full  examination  is  perhaps  obvious,  but 
it  may  be  illustrated  by  reference  to  two  points.  A  lesion  of  one  internal  capsule 
may  give  rise  to  paralysis  of  the  opposite  arm,  but  it  will  be  likely  to  cause,  in 
addition,  some  alteration  in  the  abdominal  and  leg  reflexes  of  the  corresponding 
side.  Similarly,  a  lesion  of  the  8th  cervical  or  ist  dorsal  spinal  segments,  or  of 
their  corresponding  spinal  roots,  will  also  affect  the  fibres  leaving  the  cord  at 
that  level  and  passing,  via  the  cervical  sympathetic,  to  the  eye  of  the  same  side. 
In  this  way  atrophic  paralysis  of  the  muscles  of  one  hand  may  be  associated 
with  a  small  pupil  and  a  small  palpebral  fissure  on  the  same  side,  a  coincidence 
which  at  once  points  to  the  cord  or  roots  as  the  site  of  the  lesion,  and  acquits 
the  peripheral  nerves  of  being  concerned  in  the  production  of  the  palsy.  In 
such  a  case  the  further  investigation  of  the  abdominal  refiexes,  the  knee-jerks, 
and  plantar  responses,  will  help  to  decide  whether  the  lesion  is  intramedullary 
or  extramedullary  ;  in  the  former  event  the  abdominal  reflex  on  the  same  side 
would  be  absent,  the  knee-jerk  would  be  increased,  and  the  plantar  response 
would  be  of  the  extensor  type,  while  in  the  latter,  unless  the  lesion  exerted  con- 
siderable pressure  on  the  cord,  the  reflexes  below  the  arm  would  be  normal. 

Any  attempt  to  enumerate,  let  alone  discuss,  all  the  possible  lesions  which 
can  give  rise  to  paralysis  in  the  upper  extremity,  is  out  of  the  question,  and  we 
must  be  content  to  consider  the  broad  principles  of  diagnosis  in  connection  with 
the  more  familiar  instances  of  brachial  palsy.  For  this  purpose  a  classification 
based  chiefly  on  the  presence  or  absence  of  muscular  atrophy  will  be  adopted. 
This  will  be  of  practical  use  because  the  mere  inspection  of  a  paralyzed  limb 
generally  enables  the  observer  to  detect  whether  a  case  belongs  to  the  one 
category  or  the  other. 

Paralysis  without  Muscular  Atrophy. 

This  heading  embraces  cases  in  which  there  may  be  general  impairment  of 
nutrition,  and  perhaps  muscular  wasting,  due  to  disuse,  but  in  which  there  is  no 
localized  muscular  atrophy  and  no  alteration  in  the  response  of  the  muscles  to 
electrical  stimulation.  The  cases  may  be  divided  into  two  groups  :  (i)  Those 
in  which  there  is  some  affection  of  the  upper  motor  neuronic  system  (pyramidal 
lesions),  and  (2)   Cases  without  lesion  of  the  pyramidal  tract. 

I.  Paralysis  due  to  Pyramidal  Tract  Lesions. — The  most  familiar  example 
of  this  group  is  afforded  by  cases  of  brachial  naonoplegia  due  to  a  vascular 
lesion  {thrombosis,  hceniorrhage,  or  embolism)  in  the  internal  capsule  or  other 
part  of  the  pyramidal  tract  in  its  course  through  the  brain.  In  the  dia- 
gnosis of  this  condition  the  points  of  importance  are  :  The  presence  of  some 
cardiovascular  condition  capable  of  producing  the  lesion,  such  as  disease  of 
the  heart,  kidneys,  or  arteries ;  the  sudden  or  rapid  onset  of  the  symptoms,  with 
or  without  loss  of  consciousness  or  other  cerebral  disturbance.  The  arm  retains 
its  natural  contours,  and  the  muscles  are  not  atrophied,  although  they  may 
appear,  after  some  time  has  elapsed,  to  be  smaller  than  those  of  the  other  arm. 
The  paralysis  may  aftect  the  whole  limb  and  include  inability  to  shrug  the 
shoulder ;  or  the  movements  of  the  hand  and  fingers  may  be  more  impaired  than 
those  of  the  elbow  and  shoulder.  There  is  a  tendency  for  the  arm  to  exhibit 
more  and  more  resistance  to  passive  movement,  that  is  to  say,  to  develop 
spasticity.  At  the  same  time,  if  left  to  itself,  the  limb  will  adopt  a  fixed  position, 
which  includes  adduction  of  the  upper  arm  to  the  trunk,  flexion  and  pronation 
of  the  forearm,  and  flexion  of  the  wrist  and  fingers.  If  any  movements  are 
possible,  they  will  be  those  of  flexion  rather  than  of  extension  at  the  various 
joints.  The  muscle  tone  is  increased,  and  the  tendon-jerks,  such  as  the  biceps 
and  supinator  jerks,  are  exaggerated  when  compared  with  those  of  the  opposite 


PARALYSIS     OF     THE     UPPER     EXTREMITY  547 

limb.  Eventually  contractures  may  develop,  and  it  will  be  found  impossible 
to  extend  the  upper  arm,  forearm,  hand,  and  fingers  into  one  straight  line. 

Such  is  the  clinical  picture  afforded  by  spastic  paralysis  of  the  arm,  and  one 
case  will  differ  from  another  only  in  the  degree  of  spasm  and  the  degree  of 
paralysis  ;  but  the  amount  of  spasticity  and  the  paresis  do  not  always  correspond. 
In  one  patient  the  rigidity  forms  the  chief  obstacle  to  voluntary  movement  ; 
in  another  the  arm,  though  powerless,  shows  comparatively  little  increase  in  tone. 

The  fact  that  the  pyramidal  fibres  destined  for  the  face,  trunk,  and  leg  run  in 
close  proximity  to  those  for  the  arm,  is  sufficient  reason  for  suspecting  that,  even 
if  no  other  paralysis  is  complained  of,  there  may  be  signs  of  disturbed  function 
to  be  found  in  other  parts.  The  side  of  the  face  corresponding  to  the  paralyzed 
arm  may  not  move  so  quickly  or  so  powerfully  as  the  other  side  in  a  voluntary 
effort  to  show  the  teeth,  although  no  difference  may  be  detected  when  the  patient 
smiles.  The  corresponding  abdominal  reflexes  may  be  found  wanting.  The 
knee-jerk  may  be  increased  ;  ankle-clonus  and  an  extensor  plantar  response 
may  be  elicited  ;    all  on  the  same  side. 

This  spastic  arm,  in  all  degrees  of  severity,  may  result  n,ot  only  from  a  vascular 
lesion  in  the  brain,  but  also  from  a  cevebfal  abscess,  a  cerebral  tumour,  or  cerebral 
inflammation  (encephalitis).  The  arm  will  present  identical  features,  so  that  the 
diagnosis  must  be  made  from  a  consideration  of  other  data.  Thus  a  cerebral 
abscess  only  becomes  likely  when  there  is  some  infective  process  either  in  the 
bones  of  the  skull  (mastoid  or  frontal  sinus  disease)  or  in  a  distant  part  such  as 
the  heart  or  lungs  (ulcerative  endocarditis  or  bronchiectasis).  Headache, 
vomiting,  and  optic  neuritis,  with  a  slow  pulse,  slow  respiration,  and  subnormal 
temperature  may  help  in  the  diagnosis.  In  cases  of  cerebral  tumour  the  develop- 
ment of  the  brachial  palsy  is  nearly  always  slow  and  progressive,  spreading  from 
one  part  of  the  limb  to  another,  and  again  there  may  be  headache,  vomiting, 
and  optic  neuritis.  It  should  be  remembered,  however,  that  these  signs  of 
increased  intracranial  pressure  are  not  always  present,  and  that  the  presence 
of  a  tumour  may  always  be  suspected  when  a  spastic  paralysis  of  one  limb  comes 
on  in  a  slow  and  progressive  manner.  Some  tumours  grow  at  the  expense  of 
neighbouring  tissues  in  such  a  way  that  pressure  is  raised  but  little  or  not  at 
all.  Encephalitis  will  need  to  be  considered  when  there  is  a  history  of  acute 
constitutional  disturbance  with  fever,  vomiting,  headache,  and  perhaps  convul- 
sions preceding  or  attending  the  onset  of  the  paralysis.  The  latter,  however, 
is  not  progressive.  It  reaches  its  maximum  within  a  few  hours,  and  shows  a 
general  tendency  to  improve  after  the  acute  symptoms  have  passed  off. 

Disseminated  sclerosis  is  another  disease  in  which  a  spastic  monoplegia  of  the 
arm  is  not  uncommon.  The  diagnosis  is  easy  if  it  occurs  as  a  late  manifestation 
in  the  disease,  when  nystagmus,  optic  atrophy,  spastic  paraplegia,  and  sphincter 
trouble  are  already  present,  or  if  there  is  a  history  of  previous  transient  palsies 
affecting  other  limbs.  When,  however,  paralysis  of  one  arm  is  the  first  symptom 
of  the  disease,  as  it  may  be,  the  diagnosis  may  present  difficulties.  The  rapid 
onset  of  the  palsy  in  a  healthy  young  adult  without  constitutional  disturbance, 
severe  headache,  or  vomiting,  and  perhaps  the  discovery  of  absent  abdominal 
reflexes  and  an  extensor  plantar  response,  should  direct  suspicion  to  the  possi- 
bility of  a  patch  of  disseminated  sclerosis  being  responsible  for  the  trouble. 

Diseases  of  the  pons,  medulla,  and  that  part  of  the  spinal  cord  which  lies  above 
the  cervical  enlargement,  whether  of  vascular,  inflammatory,  or  neoplastic  origin, 
may  cause  spastic  palsy  of  the  upper  limb,  but  it  is  rarely  a  monoplegia.  The 
arm  and  leg  on  one  side  or  both  arms  and  both  legs  (double  hemiplegia)  are 
much  more  likely  to  be  involved  simultaneously,  and  the  site  of  the  lesion  is 
inferred  from  the  knowledge  that  the  two  pyramidal  tracts  are  in  close  proximity 
in  those  regions. 


54S  PARALYSIS     OF     THE     UPPER     EXTREMITY 

2.  Paralysis  without  Lesions  of  the  Pyramidal  Tract. — It  has  not  been, 
uncommon,  in  the  writer's  experience,  for  a  patient  in  the  earhest  stage  of 
paralysis  agitans  to  complain  of  loss  of  power  in  one  arm.  This  has  sometinaes 
led  to  a  wrong  diagnosis,  the  trouble  being  described  vaguely  as  due  to  neuritis, 
or  even  regarded  as  hysterical.  This  mistake  will  be  avoided  if  notice  is  taken 
of  the  fact  that  the  limb  is  not  only  weaker  than  its  fellow,  but  that  it  is  somewhat 
stiff  and  conspicuously  slow  in  carrying  out  movements.  A  lack  of  expression 
in  the  face,  or  tendency  to  carry  the  arm  in  a  flexed  position  across  the  trunk, 
and  perhaps  some  hesitancy  in  the  gait,  should  guide  the  observer  to  a  correct 
diagnosis  even  if  tremor  is  absent,  as  it  often  is  at  this  stage  of  the  maladj^  It 
must  be  remembered  that  this  form  of  paralysis  is  unattended  by  changes  in 
the  reflexes. 

Children  suffering  from  chorea,  and  especially  hemichorea,  are  often  brought 
to  a  doctor  with  the  mother's  complaint  that  he  or  she  has  lost  the  use  of  an  arm. 
Examination  will  show  that  there  is  really  some  weakness  of  the  affected  limb, 
which  is  demonstrated,  not  so  much  by  the  poorness  of  the  grasp,  as  by  the  fact 
that  the  child  is  unable  to  maintain  a  steady  pressure.  He  will  grasp  the 
observer's  fingers,  but  quickly  release  the  pressure,  although  urged  to  continue 
the  squeeze.  In  the  same  way,  when  asked  to  put  out  his  tongue  he  will  do  so, 
but  withdraw  it  at  once.  When  required  to  extend  his  arm  in  front  of  him 
with  the  palm  of  the  hand  facing  downwards,  it  will  generally  be  noticed  that 
the  wrist  is  slightly  flexed  although  the  fingers  are  extended.  These  are  points 
which  may  be  useful  in  coming  to  a  right  conclusion  when  choreic  movements 
are  not  conspicuous  ;  but  attention  must  also  be  paid  to  the  condition  of  the 
heart  and  to  any  history  of  rheumatism.  No  information  of  value  can  be 
obtained  from  the  state  of  the  reflexes  unless  the  choreic  form  of  the  knee-jerk 
is  present. 

Hysterical  Paralysis. — A  brachial  palsy  of  hysterical  origin  may  resemble 
one  which  is  due  to  a  pj^ramidal  lesion  in  presenting  a  marked  amount  of  rigidity, 
or,  on  the  other  hand,  the  whole  limb  may  be  flaccid  and  limp.  Some  general 
wasting  of  the  muscles  may  be  present,  but  there  is  no  alteration  in  their  electrical 
reactions.  Organic  pyramidal  lesions  must  be  excluded  by  an  examination  of 
the  reflexes.  The  supinator,  biceps,  and  triceps  jerks  may  be  tried,  but  they  will 
not  be  appreciably  more  brisk  than  those  of  the  opposite  limb.  The  abdominal 
and  leg  reflexes  will  be  natural  in  type.  If  the  limb  is  rigid  the  observer  will 
probably  be  able  to  overcome  the  rigidity  by  steady  pressure,  and  to  extend  the 
arm,  forearm,  hand,  and  flngers  into  one  straight  line.  \^'hen  the  patient  is 
asked  to  perform  a  certain  movement,  the  observer  can  often  see  that  in  the 
effort  to  carry  it  out  the  antagonistic  muscles  are  put  into  action  rather  than, 
or  as  well  as,  those  which  are  necessary  for  its  execution.  Thus  the  triceps  will 
contract  as  well  as  the  biceps  when  the  patient  is  requested  to  flex  the  elbow, 
with  the  result  that  the  forearm  is  moved  very  little  or  not  at  all.  This  may 
also  be  demonstrated  when  the  observer  resists  the  movement  of  flexion  by 
grasping  the  wrist  and  then  unexpectedly  relaxes  his  resistance.  In  an  organic 
palsy  this  will  be  followed  by  further  uncontrolled  flexion  at  the  elbow,  whereas 
in  an  hysterical  patient  the  contraction  of  the  triceps  maintains  the  forearm  in 
its  former  position. 

There  is  another  point  of  importance  in  distinguishing  a  palsy  of  cerebral 
origin  from  one  which  is  hysterical.  In  the  organic  case,  even  when  no  voluntary 
movement  whatever  can  be  carried  out  by  the  fingers,  the  latter  may  be  observed 
to  move  involuntarily  in  association  with  energetic  movements  in  the  opposite 
limb.  Thus,  when  the  patient  is  asked  to  grasp  some  object  as  tightly  as  he 
can  with  the  sound  hand,  flexion  of  the  fingers  may  be  detected  in  the  paralyzed 
side.     The  same  phenomenon  is  seen  in  connection  with  involuntary  movements. 


PARALYSIS     OF     THE     UPPER     EXTREMITY  549 

such  as  yawning.  The  writer  remembers  being  requested  to  see  a  case  in  which 
there  was  paralysis  of  one  arm,  and  in  which  the  diagnosis  between  organic 
and  functional  disease  was  in  doubt.  The  first  question  he  asked  the  patient  was 
whether  he  could  open  his  hand  and  extend  his  fingers  ;  the  patient  replied  in 
the  negative,  but  immediately  volunteered  the  statement  that  the  fingers  became 
extended  whenever  he  yawned.  This  settled  the  point  in  dispute  at  once, 
because  such  associated  movements  do  not  occur  in  hysterical  palsies.  In  many, 
if  not  most,  cases  of  hysterical  palsy  of  an  arm,  the  Hmb  is  also  anaesthetic,  and 
this  anaesthesia  can  generally  be  recognized  as  hysterical  on  account  of  its 
complete  character.  In  a  cerebral  palsy  there  may  be  some  loss  of  sensibility 
to  light  touches  and  some  impairment  of  pain  sense,  but  the  hysterical  patient 
is  usually  insensitive  to  all  forms  of  stimulation,  even  pinching  or  a  strong 
faradic  current.  IMoreover,  the  distribution  of  the  anaesthesia  does  not  correspond 
to  any  form  seen  in  organic  disease,  and  is  frequently  of  a  glove  or  sleeve  type 
with  a  very  sharp  line  of  demarcation. 

Paralysis  v.-ith  Muscular  Atrophy  (or  Atrophic  Palsy). 

In  this  categorv  are  included  all  cases  of  brachial  palsy  in  which  there  is  true 
muscular  atrophv  associated  with  some  alteration  in  electrical  reactions,  either 
the  tvpical  reaction  of  degeneration  or  quantitative  diminution  of  excitability 
to  galvanic  and  faradic  currents.  In  all  such  cases  there  is  some  organic  lesion, 
and  the  lesion  affects  some  part  of  the  lower  motor  neurons  which  innervate 
the  muscles  of  the  arms.  In  other  words,  there  must  be  some  disease  involving 
(i)  the  spinal  segments  from  the  5th  cervical  to  the  ist  dorsal,  (2)  the  corres- 
ponding anterior  spinal  roots,  (3)  the  brachial  plexus,  (4)  the  peripheral  nerves 
of  the  arm,  or  (5)   the  muscles  themselves. 

In  addition  to  atrophy  and  alteration  in  electrical  response,  each  paralyzed 
muscle  tends  to  lose  its  tendon-jerk.  For  instance,  the  tendon- jerk  of  an  atrophied 
biceps  cannot  be  obtained,  and  in  all  probability  direct  percussion  of  the  muscle 
itself  will  also  fail  to  elicit  a  contraction,  or  will  give  rise  onl}'  to  an  abnormally 
slow  contraction.  Muscles  which  are  undergoing  atrophy  may  also  exhibit 
fine  fibrillary  contractions  of  a  spontaneous  kind,  but  these  are  seen  only  when 
the  disease  affects  the  nerve  fibres,  and  not  when  the  muscles  themselves  are 
primarily  affected.  That  it  is  to  say,  these  fibrillations  are  very  rarely  seen 
in  the  group  of  muscular  atrophies  to  which  the  name  of  "  myopathy  " 
is   given. 

For  the  purpose  of  making  a  diagnosis  of  the  site  of  the  lesion  in  cases  of 
atrophic  brachial  paralysis,  it  is  absolutely  essential  to  analyze  carefully  the 
distribution  of  the  atrophied  muscles.  This  must  be  done  in  order  to  answer 
the  questions  :  Are  all  the  atrophied  muscles  supplied  by  one  peripheral  nerve, 
or  are  they  innervated  by  one  or  more  spinal  segments,  or  by  one  or  more 
anterior  spinal  roots  ?  The  diagnosis  will  be  comparatively  simple  when  it  is 
found,  for  instance,  that  all  the  atrophied  muscles  are  supplied  by  the  musculo- 
spiral  nerve,  and  that  all  the  muscles  supplied  by  that  nerve  are  atrophied  and 
paralyzed.  A  lesion  of  that  ner\'e  can  then  be  diagnosed  and  its  nature 
inferred  from  other  data,  such  as  the  use  of  a  crutch  or  the  historv  of  a  fractured 
humerus,  with  the  detection  of  callus  involving  the  nerve  at  the  site  of  the 
fracture. 

Let  us  now  consider  briefly  some  of  the  ^•arious  conditions  giving  rise  to 
atrophic  palsy  of  the  upper  extremity,  and  the  features  which  are  most  character- 
istic for  the  purpose  of  their  diagnosis. 

In  cases  of  nsiiritis  there  may  be  paralysis  of  the  muscles  supplied  bv  one 
nerve  only,  or  of  muscles  supplied  by  several  nerves  (multiple  neuritis).  In 
the  former  case  the  correct  diagnosis  of  the  lesion  depends  on  a  knowledge  of 


550 


PARALYSIS     OF     THE     UPPER     EXTREMITY 


the  muscles  inner^-ated  by  each  of  the  chief  brachial  ner\^es,  and  this  may  be 
gleaned  from  the  followins:  list : — 


yerve 

Posterior  scapular 
(C.  5) 

Long  thoracic 

(C.  5,  6,  7) 
Suprascapular 

(C.  5,   6) 
Anterior  thoracic 

(C.  5,   6,  7,   8,  D.   ij 

^Musculocutaneous 
;C.  5,   6j 

Median 

(C.   6,   7,  8,   D.   I) 

forearm 


hand 


Muscles 


Ulnar 


(C.   8,   D.   I) 


forearm 


hand 


Circumflex 
(C.  5,   6) 

]Musculospiral 
(C.  6,  7,  8) 


upper  arm 


forearm 
(posterior  inter- 
osseus  branch) 


Subscapular 

(C.  5,  6,  7,  8^ 


( Levator  aneuli  scapulaj 

-  Rhomboideus  minor 
(  Rhomboideus  major 

-  Serratus  magnus 

/  Supraspinatus 
( Infraspinatus 

j  Pectoralis  major 
I  Pectoralis  minor 


Biceps 

Brachialis  anticus 
Coraco-brachialis 


;  Pronator  radii  teres 
I  Flexor  carpi  radialis 
i  Palmaris  longus 

-  Flexor  sublimis  digitorum 
.  Flexor  longus  pollicis 

Pronator  quadratus 

Flexor  profundus  digitorum  (outer  half) 

("Abductor  pollicis 

I  Opponens  pollicis 

I  Flexor  brevis  pollicis  (superficial  head) 

'..Two  outer  lumbricals. 

(Flexor  carpi  ulnaris 

I  Flexor  profundus  digitorum  (inner  half) 

/  Palmaris  brevis 

Flexor  brevis  minimi  digiti 
1  Abductor  minimi  digiti 
:  Opponens  minimi  digiti 
-,  Interossei 

!  Two  inner  lumbricals 
I  Adductor  obliquus  pollicis 
I  Adductor  transversus  pollicis 
\  Flexor  brevis  pollicis  (deep) 

/Deltoid 
[Teres  minor 

r  Triceps 

I  Anconeus 

j  Supinator  longus 

I  Extensor  carpi  radialis  longior 

('Extensor  carpi  radialis  brevior 
I  Supinator  brevis 

Extensor  communis  digitorum 
I  Extensor  minimi  digiti 
-[  Extensor  carpi  ulnaris 

Extensor  ossis  metacarpi  pollicis 

Extensor  longus  pollicis 
!  Extensor  brevis  pollicis 
L  Extensor  indicis 

( Subscapularis 

-  Teres  major 

'  Latissimus  dorsi 


When  several  nerves  are  involved  in  neuritis,  the  condition  is  one  of  midiiple 
neuritis  and,  being  generally  due  to  some  toxic  cause,  tends  to  be  bilateral  and 
symmetrical.  Multiple  neuritis  is  further  characterized  b}^  the  facts  that  the 
peripheral  muscles  are  more  affected  than  the  proximal,  that  the  extensors  of 
the  wrist  and  fingers  suffer  out  of  proportion  to  the  flexors,  and  that  there  is 


PARALYSIS     OF     THE     UPPER     EXTREMITY 


often  pain,  and  tenderness  in  the  paralyzed  muscles.  These  features  are  present 
in  alcoholic  neiiyitis,  the  most  common  form.  In  lead  palsy  the  extensors  of  the 
wrists  and  fingers  are  particularly  susceptible,  although  other  muscles  supplied 
by  the  musculospiral  nerve — such  as  the  supinator  longus  and  triceps — may  escape 
altogether.  The  association  of  dropped  wrist  with  a  blue  line  on  the  gums, 
and  other  signs  of  plumbism,  is  diagnostic  of  this  form  of  brachial  palsv.  In 
some  cases  of  multiple  neuritis  it  is  impossible  to  identify  the  causative  toxin, 
but  glycosuria,  mercury,  and  arsenic,  in  addition  to  alcohol  and  lead,  must  be 
remembered  in  this  connection.  Leprosy  may  produce  a  precisely  similar 
condition  [Fig.  144),  but  it  is  rarely 
met  with  in  Great  Britain.  (See  also 
Atrophy,  Muscular.) 

In  most  cases  of  single  nerve  palsy 
the  diagnosis,  based  on  the  distribu- 
tion of  the  muscular  atrophy  and 
paralj'sis  with  altered  electrical  re- 
actions, can  be  confirmed  by  the 
detection  of  sensory  loss  in  the 
cutaneous  area  supplied  by  the  same 
nerve.  In  other  cases  the  sensory 
fibres  appear  to  offer  more  resistance 
than  the  motor  to  the  exciting  cause 
of  the  neuritis,  and  little  or  no  dis- 
turbance of  sensibility  can  be  found. 
(For  areas  supplied  by  the  peripheral 
nerves,  see  Plate  XI,  and  Sensation, 
SOME  Abnormalities   of.) 

Reference  may  be  made  to  one  or 
two  of  the  single  nerve  palsies  which 
present  special  points  in  relation  to 
diagnosis. 

In  paralysis  of  the  serratus  mag  mis 
due  to  injury  or  neuritis  of  the  long 
thoracic  nerve,  the  patient  may  com- 
plain of  general  weakness  of  the  arm, 
and  particularly  of  inability  to  raise 
it  above  the  horizontal  position.  The 
trouble  arises  from  the  fact  that  the 
scapula  is  no  longer  held  against 
the  thoracic  wall,  and  cannot  be 
rotated  in  accordance  with  the  move- 
ments of  the  limb.     The  origin  of  this 

disability  may  be  overlooked  if  the  arm  only  is  examined.  If,  however,  the 
position  of  the  scapula  is  observed  when  the  arm  is  moved  in  different  directions, 
the  correct  diagnosis  can  be  arrived  at.  ^Yhen  the  arm  hangs  at  rest  by  the  side, 
the  scapula  is  seen  to  be  slightly  raised  and  displaced  outwards,  with  the  inferior 
angle  inclining  towards  the  vertebral  column  and  perhaps  somewhat  separated 
from  the  chest  wall.  When  the  arm  is  raised  forward  to  the  horizontal  position 
and  pressed  against  some  resistance,  the  inner  border  of  the  scapula  projects 
backwards  and  presents  a  "  winged  "  appearance.  This  deformity  ought  alwaj's 
to  suggest  paralysis  of  the  serratus  ma.gnus. 

The  movements  of  the  upper  limb  are  also  hampered  somewhat  in  cases  of 
neuritis  or  injury  to  the  suprascapular  nerve,  and  the  patient  may  complain  of 
difficulty    or    fatigue    in    writing.     Examination    will    show    flattening    of    the 


Fig.  144. — Paresis  of  the  arms  due  to  peripheral 
neuritis  in  an  arrested  case  of  lepra  maculo-anaes- 
thetica  in  a  Norwegian. — From  a  photogiapk  by 
/v.  Hnnsen,   Inspector-General  of  Leprosy  in 

yoru<ay. 


552  PARALYSIS     OF     THE     UPPER     EXTREMITY 

infraspinous  fossa  and  weakness  in  rotating  the  humerus  outwards  against 
resistance.  The  infraspinatus  muscle  may  be  tested  electrically  and  show  the 
reaction  of  degeneration,  but  the  supraspinatus  is  not  accessible,  being  covered 
by  the  trapezius. 

Adhesions  within  the  shoulder- joint  with  secondary  wasting  of  the  deltoid 
may  simulate  parah'sis  in  the  distribution  of  the  circumflex  nerve,  owing  to  the 
difficulty  in  abducting  the  arm  ;  but  a  little  care  in  examination  and  electrical 
testing  of  the  deltoid  muscle  will  suffice  to  make  a  diagnosis.  In  circumflex 
palsy,  moreover,  some  sensory  loss  may  be  found  in  the  skin  over  the  upper 
and  outer  aspect  of  the  arm. 

In  cases  of  musculospiral  paralysis  it  must  be  remembered  that  the  injurv 
to  the  nerve  may  be  above  or  below  the  points  where  branches  leave  the  nerve 
to  supply  the  triceps  and  supinator  longus  muscles,  and  that  these  muscles  may 
therefore  escape.  Sensory  symptoms  are  often  absent,  but  some  anaesthesia 
is  sometimes  found  on  the  radial  border  of  the  hand. 

In  connection  with  traumatic  affections  of  the  median  nerve,  the  distribution 
of  the  paralysis  also  depends  on  the  site  of  the  wound,  and  it  has  been  pointed 
out  that  the  branch  which  supplies  the  muscles  of  the  hand  may  leave  the  main 
nerve  in  the  forearm,  and  thus  escape  injurj^  when  the  wound  is  at  the  wrist. 

Ischcsmic  paralysis  of  the  hand  (Volkmann's  contracture)  must  not  be  for- 
gotten in  cases  of  injury  to  the  forearm  when  there  is  a  history  of  the  patient 
wearing  a  splint,  and  the  condition  must  not  be  mistaken  for  ulnar  or  median 
paralysis.  The  diagnosis  depends  partly  upon  the  history,  but  chiefly  upon 
the  rigid  contracture  of  all  the  flexor  tendons  of  the  wrist  and  fingers  with  wasting 
of  the  muscles  and  other  trophic  changes  {Fig.  43,  p.  166).  The  electrical 
excitability  of  the  flexor  muscles  is  sometimes  impaired. 

Paralysis  of  one  arm  due  to  a  lesion  of  the  brachial  plexus  is  a  common  event, 
the  most  frequent  cause  being  some  form  of  injury.  AVhen  the  whole  plexus 
is  damaged,  complete  brachial  palsy  with  atrophy  of  the  muscles  and  extensive 
sensory  loss  results.  The  diagnosis  of  such  a  lesion  is  simple,  because  it  would 
be  impossible  for  the  spinal  cord  to  be  damaged  sufficiently  to  bring  about  such 
a  paralysis  without  giving  rise  to  symptoms  of  atrophic  palsy  in  the  opposite 
arm  and  spastic  paralysis,  with  disturbances  of  sensibility,  in  the  trunk  and  lower 
extremities. 

In  addition  to  a  lesion  of  the  brachial  plexus  as  a  whole,  two  forms  of  partial 
palsy  are  not  uncommon,  and  have  received  special  names.  The  first  is  known 
as  Erb's  palsy,  and  is  due  to  a  lesion  of  the  upper  trunk  of  the  brachial  plexus, 
which  is  composed  of  fibres  from  the  5th  and  6th  cervical  roots.  The  paralyzed 
muscles  include  the  spinati,  deltoid,  biceps,  supinator  longus,  and  to  a  less  extent 
the  extensors  of  the  wrist  and  fingers.  The  arm  hangs  by  the  side,  and  the  forearm 
remains  in  the  pronated  position,  owing  to  the  weakness  of  the  supinator  muscles, 
and  especially  of  the  biceps.  There  is  sometimes,  but  not  always,  ancesthesia 
over  the  outer  aspect  of  the  forearm  and  hand.  This  form  of  palsy  is  usually 
produced  by  a  fall  on  the  shoulder  of  such  a  kind  as  to  separate  the  latter  forcibly 
from  the  head,  and  so  to  exert  sudden  and  severe  traction  on  the  upper  part 
of  the  brachial  plexus. 

A  similar  lesion  is  often  seen  in  infants  as  a  result  of  injury  during  birth, 
and  has  been  called  Duchenne' s  palsy,  after  the  obserAer  who  first  described  it. 
In  both  Erb's  and  Duchenne's  palsy,  the  grouping  of  the  paralyzed  muscles 
resembles  that  which  may  follow  an  injury  to  the  5th  and  6th  cervical  segments 
of  the  spinal  cord,  but  in  the  latter  case  bilateral  symptoms  are  practically  certain 
to  be  present,  as  well  as  more  extensive  disturbances  of  sensation  of  the  trunk 
and  limb,  probably  of  the  dis.sociative  type.  (See  Sensation,  Some  Abnor- 
malities OF.)     In  spinal  cord  lesions,  moreover,  we  may  see  an  atrophic  paralysis 


PARALYSIS     OF     THE     UPPER     EXTREMITY 


553 


of  the  muscles  supplied  by  the  5th  and  6th  cervical  segments,  together  with  a 
spastic  paralysis  of  the  remaining  muscles  in  the  arm — that  is  to  say,  of  the 
muscles  innervated  from  the  7th  and  8th  cervical  and  ist  dorsal  segments. 
This  mixture  of  atrophic  and  spastic  paralysis  in  the  upper  limb  can  only  be 
brought  about  by  some  injury  or  disease  of  the  spinal  cord. 

The  other  form  of  partial  brachial  plexus  palsy,  Khtmpke's  palsy,  depends  on  a 
lesion  of  the  trunk  formed  by  the  8th  cervical  and  ist  dorsal  roots.  The  flexors 
of  the  wrist  and  fingers,  and  the  intrinsic  muscles  of  the  hand,  undergo  atrophy, 
and  although  the  patient  can  carry  out  all  movements  at  the  shoulder  and  elbow, 
he  is  unable  to  use  his  fingers.  The  area  of  anaesthesia  in  this  form  involves 
the  ulnar  border  of  the  forearm  and  hand  from  the  elbow  downwards.  This 
condition  may  be  distinguished  from  a  spinal-cord  lesion  affecting  the  8th  cervical 


,  I    Small  musd«or„„k   IRecii  ^i  oljiqui  capiiis) 

...  ,  ( Sterno-hyoideu. 

:n&  hjpoglossi    ^  Sterno-thyroidei 

1  Omo-hyo'deiti 

\Auncularis  suoerior   i  Sternocleido  ma.stoid 


/'V^'.  145. — Diagram  to  illustrate  the  cervico-brachial  ple.xus  and  its  branches  {after  Kocher). 


and  ist  dorsal  segments,  not  only  by  its  limitation  to  one  upper  extremity,  but 
also  by  the  absence  of  the  oculo-pupillary  symptoms  which  are  nearly  always 
present  in  spinal  lesions  of  that  level.  In  other  words,  a  lesion  of  the  spinal 
segments  in  that  region,  or  of  the  corresponding  spinal  roots  in  their  intra- 
vertebral  course,  produces  a  diminution  in  the  size  of  the  pupil  and  a  narrowing 
of  the  palpebral  aperture  on  the  same  side.  Such  a  pupil  does  not  dilate  to 
shade,  nor  when  the  skin  of  the  neck  is  pinched,  nor  when  a  cocaine  solution  is 
dropped  into  the  eye.  Although  the  presence  or  absence  of  oculo-pupillary 
symptoms  affords  a  point  of  differentiation  between  lesions  of  the  8th  cervical 
and  ist  dorsal  segments  of  the  spinal  cord,  or  of  their  corresponding  roots  on 
the  one  hand,  and  a  lesion  of  the  lower  trunk  of  the  brachial  plexus  on  the  other, 
in  the  majority  of  cases,  it  must  be  remembered  that  in  very  severe  injuries 


554  PARALYSIS     OF     THE     UPPER     EXTREMITY 

to  the  neck  the  lower  roots  of  the  plexus  may  be  actually  torn  away  from  their 
connection  with  the  spinal  cord,  in  which  case  the  oculo-pupillary  symptoms 
mentioned  above  will  be  present. 

Amyotrophic  lateral  sclerosis  is  a  condition  which  is  dependent  on  a  gradual 
degeneration  and  disappearance  of  the  anterior  cornual  cells  of  the  spinal  cord, 
associated  with  sclerosis  of  the  upper  motor  neuron  tracts.  The  muscular 
atrophy  begins  insidiously  and  progresses  gradually.  It  often  commences  in 
the  intrinsic  hand  muscles  (Aran-Duchenne  type),  less  commonly  in  the  shoulder 
and  upper  arm  muscles.  The  loss  of  power  is  in  proportion  to  the  amount  of 
atrophy.  The  alteration  in  electrical  reactions  is  usually  more  a  quantitative 
diminution  of  excitability  to  both  currents  than  a  true  reaction  of  degeneration. 
Fibrillary  contractions  are  common.  The  atrophy  usually  begins  in  one  limb 
before  the  other,  but  soon  becomes  more  or  less  symmetrical.  The  tendon- jerks 
of  all  muscles  which  are  not  atrophied  are  exaggerated.  The  abdominal  reflexes 
may  be  absent,  and  the  plantar  reflexes  may  be  of  the  extensor  type.  There  are 
no  pains,  no  sensory  loss,  and  no  oculo-pupillary  phenomena. 

In  syringomyelia  the  spinal  changes  frequently  begin  in  the  cervical  enlarge- 
ment of  the  cord,  with  the  result  that  atrophic  paralysis  is  first  noticed  in  the 
upper  extremity,  generally  in  the  intrinsic  ruuscles  of  the  hand  and  the  flexor 
muscles  on  the  ulnar  aspect  of  the  forearm.  The  onset  is  insidious  and  the 
progress  gradual.  One  limb  is  generally  affected  many  months,  perhaps  years, 
before  the  other.  Manual  deformities  are  common.  (See  Claw-hand,  Fig.  30^ 
p.  127.)  The  electrical  reactions  vary  like  those  of  amyotrophic  lateral  sclerosis. 
The  knee-  and  ankle- jerks  are  increased  as  a  rule,  and  spastic  paralysis  of  the  lower 
extremities  usually  develops  in  the  later  stages,  with  extensor  plantar  responses. 
Pains  shooting  down  the  arms  from  the  neck  occur,  but  are  not  corumon.  Trophic 
changes  develop  in  the  skin,  subcutaneous  tissues,  and  joints.  There  is  sensory 
loss  of  a  dissociative  type,  i.e.,  loss  of  sensibility  to  pain,  heat,  and  cold,  with 
preservation  of  tactile  sensibility.  Oculo-pupillary  phenomena  and  nystagmus 
are  common.  Spinal  curvature,  in  the  form  of  a  dorsal  scoliosis,  is  another 
frequent  physical  sign. 

It  is  not  necessary  that  all  these  signs  and  symptoms  should  be  present 
for  the  purpose  of  making  a  diagnosis.  The  combination  of  muscular 
atrophy,  dissociative  anaesthesia,  and  trophic  changes  in  the  skin  is  usually 
sufficient. 

Within  the  last  few  years  it  has  become  recognized  that  a  supernumerary 
cervical  rib  may  be  responsible  for  atrophic  palsy  in  the  upper  extremity. 
Paralysis  is  usually  preceded  by  pain,  chiefly  referred  to  the  inner  aspect  of  the 
arm,  and  sometimes  shooting  into  the  little  and  ring  fingers.  The  pain  is  worse 
after  exertion,  and  often  relieved  by  placing  the  hand  behind  the  head. 

Muscular  atrophy  begins  in  the  hand  muscles,  the  interossei,  thenar,  and 
hypothenar  eminences,  and  often  involves  the  flexors  of  the  wrist  and  fingers. 
It  develops  gradually  and  does  not  spread  beyond  the  distribution  just  described. 
There  is  often  sensory  loss  in  regions  corresponding  to  the  cutaneous  areas 
supplied  by  the  ist  dorsal  and  8th  cervical  spinal  roots.  The  loss  is  usually 
less  marked  to  touch  than  to  painful  thermal  stimuli.  The  atrophied  muscles 
show  the  electrical  reaction  of  degeneration.  There  are  no  oculo-pupillary 
phenomena  and  no  signs  of  disease  in  other  parts  of  the  body.  The  condition 
is  usually  one-sided,  occasionally  bilateral,  and  the  chief  point  in  diagnosis 
is  the  discovery  of  the  ribs  by  means  of  skiagraphy.  (See  also  Pain  in  the 
Extremity,  Upper  ;  and  Claw-hand.) 

Another  disease  in  which  atrophic  palsy  of  the  intrinsic  hand  muscles  is  a 
prominent  feature  is  so-called  Peroneal  atrophy.  As  the  name  suggests,  the 
muscular  atrophy  and  paralysis  generally  begin  in  the  lower,  before  they  affect 


PARALYIS     OF     THE     UPPER     EXTREMITY  555 

the  upper,  extremities,  and  further  details  concerning  the  condition  may  be  found 
under  Paralysis  of  the  Extremity,  Lower  ;  and  Atrophy,  Muscular 
{Figs.  8  and  9,  p.  71). 

The  diagnosis  of  muscular  atrophy  in  the  arm  dependent  on  a  preceding 
acute  poliomyelitis  {Fig.  7,  p.  70)  is  not  a  difficult  matter,  especially  if  an 
accurate  history  can  be  obtained.  This  will  show  that  the  onset  was  acute  and 
associated  with  some  degree  of  constitutional  disturbance,  varying  frcm  a 
transient  and  perhaps  overlooked  malaise  to  a  condition  in  which  pyrexia  up 
to  104°  F.,  generalized  pains  all  over  the  body,  vomiting,  and  convulsions  were 
conspicuous  features.  It  is  an  almost  invariable  rule  to  learn  that  the  initial 
paralysis  was  more  extensive  than  that  which  remained  permanent.  Attention 
to  the  distribution  of  the  paralysis  shows  that  it  is  irregular  and  different  in 
every  case,  but  there  is  more  liability  on  the  part  of  the  shoulder  and  upper 
arm  muscles  to  suffer  than  those  of  the  forearm  and  hand.  If  both  arms  are 
affected  there  is  little  likelihood  of  finding  any  great  degree  of  symmetry  in  the 
distribution  of  the  atrophy.  With  regard  to  the  electrical  reactions,  much  will 
depend  on  the  stage  at  which  the  case  comes  under  observation.  Some  muscles 
may  show  the  reaction  of  degeneration,  others  may  respond  fairly  well,  and 
others  show  no  response  whatever  to  either  faradism  or  galvanism.  Vasomotor 
changes,  general  defects  in  the  growth  of  the  limb,  deformities,  and  contractures 
are  common,  but  no  sensory  changes  can  be  detected  and  no  oculo-pupillary 
phenomena  are  to  be  observed.  Only  those  reflexes  are  altered  or  lost  which 
are  concerned  with  atrophied  muscles. 

Haemorrhage  into  the  spinal  cord,  or  hcsmdtomyelia,  due  to  injury,  occurs  more 
often  at  the  level  of  the  8th  cervical  and  ist  dorsal  segments  than  at  any  other. 
The  resulting  paralysis  has  much  the  same  distribution  as  that  described  in 
Klumpke's  palsy,  but  the  diagnosis  may  be  made  from  the  fact  that  the  former 
also  produces  spastic  paralysis  of  the  trunk  and  legs,  and  frequently  gives  rise 
to  areas  of  dissociated  anaesthesia.  Oculo-pupillary  phenomena  are  usually 
seen  as  well  in  cases  of  haematomyelia  at  this  level.  Moreover,  it  is  obvious 
that  injuries  to  the  cord  result  in  bilateral  symptoms,  whereas  the  results  of  a 
Klunipke's  palsy  are  confined  to  one  arm. 

Various  forms  of  root  palsies  may  be  caused  by  tuberculous  or  malignant 
disease  of  the  vertebrcB,  and  also  by  pachymeningitis ,  which  is  frequently  syphilitic 
in  origin.  The  diagnosis  of  the  nature  of  such  lesions  depends  on  the  results 
of  the  examination  of  the  vertebral  column  and  of  the  cerebrospinal  fluid. 
Here  again  the  symptoms  are  more  often  bilateral  than  unilateral,  and  may  be 
complicated  by  the  results  of  pressure  on  the  spinal  cord,  the  latter  leading  to 
spastic  paral3'sis  of  parts  below  the  level  of  the  disease. 

Tumours  originating  in  the  meninges  or  in  the  spinal  cord  at  the  level  of  the 
cervical  enlargement  are  rare,  but  they  may  produce  atrophic  paralysis  of  the 
arm  muscles,  with  spastic  paralysis  of  the  trunk  and  lower  extremities.  These 
phenomena  may  be  more  marked  on  one  side  at  first,  but  they  tend  to  become 
bilateral  with  the  gradual  growth  of  the  tumour. 

In  the  group  of  diseases  to  which  the  name  myopathy  or  muscular  dystrophy 
is  applied,  the  upper  extremity  is  often  more  or  less  completely  paralyzed. 
The  diagnosis  of  this  condition  depends  on  a  consideration  of  various  factors. 
The  gradual  onset  and  the  bilateral  symmetry  of  the  affection,  the  marked 
involvement  of  the  shoulder  and  upper  arm  as  compared  with  the  forearm  and 
hand,  are  important  characteristics.  The  absence  of  fibrillary  contraction  and  of 
the  reaction  of  degeneration  are  also  to  be  noted,  while  the  history  of  a  similar 
affection  in  other  members  of  the  family,  and  the  presence  of  muscular  atrophy 
or  muscular  pseudo-hypertrophy  in  other  parts  of  the  body,  serve  to  confirm 
the  diagnosis. 


55<5  PARALYSIS     OF     THE     UPPER     EXTREMITY 

Table  Showixg  the  Muscular  Distribution  of  the  Various  Nerve  Roots 
OF  the  Brachial  Plexus. 

G.  5-  Deltoid.     Spinati.     Teres   minor.     Rhomboids.     Diaphragm.     Biceps. 

Supinator      longus.        Serratus      magnus.        Pectoralis     major. 
Brachialis  anticus.     Coraco-brachialis. 

C.  6.         Biceps.      Coraco-brachialis.      Brachialis  Anticus.      Supinator   longus. 

Deltoid.     Spinati.     Teres  major.     Serratus  magnus.     Pectoralis 

m.ajor.     Subscapularis.     Pronators    of    forearm.     Extensors    of 

wrist. 
C.  7.  Triceps.     Extensors    of    unst    and    finsers.     Pronators    of    forearm. 

Pectoralis  major.    Subscapularis.    Latissimus  dorsi.    Teres  major. 

C.  8.         Flexors  of  tcrist  and  long  flexors  of  fingers.     Interossei  and  lumbricales. 

]\Iuscles  of  thenar  and  hypothenar  eminences. 

D.  I.         Muscles    of    the    thenar    and    hypothenar    emijiences.     Interossei    and 

lumbricales.     Flexor  carpi  ulnaris.     Oculo-pupUlary  fibres. 

A  glance  at  this  list  shows  that  nearly  all  muscles  derive  innervation  from 
more  than  one  spinal  segment,  generally  from  tw'o  or  three.  The  table  does 
not  purport  to  give  a  complete  anatomical  list  of  all  the  muscles  of  the  arm, 
but  p^o^^des  a  guide  to  clinicians  in  their  endeavours  to  localize  spinal  or  root 
lesions  from  the  distribution  of  atrophic  muscular  paralysis.  Those  muscles 
which  clinical  experience  has  taught  us  to  regard  as  the  most  useful  "  landmarks  " 
for  iadi\ddual  segments  are  printed  in  italics.  e.  Farquhar  Buzzard. 

PARALYSIS  OF  THE  HAND. — (See  Paralysis  of  the  Extremity,  Upper  ; 
Cla\\'  Haxd  ;    Atrophy,  Muscular  ;    and  Hemiplegia.) 

PARAPLEGIA.  —  Paraplegia  is  a  term  arbitraril}^  restricted  to  impl}-  partial 
or  complete  parah'sis  of  both  legs,  with  or  without  part  of  the  trunk.  It  does 
not,  however,  include  inabilit}"  to  walk  owing  to  mechanical  defects,  such  as  old 
fractures,  joint  disease  and  so  forth ;  it  is  due,  as  a  rule;  to  changes  either  in  the 
brain,  the  spinal  cord,  the  peripheral  nerves,  or  in  the  muscles  themselves, 
though  sometimes  it  is  caused  by  errors  of  function  without  any  structural 
change  in  the  neuro-muscular  system. 

For  clinical  purposes,  although  naturally  a  paraplegia  that  has  arisen  in 
childhood  vasLj  persist  into  adult  life,  and  thus  cause  overlapping  of  the  classifi- 
cation, paraplegia  in  children  ma}'  be  discussed  separately  from  paraplegia  in 
adults. 

Let  us  suppose  that  the  patient  is  a  child,  and  that  the  chief  complaint  is 
weakness  or  paralysis  of  both  legs.  The  following  table  indicates  some  of  the 
causes  that  may  produce  this  condition. 

I. — The  Causes  of  Paraplegia  in  Children. 

[A).  Conditions  in  which  there  is  no  definite  local  disease,  though  there  may  be 
some  general  pathological  condition  : — 

(j)   Simple  delayed  walking  ;    (2)  Rickets;    (3)  Cretinism;    (_i)  Idiocy. 

(B).  Paraplegia  associated  with  a  definite  nerve  lesion  of  the  upper  neurone 
type  : — 

1.  Infantile   diplegia   due   to  :    {a)    Congenital   defect  of   the  cortex  :   por- 

encephalus  ;  {h)  Infantile  encephalitis ;  (c)  Injur}-,  for  example  by 
forceps  at  delivery  ;  (d)  Superior  longitudinal  sinus  thrombosis  ; 
{e)  Meningitis  ;  ( / )  Congenital  hydrocephalus  ;  [g)  Acquired  hj-dro- 
cephalus. 

2.  Congenital   malformation,   such  as   meningocele,    spina   bifida,   or    spina 

bifida  occulta. 


PARAPLEGIA 


3.  Spinal  caries,  with  compression  of  the  spinal  cord. 

4.  Friedreich's  ataxy. 

(C).  Paraplegia  due  to  a  lesion  of  the  lower  neurone  type  : — 

1.  Acute  anterior  poliomj-elitis,  leading  to  infantile  paralysis. 

2.  Tooth's  peroneal  type  of  progressive  muscular  atrophy. 

3.  Peripheral  neuritis. 

(D).  Paraplegia  of  the  primary  muscular  type  : — 

1.  Pseudo-hypertrophic  muscular  paralysis. 

2.  The  infantile  type  of  primary  muscular  dystrophy. 

3.  The  juvenile  type  of  primary  muscular  dystrophy. 

In  arriving  at  the  diagnosis,  the  first  point  to  pay  attention  to  is  the  history  ; 
the  case  will  belong  to  one  or  other  of  two  main  groups,  the  first  containing 
those  that  have  never  been  able  to  use  the  legs  properly,  the  second  those  that 
have  lost  the  use  of  the  legs  after  having  been  at  one  time  able  to  walk,  or 
otherwise  use  them  efficiently. 

To  the  first  group  belong  all  cases  of  congenital  malformation,  such  as  h^'dro- 
cephalus  or  meningocele,  and  most  cases  of  infantile  diplegia.  Before  diagnosing 
any  of  these,  however,  it  is  necessary  to  exclude  rickets,  cretinism,  idiocy,  and 
simple  delayed  walking,  as  causes  of  an  apparent  rather  than  real  paraplegia. 
These  cannot  be  the  sole  diagnosis  if  there  is  absolute  fiaccidity  on  the  one 
hand,  or  if  there  is  spasticity  upon  the  other.  It  is  important  to  remember 
how  deceptive  the  reflexes  may  be  ;  almost  any  illness  in  an  infant  or  young 
child — bronchopneumonia  for  example,  or  simple  diarrhoea — may  so  depress 
the  knee-jerk  that  it  is  often  unobtainable  until  the  patient's  general  health 
is  restored  ;  the  plantar  reflex  is  normally  more  often  extensor  than  flexor  in 
infants  ;  ankle-clonus,  however,  does  not  occur  except  when  there  is  degeneration 
of  the  lateral  columns.  If  there  is  neither  absolute  flaccidity  nor  intermittent 
spasticity,  and  if  the  limbs  are  moved  spontaneously,  the  mere  fact  that  the 
child  is  late  in  walking  by  no  means  necessarily  indicates  nerve  disease  ;  the 
delay  may  commonly  extend  to  the  second  year,  and  occasionally  even  to  the 
third  or  fourth.  The  main  factor  in  making  a  diagnosis  in  such  a  case  is  time, 
for,  until  with  the  lapse  of  time  the  little  patient  begins  to  walk,  it  may 
sometimes  be  difficult  to  exclude  organic  paraplegia.  If  there  are  definite  signs 
of  rickets,  or  if  the  patient  is  a  cretin  or  an  idiot,  the  diagnosis  is  more  obvious. 
The  good  eftects  of  giving  thyroid  extract  over  a  prolonged  period  may  be  the 
only  conclusive  means  of  distinguishing  cretinism  from  idiocy,  and  this  remedy 
should  be  emploj^ed  in  all  such  cases,  however  hopelessly  idiotic  the  infant  may 
seem  to  be.  If  there  is  congenital  optic  nerve  blindness,  the  case  is  one  of  idiocy 
and  not  cretinism. 

Having  excluded  the  above,  the  next  thing  to  consider  is  whether  there  is 
any  congenital  malformation  of  the  brain  or  cord.  Cases  of  meningocele, 
mvelocele,  or  spina  bifida  will  generally  be  obvious  enough  ;  even  spina  bifida 
occulta  will  often  suggest  itself  from  the  presence  of  a  pigmented  or  hairy  mole 
over  the  lower  part  of  the  lumbar  spinal  region,  and  the  diagnosis  may  be 
confirmed  bv  careful  palpation  there.  Congenital  hydrocephalus  makes  itself 
evident  from  the  characteristic  enlargement  of  the  head,  which  in  extreme  cases 
can  be  mistaken  for  nothing  else,  and  which  in  lesser  degrees  can  be  distinguished 
from  the  enlargement  due  to  rickets  or  to  congenital  syphilis  by  the  fact  that 
it  is  more  uniform,  and  that  the  bones  are  fragile  and  thin,  and  separated  at 
the  sutures.  The  only  doubt  that  arises  in  a  case  of  infantile  hydrocephalus 
is,  as  to  whether  it  is  truly  congenital  or  was  caused  by  an  early  but  post-natal 
posterior  basal  meningitis.  There  is  increasing  evidence  to  show  that  the 
majority  of  these  cases  are  not   really  congenital,  that   the   head  is  not  large 


ssS  PARAPLEGIA 


at  birth,  and  that  the  enlargement  follows  some  febrile  illness,  with  or  without 
convulsions — really  a  meningococcal  meningitis. 

Congenital  defect  of  the  cortex  would  suggest  itself  as  the  cause  of  infantile 
diplegia  in  a  case  in  which  delivery  had  taken  place  without  difficult}^  and 
without  the  use  of  forceps,  the  head  and  spine  not  being  hydrocephalic  or 
deformed,  and  yet  the  limbs  being  paralyzed  from  birth  ;  they  may  be  flaccid 
or  they  may  be  spastic,  and  there  is  no  constant  type  of  reflex,  though  there  is 
a  tendency  to  increased  knee-jerk,  ankle-clonus,  and  extensor  plantar  reflex. 
Intelligence  will  very  likely  be  defective  at  the  same  time.  In  rare  cases  the 
kidneys  may  be  so  large  and  cystic  that  they  can  be  palpated,  and  the  brain 
may  then  be  cystic  also — porencephalus. 

Paraplegia  due  to  injury  at  birth,  either  by  the  use  of  forceps  or  by  excessive 
compression  in  a  contracted  maternal  pelvis,  is  a  diagnosis  that  can  only  be  made 
when  there  has  been  an  unusual  amount  of  difficulty  at  birth,  for  it  is  remarkable 
to  what  extreme  degrees  the  child's  head  may  be  squeezed  and  altered  in  shape 
without  apparent  detriment.  Seeing  that  it  is  the  lateral  aspects,  especially 
the  arm  areas  of  the  Rolandic  cortex,  that  will  be  most  affected  by  forceps, 
these  instruments  are  more  likely  to  cause  bilateral  arm  paralysis  than  ordinary 
paraplegia.  Just  the  converse  of  this  is  true  of  superior  longitudinal  sinus 
thrombosis,  for  the  leg  areas  of  the  brain  lie  close  up  against  either  side  of  this 
sinus,  whilst  the  arm  areas,  being  more  distant  from  it,  are  likely  to  be  less 
affected.  The  symptoms  of  superior  -longitudinal  sinus  thrombosis,  of  acute 
encephalitis,  and  of  meningitis,  may  be  so  similar  —  pyrexia,  general  head 
symptoms,  vomiting,  and  convulsions — that  it  is  almost  a  matter  of  guess- 
work to  choose  between  them  when  they  are  actually  in  progress ;  if  death 
occurs  in  a  few  days,  suppurative  meningitis  is  likely  ;  if  in  a  few  weeks, 
tuberculous  meningitis  ;  if  the  patient  lingers  for  many  weeks  before  dying, 
or  if  recovery  occurs  with  hydrocephalus,  posterior  basal  or  cerebrospinal 
meningitis  ;  if  recovery  occurs  without  hydrocephalus,  it  may  be  almost 
impossible  to  decide  between  meningococcal  meningitis,  acute  encephalitis, 
and  superior  longitudinal  sinus  thrombosis  ;  nor  is  the  distinction  material, 
except  in  so  far  that  it  is  important  to  remember  always  that  a  favourable  issue 
may  occur  even  in  a  case  that  seems  to  be  hopelessly  comatose  and  dying — 
a  diagnosis  of  meningitis  may  have  been  made  erroneously  when  the  condition 
was  really  one  of  acute  encephalitis  only.  If  it  seems  to  be  of  great  importance 
to  arrive  at  the  accurate  diagnosis  in  the  acute  stages,  it  may  be  justifiable 
to  perform  lumbar  puncture.  A  cytological  examination  of  the  cerebrospinal 
fluid  may  show  many  polymorphonuclear  cells  in  a  suppurative  case,  or  many 
lymphocytes  in  a  tuberculous  case.  Of  more  value  than  the  cytological  exami- 
nation, however,  is  the  bacteriological  test,  which  may  succeed  in  isolating 
the  causal  organism. 

If  one  is  able  to  exclude  the  infantile  diplegias,  and  the  conditions  which 
simulate  them,  the  probability  is  the  patient  will  have  shown  obvious  signs  of 
being  able  to  use  the  legs,  or  may  even  have  been  able  to  walk  before  the 
paraplegia  set  in.  In  that  case,  if  the  paralysis  is  of  the  upper  neurone  type, 
with  spasticity,  no  wasting  except  such  as  may  be  due  to  disuse  and  non- 
development,  no  reaction  of  degeneration,  increased  knee-jerks,  extensor  plantar 
reflexes,  ankle-clonus,  and  probably  bladder  and  rectal  trouble — especially  if 
there  is  ansesthesia  in  the  legs  at  the  same  time — by  far  the  commonest  cause 
lor  the  condition  is  spinal  caries  with  compression  of  the  cord. 

If,  on  the  other  hand,  the  patient  develops  a  lower  neurone  type  of  paralysis, 
with  wasting  of  the  affected  muscles  and  reaction  of  degeneration,  the  chances 
will  be  greatly  in  favour  of  acute  anterior  poliomyelitis  followed  by  infantile 
paralysis,  particularly  it  diphtheria  can  be  excluded,  and  if  a  clear  history  can 


PARAPLEGIA  559 


be  obtained  that  the  child  was  perfectly  well  until  he  developed  an  obscure 
febrile  complaint,  which  may  at  first  ha\"e  been  regarded  as  of  gastric  origin, 
but  which,  in  a  day  or  t\vo,  led  to  one  or  more  limbs,  possibly  all  four,  becoming 
limp  and  paralyzed,  with  rapid  subsidence  of  the  fever  and  great  improvement  in 
the  paralysis  during  the  next  few  weeks.  It  is  possible  for  a  child  to  have  had 
absolute  paralysis  of  all  four  limbs  from  acute  anterior  poliomyelitis,  and  yet  for 
complete  recovery  to  occur  ;  more  often,  however,  one  or  another  group  of 
muscles  remains  weak  ;  in  a  typical  case,  the  extensors  of  the  toes  and  ankle 
are  permanently  affected,  the  consequent  contraction  of  the  unparalyzed  calf 
muscles  leading  to  talipes  equinus  or  equino-varus.  Weakness  of  other  groups 
of  calf  muscles  leads  in  a  similar  way  to  other  forms  of  club-foot,  such  as  T. 
calcaneus,  T.  valgus,  and  so  on.  In  other  cases,  the  muscles  below  the  knee 
recover  completely,  but  some  other  group  is  involved — the  quadriceps  extensor 
femoris  for  instance,  or  the  adductors  of  the  thigh.  It  is  of  course  possible  for 
the  legs  to  recover  completely,  whilst  paresis  of  some  group  of  muscles  in  the 
shoulder,  arm,  or  forearm  persists. 

The  infantile  paralysis  which  follows  acute  anterior  poliomyelitis  is  nearh' 
always  asymmetrical,  but  it  is  by  no  means  necessarily  so,  and  it  may  cause 
persistent  partial  paraplegia.  It  is  important  to  remember  that  the  knee-jerk 
is  deficient  or  absent  onh*  when  the  quadriceps  extensor  femoris  muscle  is 
affected  ;  and  also  that  reaction  of  degeneration  is  no  longer  obtainable  in  the 
muscles  when  the  disease  is  of  sufficiently  long  standing  for  all  the  degenerate 
fibres  to  have  become  fibrous,  by  which  time  the  onh*  muscle  and  nerve  fibres 
that  remain  are  normal,  though  they  are  fewer  in  number  than  they  should  be. 

Peripheral  neuritis  in  a  child  is  decidedly  uncommon,  except  as  the  result 
of  diphtheria  ;  it  should  not  be  lightly  diagnosed.  Being  an  affection  of  the 
lower  neurone  type,  with  wasting  of  the  muscles,  flaccidit}',  reaction  of  degenera- 
tion, and  deficiencj-  in  the  tendon  reflexes,  it  may  be  difficult  to  distinguish 
between  it  and  acute  anterior  poliomyelitis.  It  might  be  urged  that  the 
occurrence  of  pain  or  other  sensory  symptoms  is  in  favour  of  peripheral  neuritis 
and  against  poliomyelitis,  but  this  is  not  really  the  case  ;  the  inflammation  in 
poliomyelitis  is  bj-  no  means  necessarily  restricted  to  the  gre}'  matter  of  the 
anterior  cornua,  and  the  acute  stage  of  the  disease  is  often  accompanied  by 
severe  pains  referred  to  the  peripheral  parts.  There  may,  however,  be  bacterio- 
logical or  other  evidence  of  the  patient's  having  had  diphtheria  during  the 
preceding  few-  weeks,  in  which  case  peripheral  neuritis  would  be  diagnosed  ; 
if  there  is  paresis  of  the  soft  palate,  as  evidenced  by  the  regurgitation  of  fluids 
through  the  nose  when  the  patient  tries  to  swallow  them,  or  bv  the  nasal  character 
of  the  voice,  then  diphtheritic  neuritis  would  almost  certainlv  be  the  correct 
diagnosis. 

There  remain  for  discussion  the  following  causes  of  paraplegia  in  children  : 
Friedreich's  ataxy,  Tooth's  peroneal  type  of  progressi\-e  muscular  atrophv, 
and  the  primary  muscular  dystrophies,  particularly  pseudo-hypertrophic 
muscular  paralysis.  There  are  two  points  common  to  all  these,  namely,  that 
they  all  are  insidious  in  onset,  slowly  progressive  for  j^ears  before  the  end  comes 
as  the  result  of  an  intercurrent  malady  :  and  that  they  are  familial  diseases, 
the  family  history'  having  an  important  bearing  upon  their  diagnosis. 

Friedreich's  ataxy  is  characterized  by  paraplegia,  often  associated  with 
deformity,  such  as  talipes  and  scoliosis,  owing  to  persistent  error  of  posture, 
without  wasting  except  such  as  may  be  due  to  disuse  or  non-development  ; 
the  knee-jerks  are  absent;  there  is  no  sphincter  trouble  unless  quite  late; 
ankle-clonus  is  absent,  but  there  is  generally  a  remarkable  condition  of  hallux 
erectus,  which  amounts  to  a  sort  of  permanent  extensor  plantar  reflex ;  there  are 
no  sensory  disturbances  ;  the  arms  may  not  be  affected  at  all,  or  they  mav  present 


^6o  PARAPLEGIA 


some  degree  of  ataxy,  with  or  without  intention  tremors — that  is  to  say,  tremors 
which  are  increased  when  the  patient  tries  to  perform  voluntary  movements — 
sometimes  even  choreiform  movements  are  present  ;  speech  is  monotonous, 
nystagmus  is  sometimes  present,  and  occasionally  there  is  optic  atrophy.  If 
progressive  paraplegia  develops  at  about  8  or  9  years  of  age  in  a  child  with  a 
family  history  of  similar  trouble  ;  if  the  knee-jerks  are  absent,  whilst  the  big  toes 
are  permanently  erect,  and  if  there  is  neither  atrophy  nor  pseudo-hypertrophy 
of  the  muscles,  the  diagnosis  is  in  all  probability  Friedreich's  ataxy.  The  patient 
may  survive  to  puberty  or  even  longer,  but  is  liable  to  death  from  phthisis, 
pneumonia,  or  other  intercurrent  malady — the  same  applying  to  all  the  familial 
diseases  now  under  discussion. 

Tooth's  peroneal  type  of  progressive  muscular  atrophy  is  apt  to  develop  after 
some  simple  specific  fever,  such  as  whooping-cough  or  measles.  The  first  point 
the  mother  notices  is  that  the  child — hitherto  normal — is  unable  to  bend  the  big 
toes  upwards  ;  a  condition  of  permanent  plantar  flexion  of  the  big  toes  ensues  ; 
inability  to  extend  the  other  toes  follows  ;  and  presently  the  patient  cannot 
dorsiflex  the  ankles.  It  is  chiefly  the  muscles  supplied  by  the  external  popliteal 
nerve,  formerly  called  the  peroneal  nerve,  that  are  affected  ;  hence  the  name 
of  the  disease.  Talipes  may  result.  The  lesion  is  not  primarily  in  the  muscles, 
but  in  the  anterior  cornual  cells  of  the  lumbo-sacral  part  of  the  cord,  so  that 
reaction  of  degeneration  is  obtainable  in  the  wasted  muscles.  The  knee-jerks 
remain  normal  so  long  as  the  quadriceps  extensor  femoris  is  unaffected,  there 
is  no  ankle-clonus,  and  the  big  toe  may  not  move  at  all  when  the  sole  is  stimulated. 
A  brother  or  a  sister  is  very  likely  to  have  suffered  from  the  same  complaint 
(see  Figs.  8,  9,  p.  71). 

In  the  primary  muscular  dystrophies  the  nerves  are  normal,  so  that  there  is 
no  reaction  of  degeneration  ;  if  a  muscle  has  become  entirely  atrophied,  there 
will  be  no  reaction  in  it  at  all  ;  but  as  long  as  any  reaction  is  obtainable  it 
is  of  the  normal  type.  The  same  applies  to  the  reflexes.  The  most  easily 
recognized  of  all  the  primarj^  muscular  dystrophies  is  pseudo-hypertrophic 
muscular  paralysis,  the  only  difficulty  being  when  no  family  history  is  obtainable, 
and  when  the  case  is  still  in  too  early  a  stage  to  be  typical.  Boys  are  affected 
more  often  than  girls,  but  it  is  generally  inherited  from  the  mother's  side.  It 
is  possible  for  some  members  to  have  presented  atrophic  myopathy,  whilst 
others  suffer  from  the  pseudo-hypertrophic  form.  When  fully  developed,  the 
most  striking  feature  of  the  case  is  the  marked  weakness  of  the  legs,  notwith- 
standing the  apparent  firmness  and  great  size  of  the  calves.  The  muscles  are 
really  atrophied,  their  apparent  enlargement  being  due  to  extensive  deposition 
of  intramuscular  interstitial  fat.  Ultimately,  if  the  patient  survives,  all  the 
muscles  in  the  body  become  wasted  and  fibrous  ;  but  whereas  some  of  them 
atrophy  from  the  first,  others  exhibit  marked  pseudo-hypertrophy  before  they 
atrophy — particularly  the  gastrocnemii,  the  solei,  the  glutei,  the  deltoids,  the 
supra-  and  infra-spinati,  and  portions  of  the  triceps.  The  muscles  of  the  hands 
and  feet  are  generally  unaffected.  The  muscles  most  frequently  atrophied  are 
the  lower  half  of  the  pectoralis  major,  the  latissimus  dorsi,  the  serratus  magnus, 
the  biceps,  and  the  flexors  of  the  knee.  There  are  no  sensory  or  sphincter 
troubles.  When  the  case  is  well  advanced,  the  way  in  which  the  patient  gets 
up  from  a  lying  posture  is  very  characteristic  ;  it  is  generally  described  as 
"  climbing  up  himself."  He  first  rolls  over  and  rests  on  his  hands  and  knees  ; 
then  puts  his  head  between  his  arms  and  raises  the  knees  from  the  ground,  so 
that  he  is  now  supported  on  his  hands  and  feet ;  he  next  brings  one  hand  nearer 
to  his  toes,  and  then,  swinging  his  body  over  first  to  one  side,  places  his  opposite 
hand  on  the  corresponding  knee,  straightens  that  leg,  and  repeats  the  performance 
on  the  other  side,  so  that  he  now  stands  with  his  legs  widely  separated  and  with 


PARAPLEGIA  561 


a  hand  resting  on  each  knee  ;  he  then  works  each  hand  alternateh-  higher  up  his 
thighs,  until  finally,  by  a  sudden  backward  movement  of  his  shoulders,  he 
attains  the  erect  attitude.  Another  feature  of  the  case  is,  that  if  one  tries  to  lift 
the  boy  up  by  putting  one's  hands  under  his  armpits,  his  shoulders  rise  right 
up  to  his  ears,  and  he  very  easily  slips  through  one's  hands.  He  is  also  unable 
to  stand  on  tip-toe,  and  the  gait  is  waddling. 

The  two  other  types  of  muscular  dystrophy  mentioned  above — the  infantile 
and  the  juvenile — are  but  different  varieties  of  the  same  malady  ;  both  are 
characterized  by  progressive  wasting  of  the  muscles  without  pseudo-hypertrophy  ; 
in  the  infantile  form  the  muscles  have  been  atrophic  from  the  first,  whereas  in 
the  juvenile  form,  the  muscles  develop  in  what  seems  to  be  a  normal  way  up  to 
a  certain  point,  and  then  gradually  waste  away.  The  disease  is  distinguished 
from  peripheral  neuritis,  (i)  by  the  absence  of  reaction  of  degeneration  ; 
(2)  by  the  persistence  of  the  reflexes  as  long  as  any  muscle  tissue  is  left  to 
respond  ;  (3)  by  the  family  history  as  mentioned  above  ;  (4)  by  the  absence 
of  sensory  changes  ;  and  (5)  by  the  absence  of  improvement  with  time.  An 
attempt  is  sometimes  made  to  classify  the  primary  muscular  dystrophies  into 
different  kinds,  according  to  the  groups  of  muscles  first  affected.  In  the 
Landouzy-Dejerine  type,  for  instance,  the  face  muscles  are  first  attacked,  the 
trouble  slowly  spreading  to  the  shoulder  and  upper  arm.  It  is  probable, 
however,  that  whatever  groups  of  muscles  may  be  the  first  affected,  the  differences 
are  those  of  degree  and  type  rather  than  of  kind,  and  that  the  muscular  wasting, 
wherever  it  may  begin,  ultimately  becomes  widespread,  and  finally  involves  all 
the  muscles. 

II. — The  Causes  of  Paraplegia  in  Adults. 

We  may  now  pass  on  to  a  discussion  of  the  differential  diagnosis  of  paraplegia 
in  adults.  It  is  clear  that  a  paraplegia  that  has  arisen  during  infancy  or  child- 
hood may  persist  into  adult  life,  in  which  case  the  diagnosis  will  be  made  upon 
the  lines  indicated  above.  It  is  also  possible  for  some  of  the  causes  of  paraplegia 
that  usualh-  affect  young  patients  not  to  do  so  until  they  have  grown  up.  The 
chief  causes,  however,  for  paraplegia  arising  for  the  first  time  in  adult  life  are 
as  follows  : — 

{A).  Causes  of  the  lower  neurone  type  of  paraplegia. 

1.  Peripheral  neuritis,  which  may  be  due  to  various  different  causes  (p.  72) 

2.  Anterior  poliomyelitis 

3.  A  pelvic  tumour  interfering  with  the  lumbo-sacral  plexus 

4.  A  tumour  affecting  the  cauda  equina 

5.  Compression  of  the  lumbar  enlargement  of  the  cord. 

(B).  Causes  of  the  upper  neurone  type  of  paraplegia. 

1 .  Transverse  myelitis. 

(a).  Primary 

(6).  Due  to  compression  by  :    (i)  Spinal  caries  ;   (ii)  Xew  growth  in  the 
vertebrae  or  meninges  ;    (iii)  Injury  ;    (iv)  Aortic  aneurysm 

2.  Disseminated  sclerosis 

3.  Amyotrophic  lateral  sclerosis 

4.  Primary  lateral  sclerosis 

5.  Ataxic  paraplegia 

6.  Combined  scleroses  of  the  cord 

7.  Syringomyelia 

8.  Meningitis 

9.  Haemorrhage  into  the  cord 

D  36 


562  PARAPLEGIA 


10.  Cerebellar  tumour  or  abscess 

11.  Bilateral  cerebral  softening  or  hemorrhage. 

(C).   Causes  not  conforming  either  to  the  lower  or  to  the  upper  neurone  type. 

1.  Locomotor  ataxy 

2.  General  paralysis  of  the  insane 

3.  Landn,''s  paralysis 

4.  Functional  paraplegia 

5.  Malingering. 

The  first  points  which  call  for  attention  in  making  a  diagnosis  are  the  history 
and  progress  of  the  case.  In  only  a  few  of  the  above  conditions  is  the  onset 
sudden  ;  these  are  certain  cases  of  acute  anterior  poliomj-elitis,  transverse 
myelitis,  meningeal  hsemorrhage,  Landr\''s  paralysis,  functional  paraplegia, 
and  malingering.  If  the  paraplegia  is  of  sudden  onset,  of  the  upper  neurone 
type,  and  not  the  result  of  injury,  it  is  almost  certainly  due  to  some  form  of 
trans\'erse  myehtis.  The  great  majority,"  of  cases  of  paraplegia,  however,  have 
an  onset  that  is  not  absolutely  acute,  and  generally  it  is  quite  gradual. 

There  are  certain  conditions  that  can,  as  a  rule,  be  either  diagnosed  or  excluded 
at  once.  If  the  patient  has  Argyll  Robertson  pupils  and  no  knee-jerks,  loco- 
motor ataxy  can  be  diagnosed  at  once.  It  is  necessary  to  remember,  however, 
that  the  pupil  mav  react  neither  to  light  nor  to  accommodation  in  some  cases 
of  peripheral  neuritis,  so  that,  if  care  be  not  exercised,  the  reaction  may  be 
mistaken  for  the  Argv'U  Robertson  type  of  locomotor  ataxy,  the  latter  being 
diagnosed  when  peripheral  neuritis  is  the  lesion  realty  present.  The  converse 
mistake  is  also  possible,  especiall}'  if  the  actual  strength  of  the  leg  muscles  be 
not  tested  ;  in  both  conditions  there  may  be  patches  of  impaired  sensation, 
but  in  peripheral  neuritis  A^ith  absent  knee-jerks,  there  is  absolute  wasting,  loss 
of  power,  and  reaction  of  degeneration,  whilst  in  locomotor  ataxy  there  is  no 
trophic  wasting,  and  often  no  great  loss  of  power  in  individual  muscles,  though 
there  is  apparent  weakness  owing  to  the  action  of  opposing  muscles  being  inco- 
ordinate and  there  is  no  reaction  of  degeneration. 

Another  difficult}-  in  connection  with  locomotor  ataxy  arises  in  anomalous 
cases  in  which  either  the  pupil  reaction  has  not  yet  become  typical,  or  else  the 
knee-jerks  are  not  yet  gone.  If  the  reaction  of  the  pupil  is  of  the  Argyll 
Robertson  type,  locomotor  ataxj^  may  sometimes  be  diagnosed  even  in  the 
presence  of  knee-jerks,  if  there  is  an  ob%'ious  history  of  other  concomitants  of 
the  disease,  such  as  lightning  pains,  gastric  crises,  or  any  of  the  rarer  crises — 
larjmgeal,  rectal,  urethral,  vesical,  renal,  general  abdominal,  or  sweating — 
marked  ataxy,  a  histon-  of  s^-philis,  perforating  ulcer  of  the  foot,  a  Charcot's 
joint,  or  bladder  or  rectal  trouble,  particularly  if  the  patient  be  a  male  who  has 
had  much  brain  wear.  The  tendo  A  chillis  jerks  maj^  disappear  before  the  knee- 
jerks  do,  and  they  should  be  carefullj^  tested.  There  is  also  in  many  cases  a 
remarkable  deficienc}^  or  even  complete  absence  of  deep  tenderness  in  such 
organs  as  the  testis,  tongue,  larynx,  or  mamma. 

If  the  paraplegia  is  ob\-iously  of  the  lower  neurone  type,  with  deficiency  or 
absence  of  the  superficial  and  deep  reflexes,  atrophy  of  the  muscles,  and  reaction 
of  degeneration,  with  or  without  paraesthesia,  the  probabilities  are  that  it  is  due 
to  one  of  the  man}'  different  causes  of  peripheral  neuritis  that  are  discussed  on 
page  72.  If  the  onset  has  been  sudden,  however,  and  if  the  parah'sis  rapidly 
began  to  clear  up  again,  except  possiblj-  in  one  group  of  muscles  in  one  leg,  there 
would  necessaril}-  be  a  suspicion  of  acute  anterior  poliomyelitis  which  occasionally 
occurs  in  adults. 

It  is  important  in  all  cases  of  suspected  peripheral  neuritis  to  make  a  rectal 
examination,  lest  there  should  be  some  peh-ic  mass,  malignant  or  otherwise. 


PARAPLEGIA  563 


interfering  with  the  lumbo-sacral  plexus.  Peripheral  neuritis  may  also  be 
closely  simulated  by  either  a  tumour  or  a  gumma  interfering  with  the  cauda 
equina,  an  uncommon  condition  that  suggests  itself  if  there  is  severe  pain 
referred  to  the  lower  part  of  the  spinal  column  behind,  or  if  the  paraplegia  comes 
on  in  such  a  way  as  to  affect  one  leg  before  the  other,  the  pelvis  being  found 
free  from  growth.  It  is  also  important  to  remember  that  transverse  myelitis 
due  to  lesions  which,  if  they  are  situated  a  little  higher  up  in  the  cord,  cause 
a  paraplegia  of  the  upper  neurone  type,  produces  wasting,  reaction  of  degenera- 
tion, and  loss  of  reflexes  when  they  affect  the  cord  at  the  level  of  the  lumbar 
enlargement. 

When  the  paraplegia  is  definitely  of  the  upper  neurone  type,  with  spasticity 
of  the  legs  without  wasting,  with  increased  knee-jerks,  extensor  plantar  reflexes, 
ankle-clonus,  and  perhaps  retention  of  urine  with  overflow,  and  incontinence 
of  fasces,  the  first  step  in  arriving  at  the  diagnosis  is  to  determine  if  there  is 
any  sensory  disturbance  at  the  same  time.  The  only  diseases  mentioned 
under  heading  B,  that  produce  obvious  sensory  disorders,  are  transverse 
myelitis,  syringomyelia,  haemorrhage  into  the  cord,  and  very  rarely  meningitis 
or  bilateral  cerebral  softening.  The  latter  can  only  be  diagnosed  when  there  has 
been  an  apoplectic  seizure  associated  with  hemiplegia,  followed  after  an  interval 
by  another  cerebral  seizure  which,  by  producing  hemiplegia  of  the  opposite 
side  to  the  one  first  involved,  results  in  paraplegia,  or  rather  diplegia.  The 
arms  and  face  are  likely  to  be  affected  as  well  as  the  legs,  and  there  will  be  either 
a  history  of  syphilis  to  account  for  endarteritis  and  thrombosis  in  a  young  male, 
or  a  bruit,  a  history  of  acute  rheumatism,  or  other  evidence  of  a  heart  lesion, 
to  account  for  embolism  ;  or  senile  changes,  with  or  without  albuminuria,  a  high 
blood-pressure,  retinitis,  and  other  signs  of  renal  and  arterial  degeneration,  to 
account  for  haemorrhage. 

Hcemorrhage  into  the  cord  is  hardly  ever  spontaneous  ;  it  may  follow  an 
injury,  such  as  a  bullet  wound  or  a  stab  in  the  back,  and  then  the  history  will 
indicate  the  diagnosis.  Acute  meningitis,  whether  tuberculous,  suppurative, 
posterior  basal,  or  cerebrospinal,  seldom  causes  complete  paraplegia  until  a 
late  stage  of  the  illness  is  reached,  by  which  time  the  nature  of  the  malady 
will  generally  be  indicated  by  the  cerebral  symptoms,  particularly  headache, 
vomiting,  convulsions,  strabismus,  and  ophthalmoscopic  changes  such  as  optic 
neuritis  or  choroidal  tubercles.  Bacteriological  investigations  of  the  fluid 
obtained  by  lumbar  puncture  may  assist  the  diagnosis  materially.  There  is  a 
chronic  form  of  meningitis,  however,  of  which  the  diagnosis  is  not  so  easy,  and 
that  is  the  chronic  hypertrophic  hcemorrhagic  pachymeningitis  which  affects 
chiefly  the  vertex  and  the  cervical  portion  of  the  cord.  The  condition  is 
generally  caused  by  chronic  alcoholism  in  syphilitic  subjects,  especially  if  there 
has  also  been  some  injury  ;  the  diagnosis  is  difficult,  but  it  may  be  suggested 
by  the  history,  and  by  the  degree  of  pain  referred  to  the  nerves  that  are  involved 
in  the  meningeal  thickening — the  chief  difliculty  being  to  exclude  spinal  caries 
in  cases  involving  the  cord.  In  syringomyelia — a  very  slowly  progressive  disease 
that  is  by  no  means  always  associated  with  paraplegia — the  nature  of  the 
symptoms  depends  upon  the  degree  to  which  the  central  canal  of  the  cord  and 
the  gelatinous  substance  around  it  are  affected,  and  also  upon  the  level  in 
the  cord  at  which  the  changes  occur.  The  diagnostic  symptom  is  that,  in 
some  region  or  another,  the  skin  will  be  found  to  have  lost  its  power  of  distin- 
guishing heat  from  cold  and  pain  from  touch,  though  it  still  retains  ordinary 
cutaneous  sensibility.  It  is  apt  to  give  rise  to  skin  lesions  in  the  paraesthetic 
parts  (Morvan's  disease),  and  also  to  acute  painless  swelling  of  the  joints,  with 
deformity  from  destruction  of  the  ends  of  the  bone's — Charcot's  joints — precisely 
similar  to  those  that  may  occur  in  locomotor  ataxy. 


564  PARAPLEGIA 


If  the  patient  has  marked  impairment  of  all  kinds  of  sensation  in  both  legs, 
with  paraplegia  of  the  upper  neurone  type,  and  no  paralysis  of  the  arms,  the 
lesion  is  almost  certainly  transverse  myelitis  of  some  kind.  The  absence  of 
sensory  disturbance,  however,  does  not  exclude  transverse  myelitis,  for  when 
the  conductivity  of  the  spinal  cord  is  interfered  with,  without  being  entirely 
inhibited,  the  sensory  columns  are  able  to  transmit  impulses  longer  than  the 
pyramidal  tracts,  so  that  paralysis  appears  before  anaesthesia.  The  same 
applies  to  a  transverse  myelitis  that  is  getting  better,  the  patient  recovering 
sensation  in  his  legs  before  he  is  able  to  move  them.  The  chief  difficulty  will 
be  to  determine  the  nature  of  the  transverse  myelitis.  There  are  two  main 
types  :  (i)  That  due  to  causes  outside  the  cord  compressing  it — especially 
spinal  caries,  secondary  growth,  the  effects  of  such  injuries  as  fractures  of  the 
spine,  bullet  wounds  and  stabs,  or  more  rarely  erosion  of  the  bones  by  an 
aortic  aneurysm  ;  and  (2)  That  due  to  softening  from  thrombosis  of  a  spinal 
artery,  the  result  of  syphilis,  or  a  fever  such  as  enteric  or  scarlet.  One  of  the 
first  points  to  attend  to  is  the  presence  or  absence  of  pain.  Lesions  such  as 
thrombosis,  which  affect  the  cord  but  not  its  posterior  nerve  roots,  are  painless, 
whereas  swellings  which  compress  the  cord  from  without  almost  always  produce 
pain,  sometimes  a  typical  girdle  pain,  on  account  of  their  irritating  the  posterior 
nerve  roots.  If,  therefore,  there  is  or  has  been  any  pain  in  the  back  other  than 
what  may  be  due  to  a  known  injury,  it  is  probable  that  transverse  myelitis 
is  not  primary  but  due  to  compression.  If  the  spine  presents  an  obvious  Pott's 
curvature,  or  if  the  patient  has  other  evidence  of  peripheral  tuberculosis,  such 
as  enlarged  or  caseating  glands  in  the  neck  ;  hip,  knee,  or  other  joint  disease, 
a  psoas  abscess,  lupus  vulgaris,  and  so  on,  especially  in  a  young  person 
who  has  been  in  the  habit  of  drinking  much  milk,  compression  by  spinal  caries 
is  fairly  certain.  The  main  difficulty  arises  when  the  cord  becomes  compressed 
without  deformity  of  the  spinal  column,  and  with  no  other  tuberculous  lesion 
apparent.  Local  tenderness  over  one  or  more  vertebral  spines  will  help  to  suggest 
the  diagnosis,  especially  if  local  pain  is  complained  of  in  the  same  region,  and  if 
the  pain  is  increased  by  any  jarring  of  the  spine.  Growth  is  fortunately  much 
rarer,  and  it  is  to  be  excluded  by  a  routine  examination  of  all  the  viscera,  most 
cases  of  spinal  new  growth  being  secondary  to  a  neoplasm  elsewhere,  especially 
of  the  breast  ;  primary  growths  of  the  spine  are  so  rare  that  they  are  generally 
taken  for  caries  at  first,  and  the  correct  diagnosis  is  not  always  arrived  at  before 
post-mortem  microscopical  examination  has  been  made.  Aortic  aneurysm 
is  a  still  rarer  cause  of  compression  myelitis  ;  if  there  is  a  distinct  pulsatile 
tumour  along  the  course  of  the  aorta,  the  nature  of  the  case  may  be  obvious  ; 
more  often,  however,  an  aneurysm  which  erodes  the  vertebrae  sufficiently  to 
bulge  into  the  spinal  canal,  does  not  at  the  same  time  enlarge  forward  to  produce 
a  tumour  that  can  be  recognized  easily  by  palpation.  The  patient  will  generally 
be  a  man  in  the  prime  of  life  who  has  had  syphilis,  who  is  not  a  life  abstainer, 
and  who  has  worked  hard.  Apart  from  a  pulsatile  tumour,  the  symptoms  will 
be  very  like  those  of  paraplegia  from  spinal  caries. 

The  relationship  of  injury  to  transverse  myelitis  is  not  always  quite  straight- 
forward. If,  for  example,  a  patient  who  has  syphilitic  endarteritis  of  his  spinal 
vessels  receives  a  kick  in  the  back  from  a  horse,  he  may  find  that,  by  next  day, 
he  is  unable  to  move  his  legs  ;  it  may  at  first  seem  obvious  that  the  kick  has 
been  the  sole  cause  of  the  paraplegia,  when  the  real  cause  is  syphilis — the  kick 
having  been  the  final  factor  which  led  to  thrombosis  in  a  diseased  spinal  artery. 
Transverse  myelitis  due  to  syphilis  is  exactly  comparable  in  its  mode  of  origin 
to  the  hemiplegia  which  results  from  endarteritis  obliterans  in  a  middle  cerebral 
artery.  There  is  no  pain  and  no  deformity  of  the  spine,  but  in  other  respects 
the  paraplegia  presents  the  same  features  as  does  that  which  is  due  to  com- 


PARAPLEGIA  565 


pression  of  the  cord.  Syphilis  is  by  far  the  most  important  cause  of  this  primary 
transverse  softening,  but  there  are  a  considerable  number  of  other  maladies 
in  which  a  similar  result  occasionally  ensues  ;  almost  any  infective  disease  may 
lead  to  it  ;  one  may  perhaps  mention  typhoid  fever,  scarlet  fever,  and  influenza 
in  particular.  In  infective  endocarditis  there  may  be  an  additional  factor, 
namely  embolism  of  the  cord,  though  this  is  decidedly  rare. 

If  it  is  found  that  the  arms  are  affected  as  well  as  the  legs,  it  is  unlikely  that 
the  lesion  is  transverse  myelitis,  unless  in  rare  and  anomalous  cases  such  as 
those  mentioned  on  page  74.  If  the  onset  has  been  slow,  the  course  progressive, 
and  wasting  is  present,  with  reaction  of  degeneration  in  the  muscles  of  the 
hands  or  arms,  with  increased  knee-jerks,  ankle-clonus,  and  extensor  plantar 
reflexes,  but  no  anaesthesia,  the  malady  is  almost  certainly  amyotrophic  lateral 
sclerosis. 

If  there  are  increased  knee-jerks,  extensor  plantar  reflexes,  ankle-clonus, 
ataxy,  intention  tremors  in  the  hands,  nystagmus,  and  a  hesitancy  in  the  voice, 
which  may  even  be  of  the  type  described  as  "  scanning,"  the  disease  is  either 
cerebellar  abscess  or  tumour,  or  disseminated  sclerosis.  If  headache  and  vomiting 
have  been  severe,  the  former  is  the  more  probable,  and  the  diagnosis  may 
be  clinched  by  finding  double  optic  neuritis.  Abscess  will  be  more  likely  than 
tumour  if  there  is  otorrhoea  or  pyrexia.  It  is  not  uncomrnDD  to  find  optic 
atrophy,  with  either  concentric  diminution  in  the  fields  of  vision  or  else  a  central 
scotoma,  in  disseminated  sclerosis,  but  optic  neuritis  is  uncommon.  The 
difficulty  in  diagnosing  disseminated  sclerosis  arises  mainly  when  the  complaint 
is  in  its  early  stages  ;  the  patches  of  sclerosis  may  be  anywhere  in  the  cord, 
and  before  the  affected  fibres  atrophy  there  is  a  period  when  they  are  some- 
times able  to  conduct  impulses,  sometimes  not  ;  when  they  are  not  able  to 
conduct,  there  are  numerous  symptoms,  and  in  a  day  or  two,  when  conducting 
power  recovers,  these  symptoms  are  gone  again  ;  this  variation  from  day  to  day 
nearly  always  leads  to  a  diagnosis  of  neurosis  for  months  or  years  before  the  true 
nature  of  the  malady  becomes  obvious.  In  some  patients  a  central  scotoma 
may  develop  early,  leading  to  peculiar  symptoms,  such  as  the  inability  to 
distinguish  a  sovereign  from  a  shilling  if  the  light  is  not  good,  or  the  liability 
to  run  into  people  without  seeing  them  when  cycling.  If  ataxy  is  marked,  the 
staggering  gait  may  lead  to  a  suspicion  of  alcoholism  ;  the  patient  staggers 
alternately  to  either  side  in  disseminated  sclerosis,  whereas  in  tumours  of  one 
cerebellar  hemisphere  the  tendency  is  to  stagger  constantly  to  the  same  side. 
Bladder  and  rectal  troubles  are  not  common  in  either  case,  and  yet  they  may 
be  prominent.  Parassthesia  may  also  develop  in  disseminated  sclerosis,  although 
as  a  rule  there  is  no  sensory  disturbance  at  all. 

If  a  patient  has  the  symptoms  of  spastic  paraplegia  and  ataxy,  without 
anaesthesia,  nystagmus,  or  changes  in  the  voice,  a  diagnosis  of  ataxic  paraplegia 
will  usually  be  made.  There  is  really  no  difference  between  this  and  what  has 
been  called  combined  scleroses  of  the  cord  ;  in  both  conditions  there  is  degenera- 
tion of  the  posterior  columns,  the  crossed  pyramidal,  and  the  cerebellar  tracts. 
Some  observers  use  the  term  combined  scleroses  only  for  syphilitic  cases, 
reserving  ataxic  paraplegia  for  similar  non-syphilitic  cases. 

Primary  lateral  sclerosis  was  a  relatively  common  diagnosis  until  it  was  found 
that  the  more  careful  the  examination  the  greater  was  the  likelihood  that 
more  than  simple  degeneration  of  the  crossed  pyramidal  tracts  would  be  found. 
Partial  compression  of  the  cord  produces  spastic  paraplegia  without  anaesthesia, 
and  thus  simulates  primary  lateral  sclerosis  as  described  above.  Disseminated 
sclerosis  may  do  so  likewise,  and  so  on.  Primary  lateral  sclerosis  should  never 
be  diagnosed,  therefore,  till  all  the  other  aftections  in  which  the  lateral  columns 
may  be  affected  have  been  excluded.     There  is  such  a  disease  as  primarj'  lateral 


566 


PARAPLEGIA 


C   I- 


D  1- 


J  ELBOW 
WHIST 
JERK 


(Outpr 

4 

- 

THIOH  <  Front 
Inner 

LEO  -  Inner  side 

BUTTOCK 

Lower  part 

Back  of  THIOH 

LEO  &\.exeei!t 
FOOT  jinm'r  part 

^ 

Fig,   146.  —  Diagram    of   sensory 
localization  in  the  spinal  cord. 


Fig.  147. — Diagram  of  localiza- 
tion of  reflex  centres  in 
the  spinal  cord. 
(Frojti  diagratiis  prepared  hy  the  late  D?:  J.  H.  Bryant.) 


PARAPLEGIA  567 


sclerosis,  however  ;  it  is  generally  syphilitic  in  origin,  and  it  leads  to  typical 
spastic  paresis  of  the  legs,  with  increased  knee-jerks,  ankle-clonus,  extensor 
plantar  reflexes,  no  wasting,  no  R.D.,  no  sensory  disturbances,  and  in  the  later 
stages,  retention  of  urine  with  overflow  and  incontinence  of  faeces  ;  the  disease 
is  generally  progressive,  but  after  reaching  a  certain  point  it  may  remain 
stationary  for  years,  or  even  improve  to  a  slight  extent  for  a  time. 

When  lateral  sclerosis  is  yet  in  an  early  stage,  a  valuable  sign  of  it  is  the 
disappearance  of  the  abdominal  reflexes  ;  the  diagrams  {F-igs.  146,  147)  may 
be  of  assistance  in  locating  the  level  of  the  cord  at  which  a  lesion  may  be  present. 

The  causes  of  paraplegia  that  remain  for  discussion  are  Landry's  paralysis, 
general  paralysis  of  the  insane,  functional  paraplegia,  and  malingering. 

Landry's  paralysis  is  probably  not  a  distinct  entity,  but  rather  a  very  acute 
type  of  perhaps  more  than  one  variety  of  paraplegia.  It  is  rare.  It  affects 
young  adults,  who,  hitherto  strong  and  well,  become  rapidly  affected  by  paralysis 
which  starts  in  the  legs  and  quickly  ascends  to  the  trunk  and  arms,  and  may 
even  involve  the  neck  and  cranial  nerves.  It  either  gets  well  quite  rapidly, 
or  else  kills  the  patients  in  a  few  hours  or  days  by  affecting  the  intercostal  muscles 
and  diaphragm,  with  consequent  asphyxia.  There  may  be  slight  pains  in  the 
affected  parts  shortly  before  paralysis  sets  in,  but  sensory  symptoms  are  generally 
slight,  or  absent.  The  nature  of  the  malady  is  obscure,  but  if  one  were  to  regard 
it  as  a  very  acute  and  widespread  anterior  poliomyelitis,  one  could  account 
both  for  its  main  symptoms,  its  rapid  fatality  in  some  cases,  and  its  equally 
rapid  recovery  in  others.  Moreover,  seeing  that  the  patient  either  dies  or 
recovers  so  quickly,  it  is  not  surprising  that  there  is  no  time  for  the  development 
of  obvious  muscular  wasting  or  reaction  of  degeneration. 

Paraplegia  in  cases  of  general  paralysis  of  the  insane  does  not  arise  until  the 
third  stage  of  that  malady  is  reached  ;  by  that  time  the  diagnosis  is  generally 
obvious  ;  it  only  remains  to  add  that  the  paraplegia  is  part  of  a  general  and 
extreme  weakness,  and  the  patient  is  bedridden. 

Functional  paraplegia  and  malingering  should  never  be  diagnosed  until  all 
organic  causes — particularly  disseminated  sclerosis  and  spinal  caries — have 
been  excluded.  Malingering  may  be  suggested  by  the  particular  circumstances 
of  the  case — the  patient  may  be  a  nervous,  self-conscious  girl  who  desires  to 
attract  sympathy,  or  an  out-of-work  who  wants  to  get  a  night's  shelter  in  a 
hospital  ;  careful  observation  generally  leads  to  the  detection  of  the  fraud. 
Functional  paraplegia  is  less  easy  to  be  sure  of,  and  in  many  patients  that  which 
may  at  first  be  regarded  as  functional  ultimately  turns  out  to  be  organic  ;  this 
is  especially  true  in  the  case  of  disseminated  sclerosis.  The  paraplegia  is  never 
of  the  primary  muscular,  or  the  lower  neurone  type,  there  being  no  wasting  and 
no  R.D.  The  muscles  remain  of  good  bulk  as  they  do  in  the  upper  neurone  type 
of  paraplegia,  but  although  the  knee-jerks  may  be  unduly  brisk,  the  plantar 
reflexes  remain  flexor,  and  there  is  no  maintained  ankle-clonus.  If  there  is 
anaesthesia,  the  distribution  of  the  latter  is  sometimes  obviously  functional  ; 
it  may,  for  instance,  start  sharply  at  the  knee  and  cease  suddenly  at  the  ankle, 
or  in  some  other  way  indicate  that  it  corresponds  neither  to  the  segments 
of  the  spinal  cord  nor  to  the  distribution  of  the  peripheral  nerves.  It  is 
by  anomalies  of  this  kind,  which  make  it  impossible  to  fit  in  the  case  with 
any  organic  lesion,  that  functional  paraplegia  is  diagnosed  by  a  process  of 
exclusion.  Herbert  French. 

PARASITES,  INTESTINAL. —  Tape-worms.  —  The  commonest  symptom  of 
the  existence  of  a  tape-worm  is  the  passage  of  the  detached  terminal  segments 
per  rectum  in  longer  or  shorter  tape-like  strips.  The  only  condition  for  which 
these  might  be  mistaken   is  muco-membranous  colitis,  in  which  lona;,  narrow. 


568 


PARASITES,     INTESTINAL 


\ 


white  mucous  casts  of  the  bowel,  a  foot  or  more  in  length,  may  be  passed 
with  the  motions  {Fig.  123,  p.  444).  It  is  easy  to  distinguish  these,  however, 
if  the  suspected  material  is  floated  in  water,  for  in  the  case  of  a  cast  of  the 
bowel,  a  central  lumen  will  be  found  which  is  not  present  in  the  tape- worm. 
There  is,  moreover,  no  regular  segmentation  in  the  case  of  muco-membranous 
colitis,  whereas  tape-worms  are  obviously  segmented.     If  any  doubt  remains, 

examination  with  a  lens  will  show  the 
glandular  structure  of  the  uterus  in 
the  tape-worm  segments,  and  no  such 
structure  in  the  strips  of  mucus  in 
muco-membranous  colitis.  It  is  some- 
times stated  that  picking  of  the  nose 
and  a  voracious  appetite  are  symptoms 
of  the  presence  of  some  kind  of  intes- 
tinal parasite  ;  but  this  is  hardly  ever 
the  case  ;  if  constitutional  symptoms 
develop  at  all,  thej^  take  the  form  of 
deficiency  of  appetite,  with  more  or 
less  anaemia,  which  may  become  pro- 
found ;  there  is  often  considerable 
EosiNOPHiLiA  iq-v.).  The  three  forms 
of  tape-worm  that  occur  in  the 
human  intestine  are  Tcsnia  solium,  T. 
mediocanellata,  and  Bothriocephalns 
latus,  the  commonest  in  Great  Britain 
being  the  T.  mediocanellata,  the  cystic 
stage  of  which  is  spent  in  cattle. 
T.  solium  is  derived  chiefly  from  pig- 
meat,  whilst  Bothrioceplialits  latus  occurs  mainly  in  those  who  live  much  on 
fresh-water  fish.  It  may  be  possible  to  make  the  diagnosis  of  T.  mediocanellata 
by  holding  the  segments  up  against  a  bright  light  and  seeing  a  median  streak 
or  water-channel,    in    addition   to   one  down  either    edge    of    each  strip,    this 


I^!,^.  14S.  —  Head  of  Tcenia  solium  :  showing 
four  sucking  discs  and  thirty-four  hooklets, 
alternately  long  and  short.  (Medium  power.) 
(From  a  specimen  in  the  possession  of  Mr. 
Pellischer,  Nezu  Bond  Street,    II  \) 


Pig.  149.  —  Head  of  Ttenia, 
soli-inn,  semi  -  diagrammatic, 
(Low  power.)  (From  French's 
Medical  Laboratory  Methoiis.) 


Fig\  150.  —  Head  of  I'l-^nia 
mediocanellata.  (Low  power.) 
(From  French's  Medical  Labor- 
atory Methods.) 


Fig.  151. — Lateral  view  of 
head  of  Bothriocephahis 
latus,  showing  longitudinal 
sucking  disc.  (Low  power.) 
(From  French's  Medical 
L  aborafo?y  Methods. ) 


middle  water-channel  giving  the  name  to  the  parasite.  The  ultimate  proof 
of  the  nature  of  the  tape-worm,  however,  is  afforded  by  the  characters  of  the 
head,  that  of  T.  solium  having  four  sucking  discs,  with  a  rostrellum  surrounded 
by  thirty-four  hooklets  [Figs.  148,  149)  ;  that  of  T.  mediocanellata  four  circular 
sucking  discs   and  no  hooklets   [Fig.    150);   whilst  that  ol  the  Bothriocephalus 


PARASITES,     INTESTINAL 


569 


Fig^.  152.  —  Ovum  of  Teenia 
soli-nni,  semi  -  diagrammatic. 
(High  power.)  (From  French's 
Medical  Laboratory  Methods.) 


latus  has  a  more  or  less  conical  head,  with  t\vo  elongated  lateral  sucking  discs 
and  no  hooklets  {Fig.  151).  The  degree  of  anaemia,  chlorotic  in  t\'pe,  is 
usualh'  greatest  with  Bothriocephalus  latus,  least  with  T.  mediocanellata,  and 
the  same  also  applies  to  the  degree  of  eosinophilia.  The  eggs  of  the  tape-worm 
are  unmistakable  [Fig.  152)  ;  they  are  spherical,  with  a  dark-brown  central 
portion,  and  a  lighter  striated  broad  capsule. 

Microscopical  Examination  of  FcBces. — One  of  the  best 
ways  of  preparing  faeces  for  microscopical  examination 
for  the  ova  of  parasites  or  for  other  solid  particles,  is  to 
put  about  as  much  as  would  cover  a  shilling  into  a  test- 
tube,  filling  the  latter  two-thirds  full  of  normal  saline 
solution  (li-  dr.  of  salt  to  a  pint  of  water),  corking  the 
tube,  and  shaking  it  vigorously  in  order  to  break  up  the 
faeces  as  miich  as  possible ;  on  allowing  to  stand  for 
twenty  minutes,  the  upper  part  of  the  fluid  remains 
opaque  with  fine  debris,  whilst  the  heavier  particles, 
including  the  ova  of  parasites,  have  sunk  to  the  bottom  ; 
the  supernatant  opalescent  or  opaque  fluid  mav  now  be 

poured  oft",  and  the  more  definite  residue  again  shaken  up  with  normal  saline  and 
allowed  to  stand  for  another  twenty  minutes  ;  this  process  is  repeated  until  the  super- 
natant fluid  becomes  clear  after  it  lias  stood  for  the  twenty  minutes,  and  then,  when  as 
much  of  the  fluid  as  possible  has  been  poured  away,  a  drop  of  the  sediment  is  taken  up 
in  a  pipette,  transferred  to  a  microscope  slide,  covered,  the  excess  of  fluid  removed  with 
filter  paper,  and  the  specimen  examined  either  with  the  ?  in.  or  \  in.  objective,  prefer- 
ably with  the  mechanical  stage.  Such  a  specimen  exhibits  all  sorts  of  vegetable  cells, 
keratin  particles,  and  so  forth,  which  may  at  first  be  regarded  as  ova,  but  when  the 
actual  ovum  of  an  intestinal  parasite  is  seen,  there  is  seldom  any  doubt  about  it. 

Round-worms.  —  The  only  round-worm  that  occurs  in  Great  Britain  is  the 

Ascaris.  lumbricoides.     This    parasite    may    or    may 

not  give   rise   to    symptoms  ;    if   it   does    so,    they 

take     the    form     of     shght     and     obscure     nervous 

and     gastro-intestinal     disorders.     IMore    often    the 

diagnosis    is    quite    unsuspected    until    one    of   the 

worms    is    found   in    the    bed,    having   crawled  out 

per    anum,   especially  when    the   patient,    generally 

a     child,     falls     ill     of     some    febrile     malady.       If 

round-worms    have   been    found    previously,    and    if 

the    existence   of  others  is   suspected,  the  diagnosis 

may  be   confirmed  by  discovering   the   tj'pical   ova 

[Fig.  153)   in  the  faeces  ;    their  chief  characters  are 

their  relatively  large  size,  oval  shape,  a,nd  irregular 

membranous   envelope   outside    the    chitinous   shell. 

This  worm  does  not  produce  eosinophiha  as  a  rule. 

but  in  exceptional  cases  it  may  do  so. 

Thread-worms.  —  Oxyuris   vermicularis,   if   present   at   all,    usually   occurs   in 

hundreds,  and  can  be  detected  immediateh'  by  examination  of  the  faeces  with 

the  naked  eye.     Each  parasite  is  rather  more  than  rj-  in.  in  length,  without  any 

colour ;  its  extremities  project  from  the  faecal  mass,  and  move  about  slowly,  hke 

threads    waving   in    the    air.     These    parasites    produce    no    eosinophiha.     The 

patients  are  nearly  always  children,  and  there  may  be  no  symptoms  at  all;  but 

more  often  there  is  considerable  irritation  around  the  anus,  and  in  3-oung  girls 

about  the  vulva.     Gonorrhoea  has  before  now  been  suspected  when  the  vulvar 

infection  was  reallv  due  to  the  Oxyuris  vermicularis. 

The  Whip-worm  {Trichocephalus  dispar)  is  in  itself  an  entirely  unimportant 
parasite  occurring  in  the  caecum  and  large  intestine,  and  producing  no  symptoms 
whatever.  The  Avorm  with  its  tail  is  about  i\  in.  in  length,  and  it  is  often 
coiled    up    watch-springwise.       Its    appearances    are    unmistakable  ;    its    ovum 


'■  Fiff.  153. — Ovum  of  Ascaris 
luinhy-icoides.  (High  power.) 
( From  French's  Aledical Labor- 
atory Methods.) 


PARASITES,     INTESTINAL 


{Fig.  154)  looks  more  or  less  like  a  running-cork,  and,  with  its  deep  brown 
central  parts  and  clear  ends,  it  is  quite  characteristic.  Whip-worms  are  present 
to  the  extent  of  nearly  10  per  cent  of  all  the  inhabitants  of  some  cities.  They 
produce  no  eosinophiha,  blood-changes,  or  symptoms. 

The  Hook-worm  [Ankylostoinnm  dtiodenale). — This  is  not  a  general  parasite  in 
Great  Britain,  but  has  affected  many  persons  in  certain  districts  as  the  result 

of  introduction  from  abroad,  particularly^  amongst 
lead-miners  in  Cornwall.  Outbreaks  also  occurred 
in  the  workers  in  the  St.  Gothard  tunnel,  and  the 
disease  is  prevalent  in  many  parts  abroad,  especi- 
ally in  India,  Egypt,  Brazil,  and  Jamaica.  The 
infection  is  carried  from  fseces  to  soil,  from  the 
Fig;.  154.— O^Tim  of  Tricocepha-      goil  to  the  hands,  thence  to  the  mouth,  and  so  to 

lus  disi>a.r.    (High  power.)    (From         , ,  t  .  ,        ^t-i  ,  r        j  i 

French's  Medical  Laboratojy  the  aumentary  canal.  ihe  symptoms  are  lor  the 
Methods.)  most    part    those    of    progressive     anaemia    and 

asthenia,  inabilitj^  to  continue  with  work,  oedema 
of  the  lower  extremities,  shortness  of  breath,  and  the  occurrence  of  boil-hke 
skin  eruptions,  described  popularl}^  as  the  "  flowers "  of  the  disease.  The 
appearance  of  the  patient  may  suggest  pernicious  anaemia,  and  the  blood- 
count  may  sometimes  seem  to  confirm  this  diagnosis  at  first ;  for  whereas 
a  great  many  of  the  patients  have  a  severe  chlorotic  tj'pe  of  anaemia,  some 
have  a  marked  reduction  of  the  red  corpuscles  and  a  sHghtly  less  reduction 
of  the  haemoglobin,  so  that  there  is  a  high  colour-index  such  as  is  characteristic 
of  pernicious  anaemia.  There  is  generally  no  leucoc^'tosis,  but  the  differential 
leucoc^-te-count  maj"  suggest  the  diagnosis  at  once,  for  nearly  all  the  patients 
present  a  considerable  degree  of  eosinophiha.  The  administration  of  anthelmintics 
such  as  thj^mol  ma}-  lead  to  the  evacuation  of  the  mature  worms,  Avhich  may 
be  recognized  in  the  faeces  [Fig.  14,  p.  94),  each  being  from  ^  in.  to  fin.  in 
length.  The  o\-a{Figs.  15  and  16,  p.  94)  are  oval,  with  a  clear  transparent  shell 
and  coiled-up  embryo  parasite.  Melaena  is  another  sj^mptom,  which  maj^  be 
prominent  in  some  of  these  cases. 

The  tW'O  intestinal  parasitic  affections  which  produce  the  most  serious 
anaemias  and  other  toxic  effects  in  man  are  Ankylostomum  duodenale  and 
BothriocephaJus  latus.  Herbert  French. 

PARESIS.— (See  Paralysis.) 

PERISTALSIS,  VISIBLE. — The  importance  of  visible  peristalsis  hes  in  the 
fact  that  it  is  always  pathological  except  in  a  few  cases  in  which  its  unimportant 
nature  is  immediately  obvious.  The  two  chief  conditions  which  render  the 
normal  movements  of  the  bowels  visible  are  divarication  of  the  abdominal  recti 
muscles,  and  ventral  herniation  of  a  laparotomy  scar.  The  latter  is  obvious  at 
once  ;  the  former  is  best  detected  when  the  recumbent  patient,  who  is  generally 
a  multiparous  woman  with  a  soft  flabby  abdomen,  tries  to  raise  her  head  and 
thorax  from  the  couch  without  the  use  of  her  arms  ;  the  contracting  recti  come 
together  then,  and  close  over  the  gap  in  the  middle  hne  in  which,  under  the 
stretched  and  unsupported  skin,  the  bowel  movements  had  been  seen.  Under 
almost  all  other  circumstances  visible  peristalsis  is  pathological  ;  it  may  then 
be  divided  into  two  types — gastric  and  intestinal. 

Gastric  Peristalsis  takes  the  form  of  a  comparatively  large  swelling  in  the 
upper  part  of  the  abdomen,  coming  and  going,  generally  appearing  from  under 
the  region  of  the  left  ribs,  progressing  slowly  downwards  and  to  the  right,  where 
it  fades  away  and  disappears ;  it  corresponds  more  or  less  with  the  greater  curva- 
ture of  the  stomach.  It  is  often  stated  that  a  return  wave,  passing  along  the 
lesser  curvature  from  right  to  left,  can  also  be  made  out,  but  this  is  exceptional. 


PHOSPHA  T  URIA  571 


Sometimes,  instead  of  progressing,  it  comes  and  goes  almost  in  the  same  spot, 
varying  in  shape  but  scarcely  in  position.  The  exact  site  of  the  wave  must 
depend  mainly  upon  the  size  and  position  of  the  stomach.  It  indicates  pyloric 
or  duodenal  obstruction,  and  its  presence  serves  to  exclude  atonic  gastrectasis. 
There  may  or  may  not  be  other  signs  of  dilated  stomach,  particularly  a  widely 
distributed  succussion  splash,  vomiting  of  large  volumes  of  fermenting  fluid  at 
relatively  long  interv^als.  and  a  greatly  increased  bismuth  ;t;-ray  shadow.  Whether 
the  pyloric  stenosis  is  simple  or  malignant  has  to  be  decided  upon  other  grounds. 
Visible  Intestinal  Peristalsis  is,  with  the  limitations  discussed  above,  one  of 
the  surest  signs  of  grave  intestinal  obstruction.  There  are  almost  certain  to 
be  abdominal  distention,  vomiting,  and  constipation  along  with  it,  and  the 
discussion  of  the  differential  diagnosis  of  the  different  causes  of  these  symptoms 
will  be  found  elsewhere.  The  great  importance  of  visible  peristalsis  is  seen 
in  those  doubtful  or  obscure  cases  in  which  the  patient  seems  hardly  ill 
enough  to  be  suffering  from  intestinal  obstruction.  It  may  be  thought  that 
cohc,  the  result  of  some  indigestible  article  of  diet,  is  a  more  hkely  diagnosis, 
and  that  a  dose  of  castor  oil  will  cure  the  malady.  Rather  than  wait  for  increas- 
ing severity-  of  the  symptoms  to  clinch  the  diagnosis  in  these  cases,  it  is  most 
important  to  arrive  at  a  diagnosis  of  the  necessity  for  laparotomy  at  the  earUest 
possible  moment  if  life  is  to  be  saved.  If  the  small  intestine  alone  is  involved, 
the  waves  are  multiple,  and  they  run  more  or  less  transverse!}^  across  the 
abdomen — the  ladder-rung  type  ;  when  the  colon  is  obstructed,  vertical 
waves,  especially  in  one  or  both  flanks,  are  the  chief  form  the  peristalsis  takes. 
Definite  and  visible  intestinal  peristalsis  is.  so  far  as  any  single  sign  can  be 
relied  on,  an  almost  infallible  indication  of  the  need  for  laparotomy  in  any 
case  in  which  the  other  symptoms  and  the  history  point  to  a  possibihty  of 
intestinal  obstruction.  Herbert  French. 

PERSPIRATION,  ABNORMALITIES  OF,— (See  Sweating.) 

PHOSPHATURIA. — This  is  a  term  the  precise  significance  of  which  is  by  no 
means  clear  ;  the  meaning  it  conveys  to  one  observer  is  not  always  that  which  it 
imphes  to  another.  Some  restrict  it  to  conditions  in  which  the  total  quantity 
of  phosphates  in  each  da^-'s  urine  is  greater  than  the  average  maximum.  Others 
use  the  term  when  there  is  a  spontaneous  deposit  of  phosphates  in  the  specimen 
glass.  Others  would  include  cases  in  which,  on  applying  the  boiling  test  for 
albumin,  a  cloud  of  phosphates  comes  down.  So  loose  is  the  application  of  the 
word  phosphaturia  that  it  is  generally  used  whenever  an^-thing  arises  to  remind 
the  observer  ocularly  of  the  fact  that  the  urine  contains  any  phosphates  at  all. 

What  is  reallj-  required  is  a  series  of  different  terms  to  express  the  following 
conditions  : — 

1.  Circumstances  under  which  a  greater  quantity  of  phosphates  is  habitual!}' 
passed  in  the  urine  than  is  the  average  maximum  in  health. 

2.  The  spontaneous  deposition  of  phosphates  in  a  urine  that  has  stood  in  a 
specimen  glass  until  cold. 

3.  The  spontaneous  deposition  of  phosphates  in  the  bladder,  so  that  the  urine 
is  thick  and  milk-like  even  when  it  is  being  passed  per  urethram. 

4.  The  deposition  of  phosphates  as  a  white  cloud  when  the  urine  is  heated. 

Absolute  Phosphaturia. — The  phosphoric  acid  in  the  urine  is  chiefly  exo- 
genous, i.e.  derived  from  phosphates  in  the  food.  It  is  chiefly  in  inorganic 
combination  as  salts  of  the  alkalies  and  alkaline  earths.  There  is  a  certain  small 
percentage  of  urinary-  phosphorus  derived  from  the  katabolism  of  nuclein  and 
lecithin,  but  the  amount  derived  from  these  in  health}-  persons  is  very-  slight  as 
compared  with  that  which  comes  direct  from  the  food,  so  that  the  phosphates 


572  PHOSPHATURIA 


almost  disappear  from  the  urine  during  starvation.  There  are  wide  variations 
in  the  amounts  excreted  by  normal  persons  ;  the  average  is  3-5  grams  per  diem, 
but  the  healthy  linaits  are  as  far  apart  as  i  gram  and  8  grams. 

It  has  been  asserted  that  persons  whose  business  entails  great  wear  and  tear 
of  the  nervous  system  excrete  more  than  the  average  amount  of  phosphates, 
and  the  same  has  generally  been  held  to  be  true  of  sufferers  from  certain  nervous 
disorders  of  the  hysterical  or  neurasthenic  type,  particularly  when  sexual  matters 
are  in  question.  There  is  very  little  evidence,  however,  to  show  that  there  is  any 
real  increase  in  the  urinary  phosphates  in  these  cases.  There  is  often  a  very 
abundant  deposit  of  phosphates  on  applying  the  heat  test  to  the  urine,  and  this 
may  give  the  impression  that  the  total  quantity  of  phosphates  present  must  be 
above  the  normal  ;   but  the  impression  has  not  been  confirmed  by  exact  analysis. 

There  is  only  one  well-defined  condition  in  which  there  is  absolutely  and 
persistently  more  phosphate  in  the  urine  than  healthy  limits  would  allow,  and 
that  is  phosphatic  diabetes — a  very  rare  condition  of  which  the  main  features  are 
thirst,  emaciation,  aching  in  the  loins  and  back,  and  polyuria  wdthout  sugar  but 
with  an  absolute  excess  of  phosphates  in  the  urine. 

Physiology  of  Phosphatic  Deposits. — In  nearly  every  case  the  deposition  of 
phosphates  is  a  purely  physiological  process.  A  molecule  of  phosphoric  acid, 
H.^PO^,  contains  three  hydrogen  atoms.  Each  of  these  can  be  separately 
replaced  by  an  atom  of  any  monobasic  metal,  such  as  sodium.  Three  types  of 
salts  are  formed,  according  as  one,  two,  or  three  of  the  hydrogen  atoms  have  been 
replaced,  as  in  the  following  examples  : — 

NaHjPO^     -  -     Sodium  dihydric  phosphate 

NaoHP04     -         -     Sodium  monohydric  phosphate 
Na3P04         •  -     Sodium  phosphate 

These  salts  may  all  be  present  in  the  same  urine,  the  proportions  of  each 
varying  with  the  amount  of  phosphoric  acid  present,  on  the  one  hand,  and  the 
total  amount  of  bases  (i.e.,  sodium,  potassium,  etc.),  and  the  total  quantities  of 
other  acids  present  in  the  form  of  chlorides,  sulphates,  and  so  forth,  on  the 
other.  The  greater  the  quantity  of  chlorides  and  sulphates,  the  greater  will  be 
the  amount  of  the  metallic  bases  required  to  form  them,  and  consequently  the 
less  will  be  the  amount  of  bases  left  to  combine  with  phosphoric  acid  ;  the 
result  must  then  be  a  relative  excess  of  NaHoP04.  Conversely,  the  scantier  the 
chlorides  and  sulphates,  and  the  more  abundant  the  bases,  the  greater  will  be 
the  proportion  of  NaoHPOj^  and  Na.^POj^. 

Now  the  three  sodium  salts  differ  from  one  another  in  at  least  two  physical 
respects — their  action  upon  litmus,  and  their  solubility  in  water.  Sodium 
dihydrogen  phosphate  (NaHoPO^)  turns  blue  litmus  red — in  other  words,  it  is 
an  acid  phosphate.  The  acidity  of  ordinary  urine  is  mainly  to  due  it.  Sodium 
monohydrogen  phosphate  (Na^HPO^)  is  also  an  acid  salt  technically  speaking, 
and  there  are  some  colour  tests  which  exhibit  the  acid  reaction  along  with  it  ; 
litmus,  however,  is  not  one  of  these,  for  Na.3HP04  turns  red  litmus  blue.  When  a 
given  urine  contains  more  Na„HPOj^  than  NaHoPO^,  the  reaction  of  that  urine 
to  litmus  is  alkaline  ;  that  is  to  say,  it  turns  red  litmus  blue  and  does  not  turn 
blue  litmus  red.  Some  urines  have  what  is  known  as  an  amphoteric  reaction — 
they  turn  red  litmus  bluish  and  blue  htmus  reddish — a  different  thing  from 
neutrality  of  reaction,  in  which  neither  red  litmus  nor  blue  is  turned  in  colour  at 
all.  The  cause  of  the  amphoteric  reaction  of  a  urine  is  the  even  balance  in  that 
urine  of  the  Na.^HPO^  on  the  one  hand  and  of  the  NaH„P04  on  the  other. 

Now  the  dihydrogen  phosphate  is  much  more  soluble  in  water  than  is  the  mono- 
hydrogen  phosphate,  whilst  the  tribasic  phosphates  are  as  a  rule  far  less  soluble 
still.     When  it  is  stated,  therefore,  that  phosphates  are  more  soluble  in  acids 


PHOSPHATURIA 


573 


than  they  are  in  alkahes,  it  must  be  remembered  that  it  is  not  a  question  of  a 
difference  of  solubiUties  of  the  same  salt  of  phosphoric  acid,  but  of  an  acid  urine 
containing  the  bulk  of  its  phosphates  in  a  salt  diff event  from  the  one  present  in  an 
alkaline  urine.  The  very  fact  of  a  urine  being  alkaline  means  that  there  is 
relatively  little  of  the  more  soluble  NaH^.PO^^  present,  and  relativelv  much  of  the 
less  soluble  Xa^HPO^  and  Na.POj^.  Conversely,  the  fact  that  a  urine  is  acid 
implies  that  the  phosphates  are  relatively  more  abundant  in  the  soluble  NaHoPO^ 
form  than  they  are  either  as  Na^HPOji^  or  Na.,POj^.  As  a  matter  of  fact,  the 
three  degrees  of  phosphates  of  sodium,  potassium,  and  ammonium  are  all  so 
soluble  that  they  practically  never  become  spontaneouslv  precipitated,  nor  do 
they  take  part  in  forming  calculi.  It  is  the  phosphates  of  calcium  and  magnesium 
that  form  precipitates,  but  what  has  been  said  above  of  sodium  phosphate  applies 
equally  to  calcium  and  magnesium  phosphates.  The  less  acid  a  urine  is,  the 
more  will  the  less  soluble  varieties  of  calcium  and  magnesium  phosphate  prepon- 
derate, and  it  is  on  this  account  that  phosphates  come  down  in  alkaline  or  neutral 
rather  than  in  acid  urines. 

Again,  it  is  often  stated  that  phosphates  are  less  soluble  in  hot  urine  than  thev 
are  in  cold,  and  this  is  given  as  the  reason  for  the  cloud  of  precipitated  phosphates 
that  so  often  forms  when  a  urine  that  is  not  alreadv  very  acid  is  boiled.  This, 
however,  does  not  express  the  real  reason  for  the  cloud  ;  the  heat  does  not 
precipitate  the  same  phosphate  as  the  cold  urine  contained,  but  leads  to  the 
formation  of  a  different,  and  less  soluble,  phosphate.  The  calcium  mcno- 
hydrogen  phosphate  dissociates  into  calcium  dihydrogen  phosphate  and  normal 
calcium  phosphate  ;    it  is  the  latter  which  is  so  insoluble  that  it  comes  down  : 

4CaHP04  =  CaalPOJ,  +  CalH.PO^jj 

Medium  solubility.  Relatively  insoluble,  and        Relativelv  the  most 

so  coming  down  as  a  cloud.       soluble  of  the  three. 

Milky  Urine. — The  urine  of  many  healthy  people,  especiallv  children,  and 
eaters  of  large  public  dinners,  is  sometimes  milk-like  when  it  is  passed  soon  after 
a  full  meal.  Many  a  person  has  become 
alarmed  at  the  sight,  and  has  feared  some 
grave  disorder  of  the  sexual  organs  or 
functions,  especially  either  gonorrhoea  or 
spermatorrhoea.  The  condition  is  physio- 
logical. It  results  from  increased  quantities 
of  hydrochloric  acid  being  required  in  the 
stomach  at  the  time,  increased  quantities 
of  bases  being  passed  in  the  urine  in  conse- 
quence. The  result  of  this  is  that  the  urine 
tem.porarily  contains  such  an  abundance  of 
bases  in  proportion  to  acids  that  the  less 
soluble  monohydrogen  phosphates  exceed 
the  more  soluble  dihydrogen  phosphates, 
and  they  may  become  precipitated  even  in 
the  urine  that  is  still  within  the  bladder. 
The  commonest  salt  to  come  down  is  cal- 
cium monohydrogen  phosphate,  CaHPOj^,  which  is  either  amorphous,  or  else 
assumes  the  form  famihar  as  "stellar  phosphate."  MgHPO^^  may  come  down 
with  it  in  the  form  of  amorphous  particles,  or  as  needles. 

Ammonio-magnesium  Phosphate. — This,  generally  known  as  triple  phosphate, 
^MgNH^POj^,  is  comparativeh-  insoluble,  and  when  precipitated  it  nearly  always 
assumes  the  form  of  prisms — the  familiar  "  knife-rester  "  or  "  coffin-Ud  " 
crystals    (Fig.    155).       It   is   clear  that   these   will  onlv  come    down  when  the 


Fig'.  155. — Triple  phosphate  crystals. 


5  74  PHOSPHA  T  URIA 


urine  contains  ammonia.  The  latter  naay  of  course  have  been  produced  by 
ammoniacal  decomposition  of  urea  after  the  urine  was  passed.  If  urinary 
decomposition  after  passage  can  be  excluded,  however,  it  is  usually  stated 
that  the  presence  of  ammonio-magnesic  phosphate  crystals  indicates  a  purulent 
lesion  in  the  urinary  tracts,  especially  in  the  bladder.  It  is  quite  true 
that  ammoniacal  urines  from  cases  of  cystitis  often  abound  in  crystals  of 
triple  phosphate.  The  diagnosis  is  given  by  the  pus  cells  and  so  forth, 
however,  and  not  by  the  triple  phosphate  crystals.  It  is  important  to 
remember,  moreover,  that  each  day's  urine  normally  contains  enough  ammonia 
for  ammonio-magnesic  phosphate  crystals  to  occur  in  an  absolutely  healthy 
urine,  even  apart  from  decomposition  on  standing.  This  fact  detracts  very 
greatly  from  the  value  formerly  attributed  to  the  detection  of  triple  phosphate 
crystals  in  the  urine.  Indeed,  the  importance  of  phosphates  in  the  urine  lies 
almost  entirely  in  the  fact  that  errors  of  interpretation  may  arise  unless  their 
physiological  behaviour  is  clearly  understood.  Microscopically  they  are  often 
amorphous,  but  the  three  well-defined  forms  of  crystals  shown  in  Fig.  155 
may  be  recognized  microscopically.  The  chief  chemical  test  is  the  addition  of 
dilute  acetic  acid,  which  causes  a  precipitate  of  phosphates  to  clear  up.  The  main 
importance  of  recognizing  them  correctly  is  to  avoid  mistaking  them  for  pus  in 
the  case  of  a  spontaneous  deposit,  for  spermatozoa,  or  gonorrhoea,  when  the  urine 
comes  milky  from  the  urethra,  and  for  albumin  in  the  case  of  the  boiling  test  for 
the  latter.  Herbert  French. 

PHOTOPHOBIA  may  occur  in  all  inflammatory  affections  of  the  conjunctiva, 
cornea,  or  iris.  It  is  most  extreme  in  children  suffering  from  corneal  affections, 
such  as  superficial  corneal  ulcers  or  interstitial  keratitis.  It  may  also  occur 
in  snow  blindness,  scurvy,  or  albinism,  and  in  normal  persons  after  staying  for 
long  periods  in  the  dark. 

It  has  no  special  diagnostic  significance  in  differentiating  between  various 
forms  of  ocular  inflammation.  Herbert  L.  Eason. 

PIGMENTATION  OF  THE  SKIN. — Anomalies  of  the  natural  pigmentation 
of  the  skin,  on  the  side  either  of  excess  or  deficiency,  may  be  due  to  irritation 
of  the  abdominal  sympathetic,  and  particularly  the  solar  plexus,  leading  to 
general  pigmentation,  or  to  the  exudation  or  extravasation  of  the  colouring 
matter  of  the  blood,  producing  local  pigmentation.  Local  pigmentation  may 
be  brought  about  by  the  action  of  irritants,  may  result  from  a  condition  of  hj^per- 
semia,  or  may  be  a  sequela  of  skin  eruptions.  The  most  familiar  errors  of 
pigmentation  are  covered  by  the  term  chloasma.  This  may  be  either  idiopathic 
or  symptomatic.  Idiopathic  chloasma  is  usually  caused  by  counter-irritants, 
such  as  vesicants,  or  some  other  form  of  external  irritation,  especially  scratching, 
as  in  vagabond's  disease — phtheiriasis  ;  but  in  some  cases  it  is  impossible  to 
trace  the  cause.  Symptomatic  chloasma  is  a  sequela  or  an  accompaniment  of 
cutaneous  eruptions,  or  is  the  result  of  abnormal  conditions  of  the  uterus  or 
of  other  abdominal  viscera,  or  of  cachexia.  It  is  most  often  met  with  as  chloasma 
uterinum,  which  may  occur  not  only  in  connection  with  pregnancy,  but  also  in 
association  with  any  form  of  uterine  irritation.  The  smooth  j^ellowish-brown 
patches  are  seen  most  commonly  on  the  forehead,  but  almost  the  entire  face 
may  be  involved,  and  also  the  trunk  and  limbs.  Somewhat  similar  irregularities 
of  pigmentation  occur  in  rheumatoid  arthritis,  pernicious  ancemia,  Hodgkin's 
disease,  Graves'  disease,  abdominal  tuberculosis,  and  other  disorders  of  the 
abdominal  viscera,  and  in  cases  in  which  arsenic  has  been  given  over  long  periods. 
In  Addison's  disease  there  is  a  general  bronzing  of  the  skin,  together  with  pigment 
deposits  in  the  mucous  membranes  of   the  mouth,  anus,  vulva,  and  urethra  ; 


PIGMEXTATIOX     OF     THE     SKIN  575 

and  pigmentarv  abnormalities  occur  also  in  cachexia  associated  with  malaria, 
cancer,  nodular  leprosy,  and  secondary  syphilis — in  malaria,  a  yellowish-brown 
to  black  ;  in  cancer,  a  sallow  tint  ;  in  nodular  leprosy,  a  fawn  colour  early  in 
the  disease,  and  a  general  bronzing  at  a  later  stage  ;  in  secondary  syphilis,  an 
earthy  tint  affecting  the  face.  In  the  rare  condition  known  as  ochronosis,  the 
skin,  cartilages,  and  sclerotics  are  blackened,  as  the  result  in  some  cases  of  alkap- 
tonuria, in  others  of  the  prolonged  absorption  of  carbolic  acid.  In  hemochroma- 
tosis, another  rare  condition,  apparently  due  to  diseases  of  the  ahmentary  tract 
and  liver,  the  patient  may  be  pigmented  from  head  to  foot,  the  prevailing  colour 
being  a  deep  blue-grey  slate  tint.  The  diagnosis  of  urticaria  pigmentosa  seu 
nigricans  is  generally  clear.  Pigmentary  deposits  in  the  skin  form  only  part  of 
the  skin  changes  characteristic  of  Kaposi's  disease.  The  pigmentation  of 
bronzed  diabetes  can  scarcely  be  misinterpreted  if,  when  the  urine  is  examined, 
glvcosuria  be  found  ;  most  cases  of  this  form  of  diabetes  have  cirrhosis  of  the 
liver  as  well,  so  that  there  is  a  non-teetotal  historj-. 

The  diagnosis  of  the  various  forms  of  chloasma  is  usually  easy,  though  the 
particular  cause  of  the  pigmentation  can  only  be  deduced,  of  course,  from  the 
general  sj'mptoms.  Chloasma  can  be  differentiated  from  chromidrosis,  hj  observ- 
ing that  in  the  latter  condition  the  colour,  which  is  derived  from  the  exuded 
secretions,  readily  disappears  if  washed  with  ether  or  chloroform.  In  tinea 
versicolor,  and  some  other  fungous  diseases  which  resemble  chloasma,  the  patches 
are  not  smooth  but  seal}',  and  the  discoloration  can  be  scraped  off".  The  pigmen- 
tary syphilide,  which  may  take  the  form  of  a  diffused  brownish  hue,  brownish 
spots,  or  dappled  patches,  is  seldom  met  with  except  on  the  neck.  Question 
may  arise  between  chloasma  and  leiicodermia  (vitiligo)  when  in  the  latter  condition 
the  white  areas  have  spread  over  the  greater  part  of  the  body,  and  are  taken  for 
the  normal  colour ;  but  in  leucodermia  the  border  of  the  area  is  concave, 
whereas  in  chloasma  it  is  convex.  Moreover,  in  leucodermia  the  history  is  that 
of  the  formation  of  white  patches  surrounded  by  a  pigmented  border,  which 
may  spread  until  large  areas,  and  even  the  whole  surface  of  the  body,  are 
affected. 

Leucodermia  has  in  its  turn  to  be  distinguished  from  sclerodermia,  morphoea, 
macular  leprosy,  pigmentary  syphihde,  and  partial  albinism.  The  skin  is  not 
stiff"  and  thickened  as  it  is  in  sclerodermia.  The  edges  are  not  streaked  with 
small  dilated  vessels,  making  a  pink  or  violet  border,  as  in  morphoea,  nor  is  there 
a.nY  interminghng  of  atropliic  striae.  The  patches  are  not  destitute  of  sensation 
as  in  nerve-leprosy,  nor,  though  it  has  been  styled  "  white  lepros}',"  has  leuco- 
dermia any  other  resemblance  to  that  affection  save  the  colour  of  the  patches. 
Doubt  as  between  leucodermia  and  a  congenital  condition  hke  partial  albinism 
could  only  arise  by  disregarding  the  historj'.  Of  albinism  itself,  whether 
partial  or  universal,  nothing  more  need  be  said  here  ;  for  though  it  is  an 
abnormality  of  pigmentation,  its  true  character  can  never  be  in  question. 
Xor  need  I  speak  of  jaundice,  for  that  condition  forms  the  subject  of  a 
separate  article. 

Discoloration  of  the  skin  may  be  due  to  the  prolonged  administration  of 
drugs.  Thus  picric  acid  may  turn  the  skin  and  the  conjunctivae  3'ellow,  arsenic 
may  cause  a  pecuhar  greyish,  brownish  or  freckle-like  pigmentation,  nitrate  of 
silver  may  set  up  the  condition  known  as  argyria,  in  which  the  integument  and 
the  mucous  membrane,  particularly  in  situations  exposed  to  light,  take  on  a 
bluish-grey  or  grej^dsh-black  colour,  especially  on  the  face  and  the  flexor  aspects 
of  the  hmbs.  This  condition  may  closely  resemble  hsemochromatosis  and 
similar  abnormahties,  but  the  history  of  protracted  use  of  the  drug  will  make 
the  diagnosis  clear.  Since,  however,  arsenic  mav  be  derived  from  some  un- 
suspected source,  as  was  the  case  in  the   peripheral  neuritis  epidemic  in  and 


5  7f>  PNE  UMA  T  URIA 


around  Manchester  due  to  beer  containing  it  as  an  impurity,  chemical  analysis 
of  the  hair  should  be  made,  which  will  serve  to  prove  or  disprove  a  suspicion 
that  the  patient  has  been  ingesting  arsenic,  as  the  latter  becomes  stored  up  in 
the  hair  that  grows  ^\-hilst  the  arsenic  is  being  taken.  Malcolm  Morris. 

PLANTAR  REFLEX,  EXTENSOR.— (See  Babinski's  Sign.) 

PNEUMATURIA — or  the  passage  of  gas  per  urethram,  either  along  with  or 
independently  of  urine — is  a  rare  symptom,  but  when  it  does  occur  it  is  a  very 
striking  one,  particularly  in  males. 

It  maj^  be  due  to  one  or  other  of  t^vo  entirely  distinct  groups  of  causes,  namely  : 

1 .  Communication  betw^een  the  rectum,  caecum,  vermiform  appendix,  or  other 
part  of  the  alimentary  canal  and  the  bladder,  ureter,  or  renal  pelvis  ;  either 
directly,  or  via  an  intermediate  gas-containing  abscess  cavity. 

2.  Infection  of  the  bladder  or  other  part  of  the  urinary  tract  by  micro- 
organisms that  produce  gas,  Avithout  there  necessarily  being  any  breach  of 
surface  of  the  mucosa. 

When  the  cause  lies  in  the  first  group,  the  patient  is  very  liable  to  pass 
fsecal  material  at  the  same  time  as  the  gas,  and  the  differential  diagnosis 
between  the  various  possible  lesions  will  be  found  discussed  under  F^ces 
PASSED  PER  Urethram.  It  should  be  added,  however,  that  the  passage  of 
gas  without  faeces  per  urethram  by  no  means  excludes  there  being  a  fistulous 
communication  between  some  part  of  the  alimentary  canal  and  the  urinary 
tract ;  the  fistula  may  be  tortuous,  so  that  gas  gets  along  it,  but  not  faeces. 
It  may  happen,  moreover,  that  a  lesion  such  as  appendicitis  has  led  to  the 
formation  of  a  local  abscess  which,  owing  to  its  infection  by  the  Bacillus  coli 
communis,  contains  gas  ;  this  abscess  may  open  into  the  bladder  and  cause  the 
discharge  of  pus  and  gas,  but  no  faeces,  per  urethram.  The  same  applies  to 
other  abscesses  which,  though  not  arising  primarily  in  connection  with  the  bowel, 
nevertheless  occasionally  contain  gas  from  infection  by  the  B.  coli  communis — 
a  suppurating  ovarian  dermoid  cj^st,  for  instance,  a  suppurating  hydatid  cyst, 
or  a  pyosalpinx. 

Sometimes  there  may  be  serious  doubts  as  to  whether  the  gas  is  finding  its 
way  into  the  urinary  passages  from  some  external  source,  as  above,  or  whether 
it  is  being  produced  in  situ.  In  the  absence  of  any  rectal  or  other  pelvic  or 
abdominal  evidence  of  disease  outside  the  bladder,  it  will  be  remembered  that 
several  different  organisms  are  able  to  produce  gas  when  they  grow  in  urine  ; 
notably  the  Bacillus  coli  communis,  and  in  glycosuric  cases,  various  yeasts, 
including  the  common  yeast.  The  urine  will  be  examined  for  sugar,  and  if 
it  be  present,  a  catheter  specimen  will  be  obtained  to  see  if  saccharomyces 
are  present  in  the  bladder-urine  ;  if  so,  and  if  there  is  no  pus  or  evidence  of 
infection  by  other  micro-organisms,  the  nature  of  the  pneumaturia  will  be  clear  ; 
as  a  rule,  in  these  cases  the  patient  voids  urine  that  is  bubbly  rather  than 
distinct  and  separate  from  the  gas.  If,  on  the  other  hand,  no  sugar  is  present,  a 
catheter  specimen  will  be  cultivated  to  find  out  whether  the  B.  coli  communis 
is  present,  and  if  so,  in  what  quantity.  If  it  is,  and  if  no  sign  of  any  fistulous 
communication  between  any  part  of  the  bowel,  or  a  gas-containing  abscess 
cavity,  and  the  urinary  tracts,  can  be  made  out,  then  there  will  be  a  presump- 
tion that  the  pneumaturia  is  due  to  coli  bacilluria,  although  the  latter  is 
far  commoner  without  than  with  pneumaturia.  The  urine  in  these  cases  may 
contain  very  little  obvious  pus  and  only  a  trace  of  albumin  ;  it  may  be  acid, 
and  not  foul  smelling  or  ammoniacal  ;  on  the  other  hand,  it  may  sometimes 
be  so  foul  and  faeculent  as  to  cause  serious  suspicions  of  a  communication 
betAveen  the  colon  and  the  bladder,  even  when  there  is  none.     A  cystoscopic 


PNEUMOTHORAX  577 


examination  will  serve  to  exclude  a  fistulous  opening  into  the  bladder, 
but  it  may  be  much  more  difficult  to  exclude  a  similar  communication  with 
the  higher  parts  of  the  urinary  tract,  especially  the  renal  pelvis.  The  latter 
condition  is  so  rare,  however,  that  it  is  wiser  to  diagnose  coli  bacilluria  only 
unless  there  is  direct  evidence  of  a  cause  for  communication  between  the  bowel 
and  the  renal  pelvis,  such  as  a  carcinoma  coli.  Herbert  French 

PNEUMOTHORAX,  or  gas  in  the   pleural  cavity,  may  exist  with  or  without 
clear  fluid,  pus,  or  blood  in  the  lower  part  of  the  pleura  at  the  same  time.     If 
there  is  any  kind  of  fluid  in  the  cavity  along  with  the  air,  the  fact  is  generally 
made  obvious  at  once,  when  the  patient's  thorax  is  auscultated  whilst  it  is 
being  actively  or  passively  shaken,   so   as  to   produce   the   typical   succussion 
splash,  often  followed  by  the  ringing  sounds  made  by  drops  of  fluid  falhng  from 
the  compressed  lung  into  the  pool  of  fluid  beneath.     The  nature  of  the  fluid — 
hvdro-pneumothorax,     pyo-pneumothorax,     or    hsemo-pneumothorax,     as    the 
case  may  be — can  seldom  be  diagnosed  except  by  obtaining  some  of  it  by  means 
of  an  exploring  needle  and  syringe.     Whether  the  pneumothorax  is  or  is  not 
associated  with  any  of  these  fluids,  the  diagnosis  is  generally  easy  on  account 
of  the  deficiency  in  movement  of  the  affected  side  of  the  chest,  the  displacement 
of  the  heart  in  the  opposite  direction,  and  hyper-resonance  to  percussion,  together 
with  remarkable  deficiency  or  complete  absence  of    the  vesicular  murmur  and 
voice  sounds.     The  coin-tap  sound,  obtained  by  placing  one  silver  coin  on  the 
chest  wall,  tapping  it  with  another  silver  coin,  and  listening  through  the  stetho- 
scope for  the  ringing  echo  produced  when  the  sign  is  positive,  may  serve  to  confirm 
the  diagnosis,  but  it  is  not  essential.      Partial  pneumothorax,  in  which  complete 
collapse  of  the  lung  is  prevented  by  former  adhesions,  is  proportionately  more 
difficult  to  diagnose,  but  the  same  type  of  physical  signs,  including  the  coin-tap 
sound  or  bruit  d'airain,  will  generally  be  found  in  these  cases,  though  in  less 
degree  than  when  the  pneumothorax  is  complete.     The  ;i;-rays  show  an  abnormal 
clearness  corresponding  to  the  air  in  the  pleural  cavity.     It  is  not  sufficient, 
however,  merely  to  diagnose  pneumothorax  ;   its  cause  has  to  be  determined 
from  amongst  the  following  : — 
Phthisis  :    {a)  early,  ip)  late. 
Rupture  of  an  emphysematous  bleb. 
Gangrene  of  the  lung  with  necrosis  of  the  pleura. 
Empyema  ruptured  through  the  lung. 
Instrumental  :   e.g.  after  tapping  a  pleural  effusion. 
Stabs,  or  gunshot  wounds  of  the  chest  wall. 
Epithelioma  of  the  oesophagus  ulcerating  into  the  pleura. 

Gastric  ulcer  or  carcinoma  ventriculi,  leaking  so  as  to  produce  a  gas-containing 
sub-diaphragmatic  abscess,  which  in  its  turn  may  perforate  the  diaphragm  and 
cause  a  pneumothorax. 

Infection  of  the  pleural  cavity  by  gas-producing  organisms,  such  as  the 
Bacillus  coli  communis. 

The  commonest  cause  by  far  is  phthisis  ;  and  when  the  occurrence  of  the 
pneumothorax  does  give  rise  to  symptoms,  it  is  generally  due  to  comparatively 
earl}^  phthisis  ;  indeed,  when  a  sudden  acute  attack  of  pain  in  one  side  of  the 
chest,  associated  with  rapid  shallow  breathing,  and  cyanosis  with  or  without 
.  haemoptysis  develops  in  a  young  adult  without  apparent  cause,  it  is  almost  certain 
that  the  patient  has  a  tuberculous  focus  at  one  apex,  even  though,  as  frequently 
happens,  there  have  been  no  abnormal  symptoms  previously,  such  as  cough  or 
night  sweats,  and  even  though  absolutely  no  abnormal  physical  signs  can  be 
detected  at  the  apex  of  the  other  lung.  There  may  be  a  Httle  sputum,  and  in 
this  tubercle  bacilli  may  be  detected. 

D  37 


578  PNEUMOTHORAX 


When  pneumothorax  is  attributed  to  rupture  of  an  emphysematous  bleb,  there 
must  always  remain  in  the  physician's  mind  a  serious  doubt  as  to  whether  it 
is  not  really  due  to  a  bleb  in  the  immediate  neighbourhood  of  an  undiagnosable 
tuberculous  deposit,  and  the  case  should  be  treated  as  one  of  potential  phthisis. 

If  the  tuberculous  process  in  the  lung  has  made  considerable  advance  pneumo- 
thorax is  far  less  common,  because  there  will  almost  certainlj^  have  been  pleurisy 
with  thickening  and  adhesions  sufficient  to  prevent  pneumothorax  occurring  ; 
nevertheless,  in  some  such  cases  pneumothorax  does  develop,  and  the  diagnosis 
of  its  cause  is  easy  both  on  account  of  the  abnormal  physical  signs  and  of  the 
sputum  with  the  tubercle  bacilli  in  it.  In  a  later  stage  still,  the  occurrence  of 
pneumothorax  may  cause  very  little  additional  disturbance,  on  account  of  the 
extent  of  lung  already  diseased,  and  although  its  cause  would  be  obvious  enough, 
the  occurrence  of  the  pneumothorax  often  escapes  detection. 

When  the  patient  has  had  a  pleuritic  or  pleural  effusion  tapped,  the  detection 
of  air  free  in  the  pleural  cavity  upon  the  next  day  is  by  no  means  an  uncommon 
occurrence  ;  it  does  not  follow  that  this  air  has  leaked  in  through  the  tapping 
instrument,  for  it  is  quite  as  commonly  derived  from  the  rupture  of  the  super- 
ficial alveoli  which  have  been  re-expanded  rather  too  rapidlj^  in  the  withdrawal 
of  fluid  by  the  aspirator.  The  air  generally  becomes  re-absorbed  in  a  few 
days,  and  the  temporary  pneumothorax  is  of  little  significance. 

Similar  escape  of  air  into  the  pleural  cavity,  as  the  result  of  cuts,  stabs, 
fractured  ribs,  or  gun-shot  wounds,  is  remarkably  rare  ;  this  rarity  depends 
upon  the  fact  that  the  two  layers  of  pleura  tend  to  cohere  in  a  way  similar  to 
that  which  makes  two  thin  sheets  of  Indian  paper  difficult  to  separate,  so  that 
when  an  injury  from  outside  penetrates  one  layer,  it  nearly  alwaj^s  perforates 
both,  and  air  from  within  the  lung  escapes  into  the  subcutaneous  tissues  instead  of 
into  the  pleural  cavity,  and  produces  surgical  emphysema  instead  of  pneumo- 
thorax. It  rarely  happens  that  an  injury  separates  a  sufficient  area  of  the 
two  layers  of  pleura  one  from  the  other  to  cause  a  pneumothorax. 

All  the  remaining  causes  of  pneumothorax  in  the  list  above  are  uncommon, 
and  none  of  them  will  arise  without  there  having  been  other  sj^mptoms  to 
indicate  the  nature  of  the  malady.  It  is  possible  for  an  empyema  to  rupture 
into  a  bronchus,  and  so  lead  to  the  sudden  expectoration  of  much  foul  pus, 
without  any  pneumothroax  arising,  or  at  least  none  of  any  extent,  because  for 
such  an  empyema  to  rupture  into  the  lung  it  must  have  been  shut  off  all  round 
by  firm  pleural  adhesions.  Gangrene  of  the  lung,  such  for  instance  as  that  which 
may  follow  upon  a  foreign  body  becoming  impacted  in  a  bronchus  ;  septic 
bronchopneumonia  due  to  inhalation  of  particles  from  a  cancerous  tongue  or 
to  septic  emboli  from  thrombosis  of  a  lateral  sinus  and  jugular  vein  in  connec- 
tion with  otitis  media  ;  growth  of  the  lung  breaking  down,  or  lobar-pneumonia 
becoming  entirely  necrotic — these  are  only  the  terminal  factors  of  an  already 
serious  disease,  and  pneumothorax  due  to  these  causes  may  even  pass  without 
recognition  on  account  of  the  severity  of  the  symptoms  already  existing  in 
the  case.  Gas-containing  abscesses  beneath  the  diaphragm,  such  as  may  either 
perforate  directly  into  the  pleural  cavity  or  lead  to  infection  of  that  cavit}'  by 
the  Bacillus  coli  communis  or  other  gas-forming  organism,  never  arise  suddenly-, 
but  are  preceded  by  a  simple  or  malignant  ulceration  of  either  the  stomach, 
duodenum,  or  colon,  the  symptoms  of  which  will  generalh'  have  existed  for  days, 
weeks,  or  months ;  so  that  if  the  possibility  of  gas  appearing  in  the  pleural  cavity 
in  this  way  is  borne  in  mind,  the  diagnosis  of  its  origin  need  not  be  difficult.  The 
;ir-rays  maj^  serve  to  show  a  large  gas  bubble  below  the  diaphragm  as  well  as 
gas  in  the  pleural  cavity,  and  that  the  gas  bubble  is  not  intragastric  may  be 
demonstrated  by  filling  the  stomach  with  a  bismuth  meal  and  finding  that  the 
gas  bubble  does  not  become  blackened.  Herbert  French 


POLYCYTH.^MIA  579 


POLYCYTHEMIA. — The  term  polycythemia  is  used  to  denote  a  material 
increase  of  the  red  corpuscles  above  their  normal  number  per  cubic  millimetre 
of  blood.  In  males  they  should  average  5,000,000  per  c.mm.  ;  in  females, 
4,500,000.  Any  considerable  increase  above  these  figures,  for  instance  up  to 
6,000,000  per  c.mm.,  or  more,  constitutes  polj^cythaemia.  Figures  as  high  even 
as  14,000,000  are  sometimes  reached.  The  following  are  some  of  the  conditions 
in  which  polycythaemia  occurs  : — ■ 

1.  Congenital  heart  disease  of  the  type  spoken  of  as  morbus  coeruleus  — 
generally  due  to  pulmonary  stenosis  (see  Fig.  50,  p.  184). 

2.  Persons  who  live  in  high  altitudes. 

3.  Patients  afflicted  with  chronic  shortness  of  breath,  with  a  tendency  to 
periodic  cyanosis,  particularly  cases  of  (a)  mitral  stenosis,  {b)  fibroid  lung  with 
and  without  bronchiectasis,  (c)  chronic  bronchitis  and  emphysema,  (d)  spasmodic 
asthma,  (e)  some  renal  cases. 

4.  Patients  who  have  recently  lost  a  quantity  of  fluid  from  the  tissues,  the 
result  of  such  conditions  as  (a)  severe  vomiting,  e.g.,  the  uncontrollable  vomiting 
of  pregnancy  ;  (b)  severe  diarrhcea,  e.g.,  the  summer  diarrhoea  of  infants, 
cholera,  ptomaine  poisoning,  arsenic  ;  (c)  inability  to  obtain  fluid  to  drink, 
especially  if  there  exists  already  a  disease  tending  to  polyuria,  such  as  diabetes 
mellitus,  diabetes  insipidus,  or  granular  kidney. 

5.  Splenomegalic  polycythaemia. 

As  a  rule,  the  diagnosis  of  the  cause  of  polycythemia  in  a  given  case  is  not 
difficult.  When  it  is  due  to  congenital  heart  disease  it  is  nearly  always  associated 
with  an  extreme  degree  of  cyanosis  without  proportionate  dyspnoea,  and 
with  clubbing  of  the  fingers,  both  these  dating  from  birth,  or  early  childhood. 
The  patient  is  generally  young,  though  some  survive  into  adult  life.  There  is 
not  always  a  cardiac  bruit,  and  the  precise  lesion  will  then  be  obscure  ;  often, 
however,  percussion  shows  increased  cardiac  dullness  to  the  right  of  the 
sternum,  and  upwards  towards  the  second  left  rib,  indicating  increased 
size  of  the  right  auricle  and  ventricle  ;  and  in  most  cases  there  is  either  a 
loud  rumbling  or  blattering  systolic  bruit  of  pulmonary  stenosis,  heard  loudest 
in  the  second  left  space  close  to  the  sternum,  but  also  audible  over  the  greater 
part  of  the  precordial  region,  and  often  over  both  sides  of  the  chest  in  front  and 
behind  ;  or  else  a  very  similar  universal  systolic  bruit,  differing  chiefly  in  having 
its  maximum  intensity  either  behind  the  sternum  between  the  two  fourth  ribs, 
or  else  in  the  fourth  left  intercostal  spaces  close  to  the  sternum,  indicative  of 
patent  septum  ventriculorum.  These  two  lesions  may  both  be  present  in  the 
same  patient,  and  they  are  the  commonest  cause  in  cases  of  morbus  coeruleus 
that  survive  infancy.  The  red  corpuscles  seldom  number  less  than  6,000,000 
per  c.mm.,  and  in  some  cases  they  have  been  no  fewer  than  14,000,000  per  c.mm. 
The  percentage  of  haemoglobin  is  also  greatly  increased,  but  usually  to  a  less 
degree  than  are  the  red  cells,  so  that  the  colour  index  falls  below  i .  This  applies 
to  nearly  all  causes  of  polycythaemia.  There  is  no  simultaneous  increase  in 
the  number  of  leucocytes  per  c.mm.,  and  the  differential  leucocyte  count  falls 
within  the  normal  limits.  It  is  noteworthy  that  cases  of  persistent  ductus 
arteriosus  seldom  present  either  cyanosis,  clubbed  fingers,  or  polycythaemia. 

Residence  at  high  altitudes  often  causes  polycythaemia.  The  increase  is 
seldom  extreme,  but  the  red  cells  not  infrequently  reach  6,000,000  or  more 
per  c.mm.  This  rule  is  not  by  any  means  universal,  however,  though  upon  the 
whole  the  higher  the  altitude  the  higher  the  normal  average  number  of  red  cells 
per  c.mm.,  particularly  in  those  who  have  resided  long  and  continuously  in  the 
mountains.  The  individuals  are  not  ill  ;  it  is  merely  that  their  red  cells  stand 
at  a  higher  figure  normally  than  do  those  of  dwellers  nearer  sea  level. 

Quite  apart  from   the  presence   or   absence   of  anasarca,   patients   suffering 


58o  POLYCYTHEMIA 


from  chronic  lesions  which  tend  to  produce  dyspncea  are  also  very  apt  to  have 
polycythaemia,  particularly  when  the  lesion  causes  marked  redness  of  the  lips. 
This  is  very  well  seen  in  many  cases  of  mitral  stenosis  when  there  has  been  a 
tendency  for  some  time  past  for  failure  of  compensation  to  ensue.  There  is  no 
similar  polycythaemia  in  aortic  cases  unless  mitral  disease  is  present  as  well, 
and  the  red  cells  are  much  less  increased  in  mitral  regurgitation  than  in 
mitral  stenosis.  In  the  latter  they  often  reach  6,000,000  or  even  7,000,000 
per  c.mm.,  and  it  would  seem  to  be  an  attempt  on  nature's  part  to  try  and 
compensate  for  the  failing  circulation  by  distributing  the  haemoglobin  over 
a  larger  corpuscular  area.  The  same  explanation  probably  accounts  for  the 
similar  polycythaemia  due  to  morbus  coeruleus,  and  to  high  altitudes,  and  to 
certain  cases  of  fibroid  lung,  bronchiectasis,  emphysema,  chronic  bronchitis,  renal 
disease  with  chronic  dyspnoea,  and  spasmodic  asthma,  in  which  some  degree 
of  polycythaemia,  though  not  the  rule,  is  sometimes  met  with,  just  as  it  is  in 
mitral  stenosis.  The  colour  index  is  less  than  i,  for  although  the  haemoglobin 
is  increased,  it  is  less  so  than  are  the  red  cells.  The  leucocytes  remain  unaltered. 
The  polycythaemia  will  seldom  if  ever  be  the  most  prominent  symptom  in  the 
case,  so  that  the  diagnosis  will  nearly  always  have  been  made  upon  other  grounds 
— the  presystolic  bruit  at  the  impulse  ;  the  displacement  of  the  heart  towards 
that  side  where  the  lung  presents  an  impaired  note,  with  or  without  crackling 
rales  and  bronchial  breathing  ;  and  so  on.  The  maintenance  of  the  poly- 
cythaemia is  important,  however,  and  therapeutic  measures  should  be  directed 
to  this  end,  for  many  cases  of  mitral  stenosis  with  5,000,000  red  cells  per  c.mm. 
are  relatively  anaemic  ;    they  should  have  6,000,000  or  more. 

The  effect  of  cholera,  ptomaine  poisoning,  arsenic,  summer  diarrhoea  of  infants, 
severe  thirst  that  cannot  be  assuaged,  the  toxcemia  of  pregnancy,  and  so  on,  in 
concentrating  the  blood  by  withdrawing  or  withholding  fluid  from  it,  and  thus 
producing  some  degree  of  polycythaemia,  is  an  acute  condition  which  is  to 
be  counteracted  by  continuous  saline  infusion  or  some  similar  method  of 
restoring  fluid  to  the  tissues.  The  polycythaemia  seldom  reaches  any  marked 
degree  except  in  quite  early  stages,  for  instance,  in  cholera  ;  later,  the  red  cells 
in  the  blood  disintegrate  more  rapidly  than  they  are  replaced,  and  the  poly- 
cythaemia is  thereby  masked.  In  measuring  the  concentration  of  the  blood  in 
these  conditions,  it  is  of  less  value  to  count  the  red  cells  than  to  measure  the 
specific  gravity.  This  is  most  readily  done  by  the  chloroform  and  benzene 
method.  The  specific  gravity  of  chloroform  is  high,  that  of  benzene  is  low, 
and  by  mixing  the  two  in  different  proportions  it  is  possible  to  obtain  fluids  of 
every  intermediate  specific  gravity.  A  mixture  of  the  two  of  the  normal  specific 
gravity  of  the  blood,  viz.,  1056,  is  made,  and  poured  into  a  specimen  glass  of 
sufficient  depth  to  allow  a  urinometer  to  float  in  it.  For  strict  accuracy,  certain 
corrections  in  the  readings  of  the  ordinary  urinometer  are  required,  but  for 
emergency  use  the  instrument  will  serve.  The  lobule  of  the  patient's  ear  is 
pricked,  a  large  drop  of  blood  is  allowed  to  fall  into  a  suitable  small  cup  or 
other  receiver  containing  some  of  the  chloroform-benzene  mixture,  and  thence 
transferred  to  the  main  bulk  of  the  fluid  in  the  specimen  glass.  If  the  blood- 
drop  sinks,  more  chloroform  must  be  added  ;  if  it  floats,  more  benzene  ; 
ultimately  a  point  is  reached  at  which  the  blood-drop  neither  sinks  nor  floats  ; 
the  specific  gravity  of  the  chloroform-benzene  mixture  is  then  the  same  as  that 
of  the  blood.  In  cases  of  collapse  from  loss  of  fluid,  there  is  a  rise  in  the  specific 
gravity  of  the  blood,  even  when  there  is  no  polycythaemia, — and  the  greater  the 
rise,  the  greater  the  need  for  infusion. 

Splenomegalic  polycythcemia  is  a  somewhat  rare  condition  that  is  also  termed 
erythrcemia,  or  erythrocythcsmia.  Its  name  suggests  its  main  features,  which 
are  :    Enlargement        the  spleen,  increase  in  the  red  cells  up  to  as   many  as 


POLYURIA  581 

10,000,000  per  c.mm.,  or  even  more,  and  duskiness  or  lividity  of  the  face  and 
of  the  extremities.  The  nature  of  the  malady  is  still  obscure,  though  some 
regard  it  as  due  to  disease  of  the  bone-marrow.  It  affects  adults  and  females 
rather  than  children  and  males,  and  its  course  is  chronic.  It  only  remains 
to  add,  that  whereas  to  be  typical  the  spleen  must  be  enlarged,  there  are  cases, 
probablv  of  the  same  affection,  in  which,  without  the  spleen  becoming  palpable, 
the  onlv  definite  clinical  signs  are  progressive  lividity  and  polycythaemia. 

Herbert  French- 
POLYDIPSIA. — (See  Thirst,  Extreme.) 

POLYURIA. — The  term  polyuria  signifies  the  passage  of  more  than  the 
average  amount  of  urine  per  diem.  It  may  be  either  (I)  Transient  or  (II)  Con- 
tinued. It  is  important  not  to  mistake  frequency  of  micturition  for  polyuria, 
for  although  the  latter  almost  necessarily  causes  the  former,  there  are  many 
conditions  that  lead  to  frequency  of  micturition  without  polyuria — for  example, 
tuberculous  ulceration  of  the  bladder,  enlargement  of  the  prostate,  or  urethral 
stenosis,  in  all  of  which  urine  may  be  passed  frequently,  but  in  small  quantities 
at  a  time.  In  case  of  doubt  the  total  amount  of  urine  passed  in  each  period  of 
twentv-four  hours  should  be  measured.  The  normal  limits  are  very  wide,  the 
average  being  about  50  ounces  per  diem,  more  being  passed  in  cold  weather 
than  in  warm,  during  rest  than  after  exercise,  waking  than  sleeping,  and  after 
drinking  than  after  taking  little  fluid  by  the  mouth.  Under  certain  conditions 
the  total  amount  exceeds  200  ounces  per  diem,  or  even  two  gallons.  The  point 
at  which  polvuria  begins  is  arbitrary  ;  if  a  patient  passes  70  ounces  or  more 
per  diem  it  is  almost  certain  to  attract  attention,  and  therefore  to  merit  the  term 
polyuria. 

In  degree,  the  polvuria  due  to  causes  in  Group  I  seldom  exceeds  100  ounces 
a  dav  ;  some  of  the  causes  in  Group  II,  especially  diabetes  mellitus  and  diabetes 
insipidus,  may  cause  polyuria  to  the  extent  of  200  ounces,  or  even  300,  400, 
500,  600,  or  more,  per  diem. 

In  arriving  at  the  differential  diagnosis  of  the  cause  in  any  given  case,  one  of 
the  first  points  to  note  is  whether  the  polyuria  is  persistent ;  or  whether,  even 
if  recurrent,  it  is  transient.  Any  of  the  causes  that  usually  give  persistent 
polvuria  may  in  some  individuals  produce  the  symptom  intermittently,  but 
upon  the  whole  one  may  classify  the  causes  of  polyuria  as  follows  : — 

I. — Causes   of   Transient   Polyuria. 

1.  After  drinking  abundance  of  water  or  other  fluid. 

2.  After  drinking  fluids  containing  diuretic  principles,  such  as  alcohol  (beer, 

gin,  whisky,  hock)  ;  caffeine  (tea,  cocoa,  coffee)  ;  citrates  or  tartrates 
(artificial  lemonades). 

3.  As  the  result  of  nervousness,  or  of  nervous  attacks,  such  as  : — 

(a)  Medical  examination  for  life  assurance 

(b)  Preparation  for  some  physical  or  mental  competition 

(c)  Hysteria,  especially  during  recovery  from  an  acute  outburst 
{d)  Neurasthenia 

{e)   After  an  epileptic  attack 

(/)    After  migraine 

{g)   After  an  asthmatic  attack 

[h)   After  an  attack  of  angina  pectoris 

{i)    Periodic  polyuria,  apparently  without  cause. 

4.  Hydronephrosis,  with  periodic  emptj'ing  of  the  renal  sac,  especially  with 

movable  kidney  or  with  renal  calculus. 

5.  The  cold  stage  of  a  malarial  attack. 


582  POLYURIA 

6.  In  some  cases  of  convalescence  from  a  febrile  illness,  such  as  enterica  or 

pneumonia. 

7.  As  the  result  of  the  clearing  up  of  extreme  oedema  or  serous  effusions, — 

for  instance,  during  recovery  from  acute  nephritis  ;  mitral  stenosis, 
with  heart  failure  ;  cirrhosis  of  the  liver,  and  so  on  ;  especially  if 
the  fluid  clears  up  quickly  after  giving  diuretic  remedies,  such  as  blue 
pill,  digitalis,  calomel,  copaiba  resin,  potassium  salts,  uva  ursi, 
broom  tops,  or  dwarf  elder. 

When  the  cause  lies  in  Group  I  its  nature  is  generally  obvious,  though  it  is 
essential  to  examine  the  urine  carefully  for  sugar,  albumin,  and  renal  tube-casts, 
for  purposes  of  exclusion.  Nevertheless,  the  diagnosis  may  be  in  doubt  until 
the  course  of  the  symptom  has  been  watched  for  a  while.  For  instance,  polyuria 
may  seem  to  be  due  to  profuse  drinking,  when  really  the  kidnej's  are  granular 
and  contracted  ;  or  in  a  life  insurance  case,  nervousness  may  seem  to  be  the 
cause,  when  there  has  really  been  a  bout  of  drinking  ;  or,  again,  the  drinking 
may  be  secondary  to  the  extreme  thirst  produced  by  diabetes  insipidus. 

Excessive  Drinking. — When  due  to  drinking  water,  tea,  wine,  spirits,  or  artifi- 
cial lemonades,  the  polyuria  ceases  when  the  drink  in  question  is  limited  or 
avoided. 

Nervousness.  — The  history  and  circumstances  of  the  case,  together  with  the 
absence  of  signs  of  gross  disease  of  heart  or  kidneys,  will  be  the  main  factors  in 
deciding  whether  the  polj-uria  is  caused  by  excitement,  nervousness,  hysteria, 
or  neurasthenia. 

Epilepsy. — The  character  of  the  convulsive  seizures,  their  recurrence  at  inter- 
vals, and  the  influence  of  bromides  upon  them,  will  serve  to  diagnose  epilepsy, 
for  polyuria  in  association  with  the  latter  nearly  always  follows  immediately 
after  an  attack  of  grand  mal.  It  may,  however,  be  associated  with  petit  mal,  or 
even  be  the  chief  phenomenon  in  some  cases  of  epilepsy. 

Migraine. — The  diagnosis  of  migraine  depends  on  the  history  of  the  case  and 
the  absence  of  optic  neuritis  and  other  evidence  of  gross  intracranial  disease. 

Asthma. — Asthma  is  sometimes  easy  to  diagnose,  sometimes  very  difficult ; 
it  may  be  mistaken  for  recurrent  bronchitis,  cardiac  dj^spncea,  renal  dj'spnoea 
or  urcemic  "  asthma,"  mediastinal  new  growth,  thoracic  aneurysm,  thymic 
"  asthma,"  laryngeal  papilloma  or  fibroma,  foreign  body  in  the  air-passages, 
syphilitic  stenosis  of  a  bronchus,  goitre,  or  hysteria.  It  so  frequently  develops 
into  emphysema  and  bronchitis  that  one  is  apt  to  forget  that  the  essential  sym- 
ptom of  asthma  is  dyspnoea,  and  not  cough.  To  diagnose  a  difficult  case  it  may 
be  necessary  to  examine  the  chest  with  the  .y-ra^^s  to  exclude  aneurysm  and  new 
growth  ;  to  examine  the  larjmx  and  vocal  cords,  the  heart,  the  retinae,  and  the 
urine ;  to  exclude  renal  and  cardiac  mischief  ;  and  even  then,  doubt  maj'  remain 
unless  there  is  a  clear  and  typical  account  of  the  nature  of  the  earlier  attacks  in 
a  patient  who  has  had  recurrences  for  years,  and  who  is  relieved  by  cocaine 
sprays  to  the  nose,  b}^  ethereal  tincture  of  lobelia,  by  inhalations  of  stramonium 
fumes,  or  by  other  anti-asthmatic  remedies  ;  it  may  sometimes  be  of  assistance 
to  know  that  Eosixophilia  [q.v.)  is  more  likely  to  be  found  during  an  attack  of 
asthma  than  as  the  result  of  any  of  the  other  conditions  that  may  simulate  it. 
The  polyuria  occurs  in  by  no  means  every  case  ;  when  it  does  so,  it  generally 
follows  immediately  after  an  attack,  and  this  applies  also  in  cases  of  angina 
pectoris,  the  diagnosis  of  which  is  not  difficult  when  the  acute  attacks  of  precordial 
pain  radiate  upwards  and  outwards  to  the  left  shoulder  and  down  the  left  arm, 
and  when  there  is  evidence  of  an  aortic  lesion,  or  of  atheroma,  and  arterio- 
sclerosis with  high  blood-pressure. 

Periodic  Polyuria,  apparently  without  cause,  is  a  condition  which  is  regarded 
by  some  as  a  clinical  entity  ;   the  diagnosis  must  always  be  difficult  to  be  sure  of 


POLYURIA  583 


however,  and  the  more  carefully  a  cause  is  looked  for,  the  fewer  will  be  the  cases 
remaining  in  this  category;  it  will  be  found  that  some  are  due  to  epilepsy; 
others  to  secret  drinking  ;  others  to  granular  kidney  ;  others  to  hydronephrosis, 
and  so  on. 

Hydronephrosis,  with  periodic  emptying  of  the  renal  sac,  is  the  chief  cause  of 
typically  periodic  polyuria.  The  diagnosis  is  arrived  at  by  having  the  urine 
carefully  measured  each  day,  and  by  carefully  palpating  the  loins  bimanually 
for  evidence  of  renal  enlargement.  When  a  kidney  swelling  can  be  detected, 
and  when  this  increases  in  size  at  the  same  time  that  less  urine  is  being 
passed,  whilst  it  materially  decreases  on  the  days  when  the  polyuria  occurs, 
the  diagnosis  of  hydronephrosis  or  pyonephrosis  is  clear  ;  and  the  distinction 
between  the  two  depends  on  whether  there  is  or  is  not  pyuria.  The  commonest 
causes  for  hydronephrosis  are  movable  kidney  and  renal  calculus  ;  and  the 
;v-rays  often  serve  to  distinguish  the  latter  from  the  former.  It  should  be  noted 
that  the  bowels  should  have  been  well  emptied  shortly  before  the  ;v-rays  are 
used  in  examining  kidney  for  stone,  for  otherwise  the  dark  and  light  areas  due  to 
alternating  faeces  and  gas  in  the  bowel  render  it  impossible  to  be  sure  about  the 
shadow  cast  by  a  calculus. 

Fevers. — The  polyuria  that  occurs  during  the  cold  stage  of  a  malarial  attack 
is  speedily  replaced  by  the  opposite  condition  when  the  hot  stage  is  reached  ; 
the  diagnosis  is  afforded  by  the  circumstances  of  the  case,  such  as  residence  in  a 
malarial  district  and  previous  attacks  of  the  malady  ;  by  the  discovery  of 
malarial  parasites  in  blood-films  ;  by  the  absence  of  leucocytosis,  the  relative 
increase  in  the  large  lymphocytes  in  the  differential  leucocyte  count,  and  by  the 
beneficial  effects  of  quinine  upon  the  disease.  Polyuria  during  convalescence 
from  other  fevers,  such  as  enterica  or  pneumonia,  is  not  uncommon  ;  it  is  a 
phenomenon  that  may  attract  some  attention  at  the  time,  but  it  seldom  gives 
rise  to  difficulty  in  diagnosis. 

(Edema  and  Diuretics. — The  considerable  polyuria  that  often  results  in  renal 
or  cardiac  cases  when  oedema  is  clearing  up  under  treatment  is  noteworthy,  but 
the  diagnosis  is  not,  as  a  rule,  difficult.  If  the  polyuria  is  due  merely  to  the 
excretion  of  accumulated  fluid,  it  will  cease  when  there  is  no  longer  any  oedema  ; 
whilst  if  it  is  due  to  granular  kidney,  or  other  underlying  malady,  it  will  continue 
even  after  the  oedema  has  gone. 

II. — Causes    of   Continued   Polyuria. 

1.  Diabetes  mellitus. 

2.  Red  granular  contracted  kidneys. 

3.  Arteriosclerosis. 

4.  Pale  granular  contracted  kidneys. 

5.  Lardaceous  or  amyloid  kidneys. 

6.  Cystic  kidneys. 

7.  Diabetes  insipidus  : 

[a)   Due  to  no  gross  nervous  lesion 

{b)   Due  to  tumour  or  injury  of  the  medulla  oblongata. 

8.  Incorrigible  drinking  of  beer  or  spirits. 

9.  Phosphatic  diabetes. 

10.  Azotic  diabetes. 

11.  Some  cases  of  acromegaly. 

12.  Some  cases  of  m^^xoedema. 

Diabetes  Mellitus. — A  very  important  step  in  the  diagnosis  is  to  examine  the 
urine  carefully.  If  sugar  is  present,  a  diagnosis  of  diabetes  mellitus  will  be  made, 
especially  if  diacetic  acid  and  acetone  are  also  present,  and  the  specific  gravity 


•584  POLYURIA 


is  between  1035  and  1045.  Some  authorities  distinguish  in  kind  as  well  as  in 
degree  between  what  they  term  true  diabetes  mellitus  on  the  one  hand,  and 
ahmentarv  glycosuria  on  the  other,  though  others  hold  that  these  differ  only 
in  degree  ;  it  is  chiefly  in  severe  diabetes  of  young  people  that  poh'uria  is  marked, 
something  between  100  and  600  ounces  of  urine  being  passed  per  diem  ;  in 
elderly  people  with  glycosuria  the  polyuria  is  often  slight  ;  in  these  cases  the 
specific  gravitv  need  not  be  above  the  normal,  and  diacetic  acid  and  acetone 
are  generally  absent.  If  no  sugar  is  present  upon  one  occasion  it  may  be  on 
another,  so  that  several  examinations  may  be  required. 

Albuminuria. — If  sugar  is  persistently  absent^  diabetes  mellitus  can  be 
excluded,  and  special  attention  should  be  devoted  to  testing  for  albumin.  If 
this  is  present,  and  the  pohoiria  cannot  at  once  be  attributed  to  anything 
so  obvious  as  the  clearing  up  of  oedema  or  the  administration  of  a  diuretic, 
the  next  thing  is  to  make  a  very  careful  microscopical  examination  of  the 
centrifugahzed  deposit  for  renal  tube-casts  ;  if  the  latter  are  absent,  and  if  the 
patient  is  a  young  adult  male,  who  seems  to  be  in  good  health,  whose  heart  and 
other  organs  present  no  abnormal  physical  signs,  and  whose  polyuria  troubles 
him  chiefl}-  at  times  of  excitement,  for  instance  when  he  is  in  for  an  examination, 
the  diagnosis  is  very  likely  to  be  that  of  "  functional  "  or  "  physiological  " 
albuminuria,  in  which  case  repeated  tests  will  show  that  the  urine  is  often  quite 
free  from  albumin,  especially  the  first  thing  in  the  morning,  and  the  blood-pressure 
would  not  be  raised.  If,  on  the  other  hand,  more  than  an  occasional  renal  tube- 
cast  was  found,  and  the  albumin  and  polyuria  Avere  persistent,  the  diagnosis  of 
one  or  other  of  the  following  renal  lesions  would  suggest  itself  :  red  granular 
contracted  kidney-,  arteriosclerosis,  pale  granular  contracted  kidney,  lardaceous 
kidney,  or  cvstic  kidne}-.  The  differential  diagnosis  bet^veen  these  is  discussed 
under  Albuminuria  (q.v.). 

Diabetes  Insipidus. — If  neither  albumin  nor  sugar  is  found,  even  on  repeated 
testing,  and  if  the  polyuria  is  extreme  and  persistent,  whilst  the  specific  gravity 
of  the  urine  is  constanth"  low  (1004  to  1008),  a  diagnosis  of  diabetes  insipidus 
will  suggest  itself,  and  it  will  probably  be  correct.  Before  this  diagnosis  is 
finally  made,  however,  precautions  must  be  taken  to  determine  that  the  patient's 
thirst  and  polyuria  are  not  due  to  habits  of  drinking  to  excess  :  it  may  be  difficult 
to  decide  this  in  cases  in  which  alcohoUc  beverages  are  consumed  ;  but  when 
the  patient  is  a  water-drinker,  and  5'et  cannot  do  with  less  than  8  or  10  pints  a 
day,  the  drinking  is  probably  a  necessity,  and  not  a  habit  ;  and  diabetes  insipidus 
is  the  probable  diagnosis.  In  cases  of  doubt,  the  difficulty  can  be  decided  by 
restricting  the  intake  of  fluid  and  determining  the  specific  gravity  of  the 
blood.  This  should  be  about  1056,  and  in  a  case  where  poh^uria  is  due  to 
drinking  habits,  restriction  of  fluids  will  not  materially  alter  it  ;  in  a  case  of 
diabetes  insipidus  with  restricted  intake  of  fluids,  however,  the  drain  of  the 
latter  from  the  blood  still  goes  on,  and  the  specific  gravity  rises  to  1060,  or  1065, 
unless  the  patient  is  allowed  fluid  by  the  mouth  again. 

Phosphatic  and  Azotic  Diabetes. — Another  point  that  needs  investigation  in 
a  case  suspected  to  be  diabetes  insipidus,  is  the  amount  of  solids  excreted  daily 
in  the  urine.  In  ordinary  diabetes  insipidus  the  total  solids  are  normal,  the 
only  increase  being  in  the  water.  There  are  rare  cases  in  which,  in  addition  to 
polyuria,  there  is  a  great  increase  in  the  total  solids  in  the  urine  also — so-called 
haruria.  Rare  though  these  cases  are,  they  have  been  divided  into  two  types, 
namely,  those  in  which  the  inorganic  salts  are  most  increased — phosphatic 
diabetes  (p.  572),  and  those  in  which  the  nitrogenous  constituents  are  mainly 
augmented — azotic  diabetes.  The  diagnosis  here  depends  mainly  on  quantita- 
tive estimation  of  the  various  urinary  substances. 

There  are  two  groups  of  diabetes  insipidus,  according  as  there  is,  or  is  not,  a 


PRIAPISM  585 


gross  lesion  of  the  central  nervous  system.  If  the  malady  follows  on  a  fractured 
base  of  the  skull,  or  if  there  are  vomiting,  headache,  optic  neuritis,  or  other 
symptoms  of  cerebral  tumour,  there  is  probably  a  gross  lesion  of  the  base  of  the 
brain  in  or  near  the  medulla  oblongata — thrombosis,  softening,  haemorrhage, 
small  aneurysm,  gumma,  glioma,  or  other  neoplasm.  In  other  cases,  the  com- 
plaint arises  after  a  fright  or  shock,  or  even  without  any  apparent  cause,  and 
there  seems  to  be  no  gross  lesion  to  account  for  it. 

Acromegaly  and  Myxoedema. — It  only  remains  to  add  that  symptoms  not 
unlike  those  of  diabetes  insipidus  have  sometimes  arisen  in  cases  of  acromegaly 
and  in  myxoedema.  There  is  probably  a  nervous  factor  in  both  cases,  coupled  in 
myxoedema  with  dryness  of  the  skin,  and  consequent  deficiency  in  perspiration  ; 
whilst  in  acromegaly  there  is  the  tumour-like  enlargement  of  the  pituitary  body 
which  may  cause  polyuria  like  any  other  lesion  near  the  medulla  oblongata. 
The  diagnosis  of  acromegaly  may  be  confirmed  by  the  Ar-rays,  which  will  show 
the  great  enlargement  of  the  bones  of  the  hands,  feet,  and  head  ;  whilst  in 
myxoedema,  if  the  general  symptoms,  the  pseudo-oedema  of  the  legs,  the  acquired 
dullness  of  intellect,  the  increasing  weight,  and  the  broadening  of  the  features, 
the  fingers,  and  the  hands,  do  not  at  once  indicate  the  nature  of  the  complaint, 
the  beneficial  effects  of  treatment  by  thyroid  extract  may  serve  to  clinch  the 
diagnosis.  Herbert  French. 

PRECORDIAL  PAIN.— (See  Pain  in  the  Chest.) 

PRIAPISM  signifies  erection  of  the  penis,  continual,  of  troublesome  degree, 
and  not.  necessarily  accompanied  by  sexual  desire.  Though  generally  spoken 
of  in  connection  with  the  male  sex,  a  precisely  similar  affection  may  occur  in 
the  female  clitoris.  The  symptom  is  not  often  by  itself  of  diagnostic  importance, 
though  it  may  be  due  to  a  considerable  number  of  different  causes.  Most  of 
the  latter  need  be  little  more  than  enumerated,  for  if  they  are  borne  in  mind 
they  will  nearly  always  lead  to  a  speedy  diagnosis.  Two  in  particular  merit 
special  mention,  however.  The  first  of  these  is  priapism  in  elderly  men.  The 
marriage  of  old  men  with  relatively  young  wives  is  often  spoken  of  as  foolish, 
and  doubtless  in  most  instances  this  adjective  is  deserved ;  but  in  the  case  of 
some  old  men  who  are  widow-ers  or  unmarried,  it  becomes  a  matter  of  physical 
necessity  for  the  relief  of  priapism  which  is  most  troublesome,  and  which  yet 
cannot  be  called  pathological.  In  some  such  cases  there  may  be  enlargement 
of  the  prostate,  or  local  inflammation  such  as  gouty  urethritis,  but  in  many  other 
cases  the  priapism  seems  to  occur,  without  pathological  cause,  as  a  sort  of  final 
outburst  of  sexual  energy  before  the  onset  of  senile  impotence. 

The  other  special  condition  under  which  priapism  may  be  exceedingly  trouble- 
some is  after  injury  to  the  upper  dorsal  region  of  the  spinal  cord.  The  damage 
may  be  so  serious  as  to  have  produced  a  fracture  dislocation  of  the  spine  with 
paraplegia,  in  which  case  the  diagnosis  will  be  obvious  ;  short  of  this,  however, 
there  may  have  been  only  a  minor  degree  of  injury,  with  contusion  and  perhaps 
multiple  small  haemorrhages  into  the  substance  of  the  cord,  in  association  with 
which  priapism  may  in  some  instances  be  very  pronounced  and  last  for  weeks 
or  months  before  recovery  occurs. 

For  the  rest,  the  causes  of  priapism  may  be  summarized  briefly  according 
to  age  periods,  the  chief  being  : — 


Priapism  in  infancy  : — 
Phimosis 
Oxaluria 

Worms,   especially  oxyuris 
vermicularis 


Balanitis 

Posthitis 

Calculus,  urethral  or  vesical 

Certain  conditions  of  mental  deficiency. 


586  PRIAPISM 


Priapism  at  puberty  : — 

The  changes  in  the  genital  organs  associated  with  the  onset  of  puberty. 

Priapism  in  young  adult  life  : — 

Sleeping  on  the  back  Fracture  of  the  dorsal  spine 

Xon-emptying  of  the  bladder  Transverse   myelitis    of   the   upper 


when  full 
Ill-litting  trousers 
Sexual  excitement 
Gonorrhoea 
Epilepsy 
After  circumcision 


dorsal  region 
Spinal  meningitis 
Certain  aphrodisiac  drugs  : — 

Cantharides 

Turpentine 

Alcohol,  especially  port  wine  in 


Masturbation  some    persons,    champagne    in 

Convalescence  from  an  acute  others 


disease 
Tetanus 
Hydrophobia 
Leukaemia 


Strvchnine 
Cannabis  indica 
Camphor 
Phosphorus 
Damiana. 


Priapism  in  older  men  : — 

The  male  menopause 

Local  irritation  as  the  result  of  : — 

Gouty  urethritis  j  HaBmorrhoids 

Enlarged  prostate  |  A  loaded  rectum. 

Hemorrhage  into  the  middle  lobe  of  the  cerebellum 

Lesions  of  the  pons  varolii. 

Very  seldom  indeed  will  priapism  be  the  only  symptom  in  the  case  ;  the 
diagnosis  will  be  made  from  the  history  and  from  the  other  symptoms. 

Herbert  French. 

PROLAPSE  OF  THE  UTERUS.— As  a  matter  of  practical  fact,  the  uterus  only 
descends  as  a  result  of  a  much  wider  displacement  of  all  the  movable  structures 
which  go  to  make  up  the  pelvic  floor.  This  is  composed  of  a  movable  or  pubic 
portion,  and  a  fixed  or  sacral  portion,  and  it  is  descent  of  the  pubic  portion  which 
produces  the  actual  lesion  known  as  prolapse  of  the  uterus.  In  other  words, 
the  uterus  onlj'  descends  because  it  is  a  part  of  the  pubic  portion  of  the  pelvic 
floor.  Modern  anatomical  research  has  shown  that  the  uterus,  bladder,  and 
anterior  vaginal  wall  are  normally  kept  in  position  chiefly  by  the  connective 
tissue  sheaths  which  accompany  the  blood-vessels  supplying  them,  and  that 
it  is  injur}'  and  stretching  of  this  connective  tissue  which  allows  of  descent  of 
the  organs  named.  There  is  no  doubt,  however,  that  injuries  to  the  fixed  portion 
of  the  pelvic  floor,  the  perineal  bod}',  and  levatores  ani  muscles  and  their  fasciae, 
will  contribute  something  to  the  facihty  with  w-hich  the  structures  mentioned 
may  descend.  In  practice,  therefore,  prolapse  of  the  uterus  and  descent  of  the 
pelvic  floor  lead  to  the  appearance  of  a  swelling  at  the  vaginal  orifice.  There 
are  other  swellings  which  come  do^^-n  the  ^•agina  and  appear  at  the  vulva,  and 
from  them,  therefore,  prolapse  of  the  uterus  has  to  be  diagnosed.  These  swell- 
ings are  :  (i)  Hypertrophic  elongation  of  the  cervix  uteri;  (2)  A  tumour  protrud- 
ing from  the  vagina  ;  (3)  Inversion  of  the  uterus  ;  (4)  Cystocele  and  rectocele  ; 
(5)  Extroversion  of  the  bladder  through  an  i^ijiiry  in  its  floor. 

I.  Hypertrophy  of  the  Cervix. — The  hypertrophy  may  be  of  the  vaginal,  the 
intermediate,  or  the  supravaginal  portion.  The  first  is  always  congenital,  and 
consists  of  elongation  of  the  portio  vaginahs.  It  may  protrude  from  the  vaginal 
entrance,  but  the  vaginal  fornices  will  be  found  unaltered  at  their  usual  level, 
and  the  sound  will  pass  an  increased  distance  proportionate  to  the  length  of  the 


PROLAPSE     OF     THE     UTERUS  587 

portio.  The  os  uteri  forms  the  apex  of  the  protrusion.  The  fundus  remains 
at  its  usual  level.  In  hypertrophy  of  the  intermediate  portion,  the  anterior 
fornix  of  the  vagina  is  carried  downwards  with  the  cervix,  and  may  be  obliter- 
ated, whilst  the  posterior  fornix  remains  at  its  usual  level,  because  the  elongated 
portion  lies  between  the  insertion  levels  of  the  anterior  and  posterior  vaginal 
walls.  The  sound  passes  an  increased  distance,  and  the  os  uteri  forms  the  apex 
of  the  protrusion.  The  fundus  remains  at  its  usual  level.  In  hypertrophy  of 
the  supravaginal  portion,  both  fornices  are  carried  down  with  the  cervix,  and 
both  may  be  obliterated.  The  bladder  is  displaced  downwards,  but  the  rectum 
does  not  descend.  The  fundus  uteri  will  be  found  on  bimanual  examination  to 
be  at  its  usual  level,  whilst  in  true  prolapse,  the  fundus  uteri  descends  as  a 
whole  with  the  rest  of  the  uterus.  It  is  common  for  some  prolapse  of  the  uterus 
as  a  whole  to  accompany  elongation  of  the  cervix,  and  this  can  only  be 
appreciated  by  a  careful  bimanual  examination. 

2.  A  Tumour  protruding  into  or  from  the  vagina  is  most  commonly  a  fibromyoma 
of  the  uterus.  It  may  be  either  a  pedunculated  growth  from  the  cervix,  or  a 
pedunculated  growth  protruding  through  the  cervix,  in  either  case  hanging  free 
in  the  vagina.  It  may  grow  from  the  cervix  in  the  connective  tissue  in  front, 
between  the  uterus,  bladder,  and  anterior  vaginal  wall ;  or  behind,  between  the 
uterus,  rectum,  and  posterior  vaginal  wall.  In  either  case  the  vaginal  wall  is 
stretched  over  the  growth.  In  such  cases  the  uterus  will  be  felt  high  up,  the 
growth  hanging  from  or  protruding  through  the  cervix  in  the  case  of  pedunculated 
growths.  In  the  latter  the  hard  ring  of  the  cervix  is  felt  encircling  the  pedicle. 
In  the  case  of  sessile  interstitial  growths,  the  cervix  is  high  up  in  front  or  behind 
the  growth,  as  the  case  may  be,  and  if  the  tumour  is  a  large  one,  may  be  out  of 
reach  altogether.  In  any  case  there  is  no  descent  of  the  uterus,  and  it  may  even 
be  higher  than  usual.  The  growth  may  be  a  fibroid  growing  from  the  vaginal 
wall,  a  mucous  polypus  of  the  cervix,  or  a  malignant  groivth. 

3.  Inversion  of  the  Uterus  may  be  chronic,  or  may  be  encountered  immediately 
after  labour  as  an  acute  condition  which  could  hardly  be  mistaken  for  anything 
else,  except  perhaps  extrusion  of  a  fibroid  immediately  after  delivery.  In  the 
latter  case  the  tumour  protrudes  through  the  cervix,  whilst  the  whole  uterus 
can  be  felt  above  it  bimanually,  whereas  in  inversion  the  uterus  turns  inside- 
out,  partially  or  completelj^,  a  cup-shaped  depression  is  felt  above  instead  of 
the  rounded  fundus,  and  a  finger  or  the  sound  will  only  pass  a  short  way  by 
the  side  of  the  mass,  or  not  at  all  if  inversion  is  complete.  Both  conditions 
may  be  accompanied  by  haemorrhage,  but  that  with  inversion  may  be  exceed- 
ingly severe.  Acute  inversion  is  always  accompanied  by  great  shock,  whilst 
extrusion  of  a  fibroid  is  not. 

Chronic  inversion  is  more  likely  to  be  mistaken  for  prolapse  or  a  polypoid 
fibromyoma.  It  is  distinguished  from  prolapse  in  that  the  uterus  does  not 
necessarily  descend  as  a  whole,  the  cervical  ring  is  felt  high  up  in  its  usual 
position,  and  the  sound  will  only  pass  a  short  distance  all  round  the  protruding 
mass,  according  to  the  degree  to  which  the  uterus  is  inverted.  A  cup-shaped 
depression,  instead  of  the  rounded  fundus,  is  felt  in  the  vaginal  vault  by  a  hand 
on  the  abdominal  wall. 

4.  Cystocele  and  Rectocele  more  often  accompany  prolapse  of  the  uterus,  but 
may  occur  independently  of  it.  They  are  essentially  bulgings  of  the  anterior  or 
posterior  vaginal  walls  towards  or  through  the  vaginal  entrance,  the  bladder  or 
rectum  being  attached,  and  following  them  of  necessity.  A  sound  passed  into 
the  bladder,  or  a  finger  in  the  rectum,  will  directly  enter  the  bulging  vaginal  wall, 
whilst  the  uterus  will  be  felt  bimanually  above  in  its  normal  position. 

5.  Extroversion  of  the  Bladder  can  occur  either  through  a  congenital  defect 
in  its  wall,  or  through  an  injury  to  its  basal  portion.      For  instance,  in  removing  a 


PRURITUS 


growth  from  the  vaginal  wall,  a  gap  may  be  left  in  the  bladder  through  which 
extroversion  may  occur.  The  mucous  membrane  will  be  exposed  in  the  vagina, 
and  on  it  will  be  seen  the  two  orifices  of  the  ureters,  with  urine  issuing  by  inter- 
mittent jets.     The  uterus  in  such  a  case  ma}'  have  its  normal  position. 

Thos.  G.  Stevens. 
PROPTOSIS. — (See  Exophthalmos.) 

PRURITUS. — Itching  may  be  a  substantive  affection,  associated  with  no 
visible  lesions  of  the  skin,  save  those  due  to  scratching,  or  a  subjective  symptom 
of  a  large  number  of  cutaneous  diseases.  It  is  to  the  former  condition  that 
the  word  "  pruritus  "  should  be  restricted  ;  but  in  this  article  the  subject  of 
itching  generally  will  be  dealt  with.  In  both  senses  of  the  term,  the  idiopathic 
and  the  symptomatic,  hyperaesthesia  appears  to  be  the  most  important  pre- 
disposing cause.  The  diseases  of  which  itching  is  a  symptom  may  be  either 
neuroses,  such  as  hysteria,  hypochondriasis,  and  other  affections  of  the  nervous 
centres,  or  general  nutritive  disorders  affecting  the  nervous  system  secondarily, 
such  as  arthritism  and  diabetes  mellitus  ;  or  the  irritation  may  be  set  up  by  the 
attacks  of  parasites,  or  by  definite  skin  lesions.  Itching  varies  in  character  : 
it  may  be  interpreted  by  the  patient  as  a  tingling,  or  pricking,  or  as  a  formication — 
a  feeling  as  of  insects  crawling  on  the  skin.  It  varies  also  in  degree,  from  a  mild 
sensation  which  is  welcome  to  the  patient  from  the  pleasure  he  finds  in  scratching, 
to  an  irritation  so  severe  and  persistent  as  to  endanger  his  life  from  sleeplessness, 
or  his  reason  from  the  nervous  irritability  which  it  sets  up.  The  affections 
in  which  itching  is  slight  are  seborrhoea,  erythema,  pityriasis  rubra  pilaris,  and 
pemphigus  ;  it  is  more  severe,  in  varying  degrees,  in  eczema,  prurigo,  some 
cases  of  psoriasis,  dermatitis  herpetiformis  and  dermatitis  gestationis,  lichen 
planus,  lichenization,  and  lichen  urticatus,  in  pityriasis  rubra,  mycosis  fungoides, 
and  sometimes  in  pityriasis  rosea,  cheiropompholyx  and  chilblain,  prickly  heat, 
tinea  marginata,  urticaria,  scabies,  the  various  kinds  of  pediculosis,  mosquito- 
and  bug-bites,  and  jellyiish  and  other  stings.  Even  in  the  affections  in  which 
it  is  usually  severe,  it  varies  much  in  degree  in  different  cases.  Itching  seldom 
has  any  distinct  diagnostic  value,  but  in  cases  in  which  the  cutaneous  lesions 
may  admit  of  more  than  one  interpretation,  its  presence  or  absence  may  suffice 
to  turn  the  balance. 

Pruritus  proper  is  an  affection  of  which  the  diagnosis  is  as  easy  as  the  etiology 
is  involved.  It  may  be  general  or  local.  Of  general  pruritus  there  are  four 
varieties — pruritus  universalis,  pruritus  hiemalis,  pruritus  senilis,  and  bath  pruri- 
tus. The  local  varieties  affect  chiefly  the  anus,  the  vulva,  and  the  scrotum,  but 
the  nares,  the  palms  of  the  hands,  and  the  soles  of  the  feet  may  be  the  seat  of  the 
irritation.  One  of  the  most  curious  forms  of  pruritus  is  that  which  is  associated 
with  bathing.  According  to  Stelwagon,  who  has  made  it  a  subject  of  special 
study,  it  most  commonly  affects  the  legs  from  the  hips  downwards ;  but  the  fore- 
arms also  maj^  be  involved,  and  it  may  have  even  wider  range.  It  is  an  affection 
of  adolescence  and  adult  life,  and  is  more  frequent  in  males  than  in  females. 

If  no  lesions  of  the  skin  are  present  save  those  which  can  be  accounted  for, 
directly  or  indirectly,  by  the  scratching,  the  diagnosis  of  pruritus  "imposes 
itself,"  Care  must,  however,  be  taken  to  exclude  all  possible  sources  of 
parasitic  irritation  ;  and  it  must  always  be  remembered  that  lice  and  acari 
sometimes  find  harbourage  in  the  most  unexpected  quarters.  If  the  scratches 
are  on  the  shoulders,  or  in  the  genital  region,  the  presence  of  lice  must  be 
suspected  ;  if  on  the  wrists  and  between  the  fingers  the  burrows  of  the  Acarus 
scahiei  must  be  sought  for.  Only  when  careful  investigation  fails  to  reveal  any 
local  source  of  irritation  should  the  case  be  diagnosed  as  one  of  pruritus. 

Malcolm  Morris. 


PTOSIS 


589 


PTOSIS  is  the  term  applied  to  drooping   of  the  upper  eyelid  with  inability 
to  raise  it  to  the  full  extent  (Figs.  156  and  157;  158  and  159)  ;  it  must  not  be 


Paralysis   of   the   Left  Third   Nerve. 


J^',^.  156. — The  patient's  face  at  rest ;  there 
is  complete  ptosis  from  paralysis  of  the  lett 
levator  palpebrje  superioris.  Note  the  scar 
of  the  healed  gumma  on  the  left  cheek  near 
the  left  an?le  of  the  nose. 


J-^i£.  157. — The  patient  is  trying  to  look  to 
his  right ;  the  left  eyelid  is  being  held  up  to 
show  that  the  left  eye  is  unable  to  look  to 
the  right  owing  to  paralysis  of  the  left  in- 
ternal rectus  muscle. 


Left-sided  Nlcle.^r  axd  Infranuclear  7TH  Nerve  Paralysis  and  Complete  Ptosis  fro.m  Paralysis 
OF  the  Left  3RD  Nerve  ;  the  result  of  Cerebral   Syphilis. 


J^i]g:   159. — When  voluntary  effort  was  made  to  show 
the  teeth  and  close  the  eyes. 


590  PTOSIS 

confused  with  the  inequahty  of  the  palpebral  apertures  sometimes  observed 
in  people  accustomed  to  screw  up  one  eye. 

It  is  usually  caused  by  paralysis  of  the  third  nerve,  in  which  case  it  may  also 
be  associated  with  paralysis  of  other  ocular  muscles,  either  external  or  internal 
{Fig.  157).  Sometimes  it  is  accompanied  by  paralysis  of  other  motor  cranial 
nerves,  the  7th  for  instance  (Figs.  158  and  159),  in  which  case  the  multiple 
cranial  nerve  paralyses  immediately  suggest  a  s^rphilitic  cause^  which  may  be 
verified  in  many  cases  by  means  of  Wassermann's  serum  reaction. 

In  paralysis  of  the  cervical  sympathetic,  slight  ptosis  may  be  associated  with 
diminution  in  the  size  of  the  pupil  on  the  affected  side,  and  retraction  of  the 
eyeball  or  enophthalmos.      It  may  also  occur  in  myasthenia  gravis. 

Ptosis  of  the  lids,  associated  with  much  oedema  and  infiltration  of  the  lids, 
is  also  found  in  all  inflarnmatory  affections  of  the  conjunctiva,  and  is  a  very 
constant  sj^mptom  in  trachoma. 

Congenital  ptosis  is  usually  bilateral,  and  associated  with  smoothness  of  the 
npper  hds  and  absence  of  all  the  usual  cutaneous  folds.  The  levator  palpebrae 
is  absent  or  ill-developed,  and  efforts  to  open  the  eye  are  made  by  the  occipito- 
frontahs  muscle.  Herbert  L.  Eason. 

PTYALISM. — Ptyalism  is  the  term  generally  emploj^ed  to  denote  excessive 
secretion  of  saliva.  It  is  not  easy,  however,  to  determine  in  every  case 
whether  there  is  really  any  excess,  or  whether  the  patient  is  not  merely 
allowing  the  normal  sahva  to  dribble  from  the  corners  of  the  mouth.  It  is 
difficult  to  draw  an  absolute  distinction,  therefore,  between  dribbling  of  saliva 
and  ptyalism,  though  in  practice  the  nature  of  the  case  may  be  obvious  enough. 
One  has  but  to  consider  the  various  conditions  under  which  trouble  with  the 
rsaliva  may  arise,  to  see  how  in  some  cases  the  difficulty  is  solely  one  of  swallowing 
the  normal  secretion,  as  in  bulbar  paralysis  and  in  babies  ;  how  in  others  there 
is  both  excess  of  secretion  and  difficulty  in  swallowing  it,  as  in  mercurial 
:Stomatitis  ;  and  how  in  others,  again,  there  is  too  much  secretion  but  no  difficulty 
in  swallowing  it,  as  in  functional  or  hysterical  cases  of  ptyaiorrhoea. 

When  a  case  is  being  investigated,  the  first  step  in  arriving  at  the  diagnosis 
■of  the  cause  is  to  inquire  carefully  as  to  the  nature  of  any  medicine  or  drug  that 
the  patient  may  be  taking  orally  or  appljdng  externally,  especially  : — 


Mercury 

Pilocarpine 

Jaborandi 

Iodide 

Bromide 

Phosphorus 


Arsenic 

Antimony 

Aconite 

Chlorate  of  potash 

Cantharides 

Copper  salts. 


Mercury  is  the  most  important  of  these  ;  its  effects  are  most  serious  when  the 
mouth  is  not  kept  scrupulously  clean,  particularly  when  there  is  also  nephritis, 
as  is  not  uncommon  in  severe  secondary  syphilis. 

If  the  salivation  is  not  due  to  any  drug,  it  may  be  the  result  of  one  of  the  many 
iorms  of  general  stomatitis  : — 

Aphthous  1     Tuberculous 

Dyspeptic  Due  to  sprue 


Septic 

Suppurative 

Ulcerous 

Mahgnant 

Vciriolous 

Diphtheritic 

Syphihtic 


scurvy 

pyorrhoea  alveolaris 

necrosis  of  the  jaw 
angina  Ludovici 
cancrum  oris 
pernicious  anaemia 
haemophilia. 


PTYALISM 


591 


The  exact  nature  of  a  severe  stomatitis  in  any  given  case  will  be  diagnosed 
by  making  a  careful  local  examination,  ocular  and  digital,  assisted  by  the  history 
and,  if  need  be,  bv  bacteriological  examination  of  swabbings  from  the  mouth, 
by  Wassermann's  serum  reaction  for  syphihs,  or  by  microscopical  examination 
of  a  fragment  of  the  affected  tissues.  Tuberculous  stomatitis  is  one  of  the 
rarest  forms,  but  when  it  occurs  it  is  very  severe  ;  it  may  be  primary,  but  more 
often  it  is  associated  with  obvious  and  rapidly  progressive  phthisis. 

If  drugs  and  general  stomatitis  can  be  excluded,  local  examination  may  still 
serve  to  detect  a  local  cause  acting  by  reflex  irritation  of  the  fifth  nerve, 
especially  : — 


A  jagged  carious  tooth 

A  rough  filling 

A  stump  left  beneath  a  tooth-plate 

A  broken  or  ill-fitting  tooth-plate 

A  foreign  body,  such  as  a  fishbone, 

impacted  in  the  gum 
Neuralgia  of  the  fifth  nerve 


A  ranula 
A  gumboil 

A  myeloid  sarcoma  of  the  jaw 
An  epulis 

A  salivary  calculus 
An  eschar  left  by  some  recent  irritant 
or  corrosive  substance,  or  injury. 


If  careful  examination  serves  to  exclude  all  these,  the  salivation,  apparent 
rather  than  real,  may  be  found  to  result  from  mechanical  difficulties  in  swallowing, 
the  effect  of  such  lesions  as  : — 


Mumps 

Acute  tonsillitis 

Quinsy 

Fracture  of  the  jaw 

Dislocation  of  the  jaw 


Fixation  of  the  jaw,  as  by  osteo- 
arthritis of  the  temporo-maxillary 
joint 

Painful  affections  of  the  larynx,  phar- 
ynx or  oesophagus. 


In  the  absence  of  any  obvious  structural  lesion  locally,  it  may  yet  be  clear 
that  inability  to  swallow,  owing  to  paralysis  of  some  kind,  is  the  cause  of  the 
apparent  salivation,  for  instance  in  cases  of  : — 


Bulbar  paralysis 
Pseudo-bulbar  paralysis 
Bilateral  facial  paralysis 
Myasthenia  gravis. 


Hypoglossal  nerve  paralysis 
Diphtheritic  paralysis 
Paralysis  agitans 
Hydrophobia. 


The  differential  diagnosis  of  these  conditions  is  discussed  elsewhere,  and  of 
them  all  it  is  only  in  bulbar  and  pseudo-bulbar  paralysis  that  the  dribbling  of 
much  saliva  is  a  prominent  symptom.  The  sequence  of  events  that  is  sum- 
marized by  the  term  labio-glosso-pharyngo-laryngeal  paralysis  is  sufficiently 
characteristic  as  a  rule  ;  pseudo-bulbar  paralysis,  being  of  cortical  instead  of 
medullary  origin,  has  not  the  wasting  of  the  tongue  that  is  prominent  in  the 
latter. 

The  salivation  that  results  from  gastric  or  hepatic  reflexes  is  almost  piiysio- 
logical,  though  sometimes  it  reaches  a  pathological  degree  in  certain  cases  of  : — - 
Dilatation  of  the  stomach         I      Gastric  carcinoma 


Gastric  ulceration 
Duodenal  ulcer 
Acute  dyspepsia 
Acute  gastritis 


Biliousness 
Hepatic  disorder 
Pancreatitis. 


Mere  slovenliness  and  lack  of  proper  cerebral  control  are  responsible  for  the 
slobbering  and  salivation  of  : — 

Idiots  I     Dements 

Imbeciles  and  other  mental  cases. 


592  PTYALISM 


Finally,  there  is  sometimes  a  very  remarkable  degree  of  salivation  that  can 
be  attributed  to  nothing  but  functional  disorder — ptyalorrhcea.  It  can  scarcely 
be  called  hysterical,  because  it  may  occur  in  men  as  well  as  in  women,  generally 
in  later  life  rather  than  at  a  time  when  hysteria  is  commonest.  The  condition 
is  a  sort  of  salivary  neurosis,  which  may  come  on  suddenly  and  without  obvious 
cause,  or  as  the  result  of  some  worry,  shock,  or  mental  emotion.  It  may 
possibly  be  a  functional  affection  of  the  5th  nerve  analogous  to  the  far  more 
distressing  tic  douloureux.  It  is  sometimes  a  very  prominent  symptom  amongst 
the  neuroses  that  are  apt  to  accompany  pregnancy.  It  can  only  be  diagnosed 
when  a  careful  examination  has  served  to  exclude  any  likelihood  of  organic 
disease,  when  the  history  is  suggestive,  and  when  the  excessive  salivation  ceases 
after  a  time  almost  as  suddenly  as  it  began.  In  many  such  cases,  notwith- 
standing the  diagnosis  being  "  functional,"  it  will  be  found  that  there  is  a  high 
systolic  blood-pressure,  with  other  signs  of  arteriosclerosis,  suggesting  that  there 
are  errors  in  the  circulation  which  may  involve  the  vasomotor  and  other  brain 
centres,  and  thus  produce  the  symptom.  Herbert  French. 

PULSATING  TUMOURS.— (See  Swelling,  Pulsatile.) 

PULSATION,  UNDUE  ABDOMINAL  AORTIC— Excessive  pulsation  of  the 
abdominal  aorta  may  occur  in  cases  of  aortic  regurgitation,  when  all  the  arteries 
throughout  the  body  may  pulsate  with  undue  violence.  Apart  from  aortic 
regurgitation,  however,  it  is  nearly  always  an  entirely  functional  disorder  of  the 
aorta.  It  occurs  much  more  frequently  in  women  than  in  men,  the  patients 
generally  being  unmarried  or  childless,  between  20  and  40  years  of  age.  They 
complain  of  pain  in  the  abdomen,  especially  in  the  epigastrium  ;  a  feeling  of 
discomfort  and  distress  ;  a  sensation  of  pulsation  and  throbbing  over  the  abdo- 
minal aorta  ;  nausea,  retching,  sickness,  and  constipation  ;  they  are  usually  thin, 
anaemic,  extremely  nervous,  often  hysterical,  and  sometimes  decidedly  hypochon- 
driacal. There  may  be  nothing  else  the  matter  with  them  at  all,  or  they  may  be 
suffering  from  some  other  complaint  of  which  much  nervousness  is  a  feature, 
exophthalmic  goitre  for  example.  The  condition  is  not  infrequently  associated 
with  movable  kidney  and  enteroptosis  ;  in  many  patients  the  symptoms  may 
suggest  some  organic  disease,  such  as  gastric  ulcer,  appendicitis,  or  ovaritis, 
without  any  of  these  being  present. 

On  palpation  of  the  abdomen  the  pulsation  may  be  found  to  be  forcible  ;  but 
the  normal  cylindrical  outline  of  the  aorta  can  generally  be  felt  to  be  quite  free 
from  any  saccular  bulging  or  fusiform  dilatation  ;  there  is  no  thrill  over  it  ;  on 
applying  a  stethoscope  lightly  to  the  pulsating  region,  no  murmur  will  be 
audible  ;  but  firm  pressure  of  the  stethoscope,  sufficient  to  compress  the  aorta 
slightly,  will  bring  out  a  systolic  bruit.  The  heart,  lungs,  and  urine  are  usually 
normal.  The  knee-jerks  are  apt  to  be  much  exaggerated,  though  the  plantar 
reflexes  remain  flexor,  and  there  is  no  ankle-clonus.  The  chief  importance  of  the 
condition  clinically  is  that  it  is  apt  to  be  mistaken  for  an  aneurysm  of  the 
abdominal  aorta.  Abdominal  aneurysm  is  so  extremely  rare  in  women,  however, 
that  it  should  never  be  diagnosed  unless  the  pulsation  can  be  made  out  to  be 
definitely  expansile,  or  unless,  in  addition  to  pulsation,  a  definite  tumour  can  be 
felt  attached  to  the  aorta.  Herbert  French. 

PULSE,  UNDULY  RAPID.— (See  Tachycardia.) 

PULSE,  UNDULY  SLOW.— (See  Bradycardia.) 

PULSES,  UNEQUAL. — Inequahty  of  theTpulses  may  be  a  perfectly  natural 
phenomenon  ;  one  frequently  finds  that  the  radial  arteries  of  the  two  sides  are 
not  of  the  same  calibre,  owing  to  variable  degrees  of  collateral  circulation  by 


PUPIL.     ABNORMALITIES     OF     THE  593 

an  enlarged  comes  nervi  median! .  Inequality  of  the  pulses  is  a  much  more 
important  sign  when  known  to  have  developed  in  a  patient  whose  pulses  were 
formerly  normal.     In  such  a  case  the  cause  is  probably  one  of  the  following  : — 


Thoracic  aneurysm 
Mediastinal  new  growth 
Accessory  cervical  rib 


Embolism 
Atheroma. 


Of  these,  by  far  the  most  common  in  the  present  connection  is  thoracic 
aneurysm,  and  even  this  is  distinctly  rare,  for  it  is  only  in  a  small  minority  of 
aneurysm  cases  that  the  pulses  are  unequal.  It  is  true  that  when  very  careful 
simultaneous  records  are  made  from  the  two  radial  pulses,  slight  differences  in 
size  and  definite  differences  in  time  can  be  detected,  the  one  being  delayed 
behind  the  other ;  but  in  clinical  medicine  such  minute  methods  of  investigation 
are  seldom  applicable,  and  it  is  only  in  a  very  small  proportion  even  of  these 
cases  that  the  diagnosis  cannot  be  arrived  at  in  other  ways. 

Definite  inequality  of  the  pulses,  or  definite  delay  of  one  behind  the  other, 
as  gauged  by  simultaneous  palpation  of  the  two  radial  pulses,  is  distinctly 
uncommon,  but  when  it  does  occur  it  is  highly  suggestive  of  thoracic  aneurysm  : 
if  the  latter  involves  the  origin  of  the  innominate  artery,  the  right  pulse  will 
be  smaller  than  the  left ;  whereas  if  the  aneurysm  affects  that  part  of  the  arch 
from  which  the  left  subclavian  artery  is  derived,  the  left  radial  pulse  will  be 
smaller  than  and  delayed  behind  the  right.  Similar  delay  or  inequality  might 
be  produced  by  new  growth  compressing  either  the  innominate  artery  on  the 
right  side  or  the  subclavian  artery  on  either  side  ;  but  this  is  rare. 

An  accessory  cervical  rib  might  stenose  the  subclavian  artery,  but  the  condition 
is  generally  bilateral,  so  that  it  rarely  produces  inequality  of  the  radial  pulses  ; 
its  symptoms  are  more  likely  to  be  those  of  interference  with  the  lower 
part  of  the  brachial  plexus,  with  consequent  pain,  paraesthesia  or  paresis 
corresponding  with  the  nerves  distributed  upon  the  ulnar  aspect  of  the  arms 
and  hands. 

Embolism  of  one  or  other  radial  artery  will  rather  obliterate  it  altogether 
than  cause  it  to  be  less  in  size  than  that  of  the  other  side.  It  will  almost  always 
be  due  to  fungating  endocarditis,  of  which  there  will  be  other  evidence  in  the 
form  of  cardiac  bruits,  pyrexia,  progressive  anaemia,  enlargement  of  the  spleen, 
haemorrhages,  and  evidence  of  multiple  emboli. 

Atheroma  of  the  brachial  or  subclavian  artery  on  one  side  might  cause  the 
corresponding  radial  pulse  to  be  less  than  that  on  the  other ;  but  this  very  rarely 
happens,  and  in  such  a  case  it  would  be  more  probable  that  atheroma  of 
the  aorta  with  an  aneurysmal  dilatation  would  be  diagnosed  than  atheroma 
restricted  to  the  vessels  in  the  upper  arm,  unless  the  ;\?-rays  exhibited  no  trace 
of  aneurysmal  opacity  in  the  thorax.  Herbert  French. 

PUPIL,  ABNORMALITIES  OF  THE.  —  Abnormalities  of  the  pupil  may  be 
classified  into  : — I.   Irregularities  in  shape  ;   II.  Irregularities  in  size. 

I.  Irregularities  in  Shape. — The  normal  pupil  is  circular  or  slightly  oval. 
Its  outline  may  become  irregular  owing  to  an  adhesion  between  the  iris  and 
the  lens,  the  result  of  old  iritis.  These  adhesions  are  most  evident  when  the 
pupil  is  dilated.  A  similar  irregularity  sometimes  occurs  with  the  persistence 
of  a  pupillary  membrane — a  congenital  affection.  The  adhesions  due  to  this 
cause  may  be  distinguished  from  inflammatory  adhesions  by  the  fact  that  they 
arise  from  the  anterior  surface  of  the  iris  at  a  slight  distance  from  the  pupil, 
and  not  from  the  posterior  surface  and  the  extrpme  edge. 

The  pupil  may  also  become  irregular  in  shape  as  the  result  of  injuries,  such  as 
rupture  of  the  sphincter,  and  tearing  of  the  root  of  the  iris  from  its  ciliary 
D  38 


594  PUPIL,     ABNORMALITIES     OF     THE 

adhesion  (iridodialysis)  ;  of  dislocation  of  the  lens  ;  or  of  partial  adherence 
to  an  old  perforated  corneal  ulcer. 

II.  Irregularities  in  Movement  and  Size. — Before  considering  the  irregularities 
in  the  movements  and  size  of  the  pupil,  it  is  desirable  to  remember  that  its 
normal  size  varies  during  life.  In  extreme  infancy  it  is  small.  It  becomes 
larger  during  j^oung  adult  and  middle  life,  and  ultimately  becomes  small  again 
in  old  age.  It  is  also,  as  a  general  rule,  small  in  hypermetropic,  and  large  in 
myopic  eyes. 

There  are  also  four  normal  pupillary  reflexes  ;  (i)  The  light  reflex  ;  (ii)  The 
reflex  to  accommodation  ;  (iii)  The  reflex  to  sensory  stimulation  ;  (iv)  Psychic 
reflexes.  The  reflexes  to  light  and  to  accommodation  are  both  constrictive, 
the  constriction  in  accommodation  being  more  in  the  nature  of  an  associated 
muscular  action.  The  sensory  and  psychic  reflexes  are  both  dilatations,  the 
dilatation  being  caused  by  either  sudden  sensory  stimuli  or  some  sudden 
emotion,  such  as  fright  or  terror. 

The  pathological  variations  in  the  pupil  are  best  classified  after  Uhthoff  as 
follows  : — 

1.  Loss  of  the  Pupillary  Light  Reflex,  either  with  or  without  constriction  of 
the  pupil,  constitutes  the  Argyll  Robertson  pupil.  The  pupil  is  constricted  in 
nearly  all  tabetic  cases,  and  the  affection  is  most  commonly  bilateral.  It  never 
occurs  in  healthy  individuals,  but  has  been  observed  most  frequently  in  loco- 
motor ataxia,  to  an  extent  varying  according  to  different  observers  from  70  to 
90  per  cent  of  all  the  cases.  The  condition  is  usually  permanent.  It  also  occurs 
in  general  paralysis  of  the  insane. 

2.  Loss  of  Convergent  Accommodation  Reflex  and  Retention  of  the  Light  Reflex. — 
This  condition  is  extremely  rare,  but  has  been  observed  in  syphilis,  basal  menin- 
gitis, myelitis,  and  tumour  of  the  corpora  quadrigemina. 

3.  Loss  of  the  Convergence  pupillary  reflex  may  be  unilateral  or  bilaterpj. 
It  occurs,  rarely,  in  locomotor  ataxia,  and  after  some  cases  of  diphtheria  and 
alcoholic  intoxication. 

4.  Loss  of  all  Reflex  Movements  of  the  Pupil. — In  this  condition  there  is  paralysis 
of  Ihe  sphincter  of  the  pupil  and  of  the  ciliary  muscle,  the  extrinsic  muscles  of 
the  eye  being  unaffected.  The  site  of  the  lesion  must,  doubtless,  be  nuclear, 
and  it  is  most  frequently  unilateral,  though  occasionally  bilateral.  Syphilis  is 
the  most  frequent  cause.  It  may  also  occur  after  diphtheria,  and  injury,  or  in 
some  intracranial  diseases. 

5.  In  the  condition  in  which  there  is  a  lesion  of  the  optic  tract  on  one  side, 
between  the  chiasma  and  the  globe,  there  will  be,  as  a  result,  a  loss  of  direct 
light  reflex  in  that  eye,  and  of  the  consensual  light  reflex  in  the  opposite  eye  (see 
Hemianopsia).  ' 

6.  Loss  of  Sensory  or  Psychic  Reflex  occurs  in  lesions  of  the  dilatator  pupillary 
tract,  such  as  paralysis  of  the  cervical  sympathetic  ;  in  which  condition  it  is 
associated  with  slight  ptosis  of  the  upper  lid,  enophthalmos,  and  diminished 
tension  of  the  globe. 

7.  Abnormal  Constriction  of  a  Pupil,  with  Retention  of  the  Light  and  Convergent 
Reflexes,  may  occur  from  abnormal  stimuli  of  the  sphincter,  or  paralysis  of  the 
dilatator  pupillce  as  the  result  of  acute  encephalitis,  intracranial  abscess  or 
growth,  in  which  the  lesion  irritates  but  does  not  destroy  the  centre  for  conver- 
gence. In  all  cases  of  brain  disease  the  constriction  is  ultimately  replaced  by 
dilatation. 

8.  Abnormal  Dilatation  of  the  Pvipil,  with  Retention  of  the  Light  and  Convergent 
Reflexes,  is  met  with  in  cases  of  stimulation  of  the  cervical  sympathetic.  It 
may  also  be  observed  in  certain  mental  states,  such  as  epilepsy,  acute  mania,  or 
catalepsy. 


PURPURA  595 


9.  Inequality  in  the  size  of  the  Pupils  is  observed  frequently,  and  may  have  no 
pathological  significance  ;  but  pronounced  difference  in  the  size  of  the  pupils  is 
nearlv  always  symptomatic  of  some  organic  lesion.  In  cases  where  the  abnormal 
pupil  is  the  smaller,  the  condition  is  usually  due  to  hyperaemia  of  the  iris,  such 
as  occurs  in  iritis  ;  paralysis  of  the  cervical  sympathetic  ;  or  the  use  of  a  m^^otic 
drug  such  as  physostigmine.  In  cases  where  the  abnormal  pupil  is  the  larger, 
the  dilatation  is  usually  due  to  stimulation  of  the  sympathetic,  the  use  of  a 
mydriatic,  paralysis  of  the  fibres  of  the  third  nerve,  or  increased  ocular  tension, 
such  as  may  occur  in  glaucoma. 

In  cases  of  inequality  of  the  pupils  one  may  suspect  tabes,  general  paralysis 
of  the  insane,  a  unilateral  lesion  of  the  third  nerve  or  cervical  sympathetic, 
trigeminal  neuralgia,  carotid  or  aortic  aneurysm,  a  unilateral  intracranial 
lesion,  or  glaucoma. 

10.  Irregularities  in  the  shape  of  the  pupils  other  than  those  mentioned  above 
may  occur  in  tabes  and  various  cases  of  insanity.  There  is  no  marked  or  sharp 
irregularity,  it  only  being  noticed  that  the  pupil  is  not  circular  owing  to  paralysis 
of  certain  fibres  of  the  iris. 

11.  Hippus. — This  term  is  applied  to  a  condition  in  which,  when  both  eyes 
are  shaded,  and  then  illuminated,  the  pupils  will  alternately  dilate  and  contract. 
It  is  sometimes  associated  with  nystagmus,  and  occurs  also  in  disseminated 
sclerosis,  and  in  some  cases  of  brain  tumour.  It  is  observed  most  frequently 
when  there  is  a  central  scotoma  in  the  field  of  vision,  with  some  injury  to  the 
macular  or  axial  fibres  of  the  optic  nerve.  It  is  also  common  in  alcoholic 
subjects. 

12.  Paradoxical  Pupillary  Reflex  :  pupils  dilating  under  the  stimulus  of 
light.  This  condition  is  extremely  rare,  and  has  only  been  observed  in 
patients  affected  with  grave  lesions  of  the  central  nervous  system,  usually 
locomotor  ataxy. 

13.  Heniianopic  Pupillary  Reflex  :  lesions  of  the  brain  situated  in  the  optic 
tract  above  the  corpora  quadrigemina  may  give  rise  to  partial  loss  of  vision, 
but  will  not  affect  the  pupil-reflex  arc.  For  example,  a  lesion  in  the  right  occipital 
cortex  may  give  rise  to  a  left  homonymous  hemianopsia,  but  the  pupil  will 
react  even  when  a  Hght  is  thrown  on  the  blind  side  of  the  retina  (see 
Hemianopsia).  In  cases,  however,  where  the  lesion  is  situated  in  the  optic 
tract  below  the  corpora  quadrigemina,  hemianopsia  may  also  occur,  but  under 
these  circumstances  no  pupillary  reflex  for  hght  can  be  obtained  on  stimulus 
of  the  blind  side  of  the  retina,  the  pupil  reacting  to  light  when  the  opposite 
side  of  the  retina  is  stimulated.  This  reaction  is  termed  the  hemiopic 
pupillary  reflex,  and  is  of  great  value  in  the  localization  of  intracranial 
lesions.  Herbert  L.  Eason. 

PURPURA  signifies  haemorrhage  into  the  skin,  and,  according  to  the  size  of 
the  extravasation  of  blood,  the  lesions  are  spoken  of  as  puncta  or  spots,  vibices 
or  lines,  petechiae  or  small  patches,  ecchymoses  or  bruises.  The  lesions  cannot 
be  obliterated  by  pressure  with  the  finger,  which  distinguishes  the  effused  blood 
from  mere  congestion.  The  diagnosis  of  the  actual  fact  of  purpura  is  seldom 
difficult  ;  the  persistence  of  the  discoloration  under  pressure  difierentiates 
it  from  erythematous  lesions,  and  the  colour  generally  serves  to  distinguish  it 
from  pigmentation  of  the  skin  other  than  that  due  to  haemorrhage.  In  a  case 
of  doubt,  the  course  which  the  lesions  follow  will  serve  to  distinguish  purpura, 
which  changes  and  disappears,  from  capillary  naevi  or  from  pigmentation  of  the 
skin,  which  persist.  It  may  be  more  difficult,  however,  to  decide  what  is  the 
nature  of  the  purpura  in  any  given  case  ;  the  following  is  a  list  of  its  better 
recognized  causes  : — 


596 


PURPURA 


CAUSES    OF    PURPURA. 


I. — -Due  to  Local  Injuries  : 

Flea-bites 
Pediculosis 
Leech-bite 
Blows 

2. — The  Effect  of  Drugs  and  Poisons 

Antipyrin 

Iodoform 

Iodide  of  Potassium 

Sulphonal 

Copaiba 

Belladonna 

Chloral 

Chloral  hydrate 

Butyl-chloral  hydrate 

Veronal 

3. — In  Fevers  : 

Typhus  fever 

Cerebrospinal  fever 

Small-pox 

Pyaemia 

Septicaemia 

Malignant  endocarditis 

General  tuberculosis 

Dysentery 

Cholera 

Yellow  fever 

4. — In  association  with  Jaundice  from  whatever  cause  (see  Jaundice). 
5. — ^Bright's  Disease. 


Sprains 

Rupture  of  a  muscle 
Rupture  of  a  vein,  especially  a  vari- 
cose vein. 

Mercury 

Arsenic 

Quinine 

Ergot 

Salicylic  acid 

Potassium  chlorate 

Diphtheritic  antitoxin 

Ptomaine 

Snake-bite  poison. 


Weil's  disease,  or  bilious  typhoid 

Plague 

Remittent  fever 

Severe  malarial  fever 

Blackwater  fever 

Measles 

Diphtheria 

Typhoid  fever 

Scarlet  fever. 


Peripheral  neuritis. 

Pseudo-leukaemia  infantum 

Scurvy 

Barlow's  disease 

Haemophilia 

Chloroma. 


6. — Chronic  Alcoholism  : 

Cirrhosis  of  the  liver 
7. — The  so-called  Blood  Diseases': 

Splenomedullary  leukaemia 

Lymphatic  leukaemia  i 

Hodgkin's  disease]] 

Lymphadenoma 

Sarcomatosis 

Splenic  anaemia 
8. — Peliosis  Rheumatica. 
9. — Henoch's  Purpura. 
10. — Purpura  Simplex  . 

Morbus  maculosus  of  Werlhof 

Purpura  haemorrhagica 

Purpura  fulminans. 

A  number  of  the  above  conditions  require  but  little  discussion,  for  if  they 
are  but  borne  in  mind,  their  diagnosis  as  the  cause  of  purpura  in  any  particular 
case  will  generally  be  easy. 

Flea-bites  are  by  far  the  commonest  cause  of  purpura  in  the  out-patient 
department  of  a  hospital,  and  they  may  sometimes  be  so  very  numerous  as  to 
raise  a  misleading  suspicion  that  the  patient  is  suffering  from  some  serious  disease. 


PURPURA  597 


The  relati\-ely  small  haeniorrhagic  foci,  and  their  pre\-alence  on  the  parts  covered 
by  the  clothes  rather  than  upon  the  hands,  face,  or  exposed  parts  of  the  legs, 
serve  to  indicate  the  diagnosis,  even  in  a  severe  case. 

The  commonest  variety'  of  pediculosis  to  produce  purpura  is  P.  corporis  or 
vestimentorum  ;  the  circumstances  of  the  case  and  the  distribution  of  the  purpura 
itself  and  of  the  marks  of  scratching,  particularly  in  the  regions  where  collars 
and  other  constrictions  in  the  dress  occur,  -would  indicate  the  diagnosis. 

The  haemorrhage  around  a  leech-bite  is  so  characteristic  that,  once  seen,  it 
cannot  be  mistaken  for  anything  else. 

Blows  and  sprains,  if  sufficiently  severe,  produce  purpura  even  in  the  healthy, 
in  whom  the  history  gives  the  diagnosis  ;  it  is  important  to  bear  in  mind,  how- 
ever, that  there  are  some  normal  individuals  who  bruise  with  such  ease  that 
there  may  be  no  clear  evidence  of  injury  unless  careful  inquir}^  is  made,  when 
some  trivial  stumble  or  knock  may  be  recalled  to  mind  by  the  patient.  Such 
easy  bruising  may  of  course  occur  in  any  of  the  blood  diseases,  but  it  is  not 
uncommon  in  certain  otherwise  health}-  women.  A  case  of  epilepsy  may  some- 
times come  under  observation  for  multiple  bruises  simulating  some  other  kind 
of  purpura,  but  due  to  injuries  produced  during  the  attacks,  which  may  them- 
selves be  unsuspected  if  they  occur  during  the  night. 

Spontaneous  rupture  of  a  muscle  leads  to  very  extensive  purpuric  extravasation 
of  blood,  but  the  diagnosis  is  not  difficult  if  the  history  is  clear,  and  one  can 
often  feel  the  place  where  the  muscle  has  given  way  unless  it  is  too  deep-seated 
to  palpate,  as  in  the  case  of  the  plantaris  longus,  which  is  apt  to  rupture  during 
sudden  efforts,  such  as  may  be  made  in  playing  tennis  or  the  organ. 

The  purpuric  discoloration  of  the  skin  around  varicose  veins  in  the  legs,  together 
with  its  resultant  dark-brown  pigmentation,  is  familiar  to  all. 

As  regards  drugs,  the  list  above  indicates  that  there  are  many  which  may 
sometimes  produce  purpura  ;  it  may  be  said  at  once,  however,  that  none  do 
so  at  all  commonly.  Nevertheless  the  possibihty  should  be  borne  in  mind,  and 
enquiry  made  as  to  the  remedies  the  patient  may  have  been  taking.  Anti- 
diphtheritic  serum  and  ptomaines  merit  particular  attention.  The  commonest 
eruption  resulting  from  anti-diphtheritic  serum,  or  from  other  forms  of  antitoxic 
horse-serum  administered  h^^-podermically,  is  urticaria  ;  purpura  is  relatively 
rare  ;  either  form  occurs  as  a  rule  about  nine  or  ten  days  after  the  serum  has 
been  given,  and  is  generalh'  associated  with  lassitude,  muscular  and  joint  pains, 
anorexia,  and  more  or  less  p^rrexia,  lasting  from  a  few  hours  to  two  or  three 
days.  Ptomaine  poisoning  is  often  very  difficult  to  recognize  with  certainty  unless 
it  occurs  in  epidemic  form.  It  is  due,  however,  in  most  cases  to  the  products  of 
the  action  of  Gaertner's  bacillus,  and  seeing  that  the  blood-serum  of  patients 
affected  by  this  bacterium  develops  agglutinating  powers  against  it  similar  to 
Widal's  reaction  for  typhoid  fever,  this  serum  test  should  not  be  omitted  ; 
if  it  proves  positive  the  diagnosis  is  clear  ;  a  negative  result,  however,  does  not 
exclude  ptomaine  poisoning. 

In  the  great  majority  of  acute  fevers,  the  occurrence  of  purpura  is  of  prognostic 
rather  than  of  diagnostic  value  ;  in  diphtheria,  for  example,  even  a  single  well- 
defined  purpuric  spot  is  a  sign  of  grave  omen,  but  it  does  not  assist  at  all  in  the 
diagnosis  of  the  disease,  which  has  to  be  recognized  upon  other  grounds.  The 
same  applies  to  measles,  scarlet  fever,  and  so  on  ;  indeed,  the  only  two  fevers 
in  the  above  list  in  which  purpura  is  of  essentially  diagnostic  value  are  typhus 
and  cerebrospinal  fever.  The  former  of  these  is  now  very  rare  in  Great  Britain, 
but  Avhen  it  was  common  and  t^'phoid  fever  began  to  be  differentiated  from  it, 
the  point  upon  which  greatest  stress  was  laid  was  that  in  true  tj-phus  or  gaol 
fever  there  is  always  more  or  less  purpura,  whereas  in  typhoid  fever  all  the  red 
spots  fade  upon  pressure.      It  happens  occasionally,  even  yet,  that  typhus  fever 


PURPURA 


develops  in  the  poorest  parts  of  cities,  and  this  point  is  most  useful  in  distin- 
guishing it  from  typhoid.  In  the  latter,  if  flea-bites  are  excluded,  purpuric  spots 
are  exceedingly  rare.  Cerebrospinal  fever  presents  many  characters  that  are 
common  to  it  and  to  other  forms  of  acute  meningitis  ;  but  if  with  these  there 
is  a  purpuric  eruption,  it  is  at  once  differentiated  from  the  others,  though  the 
absence  of  purpura  does  not  exclude  the  disease.  So  characteristic  is  the  purpura 
in  some  cases  that  the  malady  has  earned  the  title  of  spotted  fever,  which  used 
to  occur  in  widespread  epidemics,  and  still  does  in  smaller  ones  from  time  to 
time.  The  diagnosis  may  be  clinched  by  bacteriological  examination  of  the 
cerebrospinal  fluid  obtained  by  lumbar  puncture. 

Small-pox  may  present  cutaneous  hemorrhages  of  three  different  kinds  ; 
there  may  be  hsemorrhage  into  the  pustules  in  a  late  stage,  when  the  diagnosis 
has  already  been  made  and  when  the  prognosis  is  not  thereby  made  worse ;  there 
may  be  heemorrhage  between  the  pustules,  vesicles,  or  papules,  the  diagnosis  having 
already  been  made,  in  which  case  the  prognosis  is  not  good  ;  and  there  may 
be  a  hsemorrhagic  eruption  either  all  over  the  body  or  in  the  so-called  bathing- 
drawers  region  in  the  prodromal  stage  of  the  disease,  in  which  case  the  patient 
will  almost  certainly  die  before  the  true  small-pox  eruption  develops,  so  that  if 
there  is  not  an  epidemic  at  the  time,  the  diagnosis  may  be  exceedingly  difficult. 
Almost  any  condition  in  which  there  are  pyogenic  micro-organisms  circulating 
in  the  blood-stream  may  be  associated  with  extensive  purpura,  and  this  applies 
to  pycBmia  and  septiccBmia  in  general.  The  diagnosis  will  be  confirmed  best  by 
obtaining  cultivations  from  the  blood,  though  there  will  very  likely  have  been 
rigors,  pyrexia,  and  other  symptoms  pointing  to  the  nature  of  the  case. 
Malignant  endocarditis  is  only  a  variety  of  pyaemia  or  septicaemia.  Seeing  that 
it  is  very  rare  to  get  purpura  in  association  with  chronic  valvular  disease  of  the 
heart  if  both  purpura  rheumatica  and  infective  endocarditis  can  be  excluded, 
the  occurrence  of  purpura  in  a  heart  case  may  be  one  of  the  main  symptoms 
indicating  that  fungating  endocarditis  has  supervened.  So  indefinite  is  the 
nomenclature  in  regard  to  this  disease,  that  the  terms  malignant,  ulcerative, 
fungating,  infected,  and  infective  endocarditis  are  used  indiscriminately  by 
different  observers  to  denote  the  same  condition.  The  disease  may  be  further 
indicated  by  sudden  changes  in  the  bruits,  by  evidence  of  embolism,  by  pro- 
gressive anaemia,  by  enlargement  of  the  spleen,  by  irregular  pyrexia,  by  retinal 
haemorrhages,  or  by  optic  neuritis. 

General  tuberculosis  is  not  a  common  cause  of  purpura,  and  yet  in  a  few 
instances  extensive  purpura  has  been  the  first,  and  for  the  time  being  the  only, 
symptom  of  an  obscure  illness  which  has  ultimately  turned  out  to  be  general 
tuberculosis.  The  patient  has  generally  been  a  child,  and  the  diagnosis  has 
only  been  possible  when  the  course  of  the  case  has  been  watched.  The  same 
may  be  said  of  sarcomatosis  in  certain  cases,  though  this  has  been  included 
under  a  different  heading  in  the  above  list. 

Jaundice  is  well  worthy  of  being  borne  in  mind  as  a  cause  of  purpura,  for 
although  the  occurrence  of  the  latter  symptom  does  not  assist  in  differentiating 
one  kind  of  jaundice  from  another,  one  might  be  misled  into  diagnosing  some- 
thing more  serious  than  is  necessary  if  one  did  not  bear  in  mind  that  any  kind 
of  jaundice  may  produce  purpura.  Moreover,  some  of  these  patients  may  seem 
to  have  been  grossly  illtreated  if  one  were  to  judge  only  by  the  degree  of  bruising 
that  may  result  from  ordinary  palpation  ;  the  danger  of  fatal  oozing  after 
operation  is  always  to  be  remembered  when  surgical  measures  are  thought  of 
in  a  jaundiced  subject.  Spontaneous  haemorrhage  into  the  skin  is  less  common 
here  than  is  haemorrhage  from  what  otherwise  would  be  trivial  causes. 

Bright' s  disease,  particularly  the  chronic  varieties  of  the  complaint,  is  capable 
of  producing  haemorrhage  anywhere  in  the  body.      Purpura  is  not  a  very  common 


PURPURA  599 


form  of  such  haemorrhage,  but  when  it  does  occur  it  may  be  extensive.  The 
diagnosis  is  discussed  under  Albuminuria  {q.v.). 

Chronic  alcoholism,  especially  if  it  has  already  led  to  either  cirrhosis  of  the 
liver  or  to  peripheral  neuritis,  is  occasionally  a  cause  of  considerable  purpura, 
though  the  latter  is  generally  confined  to  the  legs,  particularly  to  the  parts  below 
the  knees.  In  many  instances  the  diagnosis  is  easy,  even  if  the  history  is  not 
given  with  perfect  honesty ;  but  considerable  difficulty  sometimes  arises  in  the 
case  of  ladies  who  have  contracted  the  habit  of  secret  drinking,  their  relatives 
and  friends  being  entirely  unaware  of  it. 

Any  of  the  so-called  blood  diseases  may  present  purpura  as  a  prominent 
symptom,  and  in  some  cases,  particularly  in  lymphatic  leukcsmia  in  children, 
extensive  purpura  may  be  the  first  symptom  that  anything  is  wrong.  More 
often,  however,  the  disease  has  already  given  rise  to  anaemia  or  to  enlargement 
of  the  spleen  or  lymphatic  glands,  or  to  some  other  prominent  haemorrhage, 
and  the  diagnosis  has  already  been  made  by  the  time  the  purpura  supervenes. 
(See  An.emia  ;  Spleen,  Enlargement  of  the  ;  and  Lymphatic  Gland 
Enlargement.)  Broadly  speaking,  the  method  of  diagnosis  should  be  to 
have  the  blood  examined  in  the  first  instance  ;  if  there  is  a  very  great  increase 
in  the  number  of  leucocytes  per  cubic  millimetre,  the  diagnosis  is  some  form 
of  leukaemia  ;  if  there  is  no  such  leucocytosis,  and  if  there  is  enlargement  of 
the  lymphatic  glands,  the  diagnosis  is  lymphadenoma  or  Hodgkin's  disease  ; 
if  the  spleen  is  much  enlarged  but  the  lymphatic  glands  are  normal,  splenic 
anaemia  suggests  itself  in  an  adult,  or  pseudo-leukjemia  infantum    in  a  child. 

Scurvy  in  an  adult  is  relatively  rare,  but  is  sometimes  met  with  in  those  who 
have  been  obliged  to  live  upon  a  diet  containing  no  fresh  vegetables  for  reasons 
of  poverty  ;  for  instance,  a  man  may  try  to  live  for  a  month  or  more  on  plain 
bread,  in  which  case  typical  scurvy  may  develop  in  him,  with  the  spongy  heaping 
up  of  the  gums  both  inside  and  outside  the  teeth,  and  with  the  knotty  haemo- 
rrhagic  swellings  in  the  muscles  of  the  calves,  as  well  as  purpura.  Children  who 
are  fed  upon  patent  foods  without  a  sufficiency  of  fresh  cow's  milk,  or  vegetable 
food,  or  fresh  meat,  not  infrequently  develop  a  milder  form  of  scurvy,  with 
marked  tenderness  of  the  periosteunr  of  the  long  bones,  pasty  pallor,  mouth 
bleeding  from  spongy  gums,  and  possibly  purpura  ;  this  is  infantile  scurvy  or 
Barlow's  disease,  which  should  not  be  confused,  as  it  is  apt  to  be,  with  rickets. 

HcBmophilia  is  generally  indicated  at  once  by  the  history  of  persistent  oozing 
from  slight  cuts  and  scratches,  and  also  by  the  fact  that  other  members  of 
the  family,  especially  males,  have  suffered  in  a  similar  way. 

Chloroma  is  a  very  rare  disease,  in  some  ways  related  to  sarcomatosis,  and  in 
others  to  lymphatic  leukaemia  ;  it  produces  swellings  in  connection  with  the 
bones,  especially  of  the  head,  together  with  enlargement  of  the  lymphatic, 
lachrymal  and  salivary  glands  ;  it  develops  in  early  life,  proves  slowly  fatal, 
and  the  diagnosis  is  confirmed  by  the  green  colour  of  the  new-formed  tissue — 
"  green  cancer."     The  blood  changes  are  negative. 

Peliosis  rheumatica,  or  purpura  rheumatica,  or  Schonlein' s  disease,  was  formerly 
regarded  as  being  related  to  acute  rheumatism  ;  but  it  is  exceedingly  rare  for  a 
patient  affected  by  it  to  present  unmistakable  signs  of  valvular  heart  disease, 
although  there  may  be  a  local  systolic  bruit  at  the  impulse.  The  reason  why  it 
is  thought  to  be  related  to  acute  rheumatism  is,  that  in  addition  to  the  extensive 
purpura,  which  comes  out  in  successive  crops  and  may  affect  any  part  of  the 
body,  though  it  is  commoner  upon  the  lower  limbs  than  elsewhere,  there  is 
considerable  pain,  redness,  and  swelling  of  many  joints,  which  may  become 
affected  successively  ;  the  temperature  rises  during  an  attack  to  103°  F.  or 
104°  F.,  the  throat  generally  being  sore  at  the  same  time.  It  is  not  impossible 
that  the  purpura  is  due  to  the  absorption  of  microbes  or  their  toxins  from  the 


6oo  PURPURA 


acute  tonsillitis  ;  but  be  this  as  it  may,  the  diagnosis  is  not  difficult  when  the 
purpura,  the  joint  pains,  and  the  pyrexia  are  present  together.  The  disease  is 
little  influenced  by  sodium  salicylate  ;  it  may  be  associated  with  more  or  less 
erythema  as  well  as  purpura  ;  the  malady  affects  young  persons,  especially 
between  the  ages  of  ten  and  thirty  ;  it  is  not  confined  to  either  sex,  but  is 
commoner  in  males  than  females. 

Henoch's  purpura  is  chiefly  met  with  in  children  (Fig.  iii,  p.  382),  and  the 
same  patient  may  suffer  from  recurrent  attacks,  which  usually  cease  at  or  before 
puberty.  In  addition  to  the  haemorrhages  beneath  the  skin,  there  is  generally 
some  tendency  to  joint  pains  not  unlike  those  of  peliosis  rheumatica,  but  in 
addition  to  this  the  child  is  seized  with  more  or  less  severe  acute  abdominal 
symptoms,  varying  from  simple  vomiting  and  stomach-ache  to  severe  prostration 
with  agonizing  cramp-like  attacks  of  colic,  some  of  which  may  be  followed  by 
the  passage  of  blood  and  mucus  per  rectum  to  such  an  extent  as  to  simulate 
acute  intussusception  ;  the  abdominal  attacks  are  probably  the  result  of  sub- 
mucous intestinal  haemorrhages.  There  is  every  degree  of  the  affection,  from 
mUd  to  very  severe,  but  the  association  of  the  purpura  with  the  abdominal 
attacks  in  childhood  suggests  the  diagnosis  at  once,  especially  if  there  has  been 
a  similar  attack  previously.  The  chief  error  to  avoid  is  mistaking  for  Henoch's 
purpura  that  which  is  really  an  acute  nephritis ;  the  urine  should  be  examined 
periodically  for  albumin  and  renal  tube-casts,  even  if  there  is  no  oedema,  though 
the  occurrence  of  blood  alone  would  not  be  sufficient  to  indicate  acute  nephritis, 
seeing  that  haemorrhage  from  the  kidney  may  be  due  to  Henoch's  purpura  itself. 

It  is  only  when  every  precaution  has  been  taken  to  exclude  all  the  above 
causes  of  purpura  that  one  can  be  satisfied  with  any  of  the  remaining  four 
diagnoses,  namely  purpura  simplex,  purpura  hcBmorrhagica  {morbus  maculosus  of 
Werlhof),  or  purpura  fulminans.  These  differ  from  each  other  only  in  degree  ; 
broadly  speaking,  purpura  simplex  signifies  haemorrhage  into  the  skin  only; 
purpura  haemorrhagica  has,  in  addition,  haemorrhages  from  the  mucous  mem- 
branes, particularly  of  the  mouth,  nose,  and  bowel,  less  commonly  of  the  urinary 
passages  ;  whilst  purpura  fulminans  is  the  term  used  to  denote  a  condition  in 
which  a  person  may  seem  perfectly  healthy  to-day,  may  be  seized  with  acute 
purpura  and  be  dead  before  to-morrow,  without  developing  any  other  sym- 
ptoms to  indicate  the  nature  of  the  complaint.  These  kinds  of  purpura  have 
sometimes  been  spoken  of  as  idiopathic,  but  they  must  have  some  under- 
lying cause,  it  only  it  can  be  found.  It  is  better  probably  to  label  them  cases 
of  purpura  of  which  the  exact  cause  is  not  yet  known,  than  to  be  content  with 
such  a  term  as  purpura  simplex,  and  it  is  probable  that  if  bacteriological 
examinations  were  made,  a  bacterial  cause  would  be  discovered,  particularly  in 
connection  with  the  tonsils,  the  gums  in  states  of  septic  gingivitis  or  pyorrhoea 
alveolaris,  the  uterus,  the  bowel,  or  the  circulating  blood  itself.       Herbert  French. 

PUS  IN  THE  CHEST.— (See  Chest,  Pus  in.) 

PUS  IN  THE  STOOLS  in  sufficient  amount  to  be  recognizable  by  the  naked 
eye,  indicates  the  rupture  of  an  abscess  into  the  intestinal  tract.  The  symptom 
is  a  rare  one,  however,  for  even  when  a  large  appendicular  abscess  perforates 
into  the  caecum,  the  pus  either  becomes  indistinguishable  when  mixed  with  the 
faeces,  or  unrecognizable  on  account  of  digestion  and  decomposition.  The  less 
the  pus  is  mixed  with  other  intestinal  contents,  the  nearer  to  the  anus  has  the 
site  of  rupture  been  ;  but  the  diagnosis  of  the  source  of  the  abscess  needs  to  be 
'determined  upon  other  grounds,  particularly  the  history,  and  upon  the  results 
of  general  physical  examination,  including  that  of  the  rectum  and  vagina. 
Abscesses  which  are  most  apt  to  cause  a  discharge  of  pus  with  the  stools  are  of 


PUSTULES  601 

the  appendicular,  cholecystic,    perinephric,  psoas,   pelvic,   perigastric,  or  other 
local  peritoneal  types,  and  pyosalpinx. 

Microscopical  quantities  of  pus  in  the  stools  may  be  due  to  any  of  the  causes 
ahready  mentioned  ;  but  they  may  also  be  derived,  not  from  lesions  outside  the 
intestines,  but  from  affections  of  the  mucous  membrane  itself  :  acute  or  chronic 
coHtis,  with  or  without  ulceration  ;  dysentery;  cholera;  dengue;  mucous  or  muco- 
membranous  coUtis  ;  tuberculous,  typhoidal,  malignant,  or  venereal  ulceration  of 
the  bowel.  The  pus  corpuscles  may  be  recognizable  as  such  under  the  microscope  ; 
but  it  is  difficult  to  determine  when  the  leucocytes  derived  from  the  intestinal 
catarrh  are  merely  leucocytes  in  excess,  and  Avhen  their  numbers  become 
sufficient  to  merit  the  term  actual  pus.  Examination  with  the  sigmoidoscope 
is  sometimes  in\-aluable  when  the  diagnosis  has  not  been  indicated  clearly  by 
other  methods.  Herbert  French. 

PUSTULES. — The  pustule,  one  of  the  primary'  cutaneous  lesions,  is  an  epider- 
mic elevation,  either  unilocular  or  multilocular,  containing  a  purulent  hquid, 
and  differing  from  a  vesicle  or  a  bulla  only  in  the  character  of  its  contents. 
Alwa^-s  a  product  of  inflammation,  it  may  originate  as  a  pustule  or  may  develop 
from  a  papule,  but  much  more  often  it  is  a  transformed  vesicle  ;  if  the  metamor- 
phosis is  imperfect,  the  lesion  is  styled  a  papulo-pustule  or  a  vesico-pustule. 
Frequently  the  transformation  from  a  papule  or  a  vesicle  is  so  swift,  that  the  true 
origin  of  the  lesion  may  escape  notice  ;  but  in  such  cases  it  is  usual  to  find 
papules  or  vesicles  intermingled  with  the  pustules.  The  pustular  cavity  maj^  be 
situated  in  the  epidermis,  in  the  derma,  or  in  a  follicle  ;  a  purulent  accumu- 
lation beneath  the  derma  is  either  an  abscess  or  a  gumma.  Epidermic  pustules 
may  be  superficial,  as  in  impetigo,  or  deep,  as  in  the  condition  known  as 
ectMnna,  which  I  regard  as  but  a  severe  form  of  impetigo.  Dermic  pustules, 
e.g.,  in  miharv  abscess  of  new-born  children,  are  seldom  met  with,  while  follicular 
pustules,  such  as  those  of  sjxosis,  are  of  frequent  occurrence,  the  pyogenic  cocci 
eftecting  entrance  into  the  folhcle  when  this  is  not  the  original  site  of  the 
suppuration.  In  colour,  pustules  are  usually  3'ellowish  or  greyish,  with  a  red 
areola  ;  but  when  the  contents  are  mixed  with  blood,  the  yellow  may  be  tinged 
with  red  or  brown.  If  a  pustule  is  punctured  or  ruptured,  the  hquid  is  seen  to 
be  more  or  less  turbid  and  yellowish  ;  under  the  microscope  it  is  found  to  consist 
largely  of  leucoc^-tes  and  serum  as  well  as  cocci.  Pustules  vary  greatly  in  size  : 
they  ma 3"  be  as  small  as  a  pin-point,  as  in  some  of  the  pustules  of  eczema,  or  as 
large  as  a  split  pea,  as  in  severe  impetigo.  The  small  ones  may  remain  of  incon- 
siderable dimensions,  or  maj' become  large  by  excentric  extension.  The  prevalent 
shape  is  roundish  or  convex,  as  in  furuncle  and  acne  ;  but  it  may  be  acu- 
minate, as  is  frequent  in  sycosis  and  eczema,  or  flat  and  irregular,  as  in  impetigo 
and  s\-philis,  while  in  rare  instances,  as  sometimes  in  scabies,  it  maj^  be  oblong, 
with  a  tendency-  to  the  hnear  form.  In  variola  and  the  varioHform  syphihde, 
the  pustules  may  be  flattened  or  concave,  either  because  the  fluid  ma}-  not  fully 
distend  the  cleft  in  which  it  Hes,  or  from  flaccidity  of  the  sac,  due  to  commencing 
absorption.  Pustules  mav  develop  slowly,  as  sometimes  occurs  in  impetigo  and 
in  the  pustular  syphiloderm  ;  but  as  a  rule  they  run  a  rapid  course,  and  terminate 
either  hy  rupture — much  more  often  accidental  than  spontaneous — or  b}-  desicca- 
tion. In  either  case,  a  yeUow,  brown,  or  blackish  crust,  more  or  less  thick 
and  irregular,  is  formed  ;  but  if  the  termination  is  by  desiccation,  the  crust 
has  a  less  pronounced  coloration,  and  is  friable  instead  of  firm. 

A  cutaneous  affection  in  which  the  pustule  plays  a  leading  part  is  impetigo,  in 
both  its  principal  forms — the  impetigo  contagiosa  of  Tilbury  Fox,  otherwise 
impetigo  vulgaris,  and  the  folhcular  impetigo  of  Bockhart,  the  one  due  primarily 
to  the  streptococcus  and  secondarily  to  the  staphylococcus,  the  other  solely  to  the 


6o2  PUSTULES 

staphylococcus.  In  impetigo  vulgaris,  usually  following  slight  febrile  disturbance, 
small  erj'-thematous  spots  appear,  on  which  form  vesicles  containing  a  turbid 
fluid  that  quickly  becomes  purulent.  When  the  pustules  break,  as  they  soon  do, 
they  discharge  a  fluid  that  quickly  dries  up  into  scabs  that  are  at  first  yellowish, 
and  afterwards  green.  Dotted  about  among  the  scabs  are  pustules,  which  may 
coalesce  so  as  to  form,  on  rupture,  crusts  of  considerable  size.  The  eruption 
may  be  limited  to  a  few  discrete  lesions,  or  may  extend  over  large  areas  of  the 
bodj^.  In  parts  where  the  pustules  are  exposed  to  friction,  as  on  the  limbs, 
they  are  generally  ruptured  at  an  early  stage,  and  a  flat  irregular  scab, 
surrounded  by  an  areola,  forms  over  them — the  condition  known  as  ecthyma. 
Sometimes  the  distribution  is  annular  {impetigo  circinata  or  gyrata).  In  the 
condition  known  as  impetigo  bullosa  the  lesions  are  much  larger,  and  are  not 
always  transformed  into  true  pustules.  With  impetiginous  eruptions,  though 
not  with  these  alone,  cutaneous  diphtheria  is  sometimes  associated,  especially 
in  children.  The  most  typical  form  of  this  affection  has  the  appearance  of  an 
impetiginous  eczema,  associated  with  conjunctivitis,  and  occasionally  with 
otorrhoea  and  rhinitis.  No  diphtheritic  membrane  may  be  present,  and  if 
cutaneous  diphtheria  is  suspected,  the  Klebs-Loffler  bacillus  should  be 
sought  for  bacteriologically. 

The  differences  between  impetigo  vulgaris  and  follicular  impetigo  are  well 
marked.  The  latter  is  pustular  from  the  beginning,  and  always  situated  around 
a  hair-follicle.  It  starts  as  a  round  pustule,  often  pierced  by  a  long  or  coarse 
hair,  and  it  may  be  quite  small,  or  as  large  as  a  pea  ;  the  pus  collects  under 
the  horny  layer,  which  it  distends  and  raises.  The  eruption,  usually  multiple, 
has  no  sites  of  election,  but  appears  wherever  a  breach  in  the  horny  layer 
affords  entrance  to  the  pyogenic  organism.  The  pustules  are  more  resistant  than 
those  of  impetigo  contagiosa,  and  are  less  quick  to  break.  When  they  rupture, 
yellow  crusts,  smaller  and  thinner  than  those  of  impetigo  vulgaris,  are  formed. 
The  pustules  of  follicular  impetigo  can  hardly  be  mistaken  for  those  of  any 
other  affection.  The  other  form  of  impetigo,  however,  has  in  rare  cases  to  be 
diagnosed  from  pemphigus.  In  the  latter  the  lesions  start,  not  as  small  vesicles 
but  as  bullae,  and  the  fluid  they  contain  is  only  sometinaes  inoculable.  Usually, 
too,  there  is  marked  systemic  disturbance.  But  it  is  with  pustular  eczema 
that  impetigo  vulgaris  is  most  likely  to  be  confused,  especially  when  the  pustules 
of  the  latter  condition  have  run  together  into  a  patch.  In  eczema,  however, 
the  pustules  are  smaller,  there  are  severe  itching  and  burning,  there  is  an 
inflammatory  areola  around  the  crusts,  which  is  seldom  the  case  in  impetigo 
vulgaris,  and  other  definitely  eczematous  lesions  will  usually  be  found  if  care- 
fully sought  for,  including  infiltration  and  thickening  of  the  integument. 

Like  follicular  impetigo,  sycosis  vulgaris  is  a  staphylococcic  infection.  The 
lesions  begin  as  papules,  or  as  nodules  which  form  round  the  hairs — usually  of 
the  face,  and  especially  of  the  chin,  but  sometimes  attacking  also  the  eyebrows, 
eyelashes,  and  the  axillary  and  pi:bic  regions — and  presently  develop  into 
pustules,  each  of  them  pierced  by  a  hair.  As  the  result  of  suppuration,  the  hairs 
are  loosened,  and  if  one  is  pulled  out,  a  drop  or  two  of  pus  usually  exudes.  In 
severe  cases,  the  pustules  may  be  so  closely  packed  together  as  to  form  infiltrations, 
which  may  assume  a  f ungating  character.  The  chief  diagnostic  features  of  the 
affection  are  its  inflammatorj^  character,  its  origin  in  the  hair-folhcles,  and  its 
limitation  to  the  hairy  parts,  usually  as  I  have  said,  of  the  face.  The  differential 
diagnosis  from  tinea  sycosis  has  been  given  under  Fungous  Affkctions  of  the 
Skin.  Eczema  is  not  limited  to  the  hairy  parts,  and  if  the  follicles  are  involved 
it  is  only  secondarily,  nor,  as  a  rule,  is  the  inflammation  so  severe  as  in  sycosis 
vulgaris.  Of  sycosis  vulgaris  again,  intense  itching  is  not  a  feature.  Sometimes, 
when  the  sycosis  is  widely  diffused,  the  crusts  may  have  to  be  removed  to  clear 


PUSTULES  603 

up  the  diagnosis  ;  when  this  is  done,  the  folhcular  imphcation  will  soon  be  per- 
ceived. Tertiary  syphilitic  ulceration  is  not  restricted  to  the  follicles,  and  behind 
it  there  lies  a  history  of  earlier  specific  lesions,  as  well  as  of  the  primary  infection, 
unless  this  should  have  escaped  notice.  If  there  is  ever  any  doubt  as  between 
sycosis  vulgaris  and  acne  vulgaris,  the  presence  of  the  latter  on  non-hairy 
parts  should  of  itself  suffice  to  decide  the  question. 

The  pustules  of  acne  vulgaris  can  scarcely,  indeed,  be  confounded  with  those 
of  any  other  affection,  except  with  the  lesions  of  small-pox  (see  below)  and  those 
of  bromide  and  iodide  eruptions.  In  these  drug  eruptions,  however,  comedones 
are  absent,  the  lesions  occur  on  any  part  of  the  body,  and  are  generally  a  brighter 
red,  while  the  fluid  they  contain  is  rather  thinner.  Drug  eruptions,  again,  occur 
at  any  time  of  life,  whereas  acne  vulgaris  is  essentially  a  disease  of  puberty. 
Pustular  syphilides  may  attack  any  part  of  the  body,  and  are  generally  grouped, 
which  is  never  the  case  with  the  pustules  of  acne. 

A  furuncle  is  so  characteristic  that  the  only  lesion  from  which  it  can  ever  require 
to  be  differentiated  is  a  carbuncle.  The  pathological  process  is  the  same  in  both  ; 
but  while  in  furuncle  there  is  but  one  point  of  suppuration  and  opening,  in  carbun- 
cle there  are  several.  The  only  condition  from  which  a  carbuncle  has  in  turn  to 
be  diagnosed,  except  a  furuncle  and  malignant  pustule  (see  below),  is  diffuse 
celluhtis,  in  which  there  is  no  circumscribed  outline. 

In  malignant  pustule  (anthrax),  following  itching  and  burning  at  the  site  of 
inoculation,  a  livid  red  papule  usually  appears,  on  which  a  bulla  or  pustule 
quickly  forms  and  breaks,  drying  up  into  a  black  gangrenous  eschar.  This  is 
fringed  with  tiny  vesicles  or  pustules,  and  surrounded  by  a  broad  areola  of  sohd 
oedematous  infiltration,  the  skin  over  which  is  tense  and  violaceous.  There  are 
constitutional  symptoms,  with  septic  fever.  The  diagnosis  rests  mainly  upon  the 
presence  of  a  gangrenous  patch  surrounded  by  infiltration  in  a  patient  whose 
occupation  exposes  him  to  infection  with  the  anthrax  bacillus,  especiall}'  from 
cattle,  hides,  or  wool.  The  organism  may  be  detected  without  difficulty  under 
the  microscope.  It  is  only  at  the  outset  that  the  lesion  can  be  mistaken  for  a 
carbuncle.  The  primary  lesion  of  sypliilis  can  be  excluded  by  its  indolence,  and 
by  the  absence  of  gangrene  and  of  febrile  symptoms. 

In  glanders,  the  cutaneous  lesions  begin  as  red  spots,  which  pass  through  the 
papular  and  vesicular  or  bullous  stage  into  pustules  that  give  rise  to  widespread 
ulceration.  The  condition,  with  its  severe  constitutional  disturbance  and,  except 
in  some  chronic  cases,  the  peculiar  discharge  from  the  nostrils,  is  usually  easy  of 
recognition  ;  and  in  exceptional  cases  in  which  the  diagnosis  is  in  doubt,  recourse 
should  be  had  to  mallein,  or  the  bacillus — B.  mallei — may  be  sought  for  with 
the  aid  of  the  microscope. 

In  scrofulodermia  (tuberculides),  usually  an  affection  of  childhood  and  adoles- 
cence, pustular  lesions  take  the  form  which  has  been  stj'led  by  Diihring  the  large 
fiat  pustular,  and  the  small  pustular  scrofuloderm.  The  former  begins  as  one  or 
more  superficial  indurations  which,  becoming  pustular,  extend  peripherallj^  and 
form  a  fiat,  yellowish,  crusted  pustule  of  considerable  size,  surrounded  by  a 
violaceous  areola.  ^Neighbouring  pustules  may  coalesce.  When  the  crust  is 
removed,  a  granular  scrofulous  ulcer  is  seen.  The  small  pustular  scrofuloderm 
is  usually  a  papulo-pustule  rather  than  a  fuUy-developed  pustule,  the  pus  being 
frequently  limited  to  the  central  part  of  the  summit,  while  the  outer  part  of  the 
lesion  remains  hard.  The  crusting  is  sometimes  a  slow'  process,  which  may 
occupy  several  weeks,  and  when  the  crust  drops  off  it  leaves  indelible  scars  not 
unlike  those  of  variola.  The  only  diseases  with  which  scrofuloderma  generally 
can  be  confused,  are  lupus  and  syphiUs.  The  absence  of  "apple-jelly  "  nodules 
and  of  infiltration  will  distinguish  it  from  lupus,  though  the  tAvo  conditions  raa}' 
coexist.     The  syphilitic  ulcer  is  met  with  in  adults,  and  is  usually  a  much  more" 


6o4  PUSTULES 

active  process  than  scrofulodermia,  nor  has  the  lesion  the  undermined  border 
which  is  characteristic  of  the  latter  affection.  Concomitant  s^'philitic  signs  will 
usually  be  present,  just  as  in  scrofulodermia  there  will  generallv  be  other  tuber- 
cular symptoms. 

In  syphilis,  the  pustule  is  a  much  less  frequent  lesion  than  the  papule,  and  is 
generally  found  in  association  with  a  cachectic  state  of  health.  It  appears  in  two 
different  forms,  the  acuminate  and  the  flat  pustular  sj-phihde,  and  in  both  the 
lesion  may  be  either  small  or  large.  The  small  acuminate  or  mihary  syphihde, 
not  usually  much  larger  than  a  pinhead,  in  most  instances  begins  as  a  papule,  and 
papules  will  generally  be  found  intermingled  with  the  pustules.  When  the 
crusts  into  which  the  pustules  dry  are  detached,  there  may  be  some  scarring,  or 
the  lesions  may  leave  no  trace  except  stains,  which  presenth'  disappear. 

The  diagnosis  of  these  small  acuminate  pustules  seldom  presents  any  difficulty  ; 
but  it  is  not  so  with  the  large  acuminate  pustules,  the  acneiform  syphilides,  which 
may  be  mistaken  not  only  for  acne,  but  also  for  variola  and  iodide  eruptions. 
Appearing  on  a  base  which  may  at  first  be  pink,  and  afterwards  copper,  they 
may  be  pustular  from  the  beginning,  or  raa,y  start  as  vesicles  or  as  papules  ; 
they  are  more  or  less  generahzed,  about  the  size  of  a  pea,  disseminated,  or 
grouped  irregular^,  and  while  they  are  predominantly  acuminate,  some  of  them 
may  be  rounded.  Some  of  the  pustules  may  be  dimpled,  and  occasionally  the 
majority  of  them  display  this  character.  When  the  crusts  fall  off,  brownish 
stains  are  seen,  and  there  may  be  shght  scarring,  which,  however,  is  seldom  per- 
manent. The  grouping  which  is  characteristic  of  these  pustular  syphilides,  and 
the  drjdng-up  of  the  pus  into  scales,  are  important  points  in  differentiating  them 
from  the  lesions  of  acne,  which,  further,  instead  of  being  generalized,  seldom  affect 
parts  other  than  the  face,  the  back  of  the  neck,  the  chest,  and  the  back  between 
the  shoulders.  The  comedones  of  acne  are  another  distinguishing  feature,  the 
eruption  is  of  a  more  sluggish  and  chronic  character,  and  there  is  no  cachexia. 
The  diagnosis  as  betAveen  pustular  syphihdes  and  variola  is  given  below.  The 
pustules  met  with  in  iodic  eruptions  are  seldom  either  generalized  or  profuse. 

Small  flat  pustular  syphilides  ("  impetiginous  syphihdes  ")  inaj^  begin  as  such, 
or  may  develop  from  macules  or  papules.  They  are  discrete ;  but  in  such  regions 
as  the  face  and  scalp  maj-  run  together.  The  eruption  is  of  a  generalized  character, 
with  a  preference  for  the  genitals,  the  scalp,  and  the  face.  The  crusts  into 
which  the  pustules  quickly  dxy  axe  frequently  adherent ;  beneath  them  there  is 
superficial  ulceration  ;  occasionally  they  are  surrounded  by  an  areola  of  the 
characteristic  raw-ham  colour.  When  the  eruption  is  extensive,  the  patient  is 
often  anaemic  and  cachectic.  The  affections  from  which  these  syphilides  have 
to  be  differentiated  are  pustular  eczema  and  impetigo.  The  ulceration  which 
underhes  the  crusts  in  the  syphilides  is  not  found  in  either  of  those  conditions, 
nor  is  itching  present  as  in  eczema.  In  impetigo,  the  pustules  most  frequenth' 
affect  the  face  and  hands,  and  are  superficial  ;  and  the  eruption  is  mild  in  charac- 
ter and  of  shorter  duration. 

The  large  flat  pustular  syphilides  ("  ecthymatous  syphihdes  ")  differ  httle 
from  the  small  ones  except  in  size,  and  the  only  lesions  with  which  the}''  are 
likely  to  be  confused  are  those  of  severe  impetigo  vulgaris.  The  diagnosis  from 
that  condition  must  rest  upon  the  slow  development,  the  greater  number  of  the 
pustules,  the  coppery  areola  and  base,  the  accompanying  cachexia,  and  the 
pigmented  scars.  But  it  should  be  remembered — and  this  applies  not  to  pustular 
syphilides  only,  but  to  syphiUs  generally — that  in  m.ost  cases  a  sure  diagnosis 
of  sj'philis  can  only  be  made  when  all  the  factors  of  the  case  are  taken  into 
account  :  the  history,  character,  course  and  termination  of  the  lesions,  and 
their  reaction  to  mercury  or  arsenic  and  the  iodides.  The  distinctive  characters 
of  secondary  lesions  generally  are   their  symmetry,   their  coppery  colour,   the 


PUSTULES  605 


positions  in  which  they  occur,  their  polymorphism,  and  the  absence  of  itching, 
together  with  enlarged  glands,  sore  throat  or  tongue.  In  doubtful  cases,  the 
whole  cutaneous  surface  should  be  examined  for  characteristic  marks  or  lesions. 
If  the  diagnosis  is  still  uncertain,  the  Wassermann  test  should  be  applied. 

Of  all  diseases  of  which  the  pustule  is  one  of  the  manifestations,  small-pox  is 
that  which  presents  the  greatest  difficulty  in  diagnosis.  The  lesion,  occasionally 
preceded  by  a  roseolar  rash  not  unlike  that  of  scarlatina,  begins  as  a  mere  fleck, 
of  pin-head  size,  flush  with  the  surface  and  impalpable.  In  the  course  of  a  few 
hours  it  swells  up  into  a  pink  papule,  which  can  be  felt  embedded  in  the  skin 
like  a  small  shot.  In  a  few  days,  the  papule  undergoes  vacuolation,  at  the  same 
time  getting  bigger,  and  becoming  grey  and  translucent.  So  the  papule  passes 
into  the  vesicle,  which  is  loculated,  so  that  if  it  is  punctured  the  contained  fluid 
is  not  entirely  discharged.  As  a  rule,  the  smaller  vesicles  are  hemispherical,  the 
larger  flat-topped,  and  occasionally  the  crown  is  indented.  After  about  twenty- 
four  hours  the  contents  become  turbid  and  the  covering  dull  and  whitish,  and 
so  the  pustular  stage  is  entered  upon.  While  the  lesion  is  undergoing  this 
transition,  the  grey  translucent  centre  is  encircled  at  the  periphery  of  the  crown 
by  a  white  or  yellow  ring.  By  the  sixth  day  from  its  birth,  the  lesion  has  become 
vellow  throughout  and  the  crown  dome-shaped,  and  so  the  pustule  attains 
maturit}',  and  if  of  full  size  measures  about  three-eighths  of  an  inch  across.  Even 
in  unmodified  small-pox,  however,  the  lesions  often  fail  to  reach  those  dimensions. 
As  the  pustule  develops,  the  erythematous  zone,  the  areola,  which  encircled 
the  papule  and  was  biggest  and  brightest  in  the  vesicular  stage,  begins  to 
wane,  and  has  disappeared  by  the  time  the  pustule  reaches  maturit}^.  This 
occurs  about  the  ninth  day.  As  the  pustules  dry  up  or  burst,  scabs  are  formed, 
which  on  separation  leave  dark  stains,  scars  and  "  pits,"  the  number  and  depth 
of  the  pits  usually  being  determined  by  the  severity  of  the  disease.  In  mild 
attacks  the  pustules  remain  discrete,  in  severe  cases  they  run  together  (confluent 
small-pox,  Fig.  160,  p.  606).  In  bad  cases,  hajmorrhage  takes  place  into  the 
skin  and  the  interior  of  the  pustules.  The  mucous  membranes  of  the  air-passages 
mav  be  invaded,  the  extent  to  which  they  are  involved  being  determined  by  their 
susceptibility^  rather  than  by  the  severit}^  of  the  attack.  In  modified  small- pox 
the  eruption  may  resemble  that  of  the  unmodified  disease,  as  here  described, 
the  difference  being  that  the  lesions  are  less  abundant  and  are  seldom  confluent. 

It  has  been  usual  in  the  diagnosis  of  small-pox  to  lay  the  chief  stress  upon 
the  solidity  and  hardness  of  the  papule,  the  umbilication  of  the  vesicle,  and  the 
loculation  of  its  cavity;  but  in  his  masterly  monograph  ("  The  Diagnosis  of 
Small-pox  ")  to  which  I  owe  the  following  description,  Ricketts  has  shown 
that  the  distribution  of  the  lesions  is  of  more  diagnostic  value  than  their  char- 
acter, as  also  it  is  more  easily  observed.  The  parts  most  liable  to  the  eruption 
are  the  face  and  hands,  exposed  as  these  are  to  constant  stimulation  from  wind 
and  weather  and  other  causes  ;  and  of  the  two,  the  face,  as  the  more  exposed 
part,  is  more  liable  than  the  hands.  Next  to  the  hands  in  susceptibility  come 
the  upper  limbs,  then  the  trunk,  then  the  lower  limbs  ;  the  order  being  deter- 
mined by  the  amount  of  friction  with  the  clothes  which  these  parts  undergo.  As 
to  the  trunk,  the  rash  is  thicker  behind  than  in  front,  and  thickest  on  the 
shoulders,  where  there  is  most  friction.  The  incidence  is  smallest  on  the  great 
flexures  of  the  body,  because  these  are  the  most  sheltered  parts,  while  the 
extensor  surfaces  of  the  limbs,  and  especially  the  elbow,  receive  a  disproportionate 
share  of  the  rash.  The  neck,  sheltered  by  the  head  and  the  shoulders,  fares 
better  than  either  of  those  parts  ;  the  back  of  it  suffers  more  than  the  front. 
On  the  flank,  protected  as  it  is  by  the  arm,  the  rash  is  less  profuse  than  on  the 
adjoining  parts  of  the  chest-wall,  either  in  front  or  behind.  On  the  foot,  the 
distribution  is  marked  by  great  inconstancy.     Usually  the  back  of  the  foot 


6o6 


PUSTULES 


receives  more  attention  than  the  sole  ;  between  the  toes,  and  the  folds  beneath 
the  toes,  enjoy  comparative  immunity;  and  the  parts  for  which  the  eruption 
shows  most  preference  are  the  instep,  especially  the  tendinous  ridges  and  the 


o  ^ 


bony  eminences,  the  tendo  Achilhs,  the  balls  of  the  toes,  the  toe-pads,  and  the 
heels.  When  the  malleoh  present  few  lesions,  as  not  seldom  happens,  it  is 
because  a  well-fitting  boot  has  been  worn,  and  so  these  prominences  have  been 
protected  from  friction.     The  absence  of  uniformity  of  distribution  in  the  case 


PUSTULES  607 

of  the  foot  is  explained  by  differences  in  the  conformation  of  the  foot,  in  the 
foot-gear  which  is  worn,  and  in  the  degree  to  which  the  patient  is  accustomed 
to  wallc.  ■  In  the  hand,  the  palm,  and  especially  the  hollow  of  it,  suffers  httle, 
and  the  brunt  of  the  attack  is  borne  by  the  extensor  surface  ;  the  rash  is  thickest 
on  the  back  of  the  wrist  and  hand,  and  over  the  heads  of  the  metacarpals.  To 
these  usual  characters  the  distribution  offers  exceptions,  some  of  them  difficult 
of  explanation  ;  but  they  are  neither  so  numerous  nor  so  considerable  as 
materially  to  lessen  its  diagnostic  importance.  Its  significance  consists  mainly 
in  the  eruption  being  neither  localized  nor  elliptic,  but  generalized  ;  in  its  being 
symmetrical  and  graded — graded,  too,  evenly  in  homogeneous  areas  ;  and  in 
its  preference  for  surfaces  exposed  to  friction. 

The  diagnosis  of  small-pox  from  chicken-pox — the  disease  with  which  it  is 
most  often  confused  —  and  from  vaccinia,  has  been  set  out  under  Vesicles. 
The  eruptions  of  measles  and  of  German  measles  differ  from  that  of  small-pox 
in  that,  instead  of  being  papular,  they  are  macular,  and  that  they  never  pass 
into  a  vesicular  or  a  pustular  stage.  In  German  measles,  further,  there  is 
enlargement  of  the  posterior  cervical  glands,  w^hich  is  never  the  case  in  small- 
pox at  ah  early  stage.  In  scarlatina,  the  "  strawberry  tongue  "  is  a  sign  which 
is  quite  diiferent  from  the  condition  of  the  tongue  in  small-pox.  The  rose-red 
lenticular  spots  which  make  up  the  rash  of  enteric  fever  are  neither  so  hard 
nor  so  prominent  as  the  papules  of  smaU-pox,  and  they  appear  chiefly'  on  the 
trunk,  and  elect  the  abdomen  and  chest  rather  than  the  back  ;  the  arms  and 
legs,  and  especially  the  face,  almost  always  escape.  The  purpuric  spots  some- 
times seen  in  enteric  may  be  misinterpreted  as  the  signs  of  severe  small-pox  ; 
but  the  absence  of  pronounced  systemic  disturbance  and  severe  pain,  and  of  an 
erythematous  rash,  should  obviate  the  confusion. 

If  the  pink,  sUghtly  elevated  macules  of  simple  purpura  are  mistaken  for  the 
eruption  of  small-pox^  the  error  is  soon  corrected  by  the  deeper  colour  which 
the  macules  take  on  ;  nor,  even  though  the  macules  may  become  papules,  have 
the  lesions  the  characteristic  hardness  of  variolous  papules.  Another  point  of 
difference  between  simple  purpura  and  small-pox  is,  that  in  the  former  affection 
the  face  and  trunk  are  seldom  attacked,  the  sites  of  election  being  the  Hmbs. 
In  erythema  multiforme,  although  the  rash  makes  its  chief  attack  upon  the 
limbs,  it  may  be  widely  diffused  and  may  even  invade  the  face.  In  such  cases, 
however,  the  diffusion  will  usually  be  less  general  than  that  of  the  variolous 
eruption,  nor  is  the  order  of  incidence  the  same.  With  the  involution  which 
the  erythematous  lesions  undergo,  the  resemblance  to  small-pox  ceases.  Even 
in  cases  of  acute  febrile  er\'thema,  in  which  the  whole  cutaneous  surface  is 
covered  by.  a  profuse  eruption,  the  distribution  is  quite  different  from  that  of 
the  small-pox  eruption. 

Confusion  between  small-pox  and  syphilis  is  much  more  hkely  to  arise  when 
the  svphihde  is  pustular  than  when  it  is  vesicular  or  papular.  The  erroneous 
diagnosis  may  be  assisted  by  the  fever  and  aching  symptoms  which  may  precede 
pustular  sj-phihdes,  and  b}'  the  fact  that  the  lesions  may  begin  as  papules.  In 
svphihs,  however,  the  constitutional  symptoms  are  less  severe,  the  eruption  runs 
a  more  indolent  course,  and  appears  in  successive  crops,  whilst  the  vesicles  which 
form  on  the  summits  of  the  papules  have  an  indurated  base.  Sometimes,  too, 
the  sj-phihtic  eruption  is  indifferent  in  distribution,  and  often  it  comprises  various 
t\'pes  of  lesions,  even  when  it  is  not  distinctly  polymorphic,  whereas  in  small-pox 
the  departure  from  homogeneity  is  much  more  limited. 

Occasionally,  impetigo  vulgaris  is  mistaken  for  mild  modified  small-pox  [Fig. 
161,  p.  608),  but  attention  to  the  points  which  mark  off  the  former  affection  from 
pustular  eczema  (see  above)  should  prevent  the  mistake.  Further  differentiating 
features  as  bet^veen  impetigo  vulgaris  and  smaU-pox  are,  that  in  impetigo  there 


6o8 


PUSTULES 


is  no  fever,  and  that  the  lesions  begin  as  vesicles  or  bullae  and  dry  up  into  flat, 
yellowish  crusts.  In  those  cases  of  sudden  and  acute  eczema  which  may  mimic 
small-pox,  guidance  is  to  be  found  in  the  small  size  and  superficiaht)^  of  the 


eczernatous  lesions,  and  the  oedema  and  infiltration  of  the  underlying  skin.  In 
scabies,  again,  the  vesicles  are  superficial,  burrows  will  generally  be  found,  and 
the  heterogeneity  of  the  secondary  lesions  will   aid  the  diagnosis.     In  all  these 


PYREXIA,     PROLONGED  609 

affections,  the  distribution  is  quite  different  from  that  of  small-pox,  the  incidence 
being  partial  or  patchy.  Thus,  in  impetigo,  the  lesions  are  frequently  confined 
to  the  face  and  extremities,  and  if  the  trunk  is  invaded,  it  is  the  front  more 
than  the  back,  the  lower  part  more  than  the  upper.  Acute  eczema  is  seldom 
widely  diffused.  In  scabies,  except  in  children,  the  face  escapes,  and  the  com- 
monest sites  are  the  hands  and  fingers,  buttocks,   and  feet. 

In  Ricketts'  experience,  no  affection,  except  chicken-pox,  is  so  frequently 
confused  with  small-pox  as  acne  vulgaris,  in  spite  of  its  chronic,  afebrile  char- 
acter, and  the  absence  of  subjective  symptoms.  If,  however,  the  rash  is  limited 
to  the  upper  part  of  the  body  and  a  few  characteristic  acne  lesions  such  as 
comedones  are  found,  small-pox  may  be  excluded. 

I  have  seen  copaiba  eruption  mistaken  for  small-pox.  The  absence  of  con- 
stitutional symptoms  such  as  pain  in  the  lumbar  region  and  fever,  the  mixed 
character  of  the  lesions,  and  the  history  are  the  chief  points  in  the  diagnosis. 

It  is  seldom  that  bromide  or  iodide  eruptions  are  mistaken  for  the  rash  of 
small-pox.  In  doubtful  cases,  attention  must  be  paid  to  the  larger  size  of  the 
pustules,  as  compared  with  those  of  small-pox,  and  to  the  symmetrical  or 
patchy  distribution.  Malcolm  Morris. 

PYREXIA,  PROLONGED. — A  pyrexia  may,  for  the  purposes  of  this  article, 
be  considered  to  be  prolonged  if  its  duration  is  more  than  ten  days.  In  the 
majority  of  cases,  no  doubt,  there  are  signs  and  symptoms,  or  facts  in  the  history, 
which  enable  the  practitioner  to  make  a  diagnosis  before  this  time  ;  but 
sufficiently  often  difficulties  arise  from  the  absence  of  the  distinctive  characters 
of  any  one  of  the  diseases  commonly  accompanied  by  such  pyrexia.  In  most 
cases  such  a  prolonged  pyrexia  is  the  result  of  one  of  the  infectious  diseases,  and 
it  is  by  a  careful  consideration  of  the  more  probable  among  these  that  one  may 
often  arrive  at  a  definite  opinion. 

The  general  infections  most  likely  to  give  rise  to  a  long-lasting  fever  are  : — 


Typhus  fever 
Typhoid  fever 
Paratyphoid  fever 
Malta  fever 
Influenza 
Tuberculosis 
Malignant  endocarditis 


Septicaemia  from  deep-seated  foci  of 
disease,  such  as : — Empyema,  Cere- 
bral abscess,  Pylephlebitis,  or  other 
form  of  suppuration 

Malaria 

Syphilis 

Bacilluria 

Bronchopneumonia. 

A  high  temperature  of  very  long  duration  occurs  often  in  connection  with 
diseases  of  the  blood  and  blood-forming  organs,  such  as  : — 

Addison's  anaemia  Leukaemia  Hodgkin's  disease. 

It  also  occurs  much  more  often  than  has  been  commonly  supposed  in  sarcoma 
and  carcinoma  of  different  organs,  and  has  been  observed  in  cirrhosis  of  the  liver. 
There  are  two  other  forms  of  pyrexia  which  should  be  borne  in  mind,  namely,  a 
prolonged  pyrexia  occurring  in  children,  often  very  difficult  to  explain ;  and  so- 
called  neurotic  pyrexias. 

Modern  research  has  a  tendency  to  rely  upon  its  own  methods  alone,  and  to 
ignore  the  older  clinical  differences.  But  this  involves  a  separate  investigation 
for  each  disease  as  it  comes  to  be  considered  ;  and  thus  it  may  happen  that  one 
patient  may  have  to  undergo,  in  addition  to  a  thorough  bedside  examination  of 
all  his  organs,  a  lumbar  puncture,  and  the  removal  of  blood  for  the  Widal  test, 
or  for  the  cultivation  of  organisms;  and  these  may  have  to  be  repeated.  A  full 
knowledge  of  the  history  of  the  illness,  of  exposure  to  infection,  and  of  the 
clinical  changes  as  far  as  they  are  manifested,  is  desirable  in  order  that  the 
D  39 


6io  PYREXIA,     PROLONGED 

researches  of  the  bacteriologist  may  be  directed  as  early  as  possible  into  the 
right  path. 

Typhus. — On  the  score  of  prolonged  pyrexia  little  need  be  said  of  this  fever. 
The  eruption  is  generally  distinctive,  and  shows  itself  before  the  fever  has  attained 
any  duration  ;  but  it  is  capable  of  being  confounded  with  t}'phoid  fever,  and 
even  with  malignant  endocarditis.  The  distinction  from  typhoid  fever  is  given 
elsewhere ;  and  a  confusion  with  mahgnant  endocarditis  is  only  possible  if  the 
latter  should  produce  a  very  uniformly  distributed  petechial  eruption  over 
the  skin,  while  the  cardiac  murmur  is  of  high  intensity ;  or  if  a  person  already 
the  subject  of  cardiac  murmur  should  contract  tj'phus,  and  have  an  ill-defined 
eruption.  In  either  case,  if  the  pj^rexia  were  prolonged  bej^ond  the  t^velfth  or 
fourteenth  day,  typhus  would  be  unhkely. 

Influenza. — -In  the  majority  of  cases  of  influenza,  uncomphcated  by  definite 
visceral  changes  such  as  pneumonia  or  gastro-enteritis,  the  fever  is  of  short 
duration,  and  does  not  come  within  the  scope  of  this  article.  But  it  is  often  as 
long  as  a  week  or  ten  days,  and  sometimes  three  weeks  or  more.  The  longer 
period,  accompanied  as  the  fever  is  by  few  distinctive  signs,  is  sufficient  to  lead 
to  a  confusion  with  tj'phoid  fever,  tuberculosis,  or  malignant  endocarditis,  either  of 
which  may  proceed  for  two  or  three  weeks,  and  the  last  t\vo  for  mam^  more  Aveeks, 
without  distinctive  cUnical  signs.  The  constant  presence  of  influenza  amongst 
us,  and  the  great  variety  in  the  characters  it  assumes,  make  it  very  difficult 
to  exclude  it  until  positive  signs  of  another  complaint  have  manifested  themselves. 
Equally  difficult,  however,  is  it  to  prove  the  existence  of  the  disease,  since  the 
organism,  Pfeiffer's  bacillus,  is  not  easilj'  found  in  the  blood  ;  and  in  the  prolonged 
cases,  the  rather  striking  peculiarities  of  the  intense  acute  attacks,  such  as  severe 
pain  in  the  head  and  back  of  the  eyQ,  and  in  the  lumbar  region,  maj^  be  absent. 

The  diagnosis  can  often  be  made  positively'-  only  via  exclusionis,  when  the 
bacteriological  tests  of  typhoid  fever  and  tuberculosis  have  failed,  and  if  there  is 
an  entire  absence  of  rose  spots,  diarrhoea,  or  enlarged  spleen  on  the  one  hand, 
or  of  pulmonary  symptoms  on  the  other.  All  the  more  must  we  bear  in  mind 
the  possibility  that  an  apparent  attack  of  recovered  influenza  may  only  be  the 
pyrexial  equivalent  of  the  earliest  tuberculous  infection,  and  if  at  any  time  in  the 
course  of  the  illness  sputum  is  available,  it  should  certainly  be  examined  for 
tubercle  baciUi. 

Typhoid  Fever. — This  should  be  comparatively  easy  to  diagnose  in  the  present 
day.  A  fever  commencing  with  frontal  headache,  perhaps  with  diarrhoea, 
generally  compelUng  the  patient  to  lie  up  in  bed  hj  the  end  of  the  first  week,  and 
showing  within  the  first  ten  days,  rose  spots  on  the  abdomen  and  a  shght  enlarge- 
ment of  the  spleen,  while  at  that  time  the  temperature  is  ioi°  F.  or  102°  F.  in 
the  morning,  and  103°  F.  or  more  in  the  evening,  and  the  pulse  is  relatively  slow, 
namely  from  80  to  100  in  the  minute,  should  be  typhoid  fever.  The  AVidal 
reaction,  that  is,  the  agglutination  of  typhoid  bacilU  by  the  patient's  blood  serum, 
becomes  positive  about  the  tenth  or  twelfth  day.  All  these  signs  ma}^  fail  for 
a  time  :  spots  may  be  absent,  the  bowels  may  be  persistently  constipated, 
enlargement  of  the  spleen  may  be  difficult  to  prove,  the  Widal  test  may  and 
often  does  fail.  Examinations  of  the  faeces  for  Eberth's  bacillus  are  not  easy ; 
but  cultivation  of  the  bacillus  from  the  blood  taken  from  the  patient's  vein 
may  yield  the  bacillus,  and  this  at  an  earher  date  than  the  Widal  reaction  can 
be  obtained. 

Apart  from  such  cultivation,  the  appearance  of  rose  spots  from  the  sixth  to 
the  tenth  day,  with  additions  to  their  number  every  day  for  five  or  six  days, 
forms  perhaps  the  most  conclusive  evidence  of  tj'phoid  fever  ;  and  the  diagnosis 
based  on  these  grounds  should  not  be  upset  b}''  one  or  tsvo  failures  to  get  a  positive 
reaction  with  the  Widal  test. 


P  Y REX  I A ,     PROLONGED 


6ii 


This  test  may  require  to  be  made  with  two  or  more  strains  of  Eberth's  bacillus, 
and  failing  them,  paratyphoid  bacilli  should  be  used.  A  positive  Widal  reaction 
in  a  case  otherwise  unlike  typhoid  fever  must  be  accepted  with  caution.  If  a 
case  is  devoid  of  spots,  and  gives  no  Widal  reaction,  the  probability  of  its  being 
typhoid  fever  might  be  asserted  from  its  mode  of  onset,  a  characteristic  chart  of 
temperature  {Fig.  162),  with  high  readings  morning  and  evening  in  the  middle  of 
the  second  week,  and  ending  in  twenty  to  twenty-five  days  after  wide  oscilla- 
tions, and  finally  a  pulse  always  under  100.  On  the  other  hand,  a  pulse  of 
more  than  100  does  not  exclude  typhoid,  as  it  is  common  enough  in  the  severe 
adynamic  forms. 

Typhoid  fever  may  be  confounded  with  many  acute  diseases  ;   as  a  prolonged 


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J^'ig-.   162. — Temperature    chart  of  a  case  of  typhoid   fever. 


pyrexia  it  is  especially  pulmonary  tuberculosis,  malignant  endocarditis,  a  long- 
lasting  influenza,  septicsemic  processes,  and  occasionally  tuberculous  meningitis 
which  will  give  difficulty. 

Paratyphoid  Fever. — Of  this  it  need  only  be  said  that  it  presents  the  features  of 
a  benign  typhoid  fever,  in  which  all  the  distinctive  characters  are  less  marked. 
Like  typhoid,  it  may  be  confounded  with  a  mild  long  influenza,  or  with  early 
tuberculosis.  Its  recognition  depends  ultimately  upon  the  agglutination  of 
paratyphoid  bacilli  by  the  patient's  blood  serum. 

Malta  Fever. — This  is  one  of  the  most  prolonged  of  the  fevers  due  to  one 
recognized  micro-organism  ;  for  in  the  undulant  form  of  the  disease  successive 
exacerbations  of  pyrexia  may  carry  on  the  illness  into  the  fifteenth  or  sixteenth 


6l2 


PYREXIA,     PROLONGED 


week  (Fig.  163).  It  closely  resembles  typhoid  fever,  and  is  proved  to  be  due 
to  infection  with  Micrococcus  melitensis,  conveyed,  almost  invariabl}^,  in  goat's 
milk.  In  British  practice  its  occurrence  is  unhkelj^,  except  in  one  who  has  been 
in  the  parts  of  the  world  where  it  is  rife, — namely,  the  Mediterranean  coast 
and  islands. 

It  differs  from  typhoid  fever  in  the  absence  of  spots,  and  of  characteristic 
diarrhoea,  but  as  these  often  fail  in  tj^phoid  fever,  the  distinction  is  not  always 
available.  However,  the  diagnosis  can  generally  be  made  by  the  Widal  test, 
since  the  blood  serum  will  agglutinate  the  Micrococcus  melitensis  as  earlj-  as  the 
fifth  dajr  of  the  disease. 

Tuberculosis. — The  onset  of  general  miUary  tuberculosis,  or  of  mihary  tuber- 
culosis of  the  lung,  has  often  for  its  only  symptom  a  moderate  pjTexia,  with 
accompanying  phj^sical  weakness  and  anorexia.  Such  a  condition  may  continue 
for  weeks  without  any  other  sign  ;  the  breathing  need  not  be  quickened,  and 
there  may  be  an  entire  absence  of  abnormal  signs  in  the  lungs.  The  morning 
temperature    is    frequently  near  the  normal,   while    the    evening   temperature 


Fig-.  163. — Temperature  chart  of  a  case  of  Malta  fever  of  undulant  tj-pe. 


alone  is  high  :  and  it  does  not  as  a  rule  increase  to  a  maximum  and  subsequently 
fall,  so  as  to  form  the  curve  which  is  characteristic  of  t^^phoid,  but  continues 
nearly  at  the  same  level  for  long  periods.  In  the  absence  of  sputum,  the  detec- 
tion of  tubercle  bacilh  is  not  available.  TubercuUn  tests  may,  however,  be 
tried,  and  will  probably  give  positive  results.  Of  these  the  most  suitable  is  the 
cutaneous  tubercuhn  test  of  von  Pirquet.  Tuberculous  infection  in  other 
locaUties  may  equally,  when  not  accompanied  b}'  striking  local  signs,  and  only 
presenting  the  pyrexia,  be  taken  for  typhoid  fever  :  for  instance,  tuberculous 
disease  of  the  kidney,  or  pyelitis,  and  especially  tuberculous  meningitis.  Head- 
ache and  fever  occur  both  in  this  and  in  typhoid,  and  ma}'-  be  for  a  time  the  only 
facts  in  the  case ;  until  in  the  one  case  spots  or  loose  motions  assert  themselves, 
or,  in  the  other,  optic  neuritis,  convulsions,  paralysis,  or  retracted  abdomen  point 
to  a  cerebral  localization. 

Infective  or  Malignant  Endocarditis. — This  may  be  mentioned  next  because  for 
days  or  weeks  the  only  prominent  feature  may  be  a  continuous  pjnrexia  with 
evening  rises  to  101°  F.,  falling  in  the  morning  to  99°  or  98-4°  F.  [Fig.  164).  In 
most  cases  a  cardiac  murmur  is  present,  and  then  one  ma^'^,  after  a  certain  lapse 


P  Y REX  I A ,     PROLONGED 


613 


of  time,  such  as  fourteen  days,  and  excluding  .the  possibiUty  of  typhoid  fever, 
often  make  a  diagnosis  with  confidence.  This  is  confirmed  by  the  occurrence 
of  enlarged  spleen,  by  rigors,  by  the  appearance  of  petechial  spots  and  small 
haemorrhages  under  the  skin,  by  the  cessation  of  pulse  in  one  or  other  of  the 
accessible  arteries,  such  as  the    radial,  posterior  tibial,  or   dorsalis   pedis,   by 


F/£:  164. — Temperature  chart  of  a  case  of  malignant  endocarditis. 

optic  neuritis  or  retinal  haemorrhages,  and  by  anaemia.  An  attempt  should 
be  made  to  obtain  an  organism  from  the  blood  by  cultivation,  but  it  is  not 
always  successful.  In  the  early  stages  the  difficulty  is  not  uncommonly 
increased  by  the  fact  that  no  murmur  can  be  heard,  in  spite  of  the  fact  that 


Fi^.  165. — Temperature  chart  of  a  case  of  pyaemia,  secondary  to  otitis  media  and  lateral 
sinus  thrombosis.     There  was  a  rigor  almost  daily. 

endocardial  changes  are  present.  The  course  of  some  of  these  cases  of  infective 
endocarditis,  which  may  be  called  chronic,  is  remarkably  prolonged,  sometimes 
for  six,  eight  or  twelve  months,  with  little  variations  in  the  accompanying 
conditions.  Long  before  that,  of  course,  typhoid  fever  and  tuberculosis  would 
have  been  excluded  ;    and  after  eight  or  ten  weeks  the  co-existence  of  cardiac 


6i4 


PYREXIA,     PROLONGED 


murmur,  with  uniform  prolonged  pyrexia,  would  make  the  diagnosis  certain. 
Cases  in  which  the  brunt  of  the  disease  falls  upon  the  brain  may  actually  have 
meningitis,  as  in  pneumococcal  cases  ;  or  they  may  be  mistaken  for  meningitis, 
or  for  typhoid  fever,  or,  if  petechise  are  present,  for  typhus.  But  in  such  instances 
the  illness  is  generally  a  short  one,  and  it  would  not  come  into  the  present 
category. 

Septiccsmia. — In  any  prolonged  pyrexia  the  possibility  of  a  focus  of  deep- 
seated  suppuration  should  be  considered.  In  many  situations  the  focus  causes 
pain,  which  at  once  directs  attention  to  the  origin  of  the  trouble  ;  but  in  some 
cases  pain  is  absent,  and  foci  in  some  situations  are  habitually  painless.  The 
disorders  to  be  thought  of  are  otitis,  abscesses  in  the  throat,  a  small  empyema, 
cerebral  abscess,  deep-seated  glandular  suppuration,  suppurative  pylephlebitis, 
appendicitis,  and  pelvic  suppurations  in  women.  If  the  blood  shows  a  leucocytosis, 
this  will  be  in  favour  of  a  suppurating  centre.  At  any  rate,  it  will  exclude 
typhoid  and  miliary  tuberculosis.     Each  possible  centre  of  infection  must  be 


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called  to  mind,  and  the  locality  concerned  must  be  investigated.  Suppurative 
pylephlebitis,  in  spite  of  the  extent  of  the  lesions  and  the  size  of  the  organ 
concerned,  has  frequently  been  overlooked,  and  has  been  mistaken  for  typhoid 
fever,  pneumonia,  peritonitis,  or  appendicitis.  It  is  relatively  rare,  but  it  is  a 
sequel  of  other  suppurative  lesions  in  the  abdomen,  and  should  therefore  be 
thought  of  when  appendicitis  or  other  similar  affection  has  been  under  treatment. 
Rigors  are  very  inconstant  in  diseases  of  this  class  ;  if  they  occur  they  compel 
attention  to  the  possibility  of  pyogenetic  centres  [Fig.  165)  ;  but  their  absence 
must  not  be  allowed  to  influence  one  in  the  contrary  sense.  They  are  most 
constant  in  visceral  pyaemia,  but  this  illness  is  not  generally  prolonged. 

Erysipelas,  though  generally  of  short  duration,  sometimes  causes  pyrexia 
lasting  more  than  a  fortnight   (Fig.  166). 

Syphilis. — Like  other  infections,  this  has  its  fevers,  both  in  the  secondary  stage, 
— that  is  the  stage  of  generalization  of  the  infection — and  in  the  late  stages  accom- 
panying gummata  and  other  local  processes.     The  secondary  fever  is  certainly 


PYREXIA,     PROLONGED  615 

not  present  to  a  marked  degree  in  most  cases  ;  a  little  feverishness  there  may- 
be, but  it  scarcely  requires  special  mention.  Only  occasionally  there  is  a  really 
prolonged  pyrexia,  with  decided  evening  elevations  of  temperature.  The  diagnosis 
is  rarely  in  question,  because  the  fever  only  accompanies  the  rash  and  sore 
throat ;  and  the  origin  in  a  local  infection  is  generally  well  known.  The  same 
help  may  be  with  us  in  the  fever  attending  gumma-formation  ;  but  if  the 
gumma  is  deep-seated,  or  in  a  viscus  such  as  the  liver,  even  though  it  should  be 
painful,  and  recognized  by  palpation  as  an  abnormal  enlargement  or  thickening, 
some  hesitation  may  be  felt  as  to  the  diagnosis,  unless  it  is  remembered  that 
such  pyrexia  may  be  present.  Moreover,  a  pyrexia  of  this  kind  has  occurred  in 
connection  with  the  lesions  of  the  inherited  disease.  Syphilitic  pyrexia  is 
frequently  of  decided  character,  with  evening  elevations  to  103°  F.  or  more,  and 
morning  falls  nearly  to  normal,  until  stopped,  as  it  may  be  at  once,  by  the 
administration  of  potassium  iodide.  In  both  these  cases  the  Wassermann  re- 
action is  available  to  make  certain  the  nature  of  the  infection. 

Bronchopneumonia. — -This  may  be  mentioned  because  it  has  sometimes  a 
duration  of  many  weeks,  and  during  the  whole  time  an  oscillating  temperature 
is  present.  The  local  signs  are,  however,  sufficient  to  explain  the  presence  of 
fever,  and  the  difficulty  lies  only  in  the  fact  that  a  general  pulmonary  tuberculosis 
may  resemble  almost  exactly  the  more  curable  bronchopneumonia  of  pneumo- 
coccal or  streptococcal  origin. 

Malaria. — Important  as  is  this  disease,  its  diagnosis  may  be  dealt  with  briefly 
here.  The  non-malignant  quartan  and  tertian  fevers  produce  isolated  pyrexias 
of  short  duration  which  do  not  come  within  the  scope  of  this  paper.  It  is  only 
the  malignant  fevers,  which  do  not  arise  in  this  country,  and  are  little  likely  to  be 
seen  in  other  than  regions  known  to  be  malarious,  which  cause  prolonged  con- 
tinuous pyrexia.  The  diagnosis  is  based  upon  a  consideration  of  the  symptoms, 
upon  the  discovery  of  the  parasite,  and  upon  the  results  of  treatment  with 
quinine.  The  symptoms,  chill,  fever  and  sweating,  have  less  value  in  a  continuous 
pyrexia  than  in  the  simple  tertian  and  quartan  fevers,  and  in  a  quotidian  fever 
the  resemblance  to  septic  poisoning  is  well  recognized.  An  enlarged  spleen  is 
present  in  malaria,  but  also  commonly  in  typhoid  fever.  Most  reliance  is  to 
be  placed  upon  a  microscopical  examination  of  blood-films  coloured  with 
Romanowsky's  or  Leishman's  stain  ;  for  in  cases  of  pernicious  malaria,  it  is 
rarely  that  the  organisms  [Plate  XII,  Fig.  E)  fail  to  be  discovered  by  this 
means.  Absence  of  leucocytosis  and  an  increase  of  the  large  mononuclears 
to  15  per  cent  in  a  differential  count  of  the  leucocytes  in  the  blood,  are  also  in 
favour  of  malaria,  at  least  in  the  first  two  weeks ;  after  which  the  results  may 
be  very  similar  in  typhoid  fever.  The  third  test  is  the  administration  of  quinine, 
which,  given  in  sufficient  quantity,  will  stop  malaria ;  and  on  the  other  hand,  if 
the  fever  continues  in  spite  of  it,  malaria  is  excluded.  An  adequate  dose  for 
this  purpose  is  3  or  4  gr.  every  three  hours,  day  and  night  for  two  or  three  days. 

Bacilluria. — This  is  usually  due  to  infection  of  the  urinary  passages  with 
Bacillus  colt  communis.  The  symptoms  may  be  slight  or  they  may  be  those 
of  cystitis  or  pyelitis  in  a  marked  degree.  With  these  there  is  a  more  or  less 
continuous  pyrexia.  The  diagnosis  consists  in  the  recognition  of  the  Bacillus 
coli  in  the  urine  by  microscopical  examination.  The  urine  is  acid,  with  an 
unpleasant  odour,  clear  when  passed,  but  cloudy  and  turbid  on  standing ; 
and  the  sediment  contains  pus  cells,  bladder  epithelium,  and  perhaps  renal  cells, 
and  hyaline  and  granular  casts.  An  amount  of  albumin,  usually  not  more  than 
O'l  per  cent,  may  be  present.  The  bacilli  are  best  detected  by  centrifuging  the 
urine,  staining  the  deposit  with  methylene  blue,  and  examining  with  an  oil- 
immersion  lens.  The  disorder  is  common  in  infants,  and  in  adults  it  is  most 
frequent  in  women  in  connection  with  pregnancy.     The  symptoms,  especially  in 


6i6 


PYREXIA,     PROLONGED 


infants,  may  be  few,  or  none  at  all  other  than  the  p^Texia,  which  is  variable  in 
degree,  generally  irregular  from  day  to  day,  may  be  accompanied  by  chills  and 
sweating,  and  may  last  several  weeks.  In  some  cases,  however,  there  is  fre- 
quency of  micturition,  pain,  perhaps  paroxysmal,  in  the  kidney  or  bladder,  and 
gastro-intestinal  s\Tnptoms.  Hence  in  an  obscure  fever  in  infants,  the  urine 
should  be  examined  carefully. 

Other  organisms  sometimes  infecting  the  urine  are  Bacillus  lactis  aerogenes, 
the  t5rphoid  bacillus,  and  Bacillus  proteiis  vulgaris. 

AncBmia. — -The  several  forms  of  pernicious,  idiopathic,  or  Addisonian  anaemia 
are  frequently  accompanied  by  a  moderate  degree  of  pj-rexia,  which  mav  persist 


167. — Characteristic  temperature  chart  of  a  case  ot 
pernicious  anaemia. 


for  man}-  weeks  [Pig-  167).  Such  an  anaemia  might  be  the  manifestation  of 
tuberculosis,  of  infective  endocarditis,  or  of  mahgnant  growths  ;  but  an  exam- 
ination of  the  blood  with  the  discovery  of  poikilocytosis,  of  a  colour-index 
above  unity,  the  lemon-yellow  tint  of  the  skin  in  some  cases,  and  the  history, 
will  generally  determine  the  diagnosis,  though  the  differentiation  of  the  par- 
ticular form  of  anaemia  may  still  remain  to  be  considered  (see  Ax.emia). 

Hodgkin's  Disease. — In  some,  but  by  no  means  all,  cases  of  this  disease,  a  very 
remarkable  form  of  pyrexia  occurs.  It  consists  of  alternating  periods  of  p^Texia 
and  apyrexia,  each  of  eight,  ten,  or  twelve  days'  duration,  lasting   in  aU   for 


PYREXIA,     PROLONGED 


617 


six,  nine,  or  twelve  months.  During  the  pyrexial  period  the  temperature,  begin- 
ning near  the  normal,  becomes  day  by  day  higher  and  higher,  till  on  the  fourth 
or  fifth  evening  it  reaches  102°  F.  or  103°  F.,  its  highest  point ;  it  gradually  dechnes 
during  the  next  four  or  five  days  to  the  normal  ;  and  then  for  three  or  four  days 
it  becomes  increasingly  subnormal,  till  a  minimum  is  reached,  and  from  this 
point  there  is  a  gradual  return  to  the  normal,  when  a  second  pyrexial  curve 
begins  (Fig.  168).  If  the  cervical,  axillary,  or  inguinal  lymph-glands,  apart 
from  or  in  company  with  the  spleen,  are  enlarged,  and  the  condition  of  the  blood 
is  normal,  or  of  the  simple  chlorotic  type,  the  diagnosis  of  Hodgkin's  disease  is 


31   JULY          TO       AUCUS7  13 

14  AUGUST      TO      AUGUST    27 

2B   AUOUS.T.  TO    fEPTEMBERIO 

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safely  made.  If  such  a  temperature  is  observed  without  any  enlargement  of  the 
spleen  or  of  the  external  glands,  a  lymphadenomatous  enlargement  of  the 
internal  glands,  bronchial  or  mediastinal,  should  be  suspected,  and  endeavours 
should  be  made  to  demonstrate  them  by  palpation,  percussion,  or  ;tr-rays. 
Leucocytosis  should  be  absent ;  but  its  occurrence  in  a  late  stage  of  the  pyrexia 
would  not  militate  against  the  diagnosis. 

Leukcemia. — Pyrexia  is  a  common  occurrence  in  the  different  forms  of 
leuksemia.  As  a  rule  the  great  size  of  the  spleen  in  one  group  of  cases  leads  to  an 
easy  diagnosis,  and  in  another  group  the  glands  are  manifestly  enlarged,  though 


Fig.  169. — Temperature  chart  of  a  case  of  sarcoma  of  the  neck  and  mediastinum. 


acute  cases  occur  in  which  these  changes  do  not  appear  early  ;  in  all  these 
forms  an  examination  of  the  blood  will  show  the  excessive  number  of  leucocytes, 
of  one  or  other  variety,  a  sufficient  explanation  of  the  occurrence  of  pyrexia. 

New  Growths. — The  belief  that  new  growths  are  not  as  a  rule  accompanied  by 
pyrexia  is  well  founded  ;  but  many  exceptions  have  been  recorded,  both  in 
regard  to  sarcoma  and  to  carcinoma.  A  case  of  sarcoma  of  the  neck  and  medias- 
tinum was  accompanied  for  the  four  months  preceding  death  by  a  pyrexia 
resembling  in  its  variations  from  week  to  week  that  which  is  so  characteristic 
of  Hodgkin's  disease  [Fig.  169),  and  carcinoma  has  now  frequently  been  known 


6i8  PYREXIA,     PROLONGED 

to  be  accompanied  for  weeks  or  months  by  fever,  especially  where  there  are 
secondary  deposits  in  the  Uver.  For  obvious  reasons  the  diagnosis  is  not  generally 
dif&cult ;  that  is,  the  tumour  is  in  evidence.  A  point  of  importance  is  that  the 
presence  of  pyrexia  does  not  help  to  distinguish  between  syphilis  and  cancer. 

Cirrhosis  of  the  Liver. — The  diagnostic  relations  of  pyrexia  in  cirrhosis  of  the 
liver  are  on  the  same  footing.  It  occurs  in  some  cases  and  is  apparently  due  to 
cirrhosis  ;  whether  because  it  is  an  inflammatory  process,  or  because  the  cirrhosis 
is  due  to  a  toxeemia  which  may  raise  the  temperature,  does  not  seem  to  be 
determined.  The  fact  is  of  interest  when  we  consider  that  ascites  due  to 
hepatic  cirrhosis  has  often  been  mistaken  for  tuberculous  peritonitis,  and,  per- 
haps less  often,  tuberculous  peritonitis  for  cirrhosis.  The  absence  of  pyrexia 
might  possibly  be  held  to  exclude  tuberculous  peritonitis,  but  its  presence  would 
leave  the  diagnosis  open,  since  it  might  be  due  to  either. 

Neurotic  Pyrexia. — This  term  may  be  applied  to  two  classes  of  case  :  in  one 
the  mercury  is  found  at  extraordinarily  high  levels  at  irregular  intervals,  often 
at  different  levels  in  different  parts  of  the  body,  and  falling  again  rapidly  to  the 
normal.  This  may  be  repeated  many  days,  but  hardly  constitutes  prolonged 
pyrexia.  In  the  second  variety  the  patient  has  a  genuine  pyrexia,  lasting  two, 
three,  or  more  weeks,  irregular  in  the  elevations  which  the  temperature  may  reach 
on  successive  days,  but  on  the  whole  resembhng  the  pyrexia  of  sepsis.  These 
cases  are  more  often  females,  and  the  fever  may  be  associated  with  symptoms 
referable  to  the  pelvic  organs,  or  may  persist  after  the  entire  subsidence  of  such 
symptoms,  so  that  skilled  obstetric  physicians  have  been  unable  to  find  any 
active  local  lesion.  The  neurotic  origin  of  such  cases  may  be  open  to  doubt,  but 
it  is  supported  by  the  variabiUty  of  the  pyrexia,  and  by  its  occasional  rapid 
cessation  without  adequate  explanation,  and  without  any  local  change.  The 
diagnosis  can  only  be  made  as  a  rule  via  exclusionis,  and  must  always  be  con- 
sidered provisional  as  long  as  there  is  any  probability  of  an  adequate  cause 
being  found. 

The  Unexplained  Pyrexia  of  Children. — This  form  of  pyrexia  is  in  a  somewhat 
similar  position  to  the  above.  All  students  of  disease  in  children  are  familiar 
with  the  fact  that  in  patients  under  nine  or  ten  years  of  age  a  mild  pyrexia  may 
occur,  lasting  two,  three,  or  four  months,  for  which  no  explanation  can  be  found. 
Since  it  arises  in  quite  j^oung  subjects,  a  neurotic  origin  is  not  so  readily  suggested 
nor  so  hkely,  as  in  the  adult  female,  and  yet  it  is  possible  that  some  cases  are  of 
this  nature.  Tuberculosis  should  be  considered  carefully,  but  is  often  safely 
and  rightljr  excluded.  Gastro-intestinal  disturbance,  such  as  constipation  ;  the 
unsuitable  nature  of  the  food  ;  and  acute  intoxication  from  the  alimentary  canal, 
are  other  possible  explanations  of  some  cases.  Since  the  prognosis  is  good,  it  is 
satisfactory  to  be  able  to  recognize  the  clinical  condition,  even  though  the  causa- 
tion is  obscure  ;  but  the  diagnosis  can  only  be  established  after  careful  exclusion 
of  t>nphoid  fever,  tuberculosis,  and  local  inflammatory  conditions  such  as  otitis, 
bacilluria,  and  other  definite  lesions  or  infections.  Frederick  Taylor. 

PYREXIA  WITHOUT  OBVIOUS  CAUSE.— It  is  barely  fifty  years  since 
the  clinical  thermometer  came  into  regular  use,  yet  now  its  report  is  the  most 
commonly  ascertained  factor  in  diagnosis  and  prognosis,  though  possibly  not 
the  most  reliable. 

A  great  deal  of  time  and  effort  has  been  spent  in  attempts  to  ascertain  the 
precise  mechanism  by  which  the  human  body  maintains  in  health  an  average 
temperature  (practically  constant)  of  98-4°  F.,  and  also  in  determining  the  exact 
factors  that  lead  in  disease,  and  also  even  in  health,  to  a  departure  from  that 
temperature. 

From  these  studies,  associated  with,  and  controlled  by,  clinical  observations, 


PYREXIA     WITHOUT     OBVIOUS     CAUSE  619 

there  have  been  established  a  number  of  general  principles  and  facts  which  must 
be  grasped  before  we  can  form  a  just  estimate  of  the  value  of  the  reading  of  the 
thermometer  in  diagnosis.  We  must  briefly  state  the  more  important  of  these 
without  discussion. 

1.  Sources  of  the  Actual  Production  of  Heat  in  Health  in  order  of  importance  : 
{a)  Muscles  at  work  ;  {b)  Glands  at  work  ;  (c)  All  minor  tissues  in  which  kata- 
bolic  changes  are  proceeding. 

2.  Provisions  for  the  Escape  of  Heat. — {a)  Temperature  changes  in  the  air, 
especially  that  expired  ;  [b)  Escape  by  the  skin,  radiation  and  evaporation  of 
sweat  ;  (c)  Escape  by  urine  and  fjeces  ;  [d)  Warming  of  food  and  anabolic 
tissue  changes. 

3.  Mechanisms  for  Regulating  the  Distribution  of  Heat  generated  Locally. — 
{a)  A  main  centre  for  regulating  the  distribution  of  the  blood,  situated  in  the 
medulla  ;  {b)  Subsidiary  centres  for  the  same  purpose  situated  in  the  cord  and 
(?)  elsewhere  ;  (c)  The  physical  properties  of  the  blood,  lymph,  and  tissue 
juices  as  regards  heat  capacity  and  their  circulatory  movements. 

These  three  belong  to  the  province  of  pure  experimental  physiology  ;  we 
have,  then,  the  further  observations  shared  by  physiology  and  clinical  medicine  : 

A.  That  the  temperature  in  perfect  health  can  be  considerably  raised  (at 
least  to  102°  F. — Hill)  by  strenuous  physical  exertion  ;  such  elevations  very 
rapidly  disappear,  possibly  with  small  oscillations. 

5.  That  in  exhaustion  from  violent  effort  or  exposure  (generally  both,  as  in 
shipwrecks  and  similar  accidents)  the  temperature  can  be,  and  is,  very  dangerously 
depressed,  this  being  possibly  the  sole  cause  of  death. 

6.  That  in  every  form  of  microbic  invasion  of  the  body,  the  temperature 
may  be  altered,  either  by  the  poisonous  products  of  the  microbes,  or  by  the 
activities  of  the  microbes  themselves,  or  by  the  effects  of  either  of  these  activities 
upon  the  mechanism  for  regulating  the  distribution  of  heat,  probably  by  all 
these  methods  and,  perhaps,  others. 

Lastly,  as  purely  clinical  observations  we  have  learnt  : — 

7.  That  in  order  that  variations  in  temperature  may  kill,  or  indeed  of 
themselves  be  of  very  serious  import,  they  need  to  be  very  extreme  (say  6  or  7 
degrees  above  or  below  normal)  or  else  very  prolonged,  the  necessary  duration 
varying,  of  course,  with  the  degree  of  departure  from  the  normal. 

8.  That,  in  the  wards  of  a  hospital  where  the  temperatures  are  taken  and 
charted  at  regular  intervals,  it  is  scarcely  possible  to  find  a  chart  of  chronic 
disease  which  does  not  show  some  oscillations  in  temperature,  the  causes  of 
which  are  obscure  or  overlooked. 

From  these  general  propositions  we  may  pass  to  the  practical  value  of  thermo- 
metric  observations  in  diagnosis.  We  may  again  generalize,  and  say,  that 
standing  alone  as  a  primary  and  isolated  observation,  the  fact  of  a  disturbance 
in  temperature  is  of  little  use  ;  but  when  this  observation  is  controlled  by  other 
factors  in  diagnosis,  and  we  have  made  a  complete  diagnosis  of  a  given  disease, 
we  are  then  in  the  position  of  knowing  by  experience  approximatelj^  the  course 
of  the  temperature  for  that  disease,  and  we  shall  get  manj^  useful  hints  frcm 
the  thermometer  as  to  complications  or  the  severity  of  the  attack  :  a  point  to 
which  we  shall  presently  refer.  Hence,  it  is  useful  in  our  present  discussion  to 
divide  all  patients  into  two  main  groups  :  (i)  Those  who  are  well  enough  to  visit 
their  doctor,  and  (2)  Those  who  are  too  ill  to  do  so. 

I.  Patients  who  are  well  enough  to  visit  their  doctor Unless    some    special 

complaint  or  physical  sign  soon  leads  to  satisfactory  diagnosis,  let  it  be  an 
accepted  rule  to  take  the  temperature  ;  by  doing  so  we  shall  have  the  primary, 
but  possibly  merely  negative,  satisfaction  of  not  having  omitted  this  element  in 


620  PYREXIA     WITHOUT     OBVIOUS     CAUSE 

diagnosis,  and  not  infrequently  we  shall  have  the  very  positive  satisfaction  of 
having  discovered,  early,  a  disease  which  we  might  otherwise  have  overlooked 
until  something  or  some  one  else  had  drawn  attention  to  it,  greatly  to  our 
discomfiture  and  loss  of  credit.  The  three  most  typical  illustrations  of  this 
position  are  perhaps  typhoid,  phthisis,  and  a  condition  which  in  our  haste  we 
label  "  Influenza." 

A  headache  lasting  four  or  five  days,  and  associated  with  some  degree  of 
pyrexia,  is,  even  standing  alone,  so  suspicious  of  the  first,  that  the  patient  must 
be  ordered  to  bed  to  be  watched.  A  nasty  (Ixy  cough,  with  general  ansmia, 
weakness,  tiredness,  and  malaise,  make  us  very  suspicious  of  the  second,  espe- 
ciallv  if  there  is  also  the  slightest  alteration  in  the  breath  sounds  anywhere. 
The  third  is  the  recently  developed  refuge  of  the  diagnosticaUy  destitute  ;  it 
leads  to  much  mortification  when  suppurating  gums  or  tonsils,  gonococcal 
discharges,  decomposing  urine,  or  other  critical  points  are  discovered  later  :  a 
position  which  may  be  avoided  by  examining  all  easily  accessible  orifices,  even 
in  the  consulting-room  ;  and  if  the  mouth,  throat,  and  nose  all  seem  healthy,  by 
labelling  the  trouble  fever  of  uncertain  origin,  and  ordering  the  patient  to  bed. 
In  fact,  if  on  examining  the  patient  in  the  consulting-room  no  cause  for  the 
pyrexia  is  apparent,  I  would  lay  down  as  a  golden  rule — Remove  the  patient  at 
once  from  Group  (i)  and  place  him  in  Group  (2)  for  further  critical  examination 
of  his  or  her  person,  blood,  and  excreta. 

2.  Patients  who  request  their  doctor  to  visit  them. — It  must  be  admitted 
that  in  this  group  also,  pjnrexia  by  itself  is  not  a  very  strong  diagnostic 
point,  for  ex  hypothesi  the  other  symptoms  are  of  considerable  severity  and 
importance,  and  therefore  point  pretty  strongly  in  some  diagnostic  direction. 
Our  residuum  from  Group  (i),  with  a  certain  proportion  of  individuals  originally 
in  Group  (2) ,  wiU,  however,  together  make  up  a  by  no  means  negligible  number 
of  patients,  in  whom  the  cause  of  pyrexia  is  obscure  to  an  ordinary  examination, 
and  we  must  lay  down  rules  of  procedure. 

Here  it  is  the  first  rule  to  systematically  examine  every  orifice  of  the  body 
for  a  possible  source  of  trouble  ;  gums,  ears,  nose,  throat  must  be  more  care- 
fully inspected,  and  vagina,  rectum,  and  urethra  must  now  be  examined  criti- 
cally ;  should  all  these  prove  health}'-,  the  fingers  and  toes  must  be  overhauled 
for  overlooked  sores  ;  and  the  bones  near  joints  investigated  for  a  possible 
osteomyelitis. 

The  Blood. — It  is  by  now  almost  certain  that  some  clue  will  have  been 
obtained  but  should  none  have  appeared  (in  some  cases  even  with  a  complete 
diagnosis),  we  must  now  proceed  to  have  the  blood  examined  by  the  best 
available  scientific  methods  ;  we  may  by  this  means  prove  that  the  blood 
itself  is   at  fault,   or  that  it  contains   some  microbes,  thus  : — 

1.  Leucocytosis.  —  Suggests  leucocythsemia  perhaps,  in  which  disease  out- 
breaks of  pyrexia  are  not  uncommon  ;  or  some  obscure  focus  of  suppuration  ; 
or  perhaps  it  proves  that  an  obvious  focus  requires  the  surgeon's  assistance  ; 
or  per  contra,  it  provides  a  slight  argument  against  tj'phoid  or  tubercle,  and  in 
favour  of  gross  parasitic  worms. 

2.  Poikilocytosis. — Suggests  a  severe  anaemia,  which,  like  leucocythaemia,  is 
known  to  have  pyrexial  periods. 

3.  Widal's  Test. — This  ma}^  clump  motile  typhoid  bacilli,  practically  proving 
the  presence  of  typhoid. 

4.  Cultivation  of  it  may  prove  to  demonstration  a  microbic  invasion,  and 
the  name  and  nature  of  the  invader,  and  possibly  suggest  the  point  of 
invasion. 

5.  The  microparasites  (malarial  or  other)  may  actually  be  recognized  in  the 
blood  under  the  microscope. 


PYREXIA     WITHOUT     OBVIOUS     CAUSE  621 

The  Urine  may  be  found  to  be  thick  or  decomposed,  and  thus  give  a  clue  to 
tubercle  of  the  genito-urinary  tract,  to  calculous  trouble,  or  to  B.  coli  communis 
invasion. 

The  Faeces  may  yield  information  :  melaena,  fatty  stools,  gall-stones,  or  even 
eggs  of  parasites  may  be  found,  thus  clearing  up  the  cause  of  an  obscure  pyrexia. 

Calmette's  Reaction  may  be  tried  for  latent  tubercle,  but  the  dropping  of 
tuberculin  into  an  eye  is  not  without  its  own  risks,  and  in  my  opinion  had  better 
be  avoided,  especially  as  by  the  time  tubercle  has  caused  pyrexia  it  has  probably 
so  far  advanced  as  to  be  discoverable  by  careful  physical  examination  of  the 
chest.  Moreover,  the  test  is  alleged  to  be  so  delicate  as  to  discover  obsolete 
tubercle,  which  is  not  the  cause  of  the  pyrexia,  and  so  may  lead  one  astray. 

When  physical  examination,  clinical  methods  of  investigating  secretions  and 
excretions,  and  bacteriological  aids  have  thus  all  been  exhausted,  there  will  still 
remain  a  few  rare  cases  in  which  the  cause  of  the  pyrexia  is  undiscoverable. 
These  are  chiefly  abdominal :  thus  gall-stones  and  their  complications,  pyle- 
phlebitis, ovarian  abscess,  and  deep-seated  phlebitis  have  all  presented  instances 
to  the  writer  ;  but  he  knows  of  no  rules  by  which  such  cases  can  be  discovered  ; 
time  or  an  autopsy,  can  alone  clear  them  up. 

Apart,  however,  from  such  obscurities,  there  still  remain  some  interesting  and 
useful  observations  to  be  made  on  certain  clinical  thermometric  measurements. 

Pyrexia  or  Subnormal  Temperatures  in  Children. 

In  children  we  know  that  the  heat-regulating,  like  other  nervous  mechanisms, 
takes  time  to  develop  proper  and  complete  connections  with,  and  control  over, 
subordinate  centres  of  regulation,  whether  these  be  foci  of  production  or 
surfaces  of  loss ;  hence  we  are  not  surprised,  still  less  alarmed,  at  temperatures 
above  normal  in  children,  which  in  adults  may  have  a  very  different  signifi- 
cance. It  is  rather  the  reverse  with  those  below  normal,  because  we  know  that 
the  growing  child  requires  very  large  supplies  of  heat  to  carry  on  the  anabolic 
functions  of  growth  and  development. 

It  is  scarcely  an  exaggeration  to  say  that  every  acute  illness  (reckoning  by 
time  only)  or  symptom  complex  in  a  child  is  associated  with  a  departure  from 
the  normal  temperature,  and  the  importance  of  ascertaining  the  cause  and 
degree  of  this  departure  can  hardly  be  exaggerated  from  a  therapeutical,  if  not 
from  a  diagnostic,  point  of  view. 

Subnormal  Temperature Suppose  we  find  a  child  in  this  condition,  the  imme- 
diate diagnosis  is  great  exhaustion  ;  such  temperatures  are  generally  found  in 
marasmic  children  who  have  been  starved,  or  its  equivalent,  i.e.  badly  fed,  or 
exposed  ;  the  indications  are  hot  food,  stimulants,  and  warmth.  Subnormal 
temperatures  are  also  found  in  summer  diarrhoea,  or  sometimes  in  conditions 
associated  with  intense  pain  ;  also,  at  an  interval  after  convulsions  (not  imme- 
diately), and  in  many  other  conditions,  the  differential  diagnosis  of  which  will 
generally  be  obvious. 

Pyrexia,  on  the  other  hand,  as  we  have  said,  owns  an  infinity  of  causes,  of 
which  we  can  only  glance  at  a  few  which  may  give  rise  to  trouble  in  diagnosis. 

1.  Excitement. — In  children's  wards,  visiting  day  almost  invariably  causes 
a  plentiful  crop  of  high  temperatures,  even  as  much  as  103°  F.,  and  the  private 
practitioner  has  to  remember  this  when  a  loving  aunt  or  an  injudicious  visitor 
of  any  sort  has  come  in  contact  with  his  little  patient  at  home.  A  bad  night 
may  easily  send  the  temperature  up  to  any  height. 

2.  Febricula. — This  is  merely  a  Latin  name  for  the  fact  of  pyrexia,  but  before 
using  the  term  let  every  system  be  carefully  examined  for  signs  of  disease.  It 
may  be  that  there  is  absolutely  nothing  else  wrong,  and  cause  No.  i  may  be  at 
work  alone.     The  following  is  a  useful  and  ordinary  average  clinical  rule  :    for 


622  PYREXIA     WITHOUT     OBVIOUS     CAUSE 

each  1°  F.  the  temperature  rises  we  may  expect  the  pulse  to  increase  in  frequency 
lo  beats  (or  in  children  15)  per  minute,  and  the  respirations  2  to  3  per  minute, 
and  if  this  ratio  is  maintained  it  is  fairly  safe  to  say  that  heart  and  lungs  are 
neither  of  them  specially  threatened,  and  hence,  if  there  be  nothing  else  to  attract 
attention,  it  is  safe  to  say  that  the  child  is  certainly  feverish,  and  we  must  nurse 
and  watch  it.  I  have  known  a  delicate  boy  of  9  or  10  thus  to  have  a  temperature 
of  1 02 '5°  to  1 03 '5  for  three  or  four  days  at  a  time  for  no  reason  that  I  could  ever 
detect ;  he  ate  well,  slept  well,  and  felt  well ;  and  this  aspect  of  affairs  should  be 
remembered. 

On  the  other  hand,  such  temporary  attacks  of  pyrexia  may  be  aroused  by  the 
presence  of  some  micro-organisms  which  have  hitherto  escaped  detection,  but 
qua  the  pyrexia  in  itself  nothing  more  can  be  said.  Deep-seated  tubercle, 
perhaps,  in  internal  lymphatic  glands,  may  be  suspected,  but  it  will  often  be 
exceedingly  difficult  to  settle  the  diagnosis. 

3.  Convulsions. — These  must  be  remembered  as  a  possible  cause  of  a  tempera- 
ture of  even  103°  F.  if  the  thermometer  be  used  at  once. 

4.  Specific  Zymotic  Diseases. — On  discovering  a  child  with  fever,  suspicion  will 
naturally  be  aroused  that  one  of  these  troubles  is  at  hand.  The  only  thing  to 
be  said  here  is  :  Do  not  attempt  to  give  a  diagnosis  on  the  thermometer  alone  ; 
the  temperature  is  raised  long  before  a  diagnosis  is  possible.  It  is  well  to  note 
that  a  temperature  of  102°  F.  only,  or  less,  is  a  point  in  favour  of  diphtheria 
against  a  tonsillitis  of  other  causation,  which  frequently  has  a  pyrexia  of  104°  F. 
or  105°  F.  Slight  pyrexia,  with  headache  and  vomiting,  make  us  suspect 
tuberculous  meningitis,  whereas  a  temperature  of  103°  F.  or  104°  F.  with  similar 
associations  renders  pneumonia  probable. 

In  Children  and  Adults. 
Here  we  may  draw  attention  to  some  of  those  cases  in  which  the  fever  of 
known  average  departs  from  its  usual  course. 

1.  Empyema. — Suggested  by  the  crisis  of  a  pneumonia,  followed  in  a  few 
days  by  intermittent  or  remittent  fever. 

2.  Endocarditis. — Suggested  in  rheumatism  by  a  temperature  of  100°  F.  to 
100-5°  F.  or  101°  F.  following  the  initial  fall  from  the  administration  of 
salicylates ;  though  the  absence  of  such  pyrexia  does  not  exclude  the  existence 
either  of  endocarditis  or  of  pericarditis. 

3.  Hyperpyrexia. — Met  with  in  rheumatism,  typhoid,  and  other  septic  con- 
ditions ;  its  onset  is  easy  to  detect  in  the  latter  conditions  ;  in  the  former, 
restlessness  with  less  complaint  of  pain  may  cause  suspicion.  The  diagnosis 
must  be  confirmed  by  a  frequency  of  registration  proportionate  to  the  severity 
of  the  initial  observation  ;  two-hourly,  hourly,  or  even  quarter-hourly  observa- 
tions may  be  necessary,  that  treatment  may  be  controlled. 

In  addition  to  such  obvious  causes,  it  must  be  remembered  that  in  cerebral 
diseases  and  injuries  of  almost  any  kind,  the  temperature  may  rise  to  most 
unusual  heights  ;  one  over  104°  F.  almost  certainly  heralds  a  fatal  event  ;  the 
same  is  sometimes  found  in  uraemia. 

4.  Attention  may  be  drawn  to  the  fact  that  malaria  is  not  quite  extinct  in 
England,  and  a  regular  succession  of  pyrexial  attacks  at  the  same  time  of  day 
suggests  this  cause. 

5.  Sudden  Drops  in  Temperature. — These  are  met  with  in  many  diseases  at 
times,  e.g.  typhoid,  and  the  patient  must  be  carefully  examined  for  other  sugges- 
tive factors — -blanching,  severe  abdominal  pain,  etc.,  indicative  of  haemorrhage, 
perforation,  or  other  complication.  Do  not  forget  that  the  crisis  in  pneumonia 
is  a  great  deal  more  of  a  crisis  for  the  patient  than  it  is  for  his  microbes,  and  be 
ready  with  the  appropriate  stimulants. 


PYURIA  623 

6.  Pyrexia  and  Malignant  Disease. — When  the  nature  of  a  swelling  in  the 
liver  or  elsewhere  is  being  critically  considered,  it  is  well  to  bear  in  mind  that 
the  discovery  of  a  temperature  hovering  about  101°  F.,  or  even  higher,  does  not 
mihtate  at  all  strongly  against  a  malignant  growth,  for  these  frequently  give 
rise  to  pyrexia,  and  so,  too,  but  more  rarely,  may  cirrhosis  of  the  liver. 

7.  In  the  differential  diagnosis  of  cerebral  abscess  from  tumour  it  must  not  be 
overlooked  that  a  subnormal  temperature,  contrary  to  the  usual  rule  of  suppura- 
tion, suggests  an  abscess  rather  than  tumour. 

8.  It  is  well  to  bear  in  mind  that  after  an  operation,  a  few  degrees  of  pyrexia, 
even  for  forty-eight  hours,  are  not  a  conclusive  proof  of  infection  of  the  wound. 

9.  When  the  source  of  a  continued  pyrexia  is  being  sought  for,  the  heart  must 
be  carefully  examined  every  day,  or  even  more  frequently,  for  infective  endocar- 
ditis is  a  by  no  means  infrequent  result  of  gonococcal  and  other  microbic  inva- 
sions, which  may  be  most  difficult  to  detect.  Fred.  J .  Smith 

PYROSIS.— (See  Heartburn.) 

PYURIA. — Pus  appears  in  the  urine  in  all  suppurative  conditions  affecting  the 
urinary  tract,  and  occasionally  from  the  rupture  of  an  extra-urinary  abscess  into 
the  urinary  apparatus.  It  may  be  present  in  large  or  in  microscopic  quantities  ; 
when  in  bulk  it  forms  a  thick,  greyish,  tenacious  sediment,  which  must  be 
distinguished  from  phosphates  and  from  urates  ;  urates  are  of  a  pinkish  colour, 
and  will  be  cleared  by  heating  the  specimen  ;  phosphates  will  be  dissolved  by 
the  addition  of  acid,  whereas  pus  will  remain  unaltered  by  either  test. 

In  alkaline  urine,  the  pus  cells  tend  to  run  together  into  a  dense  viscid  deposit, 
leaving  the  upper  layers  of  the  urine  slightly  turbid.  Urine  containing  pus  will 
always  contain  at  least  some  albumin  and  frequently  epithelial  cells  from  some 
part  of  the  urinary  tract.  If  the  specimen  containing  pus  be  gently  shaken 
with  ozonic  ether,  a  slight  effervescence  will  be  produced,  or  if  mixed  with  liquor 
potassae,  a  ropy  precipitation  occurs. 

Microscopical  Characters  of  Pus  cells  in  Urine. — The  pus  cell  when  present  in 
acid  urine  is  multinuclear,  rounded,  and  about  twice  the  size  of  a  red  blood-disc. 
The  contents  are  granular,  but  the  addition  of  acid  clears  the  cell  and  makes 
the  nucleus  stand  out  more  distinctly.  It  may  be  said,  as  a  general  rule,  that 
a  small  amount  of  pus  in  an  acid  lu^ine  is  derived  from  some  form  of  pyelitis, 
whilst  a  larger  amount  of  pus  in  alkaline  urine  is  of  vesical  origin.  There 
are,  however,  exceptions  to  this  rule,  as  for  instance,  when  a  pocket  of  pus  is 
discharged  from  a  pyonephrotic  kidney,  although  usually  the  pus  from  a  kidney 
does  not  show  the  same  viscidity  as  the  pus  in  the  urine  of  a  case  of  chronic 
cystitis  when  alkaline  fermentation  has  taken  place  in  the  bladder. 

The  following  is  a  classified  list  of  the  causes  of  pyuria  : — 

{A).  From  Diseases  of  the  Urinary  Organs. 

1.  Renal  :        Pyelitis  Pyonephrosis 

Pyelonephritis  Tuberculosis 

Renal  abscess  Calculus. 

2.  Ureteric  :    Calculus. 

3.  Vesical  :     Cystitis 

Tuberculosis,  acute  or  chronic 

Calculus 

Ulcer — Simple  Epitheliomatous 

Tumour — Sloughing  papilloma        Villus-covered  carcinoma 

Bilharzia  h^matobia. 

4.  Urethral :  Urethritis — Gonorrhoeal,  Septic,  Gouty 

Stricture. 


624  PYURIA 

(B).  From  Diseases  outside  the  Urinary  Organs. 

Leucorrhoea. 
Balanitis  with  phimosis. 

From  the  extension  of  inflammatory  processes  to  the  bladder,  or  the 
rupture  into  the  bladder  or  urethra  of  an  abscess  such  as  : — 

Prostatic  abscess 

Appendicular  abscess 

Ihac  or  pehic  abscess 

Psoas  abscess 

Pyosalpinx 

Carcinoma  of  the  pelvic  organs — uterus  or  rectum 

Carcinoma  of  the  c^cum,  sigmoid  or  pelvic  colon 

Ulceration  of  the  small  intestine — tuberculous  or  dj'senteric. 

It  is  impossible  to  determine  the  lesion  producing  pus  in  the  lurine  simply  by 
the  examination  of  the  latter.  Due  consideration  must  be  given  to  the  history 
and  the  other  sj-mptoms  of  any  case,  and  particular  care  be  taken  not  to 
lay  too  much  emphasis  upon  any  sjTiiptom  which  ma}'  point  to  a  vesical  lesion 
when  in  reality  the  trouble  is  in  the  kidne}'.  This  is  perhaps  most  likeh-  to 
occur  in  a  haematogenous  infection  of  the  kidney  by  micro-organisms,  in  which 
increased  frequency  of  micturition  is  a  marked  s\Tnptom,  whilst  the  bladder 
remains  quite  free  from  disease.  Occasionally,  after  pus  has  been  present  con- 
tinuously in  the  lu'ine  for  some  time,  it  may  disappear  entirely,  the  change  being 
accompanied  by  increase  of  pain  in  the  side,  by  an  elevation  of  temperatiure,  or 
enlargement  of  the  kidney  in  a  case  of  pyonephrosis,  when  the  obstruction  to 
the  flow  of  urine  from  that  side  has  become  temporarily  complete.  Very  little 
help  is  derived  from  the  character  of  epithelial  cells  accompan^-ing  pus  in  the 
urine.  The  shapes  of  the  cells  of  the  renal  pelvis,  iu"eter,  and  deeper  layers  of  the 
bladder  are  so  much  alike,  that  it  is  usually  impossible  to  differentiate  them. 

Some  assistance  in  the  determination  of  the  origin  of  the  pus  in  the  urine  may 
be  gained  by  instrumental  examination  : 

By  Catheter. — If  a  catheter  be  passed  and  the  bladder  washed  out  with 
clear  solution  of  boracic  acid,  it  will  be  found  that  the  medium  is  soon  rendered 
clear  if  the  pyuria  is  of  renal  origin,  but  that  it  is  much  more  difficult  to  obtain 
a  perfectl}^  clear  medium  if  the  bladder  is  the  seat  of  the  suppurative  lesion.  If 
the  medium  is  quickly  cleared,  but  yet,  after  some  ten  minutes  retention  in  the 
bladder  is  again  found  to  be  turbid,  the  pus  is  almost  certainly  descending  from 
the  kidney. 

The  Cystoscope. — Much  more  certain  evidence  is  gained,  however,  by  a  careful 
cystoscopic  examination.  By  this  means  it  can  be  determined  in  the  great 
majoritv'  of  cases  if  the  bladder  is  infected  or  if  an}'  ulceration  is  present.  In  a 
few  cases  the  bladder  may  be  so  affected  that  only  a  smaU  dilatation  is  allowed, 
or  bleeding  is  so  easily  produced  that  cystoscopy  is  rendered  futile  ;  in 
these  cases  there  will  be  little  need  for  an  inspection  of  the  bladder.  If  the 
bladder  be  found  to  be  normal,  evidence  of  a  suppurative  lesion  in  the  kidney 
may  be  obtained  from  the  appearance  of  the  ureteric  orifices  or  by  the 
variations  in  the  character  of  the  urinary  efflux  from  them.  Instead  of  the 
normal  forcible  flow  of  clear  urine  from  each  orifice,  mixing  with  the  medium  in 
the  bladder  in  a  characteristic  swirl,  urine  containing  pus  in  an}-  quantity  may 
be  seen  emitted,  appearing  in  the  field  as  a  smaU  smoky  puff  from  the  orifice 
(Plate  V,  Fig.  B)  ;  pieces  of  muco-pus  may  be  seen  to  pass  from  the  orifice,  or 
the  turbid  urine  may  be  seen  to  leave  the  orifice  in  a  gentle  trickle  instead  of  a 
jet  if  the  renal-secreting  function  is  impaired  or  if  renal  dilatation  is  present. 

Apart  from  the  alterations  in  the  urinary  efflux  from  an  orifice,  the  actual 
appearance  of  the  orifice  may  show  changes  which  indicate  renal  disease.     Thus, 


PYURIA  625 

in  pyelitis,  the  margins  of  the  orifice  are  slightly  cedematous  and  congested,  and 
appear  to  pout  into  the  bladder  (Plate  V,  Fig.  C)  ;  the  mucous  membrane  of  the 
bladder,  immediately  below  and  internal  to  the  orifice,  is  frequently  congested 
or  granular  from  the  effect  of  the  altered  urinary  flow  upon  it.  If  the  renal 
pelvis  and  ureter  are  dilated,  the  orifice  is  usually  elongated  and  patulous,  whilst 
in  tubercle  or  in  diseases  in  which  the  ureter  is  thickened,  the  whole  ureteric 
orifice  is  drawn  upwards  and  outwards  from  its  normal  situation  (Plate  V,  Fig. 
D),  and  is  seen  at  the  apex  of  a  conical  retracted  area  in  the  bladder  base. 

A.  The  following  are  the  chief  Diseases  of  the  Urinary  Organs  in  which 
pyuria  may  be  present : — 

I.  Renal  Disease.     Diseases  of  inflammatory  origin. 

Pyelitis  and  pyelonephritis  may  arise  as  an  ascending  infection  from  the  lower 
urinary  tract,  especially  when  there  is  some  obstruction  to  the  normal  passage 
of  urine.  Thus,  it  is  common  in  cases  of  prostatic  enlargement  and  stricture. 
When  cystitis  is  present,  it  is  usually  bilateral,  although  one  kidney  may  show 
much  more  advanced  disease  than  the  other.  Any  growth  or  lesion  in  the 
bladder  which  is  accompanied  by  suppurative  infection,  and  which  involves 
the  ureteric  orifice,  such  as  vesical  epithelioma,  or  the  direct  involvement  of  one 
or  both  ureters  in  the  spread  of  uterine  cancer,  may  set  up  pyelitis  in  the  kidney, 
the  infection  ascending  either  by  the  ureter  or  by  the  peri-ureteric  lymphatics. 

In  this  group  of  cases  the  primary  cause  of  the  disease  has  usually  advanced 
to  a  sufficiently  late  stage  to  be  obvious,  and  the  symptoms  of  suppurative 
ascending  infection  of  the  renal  pelvis  or  renal  tissues  are  usually  overshadowed 
by  the  symptoms  of  the  disease  causing  the  obstruction.  Aching  in  the  loin, 
rigors  or  raised  temperature,  tenderness  on  deep  palpation  in  the  renal  area, 
or  actual  renal  enlargement,  are  usually  indicative  of  renal  infection.  The 
urine  is  often  increased  in  quantity,  of  low  specific  gravity,  and  the  daily 
excretion  of  solids  is  lessened  ;  the  skin  is  dry  and  harsh  and  the  tongue  glazed. 

Pyelitis  and  pyelonephritis  may  also  arise  as  an  infection  of  the  kidney  apart 
from  any  other  disease  in  the  genito-urinary  organs.  Infection  is  conveyed  to 
the  kidney  by  the  blood-stream  (hsematogenous  form),  and  is  not  uncommon  in 
acute  fevers,  or  with  mild  forms  of  suppuration  in  other  parts  of  the  body,  or 
in  association  with  pregnancy.  In  the  less  acute  forms  a  pyelitis  may  result, 
as  in  typhoid  fever,  but  in  most  cases  the  hsematogenous  infection  produces  first 
a  suppurative  process  in  the  renal  parenchyma,  from  which  infection  spreads 
to  the  calyces  and  pelvis.  This  form  of  disease  has  been  shown  by  recent  work 
to  be  due  most  frequently  to  the  colon  bacillus  in  association  with  affections 
of  the  intestinal  canal,  less  frequently  to  the  staphylococcus,  streptococcus, 
pneumococcus,  or  typhoid  bacillus.  The  renal  pyelitis  which  ensues  when  a 
calculus  has  ulcerated  into  the  renal  pelvis  is  truly  a  hematogenous  infection. 

Acute  haematogenous  infection  of  the  renal  pelvis  without  involvement  of  the 
renal  parenchvma  usually  begins  with  slight  rigors,  tenderness  in  the  loin,  and 
increased  frequency  of  mictm-ition.  The  urine  is  faintly  turbid  and  opalescent, 
does  not  settle  to  a  pronounced  sediment,  but  remains  of  a  sheeny  appearance. 
It  contains  numerous  bacteria,  a  little  pus,  and  a  little  albumin.  When  the 
infection  first  attacks  the  renal  parenchyma  as  well  as  the  pelvis,  the  symptoms 
are  much  more  severe,  and  the  patient  may  become  rapidly  ursemic.  In  the 
less  acute  cases,  small  foci  of  suppuration  occur,  which  coalesce  to  form  an 
abscess,  with  the  general  symptoms  of  suppuration.  Renal  abscess  may  also 
result  from  injury  when  an  eft'usion  of  blood  in  the  renal  tissues  becomes  infected 
by  pj-ogenic  micro-organisms,  or  by  the  breaking  down  of  a  renal  infarct. 

Pyonephrosis — or  dilatation  of  the  pelvis  and  calyces  of  the  kidney  with  pus  or 
with  pus  and  urine — is  caused  when  suppuration  has  occurred  in  a  kidnej^  which 
is  at  the  same  time  subjected  to  some  form  of  obstruction  to  the  normal  passage 

D  4c 


626  PYURIA 

of  urine.  Pyonephrosis  is  most  commonly  caused  by  renal  calculus  or  tubercu- 
losis, but  is  by  no  means  uncommon  with  a  chronic  cystitis,  complicating  urinary 
obstruction  from  an  enlarged  prostate  or  stricture.  Carcinomatous  ulceration 
affecting  a  ureteric  orifice,  either  primary  in  the  bladder  or  by  direct  extension 
of  uterine  cancer,  is  also  a  comparatively  common  cause  of  pyonephrosis.  In 
contradistinction  to  suppurative  pyelonephritis,  the  symptoms  of  pyonephrosis 
are  less  severe  ;  at  first  they  are  those  of  the  obstructive  lesion  causing  the 
disease,  to  which  are  added  the  general  symptoms  of  suppuration.  Pyone- 
phrosis causes  a  renal  tumour  of  variable  size,  whilst  in  the  same  patient  distinct 
intermittence  in  size  may  be  observed,  a  decrease  being  associated  with  the 
discharge  of  a  larger  amount  of  pus  in  the  urine. 

The  urine  in  suppurative  disease  of  the  kidney  and  its  pelvis  requires  careful 
examination.  It  may  be  normal  with  a  localized  cortical  renal  abscess  or  with 
closed  pyonephrosis  ;  in  all  other  lesions  it  contains  pus  and  micro-organisms. 
If  the  pus-cells  are  found  in  the  form  of  casts  of  the  renal  tubules,  infection  of 
the  renal  parenchyma  is  present,  whilst  in  this  latter  the  albumin  in  the  urine 
is  in  excess  of  that  due  to  the  pus  present.  Polyuria,  with  a  diminution  of  the 
total  solids  of  the  urine  in  a  daily  examination,  is  commonly  present  in  inflam- 
matory lesions  of  the  renal  tissue. 

Renal  Tuberculosis. — The  miliary  form  of  tuberculosis  occurs  in  children  as 
part  of  a  general  dissemination  of  tubercle,  and  causes  no  urinary  symptoms. 
The  kidney  is,  however,  attacked  not  infrequently  by  primary  tuberculous 
infection,  when  it  is  unilateral  and  begins  as  a  deposit  in  the  form  of  small 
tuberculous  nodules.  These  enlarge  and  coalesce  to  form  a  larger  caseating 
area,  which  eventually  opens  into  the  renal  pelvis  by  direct  ulceration  of  a  calyx 
to  discharge  its  contents  by  the  urine,  when  the  lining  membrane  of  the  renal 
pelvis  and  ureter  become  infected  with  tubercle  and  thickened  bj^  submucous 
infiltration.  At  first,  before  ulceration  into  the  renal  pelvis  has  occurred,  the 
symptoms  of  the  disease  are  very  slight ;  there  may  be  aching  pain  in  the  loin 
and  slight  albuminuria,  but  as  soon  as  the  renal  pelvis  is  involved,  more  marked 
symptoms  occur — including  persistent  pyuria,  lumbar  aching,  increased  fre- 
quency of  micturition,  and  polyuria.  The  urine  is  pale,  of  low  specific  gravity, 
and  of  opalescent  turbidity ;  by  careful  examination  after  centrifuging,  the 
tubercle  bacillus  is  usually  found.  A  small  amount  of  blood  is  generally 
present.  The  increased  frequency  of  micturition  occurs  before  any  descending 
vesical  infection  has  occurred,  and  this  symptom,  accompanied  by  pyuria,  has 
frequentlj'  given  rise  to  a  diagnosis  of  vesical  disease.  The  occurrence  in  a 
young  adult  patient  of  persistent  pyuria  which  is  not  due  to  gonorrhoea, 
injury,  or  stone,  should  always  be  looked  upon  with  grave  suspicion,  and 
a  careful  search  made  for  the  tubercle  bacillus  ;  should  this  not  be  found  by  the 
microscope,  inoculation  experiments  into  guinea-pigs  should  be  conducted.  A 
careful  examination  of  the  bladder  should  also  be  made  by  the  cystoscope, 
when  vesical  tuberculosis  may  be  rendered  apparent  {Plate  V,  Fig.  E),  or  the 
characteristic  changes  in  the  ureteric  orifice  may  show  the  presence  of  renal 
infection  (Plate  V,  Fig.  D) .  By  digital  examination  per  rectum,  the  lower  end 
of  the  ureter  may  be  felt  to  be  thickened  and  rigid  in  renal  tuberculosis. 

Renal  tuberculosis  is  often  confounded  with  renal  stone,  and  the  colic  which 
is  usually  associated  with  stone  may  be  present  in  tuberculosis  if  a  piece  of  caseous 
debris  be  passed  down  the  ureter.  A  skiagraphic  shadow  of  a  calculus  shows 
well-defined  margins  [Fig.  97,  p.  309),  whereas  a  tuberculous  focus  in  the  kidney 
may  give  rise  to  a  faint,  blurred,  indistinct  shadow  in  the  renal  area.  The 
presence  of  tubercle  bacilli  will,  however,  determine  the  existence  of  tuberculosis, 
whilst  tuberculous  lesions  elsewhere  in  the  body,  most  frequently  in  the  testes, 
prostate,  or  vesicular  seminales,  may  also  serve  to  confirm  the  diagnosis. 


PYURIA  627 

The  symptoms  of  renal  calculus  vary  with  the  position  of  the  stone  and  the 
changes  that  have  taken  place  in  the  kidney  in  consequence  of  its  presence.  It 
may  be  situated  in  the  renal  parenchyma,  and  cause  no  symptoms  beyond  lumbar 
aching  ;  or  in  the  renal  pelvis,  when,  if  movable,  it  may  cause  acute  renal  colic, 
due  either  to  the  attempted  passage  of  the  stone  by  the  pelvic  outlet  or  to  the 
increased  intrarenal  pressure  from  blockage  of  the  ureter.  So  long  as  the  kidney 
remains  aseptic  the  urine  contains  only  a  trace  of  blood  in  microscopic  amount ; 
but  if  it  becomes  infected  with  micro-organisms,  pyelitis,  pyelonephritis,  or 
pyonephrosis  may  result,  with  their  attendant  symptoms.  Thus,  pus  only  occurs 
in  the  urine  in  a  case  of  renal  stone  when  infection  of  the  kidney  has  occurred. 

2.  Ureteric  Calculus. — A  small  renal  calculus  may  become  impacted  during 
its  passage  along  the  ureter,  and  may  cause  some  difficulty  in  diagnosis.  The 
usual  situations  of  the  obstructed  calculus  are  in  the  upper  few  inches  of  the 
ureter,  at  the  pelvic  brim,  or  at  the  vesical  end  of  the  tube  ;  in  most  cases  the 
previous  history  of  renal  colic  and  symptoms  of  renal  stone  will  be  sufficient  to 
indicate  its  partial  ureteric  descent.  A  calculus  may,  however,  be  present  in  the 
upper  end  of  the  ureter  or  at  the  pelvic  brim,  and  give  very  few  symptoms 
beyond  a  fixed  pain  in  the  course  of  the  ureter  ;  in  the  latter  situation  it  has 
frequently  been  mistaken  for  ovarian  pain  or  for  chronic  appendicitis.  If  the 
stone  blocks  the  ureter  completely,  the  kidney  of  the  same  side — in  the  absence 
of  septic  infection — becomes  functionless  and  atrophies  ;  but  if  the  calculus  only 
partially  occludes  the  lumen  of  the  tube,  renal  distention  will  occur,  with  resulting 
uro-  or  pyonephrosis.  If,  however,  the  calculus  becomes  impacted  in  the  vesical 
segment  of  the  ureter,  a  train  of  sj^mptoms  occurs  simulating  vesical  stone  or 
vesical  tuberculosis ;  namely,  increased  frequency  of  micturition,  penile  pain 
following  micturition,  and  often  a  small  amount  of  blood  and  pus  in  the  urine, 
in  addition  to  the  aching  pain  in  the  loin.  A  ureteric  calculus  impacted  in  this 
situation  may  often  be  felt  in  the  ureter  upon  a  rectal  or  vaginal  examination  ; 
it  may  be  demonstrated  by  the  x-Ta.ys  ;  whilst  the  changes  seen  around  the 
ureteric  orifice,  and  the  absence  of  a  vesical  lesion  on  cystoscopic  examination, 
will  confirm  the  diagnosis. 

3.  Vesical  Diseases. — Pyuria  may  occur  in  any  lesion  of  the  bladder  which  is 
associated  with  inflammatory  changes.  The  fact  that  urine  is  retained  in  the 
bladder  renders  the  latter  much  more  liable  to  septic  infection,  so  that  cystitis 
is  common  with  urethral  stricture  or  prostatic  obstruction.  Any  ulceration  of 
the  bladder,  tuberculous  or  malignant,  is  also  accompanied  bv  inflammatory 
changes,  when  pus  will  be  present  in  the  urine. 

Cystitis  may  be  acute  or  chronic,  and  the  essential  factor  of  either  form  is  the 
infection  of  the  bladder  by  some  micro-organism  ;  any  agent  which  produces 
either  congestion  of  the  bladder  or  retention  of  urine,  acts  as  a  predisposing  cause 
of  cystitis. 

With  acute  cystitis  the  mucous  membrane  of  the  bladder  becomes  oedematous 
and  highly  congested,  and  epithelial  desquamation  and  formation  of  pus  rapidly 
follow.  Haemorrhage  may  occur  from  the  congested  mucosa,  or  small  abscesses 
develop  in  it  and  rupture  into  the  bladder,  to  leave  small  area,s  of  ulceration. 
In  severe  cases,  patches  of  the  mucous  membrane  may  become  gangrenous.  The 
symptoms  of  acute  cystitis  are  usually  distinctive  ;  frequent  and  painful 
micturition,  elevation  of  temperature,  pain  in  the  perineum  and  suprapubic 
area,  with  the  presence  of  pus  and  blood  in  the  urine,  which  is  commonly  of  an 
acid  reaction.  Usually,  some  distinct  cause  for  the  onset  of  acute  cystitis  is 
apparent,  such  as  some  form  of  acute  lu'ethjritis  or  of  previous  instrumentation, 
and  there  is  little  difficulty  in  the  diagnosis.  The  same  symptoms  are,  however, 
produced  by  an  acute  inflammation  of  the  prostate  which,  in  nearly  all 
cases,  is  preceded  by  acute  urethritis  ;    the  presence  of  swelling  of  the  gland, 


628  PYURIA 

and  acute  pain  on  rectal  palpation,  will  determine  the  presence  of  prostatic 
inflammation. 

Chronic  cystitis  may  succeed  acute.  The  sj^mptoms  are  less  marked^  but 
increased  frequency  of  micturition  is  always  present.  The  urine  is  alkaline, 
contains  pus  and  mucus,  and  the  disease  is  commonly  associated  with  some  form 
of  urinary  obstruction,  or  with  retention  or  incontinence  due  to  some  nervous 
disease,  such  as  locomotor  atax}'  or  transverse  myelitis.  The  possibility  of 
retroversion  of  a  gra\'id  uterus  should  not  be  overlooked.  The  association  of 
pyuria  and  increased  frequency'  of  micturition,  which  is  present  in  chronic 
cystitis,  must  be  distinguished  carefully  from  that  due  to  pyelitis  or  pj-elo- 
nephritis,  for  it  has  been  shown  that  increased  frequenc}^  of  micturition  may  be 
present  without  any  vesical  infection.  In  renal  pyeUtis,  the  urine  is  usually 
acid  in  reaction,  pale  in  colour,  and  shows  a  general  turbidity,  Avith  little 
inchnation  towards  a  deposit  at  the  bottom  of  a  specimen.  The  urine  of  chronic 
cystitis  is  alkaline,  and  rapidly  deposits  a  greyish  sediment  of  pus.  In  pj^elitis 
and  pyelonephritis,  the  urine  contains  more  albumin  than  the  pus  would 
account  for,  and  on  microscopic  examination  renal  or  pus  casts  are  frequently 
found,  whereas  in  cystitis  the  albumin  is  less,  and  vesical  cellular  elements 
are  present  without  casts,  unless  the  kidneys  are  affected  also. 

Further  evidence  may  be  obtained  by  the  use  of  the  cystoscope.  In  c^'Stitis 
the  bladder  wall  is  found  to  be  trabeculated  and  the  mucous  membrane 
thickened  ;  it  has  lost  the  normal  iridescent  appearance,  and  the  vessels  of  the 
mucous  membrane  are  obscured.  With  pyelitis,  the  bladder  wall  is  normal, 
but  the  ureteric  orifice  of  the  affected  side  shows  the  thickened  or  pouting  lips 
and  slighth^  raised  area  of  thickened  mucous  membrane,  whilst  the  urine 
flowing  from  the  orifice  ma}'  be  seen  to  be  turbid  or  to  contain  small  particles 
of  muco-pus. 

Chronic  cystitis  may  be  simulated  by  an  infiammation  of  the  posterior  urethra. 
In  such  a  case,  there  is  almost  always  a  history  of  urethral  infection,  and  the 
diagnosis  can  be  made  by  tirethral  irrigation.  The  patient  is  directed  to  retain 
his  urine  for  some  three  hours,  and  after  irrigating  the  anterior  urethra  as  far 
as  the  compressor  muscle  with  sterile  water  or  boric  acid  lotion,  the  urine  is 
passed  into  two  glasses.  With  posterior  urethritis  the  urine  contained  in  the 
first  specimen  will  contain  shreds  of  muco-pus,  whilst  that  of  the  second  specimen 
is  clear  ;  whereas,  with  cj'stitis,  the  second  specimen  will  be  as  turbid  as,  or 
even  more  turbid  than,  the  first. 

Tuberculous  cystitis  occurs  usuaUj'  in  young  adults.  The  characteristic 
symptoms  are  increased  frequency'  of  micturition  during  both  da)''  and  night, 
p^Tiria,  A\ith  pricking  pain  in  the  glans  penis  at  the  end  of  micturition,  and 
the  appearance  of  a  few  drops  of  blood  in  the  last  drops  of  urine.  The  same 
symptoms  are  often  present  with  vesical  calculus  and  with  vesical  epithelioma, 
when  ulceration  has  taken  place.  Vesical  calculus  is  usualU"  present  in  older 
patients,  and  during  the  earlj-  part  of  the  illness,  before  cystitis  has  set  in,  the 
calculus  only  gives  rise  to  desire  to  micturate  during  movement,  and  to  penile 
pain.  When  cystitis  supervenes,  the  frequency  of  micturition  will  be  marked 
during  both  day  and  night.  Vesical  epithelioma  also  occurs  in  older  patients, 
and  when  ulcerated  may  cause  hagmaturia  ;  frequently  the  diagnosis  may  be 
made  by  the  palpation  per  rectum  of  an  indurated  area  in  the  bladder  base,  or 
of  some  enlarged  glands  in  the  pelvic  h-mphatic  space.  Tuberculous  cj-stitis 
in  the  early  stages,  when  the  disease  is  characterized  b}-  the  deposition  of  greA'ish 
tubercles  in  the  submucous  coat  of  the  bladder,  may  give  rise  to  increased 
frequency  of  micturition  without  other  sj'mptoms,  but  in  the  progressive  advance 
of  the  disease  the  tubercles  enlarge,  coalesce  and  ulcerate  on  the  surface,  by 
which  time  pus  and  blood  will  be  present  in  the  urine,  and  tubercle  bacilli  should 


PYURIA  629 

be  found.  It  -may  be  taken  as  a  general  rule  that  in  any  patient  of  young 
adult  life  with  increased  frequency  of  micturition  and  pyuria,  a  careful  search 
should  be  made  for  tubercle  bacilli  in  the  urine,  and  for  other  tuberculous 
lesions,  especially  in  the  testes,  prostate,  or  vesiculae  seminales. 

Tuberculous  cystitis  is  less  often  a  primary  disease  than  secondary  to  other 
lesions  in  the  genito-urinary  apparatus — most  commonly  to  tuberculous  disease 
of  one  kidney,  when,  after  the  primary  focus  has  ruptured  into  the  renal  pelvis, 
the  lining  membranes  of  the  latter,  of  the  ureter  and  of  the  bladder  become 
successively  affected.  The  diagnosis  between  primary  renal  and  primary  vesical 
tuberculosis  is  very  often  difficult,  for  it  has  been  shown  that  when  the  renai 
focus  has  ulcerated  into  the  pelvis,  and  descending  infection  has  commenced, 
the  symptoms  of  the  two  affections  are  very  similar.  Thus,  with  renal  disease, 
persistent  pyuria,  increased  frequency  of  micturition,  and  penile  pain  at  the 
termination  of  urination,  may  be  present  before  the  bladder  shows  any  sign  of 
disease  ;  blood  is  usually  present  in  small  quantity  in  the  urine,  but  its  amount 
is  not  so  definitely  greater  in  the  urine  passed  at  the  end  of  micturition  as  is 
the  case  in  vesical  disease.  In  renal  tuberculosis  there  may  be  tenderness  in 
the  loin,  the  kidney  is  usually  enlarged,  and  the  lower  end  of  the  ureter  can 
be  felt  distinctly  thickened  upon  rectal  or  vaginal  examination.  The  two 
conditions  can  usually  be  diagnosed  by  a  careful  cystoscopic  examination.  In 
vesical  tuberculosis  the  deposition  of  submucous  tubercles,  together  with  the 
shallow  ulceration  in  the  bladder  mucous  membrane,  may  be  seen  {Plate  V, 
Fig.  E),  whilst  in  renal  tuberculosis,  changes  may  be  seen  in  the  ureteric  orifice 
of  the  affected  side  {Plate  V,  Fig.  D).  At  first  the  orifice  becomes  thickened, 
oedematous,  and  slightly  patulous ;  but  later  it  is  rigid  and  patent,  or  drawn  up 
by  the  shortening  of  the  ureter  to  occupy  a  position  above  and  outside  the 
normal  situation  in  the  trigonal  area  of  the  bladder,  or  drawn  up  to  the  apex 
of  a  conical  retraction  of  the  bladder  base.  When  tuberculous  cystitis  is 
secondary  to  lesions  in  the  testes,  prostate,  or  vesicles,  the  disease  commonly 
begins  in  the  epididymis  of  one  side,  and  spreads  to  the  vesicle  or  prostate, 
whence  a  focus  may  directly  ulcerate  into  the  bladder.  The  patient  will  first 
notice  increased  frequency  of  micturition  and  vesical  pain,  followed  by  an 
attack  of  haematuria  when  actual  ulceration  into  the  bladder  base  occurs  ;  the 
formation  of  a  tuberculous  tilcer  in  the  bladder  leads  to  pyuria  and  the  other 
sj^mptoms  mentioned  above.  This  sequence  is  by  no  means  uncommon ;  the 
history  of  testicular  disease  and  the  evidence  obtained  by  rectal  examination 
will  serve  to  indicate  the  nature  of  the  condition. 

Vesical  calculus  may  give  rise  to  pyuria  when  it  is  accompanied  by  cystitis, 
but  may  be  present  a  long  time  before  any  inflammatory  infection  occurs. 
When  cystitis  is  present,  the  urine  shows  no  features  which  will  distinguish  it 
from  that  of  patients  suffering  from  some  other  form  of  cystitis,  except  that 
there  may  be  a  constant  presence  of  crystals,  or'  an  increased  amount  of  blood 
after  exercise.  The  constant  symptoms  of  vesical  calculus  are  vesical  irritability 
during  the  day  time,  penile  pain  after  micturition,  and  haematuria,  especially 
after  any  exercise.  If  the  presence  of  a  calculus  is  suspected  in  the  bladder,  an 
examination  by  the  ;i;-rays  {Fig.  98,  p.  312),  a  sound,  or  the  cystoscope,  will 
reveal  it.  Rontgen  rays  will  detect  even  a  uric-acid  stone  ;  the  cystoscope  may 
detect  a  stone  that  is  in  a  diverticulum,  partially  encysted  or  Ijdng  in  the 
pouch  behind  an  enlarged  prostate,  where  it  may  easily  be  overlooked  in 
searching  the  interior  of  the  bladder  with  a  sound. 

Ulceration  of  the  urinary  bladder,  apart  from  tuberculosis  and  epithelioma, 
occurs  as  a  simple  ulcer,  consecutive  to  chronic  cystitis,  or  as  the  result  of 
injury.  A  single  non- tuberculous  ulcer,  similar  to  gastric  ulcer,  has  been 
described  as  occurring  in  young  adults  in  the  neighbourhood  of   the   ureteric 


630  PYURIA 

orifices,  causing  haematuria  and  painful  frequent  micturition.  Later,  the  surface 
of  the  ulcer  becomes  encrusted  with  phosphatic  material,  when  the  urine 
contains  muco-pus,  and  often  small  flakes  of  phosphatic  debris  from  the  surface 
of  the  ulcer.  This  single  ulcer  is  rare,  and  can  only  be  diagnosed  by  the  use  of 
the  cystoscope.  Ulceration  may  also  occur  in  the  bladder  as  a  result  of  severe 
cystitis,  when  necrosis  has  occurred  in  the  mucous  membrane.  This  condition 
is  occasionall}^  present  in  a  case  of  obstinate  cystitis,  giving  rise  to  painful 
and  frequent  micturition,  and  may  be  diagnosed  by  means  of  the  cystoscope. 
Both  the  simple  and  the  consecutive  ulcer  must  be  differentiated  from  tuber- 
culous ulceration  of  the  bladder  ;  in  the  latter,  haemorrhage  is  usually  slight, 
and  occurs  at  the  termination  of  micturition  ;  tubercle  bacilli  may  be  found  in 
the  urine,  or  other  deposits  of  tubercle  found  in  the  epididymis,  prostate,  or 
seminal  vesicles.  The  cystoscopic  appearance  of  tuberculous  disease,  and  its 
more  generalized  distribution  in  the  \-esical  wall,  will  afford  the  strongest 
evidence   in    the  diagnosis. 

Malignant  ulceration  of  the  bladder  occurs  in  two  distinct  forms  :  [a)  The 
infiltrating  epithelioma  ;    {b)   The  villus-covered  carcinoma. 

{a).  The  infiltrating  variety  occurs  as  an  ulcer,  with  raised  edges  and  uneven 
necrotic  surface,  placed  usually  at  the  basal  portion  of  the  bladder.  It  is 
usually  met  with  in  men  over  fifty  years  of  age,  causing  increased  frequency  in 
micturition,  pain  at  the  glans  penis  following  micturition,  with  blood  and  pus 
in  the  urine.  The  bladder-wall  in  the  vicinity  of  the  ulcer  is  denselj'  infiltrated, 
and  frequently  can  be  felt  on  digital  examination  by  the  rectum,  whilst  at  the 
same  time  the  lymphatic  glands  in  the  pelvic  space  may  be  felt  to  be  enlarged. 

{b)  The  villus-covered  carcinoma  of  the  bladder  is  not  uncommon,  and  gives 
rise  to  irregular  profuse  haemorrhages.  The  tumour  is  attached  to  the  bladder 
by  a  broad  pedicle,  or  may  be  entirely'  sessile  and  covered  by  blunted  villi, 
presenting  a  coarsely  mammilated  surface.  It  occm-s  in  elderly  patients,  and 
the  tumours  are  frequently  multiple.  The  surface  is  often  necrotic,  giving  rise 
to  pyuria.  The  diagnosis  is  not  difficult,  the  frequently  recurring  haemorrhages 
m  the  urine,  associated  with  increased  frequency  of  micturition,  pain,  and 
pyuria  in  an  elderl}^  patient,  being  fairly  distinctive.  IS^ot  uncommonly  there  is 
unilateral  renal  aching  from  the  interference,  by  the  position  of  the  growth, 
with  the  flow  of  urine  from  one  ureteric  orifice,  so  that  renal  disease  may  be 
suspected  ;  but  in  all  cases  a  careful  cystoscopic  examination  will  show  the 
nature  of  the  disease.  Difficulty  may  be  experienced  in  obtaining  a  satisfac- 
torily clear  medium  for  a  cystoscopic  view,  but  in  most  cases  this  can  be 
accomplished  by  gentle  manipulations,  or  by  the  use  of  a  styptic  such  as  adrenalin 
I- 1000,  or  silver  nitrate  i-iooo.  Difficulty  may  be  found  in  distinguishing 
cystoscopically  between  a  benign  papilloma  and  villus-covered  pedunculated 
carcinoma  ;  but  the  broad  attachment  of  the  latter  to  the  bladder,  the  stunted 
villi  covering  it,  and  the  multiplicity  of  the  tumours,  will  be  signs  of  malignant 
disease  [Plate  VI,  Fig.  F).  In  rare  instances  a  benign  papilloma  may  begin  to 
slough  on  the  surface,  or  may  be  accompanied  by  cystitis,  when  pyuria  will  be 
present.  A  cystoscopic  examination  will  reveal  the  diagnosis.  Microscopical 
examination  of  the  urinary  deposit  may  show  distinctive  fragments  of  new 
growth. 

Bilharzia  hcsmaiobia  may  cause  pus  in  the  urine  in  advanced  cases.  When 
the  small  nodules  in  the  submucous  tissues  (Plate  VI,  Fig  K)  of  the  bladder 
ulcerate,  sm.all  fungating  masses  are  found  in  the  bladder.  The  typical  ova 
in  the  urine  {Fig.  13,  p.  93),  in  addition  to  pus  and  blood,  will  be  found  on 
microscopical  examination  of  the  urinary  sediment. 

4.  Urethral  Causes. — Any  condition  which  sets  up  a  purulent  urethritis  will 
cause  pyuria.     If  the  urethritis  is  recent  or  profuse,  the  local  condition  will  be 


PYURIA  631 

enough  to  indicate  the  diagnosis,  but  it  must  be  remembered  that  cystitis  may 
complicate  a  case  of  urethritis  by  direct  backward  infection.  If,  in  addition 
to  urethral  discharge,  there  is  increased  desire  to  urinate,  suprapubic  pain,  or 
haematuria,  acute  cystitis  is  probably  present.  The  anterior  urethra  should  be 
irrigated  well  with  sterile  water  or  boric  acid  lotion,  and  the  patient  then  directed 
to  pass  urine  into  two  glasses.  If  the  first  portion  passed  contains  pus  and  the 
second  is  clear,  infection  is  present  in  the  posterior  urethra  and  not  in  the  bladder, 
but  if  both  specimens  are  turbid  with  pus,  cystitis  is  present. 

The  onset  of  acute  prostatitis  complicating  urethritis  gives  rise  to  increased 
desire  to  micturate,  and  perineal  and  suprapubic  pain,  in  addition  to  pyuria, 
or  may  cause  retention  of  urine.  Digital  examination  of  the  prostate,  per 
rectum,  will  show  the  prostate  to  be  acutely  inflamed,  enlarged,  and  very 
painful. 

A  small  amount  of  pus  may  be  present  in  the  urine  in  cases  of  chronic 
urethritis  which  is  not  sufficient  to  cause  any  visible  discharge  from  the  meatus. 
The  anterior  urethra  should  be  irrigated  well,  and  the  urine  again  passed  into  two 
separate  glasses,  when,  if  the  first  washings  from  the  urethra  contain  pus,  there 
is  infection  in  the  anterior  urethra  ;  if  the  first  specimen  of  urine  contains  pus 
but  the  second  is  clear,  there  is  infection  in  the  posterior  urethra ;  whilst  if  both 
contain  pus,  cystitis  is  present.  In  any  case  of  urethral  discharge,  a  bacterio- 
logical examination  should  be  made  for  the  organism  causing  the  infection,  for 
it  is  far  from  uncommon  to  find  that  an  apparent  gonorrhoeal  urethritis  is  in 
realit}^  due  to  staphylococcal  infection. 

Pyuria  is  commonly  present  in  cases  of  stricture  of  the  urethra,  from  the 
co-existing  urethritis  or  cystitis. 

B.  Pyuria  caused  by  Disease  outside  the  Urinary  Organs. — Pus  may 
be  present  in  the  urine,  apart  from  any  disease  in  the  urinary  apparatus,  either 
b}-  accidental  contamination  of  the  urine,  or  by  the  direct  spread  of  inflam- 
matory or  carcinomatous  processes  from  neighbouring  organs  to  the  urethra, 
the  bladder,  or  more  rarely  the  ureter.  In  the  male,  the  accumulation  of  pus 
behind  a  phimosis  may  account  for  pyuria,  or  in  the  female  a  leucorrhoeal 
discharge  may  contaminate  the  urine.  In  the  latter  case  the  vulva  should  be 
cleansed  well  with  an  antiseptic,  and  a  catheter  passed  to  obtain  a  specimen 
for  examination. 

The  spread  of  inflammatory  processes,  or  the  actual  rupture  of  an  abscess  into 
any  part  of  the  urinary  tract,  will  cause  pyuria,  and  may  create  considerable 
difficulty  in  diagnosis.  If  symptoms  pointing  to  urinary  trouble,  such  as 
markedly  increased  frequency  of  micturition  or  slight  hasmaturia,  be  followed 
by  the  sudden  appearance  of  a  quantity  of  pus  in  the  urine,  there  is  strong 
probability  of  the  rupture  of  an  extra-urinary  abscess  into  the  bladder  or  urethra, 
provided  that  the  sudden  emptying  of  a  renal  abscess  or  a  pyonephrosis  can  be 
eliminated.  Frequently  the  history  of  any  case  will  give  some  indication  of  the 
primary  trouble,  of  which  the  most  frequent  are  prostatic  abscess,  appendical 
abscess,  pyosalpinx,  psoas,  iliac,  or  pelvic  abscess. 

Prostatic  abscess  is  most  frequently  a  sequela  of  an  acute  urethritis  which  has 
infected  the  posterior  rurethra  and  caused  an  acute  prostatitis.  It  may  be  due  to 
a  gonorrhoeal  or  to  a  septic  venereal  infection,  or  may  result  from  septic  instru- 
mentation in  the  urethra.  An  acute  prostatitis  is  very  prone  to  result  in  the 
formation  of  an  abscess  which  may  rupture  into  the  urethra,  bladder,  or  rectum, 
unless  appropriate  surgical  measures  be  undertaken.  The  onset  of  acute  pros- 
tatitis is  marked  by  increasing  desire  to  micturate,  pain  in  the  perineum  and 
hypogastric  areas,  and  raised  temperature,  whilst,  per  rectum,  the  prostate  is  felt 
to  be  uniformly  enlarged  and  very  tender.  If  an  abscess  result,  there  may  be 
rigors  and  increased  difficult}^  in  micturition,  even  retention  of  urine,  whilst  a 


632  PYURIA 

soft  area  may  be  felt  in  the  prostate  from  the  rectal  aspect.  A  prostatic 
abscess  may  occur  more  rarely  in  connection  with  a  prostatic  calculus  ;  it  may 
open  into  the  urethra  or  bladder,  or  may  be  present  in  advanced  genito-urinary 
tuberculosis,  when  a  prostatic  focus  may  caseate  and  ulcerate  into  the  trigonal 
area  of  the  bladder,  a  condition  which  is  usually  accompanied  by  a  sharp  attack 
of  hematuria.  A  tuberculous  focus  in  the  prostate  is  commonly  a  compara- 
tively late  feature  in  the  disease,  and  the  presence  of  nodules  in  the  epididymis 
or  seminal  vesicles,  or  the  previous  knowledge  of  vesical  tuberculosis,  will  assist 
very  largely  in  the  diagnosis. 

Pyuria  in  Inflammation  of  the  Vermiform  Appendix. — In  the  usual  position  of 
the  appendix  the  bladder  is  commonly  not  affected  ;  but  if  the  appendix  passes 
downwards  across  the  pelvic  brim,  it  is  not  uncommon  to  find  that,  should 
it  become  inflamed,  the  patient  complains  of  frequent  and  painful  micturition. 
The  appendix  may  be  adherent  to  the  bladder,  when  the  latter  will  show  on 
cystoscopic  examination  a  localized  area  of  acute  congestion  on  the  right 
lateral  wall,  and  both  pus  and  blood  may  be  present  in  the  urine  ;  further, 
a  small  abscess  may  be  formed  in  the  adhesions  betw^een  the  appendix 
and  the  bladder,  ulcerating  into  the  latter  and  giving  rise  to  pyuria.  Two 
such  cases  have  come  under  the  care  of  the  writer,  when  the  association  of 
frequently  recurring  attacks  of  pain  low  down  in  the  right  side  of  the  pelvis, 
with  increased  frequency  of  micturition  and  pyuria,  had  given  rise  to  the 
suspicion  of  ureteral  calculus.  In  each  case  a  cystoscopic  examination  showed 
a  normal  ureter,  and  a  small  ulcer  in  the  right  lateral  wall  of  the  bladder, 
surrounded  by  an  area  of  acute  cystitis.  The  diagnosis  of  these  cases  is  by  no 
means  easy  ;  in  the  first  place  the  situation  of  the  pain  is  lower  in  the  pelvis 
than  is  usual  with  appendicitis,  whilst  the  association  with  urinar^^  symptoms 
rather  points  to  vesical  disease  ;  but  the  character  of  the  onset  of  the  trouble, 
with  elevation  of  temperature  and  pulse-rate,  and  right-sided  abdominal 
rigidity,  will  point  to  an  acute  intra-abdominal  lesion.  In  other  cases,  again, 
an  abscess  resulting  from  appendicular  suppuration  may  track .  down  into  the 
pelvis  and,  if  unopened,  may  rupture  into  the  bladder.  In  these  cases,  there 
will  be  the  usual  history  of  acute  appendicitis,  followed  by  a  tumour  in  the 
right  iliac  fossa  or  pelvic  space,  with  a  continuance  of  pjTexia,  or  even  rigors, 
which  subside  on  the  appearance  of  a  large  quantity  of  pus  in  the  urine. 

A  pyosalpinx  may  rupture  into  the  bladder  or  cause  cystitis  from  the  direct 
spread  of  the  inflammatory  process  to  the  bladder.  There  will  usually  be  a 
history  of  leucorrhoea,  with  constant  aching  or  dragging  pains  in  the  lumbo-sacral 
region,  aggravated  at  intervals  with  more  severe  attacks  of  pain  and  malaise, 
The  periods  may  be  profuse  and  associated  with  more  pain  than  usual,  and  on 
vaginal  examination  a  distinct  fullness  or  tumour  may  be  felt  in  one  or  both 
fornices. 

Psoas  or  iliac  abscess  may  rupture  into  the  bladder,  and  a  psoas  abscess  has 
been  known  to  open  into  a  ureter  ;  but  the  swelling  in  the  iliac  fossa  or  inguinal 
region,  together  with  signs  of  spinal  caries,  will  point  to  the  condition. 

Carcinoma  of  the  neighbouring  organs  in  the  pelvis  frequently  attacks  the 
bladder  by  the  direct  spread  of  the  growth.  This  is  most  common  in  carcinoma 
of  the  uterine  cervix  and  of  the  rectum,  but  may  result  from  cancer  of  the  pelvic 
colon,  sigmoid,  or  caecum.  In  any  case,  the  spread  of  the  disease  to  the  bladder 
occurs  late  in  the  disease,  so  that  symptoms  of  the  initial  trouble  are  sufficiently 
manifest  to  point  to  the  diagnosis.  The  implication  of  the  bladder  is  first  shown 
by  an  increased  desire  to  pass  urine,  and  by  pain  during  the  act ;  later,  when 
the  growth  has  actually  infiltrated  the  vesical  mucous  membrane,  ulceration 
into  the  bladder  occurs,  with  the  passage  of  pus  and  blood  in  the  urine.  If  the 
growth  has  extended  from  the  uterus  or  vagina,  there  may  be  a  leakage  of  urine 


REACTION     OF     DEGENERATION  633 

into  the  latter  ;   or  if   from  the  rectum  or  colon,  some  fseces  or  flatus  may  be 
passed  per  urethram. 

Tuberculous  or  dysenteric  ulcers  of  the  small  intestine  have  in  some  instances 
become  adherent  to  the  bladder  wall,  and  caused  cystitis  by  direct  spread,  or 
liave  even  perforated  into  the  bladder.  r.  h.  focelyn  Swan. 

RAINBOW  VISION.— (See  Vision,  Defects  of.) 

RASHES. — (See  Erythema  ;    Pustules  ;    Vesicles,  Etc.) 

REACTION  OF  DEGENERATION.— In  testing  muscles  and  nerves  elec- 
trically, two  different  kinds  of  current  are  employed,  namely  :  faradic,  in  which 
there  is  a  very  rapid  alternate  making  and  breaking  of  the  current,  and  the 
.galvanic,  in  which  the  current  flows  continuously  until  it  is  voluntarily  interrupted 
by  the  operator.  The  faradic  current  continuously  excites  the  nerve  and  muscle 
all  the  time  it  flows  ;  the  galvanic  current  only  excites  when  it  is  made  and 
■when  it  is  broken  ;  not  whilst  it  is  flowing.  In  the  case  of  the  faradic  current 
there  is  no  difference  between  the  poles,  each  being  alternately  an  anode  and 
a  kathode  many  times  a  minute  ;  in  the  galvanic  current,  on  the  other  hand, 
the  pole  connected  to  the  zinc  of  the  battery  is  known  as  the  kathode,  and  it  is 
by  this  pole  that  the  current  leaves  the  body,  whilst  the  other  pole  is  known 
as  the  anode,  and  by  it  the  current  enters  the  body.  When  testing  muscles 
•or  nerves,  it  is  usual  to  have  one  pole  in  contact  with  an  indifferent  part,  such 
as  the  spine,  and  the  other  over  the  motor  point  of  the  muscle  or  nerve  to  be 
tested.  Broadly  speaking,  the  best  spot  for  stimulating  a  nerve  is  the  place 
•where  it  is  most  superficial,  and  for  a  muscle,  over  the  site  of  entry  of  its  motor 
nerve.  It  is  important  to  have  the  skin  well  wetted,  in  order  to  minimize  its 
resistance  to  electrical  conduction  ;  and  the  strengths  of  current  required  to 
produce  contractions  should  be  measured  by  a  galvanometer,  without  which  the 
relative  excitabilities  of  the  nerves  and  muscles  of  the  two  sides  of  the  body 
cannot  be  compared. 

Under  normal  conditions,  both  faradic  and  galvanic  currents  produce  brisk 
contractions  of  a  muscle  when  applied  either  to  it  or  to  its  nerve  ;  and  with 
galvanism  it  is  found  that  a  weaker  current  will  suffice  to  evoke  a  contraction 
on  making  the  circuit  when  the  kathode  is  on  the  muscle  or  nerve  than  when 
the  anode  is  similarly  employed.  This  is  usually  summarized  by  the  formula 
K.C.C.  >  A.C.C.,  which  means  "  the  kathodal  closure  contraction  is  more 
easily  obtained  than  is  the  anodal  closure  contraction."  When  the  nerve  is 
degenerated,  however,  there  is  a  change  in  these  electrical  reactions,  and  when 
there  is  complete  reaction  of  degeneration — -often  written  and  spoken  of  as 
R.D. — stimulation  of  the  nerve  itself  evokes  no  muscular  contractions  whether 
the  faradic  or  the  galvanic  current  is  employed,  stimulation  of  the  muscle  evokes 
no  contraction  when  the  faradic  current  is  used,  whilst  with  galvanism  the 
muscle  can  still  be  made  to  contract,  though  its  method  of  response  differs 
from  the  normal  in  the  following  respects  : — • 

1.  It  may  sometimes  be  evoked  by  a  strength  of  current  less  than  the  healthy 
minimum. 

2.  The  twitch  of  the  contraction  is  slow  and  sluggish,  instead  of  brisk  and 
quick. 

3.  It  may  be  evoked  at  least  as  readily  when  the  pole  upon  the  muscle  is  the 
anode  as  when  it  is  the  kathode  ;  this  is  expressed  by  the  formulH;  A.C.C.  =  K.C.C, 
or  A.C.C.  >  K.C.C,  which  mean  that  the  anodal  closure  contraction  is  obtained 
from  quite  as  small  a  current  as  is  the  kathodal  closure  contraction,  or  even 
from  a  smaller  current  than  the  minimum  required  for  the  kathodal  closure 
contraction. 


634  REACTION     OF     DEGENERATION 

In  this  connection,  however,  two  distinct  considerations  require  to  be  clearly 
understood.  In  the  first  place,  if  a  given  nerve  were  cut  across  with  a  knife, 
there  would  be  no  immediate  R.D.  ;  it  takes  a  week  or  more  for  the  process  of 
nerve  degeneration  to  reach  the  stage  that  produces  R.D.  ;  it  then  depends 
upon  what  happens  to  the  nerve  how  long  the  R.D.  persists  ;  if  regeneration 
occurs,  it  takes  from  t\velve  weeks  onwards  to  complete  itself,  and  R.D.  will  be 
found  all  that  time  ;  if  the  nerve  does  not  regenerate,  then  R.D.  may  persist 
for  t«-o  or  three  vears  or  more,  provided  that  the  muscle  fibres  are  kept,  by 
massage  and  electrical  treatment,  from  becoming  mere  strands  of  fibrous  tissue. 
Should  the  latter  change  ensue,  there  will  be  no  more  electrical  response  in  the 
fibrous  tissue  that  used  to  be  muscle  than  there  would  be  in  any  other  fibrous 
tissue. 

In  the  second  place,  it  happens,  as  often  as  not,  that  when  some  fibres  in  a 
nerve  trunk  degenerate,  others  do  not.  and  the  same  apphes  to  the  corresponding 
muscle  fibres.  It  foUows  that  there  wiU  then  be  a  mixed  reaction,  the  normal 
fibres  giving  a  normal  response,  the  degenerated  fibres  giving  R.D.  ;  the  greater 
the  proportion  of  degenerated  fibres,  the  nearer  will  the  reactions  obtained 
approach  to  complete  R.D.,  and  vice  versa.  The  result  is  spoken  of  as  partial 
R.D.  ;  some  excitabilitv-  both  of  the  nerves  and  of  the  muscles  to  faradism 
remains,  but  it  is  less  than  normal  ;  the  nerve  responds  to  galvanism,  but  not  so 
readilv  as  does  the  muscle  when  the  latter  is  stimulated  directly  ;  the  response 
of  the  muscle  wUl  be  less  brisk  than  normal,  and  yet  K.C.C.  may  still  be  more 
easily  obtained  than  A.C.C.  It  is  by  no  means  eas}'  to  be  sure  of  the  interpreta- 
tion of  a  partial  R.D.,  but  partial  is  commoner  than  complete  R.D. 

The  chief  use  of  R.D.  is  in  distinguishing  cases  of  muscular  atrophy  that 
are  due  to  organic  changes  in  the  lower  neurone  from  other  cases  of  atroph}', 
especially  when  the  latter  is  due  to  general  wasting  from  cachexia,  or  to  arthritis,, 
or  disuse,  or  a  priman,'  muscular  dystrophy.  When  R.D.  is  present  there  is  a 
lesion  in  the  lower  neurone,  either  in  the  anterior  cornual  cells,  in  the  anterior 
nerve  roots,  or  in  the  peripheral  motor  nerve  fibres.  The  differential  diagnosis 
of  the  various  affections  of  these  parts  is  discussed  under  Atrophy,  Muscular. 

It  remains  to  add  that  there  are  a  few  maladies  in  which  the  electrical 
reactions  are  pecuhar,  though  they  do  not  present  R.D.  In  tetan}',  for  instance, 
Erb  has  shown  that  A.C.C.  is  often  greater  than  K.C.C,  although  in  other  respects 
the  reactions  are  normal.  In  Thomsen's  disease  there  is  variabilit}^  in  the  polar 
responses,  but  excitability-  to  faradism  remains.  In  some  cases  of  Raynaud's 
disease,  and  in  angio-neurotic  oedema  and  allied  vasomotor  neuroses,  there  may 
be  variations  from  the  normal  galvanic  reactions.  In  myasthenia  gravis  [Figs. 
83,  84,  p.  2G1)  it  is  characteristic  that,  whereas  the  affected  muscles  respond 
readily  to  the  first  few  faradic  stimuli,  the  contractions  rapidly  diminish  in  size 
and  cease  after  a  few  minutes,  notwithstanding  the  continuance  of  stimulation. 
After  a  period  of  rest  this  myasthenic  reaction  is  obtainable  again,  and  so  on. 
This  t3^e  of  electrical  response  corresponds  precise!}^  to  the  rapid  fatigue  of 
the  voluntan.-  muscle  movements,  and  the  diagnosis  is  not  difficult,  though  the 
disease  is  rare.  Herbert  French. 

RECTUM,    ABNORMAUTIES   FELT  PER. 

Method  of  Examination. — The  patient  should  be  placed  in  a  good  light  and 
on  a  couch  of  convenient  height.  With  male  subjects  the  position  recommended 
is  the  knee-elbow,  and  with  females  the  right  lateral  with  the  knees  flexed 
and  the  right  arm  drawn  behind  the  back.  The  examination  should  be  made 
with  the  left  hand,  lea\ing  the  right  free  for  manipulations.  Most  diseases  of 
the  rectum  are  situated  within  two  inches  of  the  anus.  It  is  advisable,  therefore, 
that  to  begin  with,  the  finger  should  be  inserted  as  far  as  the  first  joint  onl}'. 


RECTUM,     ABNORMALITIES     FELT     PER  635 

and  the  lower  inch  of  the  bowel  examined  thoroughly.  The  examination  must 
not  be  concluded  until  the  finger  has  been  passed  up  as  high  as  possible  and 
the  whole  of  the  rectum  within  reach  explored,  as  well  as  the  coccyx,  sacrum, 
ischio-rectal  fossae,  and  adjoining  viscera.  The  rectal  speculum  and  the 
sigmoidoscope  may  also  be  needed  to  complete  the  examination. 

If  any  abnormality  be  felt,  the  first  thing  to  ascertain  is  (i)  Whether  it  lies 
free  in  the  lumen  or  is  attached  to  the  wall  of  the  rectum  ;  (2)  Whether  it  is  some 
abnormality  of  an  adjoining  structure  or  viscus  that  can  be  felt  through  the  rectum. 

I. — Abnormalities  lying  Free  in  the  Lumen  or  Attached  to  the  Wall 

OF  the  Rectum. 

A.  Foreign  Bodies. — Though  faeces  can  hardly  be  considered  as  foreign  to  the 
rectum,  yet  a  hard,  scybalous  mass,  enterolith,  or  hair-ball  may  amount  to  an 
abnormality. 

True  foreign  bodies  include  those  that  have  been  introduced  through  the  anus, 
and  those  that  have  been  swallowed.  Examples  of  the  first  class  are  seldom 
met  with,  and  then  are  generally  in  persons  of  weak  intellect.  Thieves  sometimes 
employ  the  rectum  as  a  hiding-place  for  stolen  goods.  The  majority  of  foreign 
bodies  felt  per  rectum  have  been  swallowed,  and  consist  of  fishbones,  pins, 
needles,  and  splinters  of  wood.  Their  importance  lies  in  the  fact  that  they 
may  cause  a  rectal  or  ischio-rectal  abscess,  and  in  treating  such  a  case  their 
discovery  and  removal  is  essential  for  a  complete  cure. 

B.  Swellings  of  the  Rectum  projecting  into  the  Lumen. 

1.  Internal  Haemorrhoids  are  rarely  palpable  to  the  finger  unless  chronically 
inflamed,  thrombosed,  or  gangrenous.  If  palpable,  they  will  be  felt  immediately 
inside  the  anus,  and  can  easily  be  hooked  out  with  the  finger  and  made  to  protrude 
through  the  anal  orifice  for  inspection.  The  existence  of  piles  having  been, 
diagnosed,  an  effort  should  be  made  to  see  if  there  is  any  causative  condition, 
such  as  a  carcinoma  in  the  bowel  above. 

2.  Abscess  (submucous)  gives  rise  to  a  more  or  less  elongated,  smooth, 
elastic  swelling  in  the  rectal  wall.  It  is  intensely  tender,  the  slightest  pressure 
causing  great  pain.  The  mucous  membrane  may  feel  hot,  and  pit  on  pressure. 
If  the  abscess  has  burst  or  bursts  during  examination,  the  finger  on  withdrawal 
will  be  covered  with  pus.  An  abscess  that  has  already  emptied  itself  feels 
like  a  small  pea  or  bean  in  the  submucous  tissue. 

3.  Polypus  is  a  term  used  to  designate,  without  reference  to  its  histological 
characteristics,  any  benign  tumour  that  is  pedunculated.  Almost  all  innocent 
tumours  in  this  position,  even  if  sessile  at  the  beginning,  become  pedunculated 
owing  to  the  downward  pressure  of  the  faeces.  The  passage  of  blood  and 
mucus,  combined  with  the  absence  of  piles  and  carcinoma,  should  lead  one 
to  suspect  the  presence  of  a  polypus.  It  may  not  be  easy  to  feel,  because  its 
consistency  is  much  the  same  as  that  of  the  mucous  membrane,  and  further, 
its  peduncle  may  allow  such  free  movement  that  it  may  easily  be  mistaken 
for  a  small  mass  of  faeces.  The  best  way  of  fixing  these  growths  is  to  sweep 
the  finger  round  and  round  the  whole  circumference  of  the  rectum  up  to  the 
highest  point  attainable.  The  growth  is  then  arrested  by  the  pedicle,  and  the 
finger  can  be  hooked  round  it,  so  that  the  growth  is  drawn  down  and,  if 
possible,  made  to  protrude  through  the  anus.  If  the  polypus  is  large,  a  rectal 
speculum  may  be  of  service.  It  is  to  be  remembered  that  polypi  are  often 
multiple. 

4.  Ulcers,  unless  malignant  or  chronically  inflamed,  can  rarely  be  felt  with 
the  finger  ;  they  must  be  exposed  to  view  with  the  speculum.  They  may  be 
tuberculous,  gummatous,  traumatic,  or  due  to  ulcerative  colitis  or  dysentery. 


636  RECTUM,     ABNORMALITIES     FELT     PER 

5.  Carcinoma  occurs  usually  in  people  over  forty.  Its  commonest  site  is 
within  the  four  terminal  inches  of  the  bowel.  The  exploring  finger  feels  a 
swelling  in  the  wall  of  the  rectum,  and  unfortunately',  because  patients  do  not 
present  themselves  early  for  examination,  the  swelling  will  be  large.  The  great 
characteristic  is  that  it  is  hard,  fixed,  irregular,  and  nodular.  The  extent  of 
the  growth  varies,  of  course,  with  the  stage  of  the  disease  :  it  may  involve  onl^'- 
a  small  part  of  the  circumference  of  the  bowel,  or  may  extend  right  round  so 
as  to  occlude  the  lumen  and  cause  a  stricture.  The  growth  is  usually  disinte- 
grated on  the  surface,  forming  a  malignant  ulcer  ;  this  surface  is  friable  and 
bleeds  easily.  There  is  nearly  alwaj's  a  belt  of  normal  mucosa  between  the 
internal  sphincter  and  the  neoplasm. 

Not  only  the  lateral  but  the  upper  limit  of  the  growth  is  to  be  ascertained 
by  inserting  the  finger  to  its  extreme  limit,  care  being  taken  not  to  split  the 
mass.  Another  point  to  be  gauged  by  a  rectal  examination,  is  the  degree  of 
infiltration  as  measured  by  the  fixity  of  the  tumour  to  the  neighbouring  struc- 
tures e.g.,  sacrum  and  coccjrx.  Following  the  rectal  examination,  the  abdomen 
is  to  be  palpated  for  evidence  of  infection  of  the  inguinal,  pelvic,  and  lumbar 
glands,  and  the  existence  of  secondary  deposits  in  the  liver. 

The  clinical  symptoms  of  carcinoma  of  the  rectum  are  ver}'  suggestive.  The 
patient  generally  complains  of  diarrhoea,  the  bowels  being  open  five  to  twenty 
times  a  day,  and  this  may  have  followed  on  a  period  of  constipation.  Xotwith- 
standing  the  apparent  diarrhoea,  the  total  amount  of  faeces  passed  is  very  small, 
and  no  sense  of  satisfaction  is  obtained  by  the  patient  after  stool.  The  action 
of  the  bowels  may  be  so  rapid  as  to  merit  the  description  "  explosive  diarrhoea." 
Haemorrhage  from  the  bowel  is  a  common  symptom,  and  in  the  later  stages 
there  is  a  discharge  of  mucus.  Pain  is  complained  of — a  dull  aching  pain  in 
the  rectum  and  at  the  bottom  of  the  back,  which  is  not  made  much  worse  by 
the  passage  of  a  motion,  quite  unlike  the  sharp  temporary  excruciating  pain 
associated  with  an  anal  fissure  or  ulcer.  Emaciation  is  rapid,  and  a  history  of 
wasting  and  diarrhoea  in  a  middle-aged  patient  should  always  lead  to  a  careful 
examination  of  the  rectum,  and  if  nothing  is  to  be  felt  with  the  finger,  a 
sigmoidoscope  should  be  used.  A  carcinoma  is  likely  to  be  overlooked  from  care- 
lessness and  from  not  making  an  examination.  ^listakes  may,  however,  arise 
between  carcinoma  and  an  adenomatous  polypus  or  ulceration,  either  traumatic 
or  tuberculous,  around  which  much  long-standing  inflammation  has  caused 
thickening.  The  facts  that  a  carcinoma  is  hard,  the  surface  often  excavated, 
and  the  edges  nodular  and  everted,  are  generally  sufflcient.  If  real  doubt  exists, 
a  piece  of  the  ulcer  may  be  removed  for  microscopic  report. 

6.  Intussusception. — Occasionally  a  piece  of  intussuscepted  bowel  maj"  come 
down  so  far  as  to  be  felt  per  rectum.  This  condition  is  associated  with  the 
passage  of  blood  and  mucus,  and  therefore  might  be  mistaken  for  a  disease 
of  the  rectum  proper.  The  fact  that  intussusception  occurs  nearly  always  in 
children,  especially  at  the  age  of  nine  months  or  thereabouts,  and  causes  intes- 
tinal obstruction,  should  make  such  a  mistake  easily  avoidable.  \ 

C.  Stricture  due  to  a  carcinoma  is  dealt  with  above,  but  a  few  remarks  re: 
to  be  made  about  fibrous  stricture.  This  may  be  present  at  the  anal  orifice^ 
at  the  level  of  the  upper  border  of  the  internal  sphincter,  or  three  to  four  inches 
up  the  rectum.  It  may  be  annular  or  tubular.  The  finger  meets  with  a  firm 
cord-like  constriction,  which  perhaps  will  not  allow  the  entrance  of  more  than 
its  tip  ;  there  will  be  no  bleeding  unless  the  finger  is  forced  through  the  stenosis 
and  the  mucous  membrane  torn. 

D.  Fistulae,  either  recto-vaginal  or  recto-vesical,  whether  congenital  or 
acquired,  maj^  be  felt  with  the  finger.  The  passing  of  urine  or  faeces  by  abnormal 
passages  indicates  the  complaint. 


RECTUM,     ABNORMALITIES     FELT     PER 


637 


E.  Malformations  of  the  Rectum. — Some  children  are  born  without  an  anus, 
or  without  the  lower  portion  of  the  rectum,  or  the  finger  introduced  may  be 
stopped  by  a  membrane  separating  the  upper  from  the  lower  portion  of  the 
bowel.  The  diagnosis  is  obvious.  The  usual  types  of  abnormalities  are  shown 
on  the  accompanying  diagrams,  Figs.  170- 
173,  reproduced  from  the  Medical  Annual, 
iQio  :  the  figures  are  a  summiary  by  Dr.  A. 
Keith  of  a  series  of  54  cases  in  male,  and 
52  cases  in  female,  children. 


Fi£:  170. — Sagittal  section  of  the  pelvis  of  a  male  child, 
showing  the  rectum  opening  into  tlie  prostatic  part  of  the 
urethra.  A  Bladder  ;  B  rectum  ;  C  recto-vesical  pouch  ; 
D  uterus  masculinus  ;  E  intracloacal  anus  ;  F  prostate  ; 
G  proctodaeum  ;  H  external  and  internal  sphincters ; 
I  Cowper's  gland. 


/^!^.  171. — Illustrating  the  degrees  of 
imperfection  in  the  male.  The  rectum  is 
shaded  ;  the  various  degrees  make  tip  a 
series  between  the  proctodaeum  and  base 
of  the  prostate. 


F/^.  172.— Sagittal  section  of  the  pelvis  of  a  female 
infant,  showing  the  rectum  opening  into  the  navicular 
fossa  of  the  vulva.  A  Bladder  ;  B  rectum  ;  C  recto- 
uterine fold  :  D  symphysis  pubis  ;  E  vulva-anus  ;  F  cer- 
vix ;  G  proctodaeum  (rarely  present  if  the  rectum  opens 
into  the  vulva)  ;  H  urethra  ;    I  clitoris  ;    K  hymen. 


7^!£:  173.  —  Illustrating  the  common 
varieties  of  malformation  in  the  female  ; 
the  various  degrees  make  up  a  series 
between  the  proctodaeum  and  the  recto- 
uterine fold. 


638  RECTUM,     ABNORMALITIES     FELT     PER 


II. — Abnormalities    of    some    Neighbouring    Structure    or    Viscus 

FELT    through    THE    RECTUM. 

It  does  not  lie  within  the  scope  of  this  article  to  give  the  differential 
diagnosis  of  all  the  morbid  conditions  that  can  be  felt  through  the  rectum  ; 
it  suffices  to  take  the  structures  within  reach  of  the  finger,  and  indicate 
the  varying  conditions  in  which  a  diagnosis  may  be  aided  by  a  rectal 
examination. 

On  the  Anterior  Wall  the  structures  that  can  normally  be  felt  are  the  prostate 
in  the  male,  and  the  uterus  in  the  female. 

Prostate. — Any  enlargement  is  easily  felt.  An  adenoma  is  the  commonest 
form.  This  is  soft,  elastic,  and  has  a  groove  in  the  middle  line.  A  carcinoma 
or  sarcoma  is  hard  and  fixed,  and  the  outlines  are  blurred.  A  prostatic  abscess 
causes  a  marked  painful  protrusion  into  the  rectum. 

The  VesiculcB  Seminales  are  not  palpable  normally.  The  fact  that  they  can 
be  felt  is  almost  sufficient  to  declare  them  diseased.  They  are  most  commonly 
affected  in  connection  with  tuberculosis  of  the  testes  or  from  present  or  past 
gonococcal  vesiculitis. 

The  Bladder  is  not  felt  if  healthy.  If  greatly  distended  it  may  form  a  tense 
resistance  in  the  anterior  wall  of  the  rectum.  Rarely,  a  large  stone  or  a  malignant 
growth  of  the  floor  may  be  felt. 

The  Uterus  is  easily  palpable.  Any  enlargement  or  retroversion  can  be 
recognized  ;  the  pressure  of  a  foetal  head  may  occlude  the  rectum. 

The  Vagina  cannot  be  felt  unless  it  is  occupied  by  a  foreign  body  such  as  a 
pessary,  or  is  the  seat  of  a  growth. 

The  Ovaries,  if  enlarged  by  cystic  disease  or  by  new  growth,  may  come  within 
reach  of  the  finger ;  pyosalpinx  is  often  a  bilateral  affection  in  which  the 
inflammatory  masses  can  be  felt  per  rectum  in  Douglas's  pouch ;  they  can  be 
detected  more  readily  by  vaginal  examination,  however,  when  this  route  is 
permissible. 

Through  the  posterior  wall  the  only  structures  that  can  be  recognized  are  the 
coccyx  and  sacrum. 

The  Coccyx  may  be  found  bent  in  and  pressing  on  the  rectum.  In  coccy- 
dynia  any  movement  of  the  coccyx  may  cause  great  pain. 

The  Sacrum  may  be  the  seat  of  either  a  growth  or  an  abscess,  which  will 
cause  a  bulging  into  the  posterior  wall.  ^ 

On  the  two  lateral  surfaces  no  structures  are\normally  recognized.  The 
ischio-rectal  foss«  are  common  sites  for  abscesses,  ati4  these  can  be  felt  as 
tense  swellings  pushing  in  the  wall.  Rarely  an  aneury^rn-.  of  the  internal  iliac 
artery  or  a  stone  in  the  lowest  portion  of  the  ureter  may  be  felt.^. 

If  anything  is  felt  with  the  tip  of  the  finger  through  the  uppe^portion  of 
the  rectum,  it  will  usually  be  something  distending  Douglas's  pouchr — This 
may  be  blood  coming  from  a  ruptured  or  leaking  ectopic  gestation,  or,  more 
likely,  a  localized  abscess,  either  parametric  or  arising  from  a  septic  Fallopian 
tube  or  the  vermiform  appendix.  In  some  cases,  an  abscess  in  this  position 
may  exert  such  pressure  on  the  rectum  as  to  cause  intestinal  obstruction. 
Some  surgeons  state  that  they  are  able  to  detect  the  appendix  if  it  is  hanging 
over  the  brim  of  the  pelvis,  but  to  do  this  the  finger  must  be  long  and  the  senses 
very  acute. 

Sometimes,  when  there  is  doubt  as  to  whether  symptoms  arising  in  connec- 
tion with  a  more  distant  organ,  e.g.,  the  stomach  or  the  gall-bladder,  are 
due  to  malignant  disease  or  not,  rectal  examination  affords  valuable  evidence 
of  malignancy  even  when  there  arc  no  pelvic  symptoms  at  all.  When  secondary 
deposits  have  arisen,  they  develop  not  infrequently  in  the  pelvic  peritoneum. 


REGURGITATION     OF     FOOD     THROUGH     THE     NOSE         6^9 

presumably  as  the  result  of  gravitation  of  malignant  particles  into  Douglas's 
pouch.  These  latent  secondary  deposits  can  sometimes  be  felt  very  definitely 
.as  a  firm  band  or  shelf — the  "  rectal  shelf  " — if  the  observer's  index  finger  is 
a  fairly  long  one.  .  George  E.  Cask. 

RECTUM,  BLOOD  PER. — (Sec  Blood  per  Anum  ;    and  :Mel.5xa.) 

REDUPLICATION  OF  HEART  SOUND.  —  It  very  seldom  happens  that 
the  diagnosis  in  a  particular  case  is  influenced  to  any  marked  degree  by  the 
presence  or  absence  of  reduphcation  of  either  heart  sound  ;  nevertheless,  the 
reduplication  is  sometimes  so  definite  that  it  attracts  special  attention  and  needs 
interpretation.  It  has  to  be  distinguished  from  other  triple  sounds,  particu- 
larly from  the  canter-rhythm  that  occurs  most  commonly  with  acute  peri- 
carditis, and  less  often  with  dilatation  of  the  heart  from  fatty  change,  especially 
in  pernicious  anaemia  and  other  conditions  of  oligochromeemia  ;  and  from  the 
beginning  of  a  mid-diastolic  bruit  at  the  impulse  in  a  case  of  acute  rheumatic 
endocarditis  of  the  mitral  valves.  One  can  lay  down  no  rules  as  to  how  these 
various  sounds  are  to  be  distinguished  ;  it  can  only  be  done  by  having  heard 
them  in  other  cases  ;  sometimes,  indeed,  opinions  differ  as  to  whether  the 
sounds  heard  in  a  given  patient  are  due  to  a  bruit  or  to  a  reduphcation. 

Reduphcation  of  the  first  sound  is  rare,  and  to  all  intents  and  purposes  it 
never  occurs  except  at  or  near  the  impulse  ;  it  indicates  some  abnormahty, 
but  does  not  specify  exactly  what  that  abnormahty  may  be.  If  there  is  no 
bruit,  the  commonest  cause  is  great  hj'pertrophy  of  the  left  ventricle  from 
granular  kidney  or  arteriosclerosis,  indicated  by  the  big  heart,  high  blood- 
pressure,  urinary  and  retinal  changes. 

Reduplication  of  the  second  sound  is  common,  especially  in  the  pulmonary 
area  (second  left  intercostal  space  close  to  the  sternum).  It  generally  indicates 
great  relative  increase  in  the  intrapulmonary  blood-pressure,  so  that  the 
pulmonary  valves  close  a  fraction  sooner  than  the  aortic  ;  the  reduplication 
may  alternate  with  simple  accentuation  (see  p.  i),  the  commonest  cause  being 
mitral  disease,  especially  mitral  stenosis.  Similar  reduplication  of  the  second 
sound  may  be  heard  at  the  impulse  also  in  these  cases,  though  more  often  the 
second  sound  here  is  weak  or  inaudible.  The  commonest  cause  for  reduphcation 
of  the  second  sound  at  the  impulse  is  great  relative  increase  in  the  systemic 
blood-pressure — especially  in  cases  of  arteriosclerosis  or  granular  kidney.  The 
second  sound  in  the  aortic  area  (second  right  intercostal  space  close  to  the 
sternum)  is  generally  very  loud  and  at  the  same  time  ringing,  or  even  reduph- 
cated  also  if  the  pulmonary  second  sound  is  of  its  ordinary  loudness.  There 
are  no  other  really  important  causes  of  reduplication  of  either  of  the  heart 
sounds.  Htibc-yt  French. 

REFLEX,  PLANTAR.— (See  Babinski's  Sign.) 

REFLEX,  PUPILLARY. — (See  Pupil,   Abnormalities  of  the.) 

REGURGITATION  OF  FOOD  THROUGH  THE  NOSE.— This  occurrence  may 
be  but  a  temporary  accident,  the  result  of  an  unsuccessful  attempt  to  stave  off 
a  sneeze,  a  cough,  or  a  burst  of  laughter  when  the  mouth  is  full  of  food  or 
Huid.  It  may  also  result  from  an  explosive  return  of  gas  from  the  stomach  or 
oesophagus,  particularly  after  drinking  gassy  fluid  such  as  soda-water,  champagne, 
ginger-beer,  cider,  or  beer.      In  such  cases  the  diagnosis  is  generally  obvious. 

Repeated  regurgitation  of  food  through  the  nose  results  from  two  main  groups 
of  causes,  namely  : — 


640         REGURGITATION     OF     FOOD     THROUGH     THE     NOSE 

A.  Structural  Imperfections  of  the  Palate  : — 

(a)  Congenital :    cleft  palate 

(b)  Acquired   perforation  :    (i.)   traumatic,    (ii.)    syphilitic,    (iii.)  malignant, 

(iv.)  tuberculous. 

B.  Paresis  or  Paralysis  of  the  Soft  Palate  or  of  the  Pharynx  : — 

{a)   Post-diphtheritic  (e)   The  result  of   pseudo-bulbar 

[b)  Post-operative  paralysis 

(c)  Syphilitic  '  (/)   Cases  of  undetermined  cause. 
{d)  The  result  of  bulbar  paralysis 

Simple  inspection  of  the  roof  of  the  mouth  is  generally  sufficient  to  decide 
whether  the  cause  belongs  to  group  A  or  to  group  B.  The  median  and  sym- 
metrical imperfection  of  a  congenital  cleft  palate  is  obvious,  and  there  is  the 
history  of  the  trouble  dating  from  birth.  There  may  be  a  harelip  or  other 
congenital  abnormality  at  the  same  time.  ^Vhen  an  ulcerative  process  is  still 
in  progress,  there  may  for  a  time  be  some  doubt  as  to  whether  it  is  syphilitic, 
malignant,  or  tuberculous.  The  history  may  help,  or  the  healing  of  the 
ulcer  under  the  influence  of  mercury  or  iodide  of  potassium  may  indicate  its 
syphilitic  nature.  If  it  is  important  to  arrive  at  the  correct  diagnosis  as  earl}'  as 
possible,  a  small  portion  of  the  pathological  tissue  may  be  excised  and  examined 
microscopically,  or  some  assistance  may  be  derived  from  the  application  of 
Wassermann's  serum  test,  or  by  direct  examination  of  scrapings  from  the  ulcer 
for  the  Spirochcsta  pallida  or  for  tubercle  bacilli.  Tuberculous  ulceration  of 
the  palate  is  very  rare',  and  is  generally  associated  either  with  lupus  or 
with  definite  phthisis.  A  new  growth  of  the  palate  may  be  either  epithelioma, 
endothelioma,  or  sarcoma,  the  distinction  between  these  depending  mainly  on 
the  microscope. 

Diphtheria If  there  is  no  structural  defect  of  the  palate,  the  regurgitation  of 

food  through  the  nose  being  due  to  paralysis,  by  far  the  most  likely  cause,  when 
this  is  the  chief  symptom,  is  previous  diphtheria.  The  existence  of  the  latter 
may  have  been  recognized  at  the  time,  but  quite  often  the  diphtherial  attack 
has  been  so  slight  as  either  to  have  caused  no  definite  illness  at  the  time,  or  else 
to  have  been  regarded  as  simple  sore  throat.  The  palate  alone  may  be  paralyzed, 
giving  rise  to  a  nasal  alteration  in  the  character  of  the  voice,  as  well  as  to  the 
regurgitation  ;  or  there  may  be  paresis  of  the  ciliary  muscles  and  the  eyes  as 
well,  causing  difficulty  in  reading  ;  less  commonly,  there  is  further  evidence  of 
peripheral  neuritis  affecting  the  limbs  and  heart.  The  trouble  may  not  come 
on  for  three  or  four  weeks  after  the  diphtheriai^ attack  and  therefore  it  ma}'  no 
longer  be  possible  to  detect  Klebs-Loffier  bacilli"~inswabbings  from  the  tonsils 
or  fauces  ;  but  in  every  such  case  it  is  important  to  looit^or  them,  both  directly 
and  by  means  of  cultures.  Probably  not  a  few  cases  ascribed  to  "  influenza," 
or  to  undetermined  causes,  are  really  post-diphtheritic.  The  paresis  recovers 
in  time,  sometimes  quickly,  but  often  not  until  three  months  or  more  have 
elapsed. 

Post-operative  Cases. — The  history  in  these  cases  will  point  to  the  diagnosis  ; 
the  accident  is  rare,  and  as  a  rule  the  effects  are  temporary  ;  it  maj'  happen 
during  the  removal  of  tonsils  and  adenoids. 

Syphilitic  Paralysis  of  the  Palate  is  not  common,  and  it  hardly  ever  occurs  by 
itself.  It  is  a  general  rule  that  luetic  affections  of  cranial  nerves  are  multiple 
and  often  asymmetrical  ;  thus  there  may  be  strabismus,  or  a  larjmgeal  paresis, 
in  addition  to  that  of  the  palate  ;  or  there  may  be  a  history  or  other  evidence 
of  syphilis. 

Bulbar  or  pseudo-bulbar  Paralysis When  this  affects  the  palate  and  causes 

regurgitation  of  food  through  the  nose,  there  have  generally  been  other  symptoms 


RETRACTION     OF     THE     HEAD  641 

for  some  time.  The  malady  is  slowly  progressive,  and  starts  with  paresis  of 
the  lips  and  tongue  ;  swallowing  is  difficult,  not  so  much  because  of  the 
regurgitation  as  because  the  tongue  is  unable  to  thrust  the  bolus  back  between 
the  fauces.  The  constant  dribbling  of  saliva  from  the  angles  of  the  mouth 
is  characteristic  of  some  cases.  The  title  labio-glosso-pharyngo-laryngea 
paralysis  indicates  the  usual  sequence  of  events.  Bulbar  paralysis  may  be 
associated  with  progressive  muscular  atrophy,  and  it  may  be  distinguished  from 
pseudo-bulbar  paralysis  by  the  atrophy  of  the  tongue,  which  occurs  in  the 
former  but  not  in  the  latter.  Bulbar  paralysis  is  due  to  a  lesion  in  the  medulla 
oblongata,  whereas  pseudo-bulbar  paralysis  has  very  similar  symptoms  due  to 
bilateral  cortical  softening.      In  either  case  the  patients  are  generally  elderly. 

Undetermined  Causes. — As  regards  such  cases,  it  may  be  repeated  that  the 
majority  are  doubtless  post-diphtheritic,  so  that  it  is  important  to  take 
swabbings  from  the  throat  of  all  such  patients,  in  order  to  examine  culturally 
for  the  Klebs-Loffler  bacillus.  Herbert  French- 

RETENTION  OF  URINE. — (See  Micturition,  Abnormalities  of.) 

RETRACTION  OF  THE  ABDOMEN. — (See  Rigidity  of  the  Abdomen.) 

RETRACTION  OF  THE  GUMS  is  occasionally  a  symptom  which  troubles 
patients  very  much,  but  in  itself  it  seldom  indicates  more  than  a  local  affection. 
In  a  mild  degree  it  may  be  due  to  excessive  use  of  a  hard  tooth-brush  ;  in  the 
absence  of  this  cause  it  suggests  that  there  is  a  local  infective  process,  especially 
tartar,  caries  of  the  teeth,  or  pyorrhoea  alveolaris.  These  conditions  are  dis- 
cussed under  the  heading  of  Bleeding  Gums,  though  very  often  retraction 
may  be  present,  even  in  an  extreme  degree,  without  actual  bleeding. 

Herbert  French. 
RETRACTION   OF    THE   HEAD. — Retraction  of  the  head  may  be  a  marked 
symptom  in  the  following  conditions  : — 
Acute  meningitis    (i.)      Suppurative 

,,  ,,  (ii.)    Tuberculous   (basal) 

„  ,,  (iii.)   Meningococcal  (posterior  basal) 

„  ,,  (iv.)   Meningococcal  (epidemic  cerebrospinal) 

Cerebellar  or  other  subtentorial  tumour  or  abscess 
Superior   longitudinal   sinus   thrombosis 
Acute  encephalitis 

Bronchopneumonia  with  partial  asphyxia 
Laryngeal  obstruction,  especially  diphtheria  in  children 
Strychnine  poisoning 
Tetanus 
Hydrophobia 
Catalepsy 

Spasmodic  torticollis 
Paramyoclonus  multiplex 
Hysteria  and  hystero-epilepsy. 
In  arriving  at  a  diagnosis  in  any  given  case,  the  probabihty  is  that  strychnine 
poisoning,  tetanus,  and  hydrophobia  will  either  suggest  themselves  at  once  on 
account  of  other  circumstances  in  the  case,  or  else  will  not  need  to  be  discussed 
at  all.     Hysteria  can  only  be  diagnosed  when  all  other  possibilities  have  been 
excluded,  and  probably  not  until  the  case  has  been  anxiously  watched  for  a  time  ; 
there  may  be  other  functional  symptoms  in  the  case  ;    the  patient  is  generally 
a  young  adult,  more  often  female  than  male.     Catalepsy  and  hystero-epilepsy 
will  be  suggested  by  the  mental  symptoms,   or  obvious  insanity. 

D  41 


642  RETRACTION     OF     THE     HEAD 

These  things  being  excluded,  the  first  thought  that  marked  and  maintained 
retraction  of  the  head  arouses  is  that  the  patient  has  some  serious  intracranial 
lesion,  probably  meningitis.  Before  coming  to  this  conclusion,  however,  it  is 
important  not  to  forget  that  extreme  dyspnoea  in  children  sometimes  produces 
considerable  head  retraction,  so  that  the  physical  signs  in  the  lungs  and  heart 
should  be  noted  carefully,  bronchopneumonia  and  capillary  bronchitis  being 
kept  specially  in  mind,  and  any  signs  of  laryngeal  obstruction  looked  for, 
especially  stridor  and  spasmodic  up-and-down  movements  of  the  thyroid 
cartilage,  with  sucking  in  of  the  thorax  above  and  below  the  clavicles, 
along  the  attachments  of  the  diaphragm,  and  in  the  intercostal  spaces. 
Diphtheria,  foreign  body  in  the  larynx,  and  retropharyngeal  abscess  have  all 
been  mistaken  for  meningitis. 

If  there  is  no  evidence  of  sufficient  throat  or  lung  trouble  to  account  for  the 
symptom,  an  intracranial  lesion  is  probable  ;  and  by  far  the  most  hkety,  especially 
in  a  child,  is  acute  meningitis,  either  tuberculous  or  posterior  basal.  Symptoms 
common  to  all  the  intracranial  affections  are  headache,  vomiting,  and  giddiness  ; 
P3^rexia,  generalized  convulsions,  coma,  incontinence  of  urine  and  faeces, 
retraction  of  the  head,  and  optic  neuritis  ;  or  even  local  symptoms,  especially 
twitchings,  convulsions,  or  paralysis  of  individual  limbs  or  parts  of  hmbs, 
according  as  one  part  of  the  brain  or  another  is  more  irritated  or  softened  than 
the  rest.  If  there  is  an  obvious  source  of  sepsis  in  connection  with  the 
cranium,  such  as  otitis  media,  mastoid  abscess,  facial  erysipelas,  a  septic  scalp 
wound,  boils,  pediculi  with  sores,  suppuration  in  the  orbit,  nose,  antrum  of 
Highmore,  frontal,  ethmoidal,  or  sphenoidal  air-cells,  or  nasopharj-nx,  the 
probabihty  is  that  any  acute  meningitic  symptoms  are  due  to  staphylococcal 
or  streptococcal  suppurative  meningitis  ;  pneumococcal  meningitis  may  occur 
without  local  sepsis,  either  alone  or  as  part  of  a  general  pneumococcal 
septicaemia  ;  suppurative  meningitis  due  to  the  Bacillus  diphtherias,  the 
typhoid  bacillus,  or  the  Bacillus  coli  communis  maj'-  occur,  but  it  is  decidedly 
uncommon  and  clinically  indistinguishable  from  other  forms  of  suppurative 
meningitis,  in  all  of  which  marked  pyrexia  and  a  fatal  ending  in  two  or  three 
days  are  the  rule.  Tuberculous  meningitis  is  much  commoner  in  childhood  than 
it  is  at  any  other  age  ;  it  is  always  part  of  a  general  tuberculosis,  and  it  is 
very  rare  in  adult  life.  At  first  there  may  be  no  pyrexia,  though  this  depends 
on  the  caseous  glands  and  tuberculous  lesions  in  the  lungs  and  elsewhere  more 
than  upon  the  meningitis.  At  first,  the  diagnosis  is  apt  to  be  uncertain,  but  as 
the  days  go  by  the  serious  nature  of  the  complaint  generally  becomes  obvious  ; 
the  effortless  vomiting,  the  irregular  pj^rexia,  severe  headache,  optic  neuritis, 
retracted  head,  possibly  choroidal  tubercles  {Plate  VIII,  Fig.  W)  or  evidence 
of  tuberculous  foci  elsewhere,  serve  to  clinch  the  diagnosis.  The  chief  difficulty, 
after  the  stage  of  retraction  has  been  reached,  is  to  decide  between  tuberculous 
meningitis  on  the  one  hand  and  meningococcal  {posterior  basal)  meningitis  on 
the  other.  The  duration  of  the  disease  is  often  of  assistance  in  this  respect — 
suppurative  meningitis  kills  in  two  or  three  days,  tuberculous  meningitis  in  two 
or  three  weeks,  whilst  posterior  basal  meningitis  ends  in  recovery  in  a  variable 
percentage  of  cases,  even  after  continuing  for  two  or  three  months.  The  tendency 
to  head  retraction  is  greatest  with  the  posterior  basal,  least  with  the  suppurative 
forms.  Optic  neuritis  barely  has  time  to  develop  in  suppurative  meningitis, 
but  it  is  present  more  often  than  not  in  both  basal  and  posterior  basal  mening- 
itis. The  way  in  which  the  heels  touch  the  occiput  in  some  cases  of  the  latter 
may  by  itself  decide  the  diagnosis.  Another  point  in  favour  of  meningococcal 
meningitis,  is  the  occurrence  of  periodic  spike-like  rises  of  the  temperature  chart 
- — pyrexial  "crises"  lasting  twenty-four  hours  or  less,  and  superposed  upon 
what  is  otherwise  a  chart  of  but  moderate  type.     When  doubt  remains  as  to  the 


RETRACTION     OF     THE     HEAD  643 

fact  of  meningitis  or  as  to  its  nature,  microscopical  and  bacteriological  examina- 
tions of  the  cerebrospinal  fluid  obtained  by  lumbar  puncture  will  often  serve 
to  establish  the  diagnosis. 

The  Cerebrospinal  Fluid. — Normal  cerebrospinal  fluid  is  clear  like  water,  alkaline 
in  reaction,  of  specific  gravity  i  -004  to  i  -007  ;  it  should  drip  out  at  the  rate  of 
60  drops  per  minute  ;  it  contains  no  albumin,  a  trace  of  globulin,  and  a  substance 
which  reduces  Fehling's  solution.  In  cases  of  acute  meningitis  it  is  opalescent, 
turbid  or  obviously  purulent,  yellowish  or  even  brown  ;  its  specific  gravity  is 
raised,  it  comes  away  at  a  greater  rate  than  60  drops  per  minute,  and  it  contains 
excess  of  globulin,  together  with  albumin  and  nucleo-proteid.  Its  alkalinity 
and  its  reducing  power  remain  as  in  health.  Microscopically,  the  normal  fluid 
is  practically  free  from  cells,  whilst  in  all  forms  of  acute  meningitis  there  are 
many  polymorphonuclear  cells,  and  in  tuberculous  cases,  many  lymphocytes 
also  ;  bacteriologically,  tubercle  bacilli  are  the  least  easy  to  find.  The  Gram- 
negative  meningococci  {Diplococci  intracellulares  meningitidis  Weichselbaumii) 
[Plate  XII,  Fig.  N)  are  characterized  by  their  occurrence  within  the  leucocytes 
in  pairs,  like  gonococci,  but  without  the  reniform  shape  of  the  latter.  The 
organisms  of  suppurative  meningitis  may  be  discovered  on  direct  staining,  but 
more  often  cultural  methods  are  required. 

Where  posterior  basal  meningitis  ends  and  epidemic  cerebrospinal  meningitis 
begins,  it  is  difficult  to  say  ;  they  are  both  meningococcal,  and  probably  they 
are  only  different  types  of  the  same  malady,  connected  together  by  sporadic 
cases  in  which  posterior  basal  meningitis  is  associated  with  more  or  less  severe 
spinal  symptoms.  The  way  in  which  the  least  touch  or  movement  causes  the 
patient  to  cry  out  with  pain  sometimes  indicates  how  inflamed  the  coverings 
of  the  posterior  nerve-roots  are,  besides  which,  the  erythematous,  vesicular  or 
purpuric  skin  eruptions  that  may  accompany  it  often  suggest  the  diagnosis. 
There  is  no  difficulty  during  an  epidemic  ;  it  is  the  sporadic  case  that  may  be 
missed.  The  clinching  point  in  the  diagnosis  is  bacteriological  investigation 
after  lumbar  puncture,  assisted  perhaps  by  the  beneficial  effects  of  the  specific 
antimeningococcal   serum. 

Superior  longitudinal  sinus  thrombosis  and  acute  polio-encephalitis  are  both 
nearly  always  diagnosed  as  acute  meningitis  in  the  first  instance.  It  is  when 
a  case  that  has  simulated  acute  and  severe  meningitis,  with  coma  and  apparently 
impending  death,  gets  rapidly  better  after  a  few  days  and  ends  in  speedy  recovery, 
with  or  without  some  impairment  of  local  or  general  brain  functions,  in  a  child 
or  young  person,  that  one  changes  one's  diagnosis  of  meningitis  to  polio- 
encephalitis, though  even  then  it  remains  one  of  opinion  chiefly.  Almost  the 
same  applies  to  superior  longitudinal  sinus  thrombosis  ;  though,  if  acute  cerebral 
symptoms  in  a  previously  healthy  child  end  in  a  gradual  and  but  partial  recover};-, 
accompanied  by  permanent  spastic  paralysis  of  the  legs,  without  much  affection 
of  the  arms,  it  is  very  possible  that  the  lesion  has  been  thrombosis  of  the  superior 
longitudinal  sinus,  with  softening  of  the  leg  areas  of  cortex  on  either  side  of  it. 

Cerebellar  or  other  subtentorial  tumours  or  abscesses  generally  cause  a  much 
more  gradual  onset  of  symptoms  than  do  any  of  the  other  conditions  named. 
Head  retraction  is  not  present  until  the  later  stages.  The  diagnosis  of  tumour 
will  rest  on  the  slow  increase  in  the  signs  of  raised  intracranial  pressure,  with 
nystagmus,  optic  neuritis  going  on  to  optic  atrophy,  and  a  tendency  to  fall 
always  in  one  definite  direction — forwards  or  backwards  if  the  tumour  is  in  the 
vermis,  to  the  right  or  to  the  left  according  as  it  is  in  the  right  or  left  hemisphere. 
There  is  often  marked  ataxy,  with  exaggeration  of  the  tendon  reflexes,  particularly 
on  the  same  side  as  the  tumour.  If  nystagmus  is  well  marked,  this  serves 
as  a  point  of  some  value  in  distinguishing  a  cerebellar  from  a  cerebral  tumour. 
Abscess  is  distinguished  from  tumour  chiefly  by  the  existence  of  some  obvious 


644  RIGIDITY     OF     THE    ABDOMEN 

cause  for  intracranial  abscess,  especially  otitis  media  on  the  one  hand,  bronchi- 
ectasis upon  the  other.  Cerebellar  abscess  may  give  rise  to  no  pjTrexia  and  no 
leucocytosis  ;  but  Avhether  the  temperature  is  raised  or  not,  the  pulse-rate  is  often 
absolutely  slowed.  Herbert  French. 

RIGIDITY  OF  THE  ABDOMEN  is  a  sign  not  to  be  regarded  hghtly,  and 
one  to  find  the  true  significance  of  which  may  call  for  the  greatest  care  and  skill. 
The  patient  should  be  examined  Ijang  on  the  back  with  the  whole  of  the  abdomen 
and  lower  thorax  exposed.  The  observer,  seated  on  a  level  with  the  patient, 
should  watch  the  abdomen  for  a  minute  or  so  and  see  whether  it  moves  or  not 
with  respiration,  and  whether  one  part  moves  more  than  another. 

It  should  be  remembered  that  some  patients,  whether  from  modesty  or  timidity, 
hold  their  abdomens  intenselj^  rigid  in  a  wholly  unnecessarj^  waj^  a  tendency 
which  may  create  a  false  impression.  This  can  be  avoided  hy  engaging  them 
in  conversation  for  a  minute  or  two,  hy  asking  them  to  take  a  few  deep  breaths, 
or  by  making  them  draw  their  knees  up  and  keep  their  mouths  open,  when  the 
normal  abdominal  walls  will  general^  relax. 

There  are  varying  degrees  of  rigidity.  The  w-hole  abdomen  may  be  rigid, 
the  upper  or  lower  part  only,  or  one  side,  as  in  the  presence  of  a  locahzed 
appendicular  abscess.  Again,  one  part  or  one  rectus  muscle  maj^  be  put,  as  it 
is  termed,  "  on  guard,"  whenever  the  patient  thinks  a  tender  spot  is  about  to 
be  touched.     The  rigidity  over  an  inflamed  gall-bladder  is  an  instance  of  this. 

The  commonest  cause  of  rigidity  is  septic  infection  of  the  peritoneum,  which 
may  follow  external  wounds,  abdominal  operations,,  childbirth,  abortion, 
endometritis,  parametritis,  extension  of  inflammation  from  or  perforation  of  the 
appendix,  ulcer  of  the  stomach,  duodenum,  or  bowels,  perforation  of  the  gall- 
bladder, suppurating  Fallopian  tube,  or  abscess  of  the  Uver,  spleen  or  kidney. 
It  is  a  safe  rule  to  believe  there  is  peritonitis  until  the  contrary  is  proved. 
As  in  the  case  of  other  disease,  diagnosis  must  not  be  based  on  one  clinical 
sign,  and  the  patient  must  be  examined  for  the  other  signs  of  peritonitis. 

The  history  of  the  onset  is  important.  In  perforative  cases,  the  beginning 
is  marked  by  intense  abdominal  pain.  This  may  be  general  and  continuous, 
or  by  being  referred  to  the  stomach  or  appendix  region  give  an  indication  of 
the  seat  of  the  mischief.  The  position  taken  up  is  on  the  back,  sometimes 
with  the  knees  drawn  up  to  relieve  abdominal  tension,  and  the  patient 
generally  lies  still,  for  any  movement  causes  increase  of  pain.  In  colic,  on 
the  contrary,  whether  intestinal,  biliarj-,  or  renal,  the  patient  rolls  about 
during  the  spasms. 

It  is  painful  to  use  the  diaphragm  :  therefore,  respiration  is  superficial  and 
costal  in  type.  The  abdomen  gradually  becomes  distended,  tense,  and  tym- 
panitic ;  the  liver  dullness  which  was  previously  present  may  disappear,  and, 
in  some  forms  of  peritonitis,  fluid  may  accumulate  in  the  abdomen  and  be 
detected  by  the  signs  of  shifting  dullness  in  the  flanks.  The  pulse  is  small 
and  rapid,  loo  to  150,  and  has  the  tendency  to  quicken.  A  friction  rub 
may  be  heard  over  the  liver  or  the  spleen  when  the  patient  breathes. 
Borborygmi  will  generally  be  absent.  Vomiting  is  an  earh%  prominent,  and 
almost  constant  feature.  The  contents  of  the  stomach  are  ejected  first,  then 
bile-stained  fluid,  and  later  green  or  brownish  fluid  wdth  a  slight  f^cal  odour. 
The  vomiting  is  often  of  a  peculiar  "  pumping  "  character.  The  bowels  may 
be  loose  at  first,  and  then  constipation  follows,  but  is  not  complete,  as  in 
intestinal  obstruction.  Micturition  is  frequent  ;  occasionally  there  is  retention 
when  the  pelvic  peritoneum  is  acutel}^  inflamed.  WTien  the  disease  is  well 
developed,  the  appearance  of  the  patient  is  very  characteristic,  exhibiting  the 
"  Hippo cratic    facies."      In   this,   as    in    other    diseases,    successful    treatment 


RIGIDITY     OF     THE    ABDOMEN  645 

demands  early  diagnosis,  and  it  is  to  be  hoped  that  this  will  be  made  long  before 
the  clinical  picture  is  complete. 

Leucocytosis  as  a  Diagnostic  Sign.— In  suppurative  peritonitis  this  is  marked 
early,  and  is  almost  invariably  present  (15,000  to  30,000  per  c.mm.).  In  very 
severe  cases,  in  which  the  patient  is  rapidly  poisoned  by  the  quantity  and  viru- 
lence of  the  toxins,  and  is  not  reacting,  it  may  be  absent.  Here,  however,  the 
other  signs  of  peritonitis  will  be  well  marked. 

It  does  not  necessarily  follow,  because  the  whole  abdomen  is  rigid,  that  the 
peritonitis  is  general.  For  instance,  in  cases  of  perforative  appendicitis  it  has 
been  shown  by  operation  that  pus  was  only  to  be  found  around  the  ccecum, 
and  yet  there  was  general  rigidity.  Without  operating,  it  is  often  impossible 
to  tell.  The  best  way  of  finding  out  whether  there  is  pus  in  the  abdomen, 
and  the  method  to  be  employed  at  once  if  there  is  any  doubt,  is  to  open  the 
abdomen  and  see. 

Other  Conditions   associated  with  Abdominal  Rigidity  which 
may   be   mistaken  for  peritonitis. 

Pneumonia  or  Diaphragmatic  Pleurisy. — In  the  early  stages  here,  before  the 
onset  of  dullness  in  the  lungs  and  other  physical  signs  in  the  chest,  the  most 
prominent  features  may  be  abdominal  pain  and  rigidity.  Laparotomy  has 
often  been  perforraed  on  the  mistaken  diagnosis  of  peritonitis.  If,  however, 
the  examination  is  thorough,  signs  pointing  to  implication  of  the  lungs  will 
usually  be  found.  Rapidity  of  respiration,  working  of  the  nares,  and  blueness 
of  the  lips  should  receive  particular  attention.  Examination  of  the  blood  will 
often  reveal  a  high  leucocytosis  (30,000  to  40,000)  ;  in  suppurative  peritonitis 
the  numbers  are  rarely  so  high. 

Colic. — The  suddenness  of  the  onset  of  pain,  its  intense  character  and  the 
abdominal  rigidity,  may  render  this  condition  extremely  difficult  to  differentiate 
from  peritonitis  due  to  perforation  of  some  viscus.  Collapse  may  be  marked, 
and  the  effect  on  the  pulse  is  considerable  ;  vomiting  is  common  also.  The  tem- 
perature is  slightly  raised  but  rarely  exceeds  100°  F.,  and  the  pulse,  though  it 
may  be  rapid,  does  not  tend  to  quicken  progressively.  The  pain  is  spasmodic, 
not  continuous  as  in  peritonitis,  and  is  generally  relieved  in  a  few  hours.  Biliary 
and  renal  colic  are  fairly  characteristic,  but  that  due  to  lead,  the  crises  of  tabes 
dorsalis,  or  gastro-intestinal  disturbances  may  easily  be  mistaken.  The  gums 
are  to  be  examined  for  a  blue  line,  the  knee-jerks  and  pupils  tested,  and  a  blood- 
count  made.  In  uncomplicated  colic  there  is  no  leucocytosis.  In  cases  of 
extreme  difficulty  the  abdomen  may  have  to  be  opened.  The  persistence  of 
borborygmi  is  in  favour  of  colic  rather  than  of  general  peritonitis. 

Intestinal  Obstruction. — The  vomiting  and  constipation  here  present  may 
lead  one  to  think  of  peritonitis,  and  indeed  the  two  conditions  may  be  present 
at  the  same  time,  as  in  the  case  of  an  ulcerating  carcinoma  of  the  bowel.  Usually 
the  rigidity  is  not  well  marked,  and  the  constipation,  which  is  not  absolute  in 
peritonitis,  is  here  complete. 

Injuries   of  the  Abdomen. — 

1.  Contusion  of  the  abdominal  wall,  with  laceration  of  muscle  :  Particularly 
in  patients  who  have  been  run  over  across  the  abdomen,  rigidity  is  a  marked 
feature,  and  there  must  always  be  a  doubt  at  first  whether  any  of  the  viscera 
have  been  torn  and  are  bleeding,  or  whether  the  escape  of  their  contents  is 
setting  up  peritonitis.  In  the  case  of  mere  contusion,  if  the  patient  is  put  to  bed 
and  kept  warm,  collapse  will  soon  disappear,  the  abdomen  will  become  less 
rigid,  and  the  pulse-rate  will  fall. 

2.  Contusion  of  the  abdominal  wall  with  injury  of  viscera  :  The  signs  here 
will  be  more  marked,  and  instead  of  tending  to  diminish  rapidly  will  become 


646  RIGIDITY     OF     THE    ABDOMEN 

worse.  If  there  is  internal  bleeding,  the  mucous  surfaces  will  be  pale,  the  skin 
cold  and  clammy,  and  the  pulse  small  and  frequent.  If  the  contents  of  a  viscus 
have  escaped,  the  signs  of  peritonitis  will  develop  rapidly.  In  all  cases  of  doubt 
an  exploratory  laparotomy  should  not  be  delayed. 

Ruptured  Tubal  Gestation. — This  may  simulate  general  peritonitis.  The 
abdominal  rigidity  here  is  not  well  marked,  and  the  signs  of  bleeding  are.  A 
moderate  degree  of  leucocytosis  is  present  (10,000  to  15,000),  but  the  number 
of  red  cells  is  much  diminished.  If  the  patient  is  a  woman  of  the  child-bearing 
age,  is  known  to  be  a  week  or  more  overdue  as  to  monthl}^  period,  and  has  begun 
to  lose  blood  per  vaginam  synchronous^  with  the  onset  of  acute  abdominal 
pain  and  pallor,  the  diagnosis  will  suggest  itself  at  once. 

Acute  Hcsmorrhagic  Pancreatitis  is  usually  diagnosed  as  intestinal  obstruc- 
tion or  acute  perforative  peritonitis.  The  attack  sets  in  with  intense  pain, 
usually  in  the  upper  and  left  part  of  the  abdomen.  Vomiting,  constipation,  and 
tjonpanitic  distention  are  present.  The  condition  is  so  rare,  and  the  signs  are 
so  unreliable,  that  an  exploratory  laparotomy  should  be  made,  and  the  nature 
of  the  case  becomes  obvious  directly  the  characteristic  opaque  yellow  patches 
of  fat-necrosis  are  seen  in  the  omentum. 

Rupture  of  an  Abdominal  Aneurysm,  Dissecting  Aortic  Aneurysm,,  Embolism  of 
the  Superior  Mesenteric  Artery,  may  simulate  peritonitis,  and  so  also  may  Acute 
Thrombosis  of  the  Inferior  Vena  Cava ;  but  all  these  conditions  are  rare,  and 
they  will  be  very  difficult  of  diagnosis  unless  the  existence  of  some  cause  for 
them,  such  as  aortic  aneurysm  or  fungating  endocarditis,  is  already  known. 

Acute  Suppurative  Nephritis  sometimes  gives  abdominal  rigidity,  and  is 
associated  with  fever  and  vomiting.  There  is  always  marked  tenderness  in 
the  loin  on  the  affected  side,  and  the  urine  will  contain  albumin,  pus,  blood, 
casts,  and  bacteria.  Thq  milder  types  of  the  infection  (see  Bacteriuria)  may 
be  mistaken  for  acute  appendicitis,  or  for  general  peritonitis,  unless  the  cen- 
trifugalized  deposit  from  the  urine  is  examined  microscopically  for  pus. 

George  E.  Gask. 

RIGORS,  or  CHILLS,  are  common  at  the  onset  of  the  most  various  acute 
febrile  disorders,  and  may  occur  at  regular  or  irregular  intervals  in  the  course  of 
many  of  the  more  severe  of  them.  The  chief  sign  of  a  rigor  is  shivering,  the 
chief  S3^mptom  a  feeling  of  cold  and  general  wretchedness.  At  its  beginning,  the 
patient  looks  chilly,  pinched,  and  blue,  and  sits  or  lies  huddled  up,  complaining 
of  the  cold  ;  his  arteries  are  contracted,  the  pulse  is  rapid,  small,  and  of  raised 
tension ;  the  extremities  are  chilled  superficially,  but  the  internal  tempera- 
ture is  raised  above  the  normal.  Very  soon  the  sensation  of  cold  induces 
involuntarjr  shivering  to  correct  it ;  the  patient  shakes  all  over,  sometimes  so 
violently  that  the  chair  or  bed  is  thrown  into  noisy  vibration  ;  his  teeth  chatter, 
and  even  the  muscles  of  the  face  twitch  involuntarily.  This  shivering  lasts  for  a 
few  minutes,  or  even  for  an  hour,  gradually  dying  away  as  the  patient  feels 
himself  to  be  warmed  up.  Thus  the  initial  stage  of  the  fever  passes  into  the 
second  stage  or  fastigium,  in  which  the  complaint  is  of  sweating,  thirst,  and 
undue  heat,  and  the  body  temperature  rises  stiU  further.  In  children,  general 
convulsions,  Avith  partial  or  complete  loss  of  consciousness,  may  occur  at  the 
onset  of  an  acute  infection,  under  conditions  that  would  give  rise  to  a  rigor  in 
adults.  In  adults,  convulsions  are  not  known  to  take  the  place  of  rigors.  Cases 
may  arise,  however,  particularly  when  only  an  imperfect  histor}'-  can  be  obtained, 
in  which  it  may  be  hard  to  say  whether  a  patient  has  had  a  rigor,  or  an 
epileptiform,  hysterical,  or  epileptic  fit.  Should  the  patient  have  lost  con- 
sciousness during  the  shivering,  or  have  fallen  down,  bitten  his  tongue,  or 
passed  his  water  during  the  attack,  or  should  he  give  a  history  of  similar 
attacks  on  previous  occasions,  the  diagnosis  of  epilepsy  would  be  more  than 


RIGORS,     OR     CHILLS 


647 


probable.  Epileptiform  fits  that  unskilled  observers  might  confuse  with  rigors, 
may  occur  in  uraemic  or  eclamptic  patients  ;  the  history  of  the  case,  and  the 
discovery  of  albumin  in  the  patient's  water,  together  with  other  evidences  of 
acute  or  chronic  renal  disease,  should  make  the  diagnosis  clear.  Fits  indistin- 
guishable from  rigors  to  the  untrained  eye  may  occur  in  hysteria  ;  in  these, 
however,  the  shivering  patient  would  be  red  in  the  face,  or  at  least  would  not 
present  the  slightly  livid  and  shrunken  facial  appearance  characteristic  of  a 
rigor,  the  temperature  would  not  be  raised,  and  the  signs  or  a  history  of  other 
hysterical  phenomena  should  be  obtainable. 

For  their  further  consideration  it  is  convenient  to  classify  rigors  according  as 
they  are  single  or  multiple. 

I.  Single  Rigors. — The  occurrence  of  a  single  rigor  at  the  outset  of  an  acute 
infectious  disorder  is  extremely  common,  and  may  be  taken  as  evidence  of  the 
severity  of  the  infection  to  some  extent  ;  in  lobar  pneumonia  this  initial  rigor 
is  often  particularly  long  and  severe.  No  exhaustive  list  of  the  disorders  that 
may  be  thus  ushered  in  can  be  given  ;  but  it  may  be  generally  stated  that  an 
initial  rigor  is  common  in  : — 


Erysipelas 
Cerebrospinal  fever 
Acute  poliomyeUtis 


Malaria 
Yellow  fever 
Weil's  disease 


Lobar  pneumonia 

Small-pox 

Influenza 

Severe  feverish  colds 

Septicaemia 

Pyaemia 

Pneumonic  tuberculosis 

Typhus 

Relapsing  fever 

It  is  less  often  seen  in  : — 
Scarlet  fever 
Measles 
Diphtheria 
Tonsillitis 
Rheumatic  fever 
Tetanus 
Miliary  tuberculosis 

And  is  comparatively  rare  in  : — 
Enteric  fever 
German  measles 
Mumps 
Gout 
Anthrax 
Hydrophobia 

The  diagnosis  of  all  these  different  morbid  conditions  must  naturally  be  made 
from  the  history  of  exposure  to  infection,  and  from  the  subsequent  signs  and 
symptoms.  It  is  clear  that  the  occurrence  or  non-occurrence  of  an  initial 
rigor  will  rarely  be  of  much  practical  assistance  in  determining  the  nature  of 
the  disorder  from  which  any  given  patient  is  suffering. 

A  rigor  after  catheterization  is  not  rare,  whether  the  kidneys  be  sound  or 
no,  and  in  some  cases  is  due  to  septic  infection  of  the  urethra  or  bladder  by 
the  instrumentation.  In  others,  however,  it  ensues  when  no  infection  has 
taken  place,  and  is  not  followed  by  any  evidences  of  urinary  sepsis  ;  in  these 
instances  the  rigor  must  be  referred  vaguely  to  nervous  shock,  and  need  not 
give  rise  to  alarm. 


After  catheterization. 

Saprsmia 

Glanders 

Sick  headache 

Acute  gastro-intestinal  disorders 

Nephritis 

Cholelithiasis 

Renal  calculus. 

Cholera 
Plague 
Dysentery 
Malta  fever 
Beri-beri. 


RIGORS,     OR     CHILLS 


2.  A  Second  Rigor  coming  on  in  the  course  of  any  of  these  disorders,  or  a 
rigor  occurring  unexpectedly  for  the  first  time  when  the  disease  is  well  estab- 
lished or  declining,  is  often  evidence  of  the  spread  of  the  infection,  or  of  the 
occurrence  of  some  complication.  For  example,  a  second  rigor  occurring  in  the 
course  of  lobar  pneumonia  may  coincide  with  the  appearance  of  signs  indicating 
the  spread  of  the  disease  to  the  second  and  previously  sound  lung  ;  a  second 
rigor  happening  after  the  crisis  may  indicate  the  establishment  of  an  empyema. 
In  enteric  fever  a  second  rigor  may  be  due  to  such  complications  as  perforation  of 
the  intestine,  acute  peritonitis,  pleurisy,  pneumonia,  middle-ear  disease,  periostitis, 
and  so  forth.  But  it  must  be  remembered  that  there  is  an  abnormal  type  of 
enteric  fever  in  which  rigors  occur  for  no  apparent  reason,  followed  by  heavy 
sweats  ;  and  that  rigors  may  be  observed  in  cases  with  constipation,  or  during 
defervescence,  or  in  enteric  patients  who  have  been  treated  with  anti-pyretic 
drugs. 

3.  Recurring  Rigors. — The  occurrence  of  a  series  of  rigors  often  gives  infor- 
mation of  more  definite  value,  for  it  is  seen  in  but  a  comparatively  limited  number 
of  local  or  general  infections,  most  of  which  have  some  characteristic  or  localizing 
signs.  In  themselves,  these  rigors  are  no  more  than  evidence  of  the  severity  of 
the  infections  in  which  they  are  seen,  and  of  the  extent  to  which  bacterial  or 
other  toxins  have  been  absorbed  into  the  blood  and  have  upset  the  thermotactic 
centres.     The  following  are  the  chief  disorders  characterized  by  a  series  of  rigors  : 

Malaria  —  tertian,    quartan,    sestivo-autumnal    or    malignant    tertian,    and 

mixed  types 
Relapsing  fever 
Acute  leuksemia 
Acute  blood-infectiorip,  including  : — 

or  a    py       1       gpgcial    forms    of    which    may    be    known   as  puer- 
(~7  ,■  ■    \  \  peral  fever,  malignant  endocarditis,   acute  infective 

•^  .      ^ .  osteomyelitis,    suppurative    pylephlebitis,  etc. 

oepticsemia  \ 

Acute  inflammations,  such  as  : — 

Pyelitis  Cholecystitis 

Pyelonephritis  I     Empyema 

Cystitis  \  I     Infective  sinus  thrombosis. 

Abscess  formation  : — ■ 

Hepatic  (tropical  abscess)  Perinephric 

Appendicular  Prostatic 

Subphrenic  Cerebral. 

Pulmonary  tuberculosis  ;  bronchiectasis. 
Enteric  fever  ;    influenza. 
Erysipelas. 

It  is  neither  possible  nor  desirable  to  detail  the  diagnosis  of  all  these  dis- 
orders ;  but  it  may  be  pointed  out  that  a  very  thorough  physical  examination 
of  any  patient  presenting  multiple  rigors  should  be  made  ;  the  condition  is 
always  of  serious  import,  and  may  be  due  to  septic  absorption  from  some  deep- 
seated  abscess  that  produces  only  the  scantiest  of  physical  signs,  but  calls  out 
urgently  for  surgical  treatment.  When  no  abnormal  physical  signs  can  be  found, 
bacterial  cultures  should  be  made  from  the  circulating  blood,  care  being  taken 
to  draw  off  a  sufficient  quantity  of  blood — 5  to  10  c.cm. — and  to  repeat  the 
cultivation  several  times  before  it  is  decided  that  the  blood-stream  is  sterile. 

In  malaria  the  rigors  tend  to  recur  at  regular  intervals  of  forty-eight  or 
seventy-two    hours   in    the   benign  tertian  and  quartan   infections,  at  shorter 


RIGORS.     OR     CHILLS  649 


intervals  if  the  infection  is  mixed.  In  the  eestivo-autumnal  form,  the  rigors  and 
also  the  course  of  the  fever,  are  much  less  regular.  In  all  cases  of  malaria  the 
parasite  can  be  found  in  the  circulating  blood,  and  the  patient,  if  not  in  extremis, 
is  cured  by  quinine  :  there  is  no  leucocytosis,  but  a  relative  increase  in  large 
lymphocytes  occurs. 

In  relapsing  fever  the  onset  is  acute,  with  a  rigor  or  a  series  of  rigors.  A  fort- 
night later,  when  the  patient  has  been  convalescing  for  a  week  or  ten  days,  relapse 
and  a  second  rigor  or  series  of  rigors  occurs.  A  second  relapse  may  be  noted  at 
the  end  of  the  third  week,  and  in  a  very  few  cases  a  third  relapse.  To  all  intents 
and  purposes  relapsing  fever  has  died  out  of  the  United  Kingdom,  but  it  is  met 
with  in  Egypt,  India,  and  other  countries.  It  occurs  in  epidemics,  and  Ober- 
meier's  spirocheete  {Plate  XII,  Fig.  I)  can  be  found  in  the  patient's  blood 
while  he  is  feverish. 

Multiple  rigors  occur  exceptionally  in  the  course  of  acute  blood-diseases,  such 
as  acute  leukaemia,  pernicious  ana;mia,  or  Hodgkin's  disease.  Severe  and  pro- 
gressive anaemia,  wasting,  fever,  heavy  sweats,  and  ha2morrhage  from  the 
mucous  membranes,  are  likely  to  occur  in  these  cases,  with  characteristic 
changes  in   the  microscopical  appearances  presented   by   the   blood. 

Multiple  rigors  are  without  doubt  commonest  in  the  various  forms  of  acute 
blood-infections,  given  the  presence  of  bacteria  of  the  proper  degree  of  virulence 
in  the  blood-stream.  Special  forms  of  these  infections  have  received  particular 
names.  Thus  puerperal  fever  occurs  after  delivery,  and  is  due  to  bacterial 
infection  of  the  uterus  and  its  spread  thence  to  the  blood  ;  the  patient  will 
probably  have  a  sanious  or  offensive  vaginal  discharge  as  well  as  the  evidences 
of  septicaemia  or  pyaemia.  In  malignant  endocarditis ,  attention  is  mainly  directed 
to  the  condition  of  the  heart,  the  presence  of  valvular  murmurs,  the  detachment 
of  emboli  from  the  inflammatory  vegetations  on  the  heart-valves  and  their 
lodgement  in  various  peripheral  arterioles.  In  acute  infective  osteomyelitis  the 
first  complaint  arises  from  the  acute  inflammation  occurring  in  the  marrow  of 
one  of  the  bones.  Portal  pycBmia  or  suppurative  pylephlebitis,  is  seen  in  patients 
with  various  acute  inflammatory  intra-abdominal  lesions,  and  is  due  to  the 
spread  of  bacterial  infection  to  the  portal  vein.  The  commonest  precursor  is 
mild  appendicitis.  The  blood  in  the  portal  vein  clots,  the  clot  is  infected  with 
microbes,  softens,  and  breaks  up,  to  be  dispersed  throughout  the  liver  in  the 
form  of  infective  emboli.  Multiple  hepatic  abscesses  result,  with  pain,  swelling, 
and  tenderness  in  the  hepatic  region  ;  jaundice  is  present  in  less  than  half  the 
cases,  with  more  or  less  coloured  stools  ,  vomiting  and  diarrhoea  are  frequent,  and 
there  is  hectic  fever.  Pycemia  is  characterized  by  the  formation  of  abscesses — 
metastatic  abscesses — in  any  of  the  tissues  or  organs  of  the  body,  oftenest  in  the 
lungs,  in  consequence  of  the  lodgement  there  of  multiple  infected  emboli.  Before 
the  days  of  antiseptic  or  aseptic  surgery,  pyaemia  was  the  common  outcome  of 
serious  surgical  operations  or  severe  wounds.  Nowadays  it  is  comparatively 
infrequent,  and  when  it  does  occur  is  secondary  to  a  severe  infected  wound,  to 
ulcerations  of  the  mucous  surfaces,  or  to  deeply-seated  abscesses  that  are  not 
amenable  to  surgical  treatment.  Occasionally  it  seems  to  be  idiopathic,  or  due 
to  some  infective  lesion  that  escapes  discovery.  Pyaemia  oftenest  begins  sud- 
denly ;  the  main  symptoms  are  hectic  fever,  rigors,  leucocytosis,  diarrhoea  and 
vomiting,  heavy  sweats,  prostration,  and  the  formation  of  secondary  abscesses 
due  to  the  arrest  of  septic  emboli.  When  the  lungs  become  the  seat  of  multiple 
abscesses,  the  breathing  becomes  rapid,  and  signs  of  bronchitis,  pleurisy,  or 
pulmonary  consolidation  appear.  Abscesses  in  the  more  superficial  tissues  or 
joints  make  their  presence  known  by  the  local  evidences  of  pain,  swelling,  redness, 
and  heat  ;  in  the  deeper  parts  or  organs,  by  pain  and  disturbance  of  function. 
The  development  of  secondary  subcutaneous  abscesses  is  common  in  the  less 


650  RIGORS,     OR     CHILLS 

acute  cases  ;  abscess-formation  in  the  heart,  and  suppurative  pericarditis,  are 
prone  to  occur  when  the  primary  lesion  is  a  periostitis  or  an  acute  necrosis  of 
bone.  Pyaemia  may  be  distinguished  from  enteric  fever  onh'  with  great  dif&cultj-, 
if  evidences  of  abscess-formation  or  some  source  of  primary  infection  are  not 
forthcoming,  especially  as  the  typhoid  state  is  common  in  the  later  stages  of 
both  diseases  ;  the  occurrence  of  multiple  rigors  is  rare  in  enteric  fever,  common 
in  pyaemia,  and  Widal's  reaction  should  be  of  assistance  here.  From  malaria, 
pyaemia  is  distinguished  bj^  not  reacting  to  quinine  ;  malarial  parasites  will  not 
be  found  in  the  circulating  blood.  Pain  and  inflammation  in  the  joints  after 
childbirth  or  a  miscarriage  may  be  diagnosed  as  rheumatism  when  the  condition 
is  really  one  of  pyaemia  or  puerperal  fever. 

The  precise  diagnosis  between  pyaemia  and  septicaemia  is  often  impossible, 
and  is,  indeed,  of  academic  rather  than  clinical  interest.  The  necessity-  for  it  is 
in  part  avoided  by  the  use  of  the  term  septicopycsmia,  the  evidences  of  which 
are  much  the  same  as  those  of  pyaemia  :  all  three  conditions  ma}^  arise  from 
identical  causes,  and  bacteria  (streptococci,  staphylococci,  gonococci,  pneumo- 
cocci,  B.  coli  communis,  B.  typhosus,  B.  influenzcs,  B.  pyocyaneus,  etc.),  may  be 
cultivated  from  the  circulating  blood  in  anjr  of  them.  Multiple  rigors  are  far 
commoner  in  pyaemia — where  several  may  occur  daily — than  thej^  are  in  septicas- 
mia.  Septiccemia,  the  disease  due  to  the  growth  of  microbes  in  the  blood  without 
the  formation  of  metastaticabscesses,  originates  in  lesions  very  similar  to  those 
that  underlie  p^^aemia,  or  resrirEs~froni  infected  but  apparently  trifling  cuts  or 
injuries,  or  even  from  neglected  chronic  suppuration  about  the  teeth.  Its  main 
symptoms  are  fever,  debilit5^  anaemia  ;  in  severe  cases  rigors  occur,  and  the 
patient  may  fall  into  the  typhoid  state.  The  bacteria  causing  it  can  be  cultivated 
from  the  circulating  blood  ;  septic  rashes  are  often  seen  in  both  pyaemia  and 
septicaemia,  but  they  are  not  seen  in  enteric  fever.  It  should  be  noted  that,  at 
the  best,  a  deal  of  looseness  attaches  to  the  meaning  of  the  term  septicaemia  ; 
for  in  lobar  pneumonia,  enteric  fever,  Malta  fever,  and  many  other  acute  febrile 
disorders,  the  specific  microbes  can  habituallj^  be  cultivated  from  the  circulating 
blood.  Technically  speaking,  therefore,  these  are  all  instances  of  septicaemia. 
Two  new  terms  have  recently  come  into  vogue  in  this  connection,  namely, 
bacillcsmia  and  hactericBmia. 

Multiple  rigors  occur  in  a  number  of  acute  inflammatory  infections  localised 
in  various  parts  or  organs  of  the  body,  provided  that  the  inflammation 
is  sufficiently  extensive  and  the  infecting  micro-organism  of  a  sufficiently 
virulent  type.  It  is  often  impossible  to  say  how  far  such  rigors  are  evidence 
of  the  absorption  of  toxins,  and  how  far  they  indicate  that  hving  bacteria  have 
gained  access  to  the  blood-stream.  Situated  in  the  genito-urinary  tract, 
these  inflammations  are  often  associated  with  a  history  of  gonorrhoea,  renal 
calculus,  or  gout,  and  produce  characteristic  pathological  changes  (haematuria, 
pyuria,  albuminuria)  in  the  urine,  or  difficulties  in  mictrurition.  If  the  gall- 
bladder or  bile-ducts  are  the  seat  of  the  inflammation,  jaundice  and  pain  in  the 
hepatic  region  will  probably  be  observed  with  the  fever  and  rigors,  and  a  history 
of  gall-stone  colic  may  be  given  ;  Charcot's  hepatic  intermittent  fever  is  due  to 
chronic  cholangitis,  with  intermittent  biliary  obstruction  due  to  a  baU-valve 
stone  often  lying  in  the  ampulla  of  Vater.  The  occurrence  of  rigors  in  a  child 
convalescing  from  pneumonia,  measles,  scarlet  fever,  or  pleurisy,  ma^^  lead  to  the 
discov-er\^  of  an  unsuspected  empyema.  Infective  sinus  thrombosis  character- 
istically occurs  in  patients  with  chronic  or  intermittent  otorrhoea,  and  indicates 
that  the  bacterial  infection  has  spread  from  the  ear  to  one  of  the  cranial  venous 
sinuses.  Its  symptoms  are  general — those  of  septicaemia  or  pyaemia,  often  with 
an  initial  rigor  and  vomiting  followed  by  high  iexer,  more  rigors  (Fig.  165, 
p.  613),  and  sweating — and  local.     The  local  symptoms  are  very  severe  pain 


RISUS     SARDONICUS  651 


about  the  ear,  excruciating  headache,  and  venous  congestion  of  the  optic  disc, 
with  others  that  vary  with  the  site  of  the  thrombosis.  If  the  sigmoid  sinus 
is  thrombosed,  oedema  and  tenderness  over  the  mastoid  appear,  and  should  the 
clotting  spread  downwards  a  thrombus  may  be  felt  in  the  internal  jugular  vein. 
Thrombosis  of  the  cavernous  sinus  is  accompanied  by  squint,  exophthalmos, 
and  oedema  of  the  orbits  and  eyelids.  Thrombosis  of  the  superior  longitudinal 
sinus  may  set  up  oedema  of  the  scalp  near  the  sagittal  suture.  The  diagnosis 
must  be  made  from  cerebral  or  cerebellar  abscess,  in  which  repeated  vomiting 
is  likely  to  occur,  and  the  localizing  signs  and  symptoms  will  suggest  brain- 
disease  ;  and  from  meningitis,  in  which  rigors  are  rare.  In  other  patients, 
some  acute  inflammatory  disorder  may  result  in  definite  abscess  formation, 
when  rigors  may  develop  from  toxic  or  septic  absorption  ;  here  again,  the 
virulence  of  the  particular  microbe  causing  the  inflammation  will  be  the  chief 
factor  in  determining  whether  rigors  occur  or  not.  In  many  cases  the  rigors 
will  really  be  due  to  a  secondary  and  probably  terminal  septicaemia  or  pyaemia. 

Tropical  abscess  of  the  liver,  usually  single,  occurs  in  patients  who  have  been 
abroad  and  have  had  dysentery,  whether  amoebic  or  bacterial.  The  early 
symptoms  of  liver  abscess  are  often  obscure,  malaise,  fever,  sweating,  rigors, 
and  gastro-intestinal  disturbances  occurring,  or  a  pleural  efl:usion  secondary  to 
spread  of  infection  through  the  diaphragm,  while  nothing  particularly  suggests 
implication  of  the  liver.  As  a  rule,  complaint  of  dull  pain  in  the  right  hypochon- 
drium,  axilla,  or  shoulder  will  be  made  ;  if  the  abscess  is  at  all  large,  absolute 
increase  in  the  size  of  the  liver-dullness  will  be  found,  particularly  in  an  upward 
direction  and  to  the  right,  the  liver  will  be  somewhat  tender,  and  the  patient  will 
prefer  to  lie  on  the  right  side.  Slight  jaundice  is  frequently  observed.  The 
diagnosis  from  infective  cholangitis  must  be  made,  where  jaundice  is  more 
marked  and  often  intermittent,  and  enlargement  of  the  gall-bladder  can  be 
made  out. 

The  diagnosis  of  the  other  forms  of  abscess  mentioned  in  the  list  given  above 
must  be  made  on  general  lines,  and  will  not  be  further  considered  here. 

Multiple  rigors  may  occur  from  septic  absorption  in  various  diseases  of  the 
lungs,  the  most  important  of  which  are  bronchiectasis,  and  advanced  pulmonary 
tuberculosis,  with  secondary  pyogenic  infection  of  the  bronchi  or  tuberculous 
cavities.  In  either  case  the  sputum  will  be  abundant,  and  will  probably  contain 
fragments  of  elastic  tissue  ;   it  is  sure  to  be  offensive  in  bronchiectasis. 

High  or  irregular  fever  with  recurring  rigors  has  been  recorded  in  a  few 
unusual  cases  of  enteric  fever  and  of  influenza  free  from  any  complication. 

A.  J.  J  ex-Blake. 
RINGWORM. — (See  Fungous  Affections  of  the  Skin.) 

RISUS  SARDONICUS. — The  term  risus  sardonicus  is  used  to  denote  the  fixed 
unmirthful  grin  that  results  from  spasm  of  the  muscles  of  both  sides  of  the 
face.  The  angles  of  the  mouth  are  drawn  outwards  and  the  eyelids  are  raised 
by  tonic  contraction  of  the  same  muscles  that  produce  the  facial  expression  of 
smiling,  but  the  spasm  is  maintained  in  a  way  that  at  once  excludes  natural 
smiling.  The  chief  causes  of  the  condition  are  tetanus,  strychnine  poisoning, 
malingering,  hysteria,  catalepsy. 

Catalepsy. — The  differential  diagnosis  is  not,  as  a  rule,  difficult.  A  cataleptic 
case  is  chronic  ;  the  facies  is  by  no  means  always  that  of  smiling,  but  if  it  should 
be,  then  the  smile  is  a  fixed  one  ;  the  chief  characteristic  of  the  condition  is  the 
maintenance  for  hours  at  a  stretch  of  some  attitude  that  would  rapidly  fatigue 
an  ordinary  person  ;  the  history  and  the  associated  mental  symptoms  of 
melancholia  or  dementia  would  point  to  the  diagnosis,  and  tetanus  and  strychnine 
poisoning  would  be  excluded  by  the  absence  of  tetanic  spasms. 


652  RISUS     SARDONICUS 


Hysteria  sometimes  takes  a  form  that  may  for  a  while  raise  doubts  as  to 
strychnine  having  been  taken,  but,  as  a  rule,  the  multiformity  of  the  contortions 
points  to  the  correct  diagnosis.  The  features  may  be  kept  fixed  for  a  time,  but 
sooner  or  later  they  become  twisted  into  all  sorts  of  shapes,  and  the  tonic  and 
clonic  spasms  of  the  bodj'  and  linibs  are  not  in  any  way  regular,  as  they  are  apt 
to  be  in  str3xhnine  poisoning  and  tetanus.  The  patient  is  hkeh'  to  be  a  woman, 
and  there  may  be  a  history  of  previous  hysteria.  During  a  quiescent  interval 
it  may  be  found  possible  to  stroke  or  touch  the  patient  without  bringing  on  a 
convulsion,  whereas  in  str3'chnine  poisoning  and  in  tetanus  the  slightest  touch 
is  apt  to  evoke  a  violent  and  generalized  spasm,  even  opisthotonos. 

Malingering  may  take  the  form  of  imitated  convulsions,  during  which  the 
features  may  be  kept  fixed  in  one  position  or  another,  sometimes  in  that  of 
smiling.  The  fixed  voluntarj'  contractions  cannot  be  long  maintained,  hoAvever. 
on  account  of  fatigue,  so  that  although  there  may  be  some  doubt  at  first,  this 
generally  disappears  soon.  The  patient  is  generally  a  man  who  has  something 
to  gain  by  malingering  :   a  night's  lodging  in  a  hospital,  for  instance. 

Strychnine  Poisoning  and  Tetanus  are  the  two  chief  causes  of  t\^ical  risus 
sardonicus.  The  main  point  to  rely  on  in  distinguishing  the  two  is  the  history, 
if  it  is  obtainable^-the Jjij ection  of  an  overdose  of  strychnine  h^-podermically, 
or  the  taking  of  a  rat-paste^  on  the  one  hand,  or  the  occurrence  of  some  small 
but  penetrating  wound  by  a  rusty  nail  or  earth-soiled  knife  or  stick  during  the 
fortnight  preceding  the  symptoms,  on  the  other.  The  absence  of  any  known 
wound,  however,  does  not  exclude  tetanus.  If  lock-jaw  and  stiffness  of 
the  neck  are  prominent  features,  tetanus  is  more  probable  than  strychnine 
poisoning,  and  vice  versa.  In  strychnine  cases,  the  patient  wiU  either  die  quickly, 
or  the  symptoms  will  rapidly  subside,  whereas  in  tetanus  they  may  persist 
unabated  for  several  days.  In  a  few  instances  the  diagnosis  may  onh'  be  settled 
by  the  discovery  of  strychnine  in  the  gastric  contents,  or  of  tetanus  bacilli 
(Plate  XII,  Fig.   T)  in  anaerobic  cultivations  from  the  infected  wound. 

It  onlv  remains  to  add  that  a  few  cases  of  facial  sclerodernita  may  simulate 
risus  sardonicus,  though  more  often  there  is  complete  smoothness  of  the  features 
and  lack  of  expression.  There  are  no  spasmodic  contractions,  the  condition 
comes  on  gradually,  is  permanent,  and  the  diagnosis  becomes  obvious  at  once 
when  the  hard  smooth  skin  is  palpated,  for  one  cannot  pick  it  up  between 
one's  fingers.  Herbert  French. 

'    RUMINATION.— (See  Merycism.) 

RUPIA.— (See  Scabs.) 

SALIVATION,  UNDUE.— (See  Ptyalism.) 

SAND,  INTESTINAL. — This  is  seen  in  the  motions,  especially  when  they  are 
fluid,  of  some  sufierers  from  membranous  colitis.  It  is  like  the  finest  sea-sand  ; 
its  colour  varies  owing  to  varj'ing  degrees  of  imbibition  of  faecal  pigment. 
Usualh'  it  is  red,  looking  something  like  fine  uric  acid,  and  it  varies  from 
this  to  a  pale  dirty  ^^ellow.  It  is  seen  best  showing  up  against  the  white 
of  the  bed-pan  in  which  it  lies.  Analysis  shows  that  it  consists  of  from 
30  to  70  per  cent  of  organic  matter,  doubtless  all  derived  from  the  faeces.  The 
inorganic  matter  is  invariably  nearly  all  calcium  phosphate,  with  traces  of 
calcium  oxalate,  magnesium,  iron,  and  perhaps  silica.  The  amount  of  sand 
passed  in  a  day  may  be  four  teaspoonfuls,  but  usualh'  it  is  much  less.  Many 
patients  pass  it  for  years,  but  not  always  constanth-  even  then  ;  it  may  be 
passed  daily  for  weeks,  and  then  for  weeks  none  is  passed.  It  is  far  commoner 
in  those  who  have  membranous  colitis  than  in  other  patients,  but  it  has  been 


/'LATE    IX. 


Fii  A. 
True  Intestinal  Sand 


Fig.  B. 

False  Intestinal  Sand,  consisting  of  sclerenchynnatous 
particles  of  pears. 


RtpToduad by  kind ptrmisiim  of  Ihi  Aulhirr, 
atUrJthr  Royal SocUljr of  MeJUinc. 


SCABS  6.53 

seen  with  malignant  disease  of  the  large  intestine  ;  it  always  indicates  some 
organic  disease  of  the  colon.  It  must  be  distinguished  from  false  intestinal 
sand,  which  looks  very  like  it  and  may  be  found  in  the  motions  of  those  who 
have  eaten  largely  of  pears.  This  is  entirely  vegetable,  and  can  be  distinguished 
easily  from  true  intestinal  sand  by  microscopical  examination  [Plate  IX). 

W.  Hale  White. 

SCABS. — The  scab,  or  crust,  one  of  the  secondary  cutaneous  lesions,  is  a 
more  or  less  irregular,  dried-up  mass  of  exudation  on  the  surface  of  the  skin. 
It  may  be  produced  by  the  desiccation  of  serum,  pus,  or  blood,  or  of  a 
mixture  of  these  fluids,  and  commingling  with  these  substances  there  may 
be  epithelial  debris,  or  fat,  or  fungous  elements.  Scabs  form  on  matured 
vesicles,  bullee  and  pustules,  on  ulcerations,  erosions,  and  on  every  kind  of 
excoriation,  pathological  or  traumatic.  If  the  exudation  is  thin,  as  some- 
times in  eczema,  they  are  soft  and  friable,  and  soon  eliminated  ;  if  it  is 
thick,  they  may  be  tougher  and  raore  adherent,  and  successive  layers  may  be 
formed,  as  in  the  rupial  crusts  of  syphilis.  Scabs  composed  largely  of  fungous 
elements  are  more  or  less  friable,  and  these,  like  those  resulting  from  the 
seborrhoeic  process,  may  partake  of  the  character  of  scales  as  well  as  of  scabs. 
Such  formations,  however,  as  for  example  the  "  crusts  "  of  favus,  are  in  the 
nature  of  scales  rather  than  of  scabs,  and  are  noticed  elsewhere.  (See  Scaly 
Eruptions  ;    and  Fungous  Affections   of  the  Skin.) 

Scabs  vary  greatly,  not  only  in  consistence,  thickness,  and  adhesiveness,  but 
also  in  colour  and  in  form  ;  and  by  attention  to  these  differences  the  diagnosis 
of  the  affections  in  which  they  occur  may  be  assisted.  Some  guidance  may 
also  be  obtained  from  the  condition  of  the  surface  from  which  the  scab  has 
been  removed  ;  it  may  be  dry  when  the  scab  has  been  long  adherent,  as  in 
some  cases  of  impetigo,  excoriated  as  in  eczema,  or  ulcerated  as  in  rupia.  But 
the  chnician  will  be  guided  much  more  by  the  primary  than  by  any  secondary 
lesion  ;  and  for  the  decisive  diagnostic  features  of  the  diseases  about  to  be 
mentioned,  the  reader  is  referred  to  the  articles  Macules  ;  Vesicles  ;  Bull^  ; 
Papules  ;    Nodules  ;    and  Pustules. 

In  irritative  herpes  the  vesicles  on  the  skin  shrivel  up  and  form  yellowish- 
brown  crusts,  which  after  a  few  days  become  detached,  as  a  rule  leaving  no  scar, 
but  only  a  brownish  stain,  which  slowly  fades  away.  In  herpes  zoster  most  of 
the  vesicles  which  do  not  abort,  reach  the  same  termination  ;  but  others,  instead 
of  drying  up,  may  burst  and  discharge  a  fluid,  which  then  forms  yellowish 
or  brownish  crusts.  In  zoster  a  scar  is  sometimes  produced.  In  erythema, 
multiforme  there  is  often  considerable  scabbing,  as  is  mentioned  under  Vesicles. 
In  eczema  the  lesions  may  dry  up  either  into  scales  (see  under  Scaly  Erup- 
tions) or  into  crusts.  Crustation  is  usually  the  third  stage  in  the  evolution  of 
the  disease,  the  discharge  from  the  vesicles  drying  into  greyish-yellow  scabs  of 
varying  thickness,  which  become  detached  and  are  succeeded  by  others  until 
the  "weeping"  ceases.  When  the  lips  are  attacked,  they  may  become  so 
stiffened  under  layers  of  crusts  superimposed  one  upon  another  that  the  patient 
can  hardly  move  his  lips  without  fissuring  the  skin.  In  the  male,  the  "  bathing- 
drawers  "  area  may  be  so  covered  with  crusts  that  the  patient  cannot  walk  or 
sit  down  without  breaking  them.  In  the  same  region  in  the  female  the  inflam- 
mation and  crustation  may  be  even  more  severe,  and  the  scabs  may  be  marked 
by  much  foulness.  One  of  the  characteristic  features  of  what  is  called  papular 
eczema  is  the  appearance  of  a  tiny  dome  of  blood-crust  on  the  papules,  due  to 
scratching.  In  seborrhoeic  eczema  there  may  either  be  scaUng,  or  the  sq  names 
may  be  massed  into  fatty  crusts  (see  Scaly  Eruptions).  The  scabs  in  eczema 
rubrum  are  extremely  thin,  like  goldbeater's  skin  ;  when  they  are  torn  off,  a  red, 
wet,  raw,  tender  surface  is  laid  bare.     The  crusts  of  scabies  may  be  distinguished 


654  SCABS 

from  those  of  eczema  by  their  being  isolated  and  distributed  irregularly,  instead 
of  being  grouped,  and  by  the  multiformitj^  of  the  lesions  with  which  they  are 
mixed — vesicles,  bullae,  pustules,  hsemorrhagic  scabs,  etc.  In  most  itching 
diseases  there  wiU  be  found  blood-scabs,  resulting  from  the  scratching  to  which 
the  patient  is  provoked. 

In  cheiropompholyx  the  bulls  into  which  the  httle  sago-grain  vesicles  run, 
dry  up  into  crusts,  the  removal  of  which  reveals  a  surface  that  is  red  and 
exquisitely  tender.  The  appearance  and  sensitiveness  of  the  underlying  skin, 
together  with  the  hmitation  to  the  hands  and  feet,  and  often  to  the  hands  alone, 
will  help  the  diagnosis.  The  crusts  of  sycosis  vulgaris  also  have  a  hmited 
distribution  ;  thej'  niay  be  confined  to  the  upper  hp,  and  in  any  case  thej^  do 
noJL  extead^JjeyeBti  the  hairy  parts  of  the  face.  They  are  brown  or  yellow  in 
colour,  thin,  and  distinctly  adherent. 

In  impetigo  contagiosa  (Tilburj-  Fox)  the  scabs  which  are  formed  from  the  dried- 
up  fluid  discharged  by  the  pustules  on  rupture  are  ^^ellowish  ;  in  uncleanly 
persons  they  are  brown,  or  even  black.  A  characteristic  feature  is  that  they 
have  around  them  no  hj^eraemic  halo,  but  look  as  if  they  might  have  been  stuck 
on  artificially.  In  the  severe  form  of  the  disease  stjded  ecthjTna,  however,  the 
flat  irregular  scab  formed  from  the  ruptured  vesicles  is  surrounded  by  a  more 
or  less  pronounced  areola.  At  first  loosely  attached,  the  scabs  in  impetigo 
contagiosa  afterwards  become  so  firmly  adherent  that  their  removal  requires 
some  force  and  gives  rise  to  a  httle  bleeding.  In  this  afiection  there  is  what 
ma}'  be  called  a  secondary  scab,  formed  hy  the  drjdng-up  of  the  thick,  purulent 
discharge — honey-hke  in  consistence  and  appearance — from  the  surface  left 
raw  by  the  removal  of  the  earUer  crusts.  The  reddish  stain  that  appears  when 
the  lesion  heals  is  not  permanent.  In  pemphigus  vulgaris  the  crusts  into  which 
the  bullae  shrink  are  brownish-j^ellow  ;  and  when  they  fall  ofi  spontaneously, 
the  surface  beneath  is  not  raw,  as  in  impetigo,  but  is  found  to  be  covered  with 
newly-formed  epidermis,  at  first  purple,  but  afterwards  turning  brown,  and 
gradually  becoming  normal  in  colour.  When  the  area  covered  by  the  scabs 
is  extensive,  there  is  an  unpleasant  sense  of  tension,  and  if  the}^  are  removed 
prematurely,  excoriation  may  be  caused.  In  the  more  serious  affection  known 
as  pemphigus  foliaceus,  the  crusts  are  3'eUowish,  and  as  the  disease  proceeds, 
large  scales  are  formed.  In  pemphigus  vegetans  the  foul-smelling  secretion  from 
the  patches  of  affected  skin  forms  a  thin  crust,  which  can  easily  be  stripped  off, 
when  a  papillarj'  excrescence,  partly  covered  Avith  a  thin  stratum  of  epidermis, 
is  revealed.  The  process  usually  ends  in  gangrene  and  death.  The  excrescences 
are  distinguishable  from  the  condA-lomata  of  syphilis  by  always  being  surrounded 
by  a  zone  of  bullae,  while  condylomata  have  an  infiltrated  border. 

In  nerve  leprosy  the  buUae,  which  have  the  same  characters  as  those  of 
pemphigus  vulgaris,  form,  on  rupture,  a  large  crust,  the  removal  of  which 
exposes  a  grey  surface  consisting  of  altered  rete,  the  epidermis  being  cast  off 
by  suppuration.  In  this  wa}^  a  succession  of  yellow  scabs  or  crusts  may  be 
formed  and  fall  off,  leaving  at  last  a  granulating  surface,  which  ultimately  is 
converted  into  a  white  scar.  If  the  bullee  abort,  they  are  followed  by  a  parch- 
ment-hke  scale  instead  of  a  crust,  and  this  in  turn  gives  place  to  a  h^^peraesthetic 
ulcer.  The  scabs  of  nerve  leprosy  have  some  resemblance  to  the  rupial  crusts 
of  secondary  SA'phihs,  but  there  is  little  danger  of  confusion  between  the  two. 
The  rupial  crusts,  greenish  or  blackish,  consist  of  several  successive  layers,  each 
one  smaller  than  the  one  immediately  below  it,  so  that  a  pj'ramidal  structure 
is  formed,  somewhat  resembling  the  shell  of  a  hmpet.  This  very  characteristic 
crust,  which  can  scarcely  be  mistaken  for  that  of  any  other  condition,  and  is 
distinguishable  from  the  psoriasis  rupioides  of  M'Call  Anderson  by  the  base  being 
ulcerated,  usuaU\'  is  formed  from  pustules,  but  may  follow  also  on  the  drying  up 


SCALY     ERUPTIONS  655 


of  bullae.  The  scabs  in  secondary  yaws  form  upon  the  yellow  heads  of  large 
papules,  and  beneath  them  are  found  reddish  raspberry-like  granulations  which 
secrete  a  little  pus,  and  after  a  time  become  pale  or  even  white.  Healing  usually 
takes  place  beneath  the  scabs,  which  fall  off  about  the  end  of  the  second  month 
from  the  onset  of  the  secondary  rash.  The  raspberry-like  granulations,  the 
characteristic  lesion  of  j'aws,  will  obviate  confusion  between  these  crusts  and 
those  of  any  other  affection.  The  crusts  of  lupus  vulgaris  are  greenish-black, 
like  rupial  crusts,  but  they  do  not  consist  of  layers  superimposed  upon  each 
other,  and  dotted  around  the  ragged  edge  will  be  seen  the  "  apple- jelly  "  nodules 
which  are  the  "  note  "  of  lupus. 

In  small-pox  the  formation  of  scabs  on  the  pustules  begins  in  the  centre  and 
causes  a  secondary  "  umbilication  "  ;  it  is  generally  attended  by  intense  itching. 
In  from  three  to  four  weeks  from  their  appearance  the  crusts  fall  off,  leaving 
a  reddened  surface,  made  uneven  by  scars  or  "  pits."  The  true  nature  of  the 
disease  will  have  been  discovered,  even  in  doubtful  cases,  before  the  crust  stage 
is  reached.  (For  the  differential  diagnosis,  see  under  Pustules.)  In  the 
diagnosis  of  ulcers,  as  in  that  of  small-pox,  the  crust  is  of  little  importance. 
These  are  dealt  with  under  Ulceration  of  the  Face  and  Ulceration  of 
THE   Foot.  Malcolm   Morris. 

SCALY  ERUPTIONS. — The  squame,  or  scale,  one  of  the  secondary  cutaneous 
lesions,  is  a  dry,  and  as  a  rule  laminated,  exfoliation  of  the  epidermis.  Dis- 
regarding the  slight,  imperceptible  desquamation  which  is  a  purely  physiological 
process,  scales  may  be  said  to  result  either  from  inflammation,  as  in  psoriasis 
and  pityriasis  rubra  pilaris  ;  from  an  abnormal  dryness  of  the  skin,  as  in  dry 
seborrhoea  and  keratosis  pilaris ;  or  from  an  earlier  acute  hyperaemia,  as  in 
scarlatina  and  other  erythematous  eruptions.  The  process  may  consist  in  an 
over-multiplication  of  the  epidermic  cells  or  in  interference  with  the  normal 
horny  transformation.  In  colour,  scales  are  ordinarily  white  or  grey,  either 
dull  and  lustreless,  as  in  seborrhoea,  or  silvery,  as  in  psoriasis  ;  but  they  are 
sometimes  a  dirty  yellow,  as  in  some  dry  syphilides,  or  even  reddish-brown, 
as  in  oily  seborrhoea.  They  may  be  large  and  thin,  as  in  pityriasis  rubra,  or 
small  and  branny,  as  in  tinea  versicolor  ;  even  in  the  same  affection  (e.g., 
pityriasis  rubra)  they  may  vary  greatly  in  size  in  different  regions.  They  may 
consist  of  a  single  layer,  as  in  squamous  eczema,  or  of  several  adherent  strata, 
as  in  psoriasis.  In  quantity  they  may  be  inconsiderable,  as  in  tinea  versicolor, 
or  most  profuse,  as  in  psoriasis  and  pityriasis  rubra.  Usually  they  are  dry  and 
friable,  but  if  mixed  with  an  oily  secretion,  as  in  seborrhoea,  or  with  a  serous 
or  seropurulent  discharge,  as  in  eczema,  they  may  partake  of  the  nature  of 
both  scales  and  crusts. 

A  brief  description  of  the  scales  met  with  in  various  affections  may  be  given 
here ;  but  except  in  a  few  diseases  of  which  they  form  a  highly  characteristic 
manifestation,  such  as  seborrhoea,  psoriasis,  and  pityriasis  rubra,  they  have 
little  diagnostic  value,  and,  as  I  have  said  elsewhere  of  scabs,  diagnosis  must 
usuallj'  rest  upon  primary  rather  than  upon  secondary  lesions. 

Sometimes  there  is  scale-formation  in  eruptions  due  to  the  internal  adminis- 
tration of  such  drugs  as  quinine  or  belladonna,  or  to  the  external  application 
of  carbolic  acid,  iodine,  etc. ;  but  it  has  no  significance  in  diagnosis.  In  keratosis 
pilaris  (xeroderma)  and  other  forms  of  ichthyosis,  there  is  always  more  or  less 
desquamation  of  the  dry  and  roughened  and  sometimes  warty  skin ;  but  here 
also  it  is  without  diagnostic  import.  Of  the  scales  of  scarlet  fever,  measles, 
German  measles,  and  other  infectious  fevers,  again,  nothing  need  be  said,  for  the 
diagnosis  ought  to  have  been  settled  before  they  appear.  Nor  need  I  speak  of 
the  scaliness  of  tinea  tonsurans,  tinea  versicolor,  and  other  fungous  affections. 


G56  SCALY     ERUPTIONS 


for  the  differential  diagnosis  of  these  diseases  has  been  given  under  Fungous 
Diseases.  The  scales  of  papular  syphilides,  again,  have  been  described  under 
Papules,  and  the  diagnosis  of  the  lesions,  both  primary  and  secondary,  from 
those  of  psoriasis  will  be  found  in  that  article.  In  the  unusual  instances  of 
urticaria  in  which  desquamation  is  present,  it  is  so  slight  as  to  be  negligible. 
In  most  forms  of  erythema,  scales  occur  ;  but  here  again  they  have  little 
significance  for  the  diagnostician,  and  it  will  be  sufficient  to  say  that  in  erythema 
simplex  the  desquamation  is  slight,  and  that  in  erythema  scarlatiniforme  it  is 
more  considerable.  In  lupus  erythematosus  the  central  scar-like  depression 
of  the  primary  eruptive  lesions  may  be  covered  either  with  thin,  papery,  greyish 
»^^r-or  with-a-^mly^dherent  scab.  In  parts  furnished  with  sebaceous  glands, 
the  skin  will  usually  be  covered  with  small  adherent  scales  of  sebum,  which 
at  the  margin  of  the  patch  plug  the  dilated  orifices  of  the  glands,  so  that  numerous 
comedones  are  formed.  From  other  forms  of  erythema,  as  also  from  ringworm, 
lupus  erythematosus  may  be  distinguished  b}^  the  slowness  and  persistence 
of  the  process.  The  lesion  itself,  atrophic  in  the  centre,  with  a  well-defined 
red  border,  and  studded  with  plugs,  can  scarcely  be  mistaken  when  it  appears 
on  its  site  of  election,  the  face.  When,  however,  it  occurs  on  the  hands,  it  may 
mimic  chilblains  so  closely  that  only  the  lapse  of  time  can  make  the  diagnosis 
certain,  lupus  erj^thematosus  being  much  more  obdurate  to  treatment,  and  not 
disappearing  in  the  summer.  For  the  diagnosis  between  lupus  erythematosus 
and  psoriasis,  see  below  ;  for  that  between  lupus  erythematosus  and  lupus 
vulgaris,  see  under  Nodules. 

We  now  come  to  affections  in  which  scales  play  a  more  important  part.  In 
seborrhcea  sicca,  there  is  an  excess  of  the  solid  fatty  constituents  of  the  sebum, 
and  the  excreted  material  takes  the  form  of  scaly  but  usually  somewhat  greasy 
masses.  In  seborrhcea  oleosa  there  is  an  abnormal  predominance  of  the  oily 
part  of  the  sebaceous  secretion,  which  dries  into  yeUoAvish  or  reddish-brown 
cakes  of  greasy  scales,  often  with  a  hyperaemic  base  and  a  fringe  of  papules 
about  the  edge.  In  the  face,  oily  seborrhoea  is  more  often  met  with  than  the 
dry  form  ;  but  seborrhoea  generally,  though  it  may  occur  on  the  trunk  and 
limbs,  almost  invariably  begins  on  the  scalp.  When  not  hmited  to  the  scalp, 
as  usually  it  is,  it  spreads  downwards  to  the  face,  round  the  neck,  the  chest,  the 
centre  of  the  back,  and  the  limbs.  In  the  hght  of  this  preference  for  the  scalp, 
and  the  downward  extension  when  the  affection  is  not  confined  to  that  part, 
a  typical  case  of  seborrhoea  is  unmistakeable.  In  cases  of  seborrhoea  which 
resemble  psoriasis,  guidance  may  be  found  in  the  scales,  which  in  the  latter  affec- 
tion are  silvery,  and  harder.  The  respective  starting-points  of  the  eruptions, 
however,  furnish  a  safer  indication,  psoriasis  almost  always  appearing  first  on 
the  elbows  and  knees  and  spreading  upwards. 

In  typical  eczema^  scaling  forms  the  final  stage  of  the  pathological  process. 
After  the  initial  erythema  comes  the  exudation,  then  the  crustation  (see 
Scabs),  next  the  dry  stage,  and  lastly  the  desquamation,  the  epidermis  being 
shed  in  scales  that  become  progressively  thinner  and  smaller  until  only  a 
brownish  stain  is  left  to  mark  the  site.  All  the  stages,  as  need  hardly  be  said, 
are  often  present  at  once  in  a  given  case.  Scaling  is  frequently  a  noticeable 
feature  when  there  is  a  predominance  of  erythematous  lesions,  as  it  is  also  in 
eczema  folliculorum.  But  it  is  in  seborrhceic  eczema  that  this  phenomenon  is 
most  prominent,  the  latent  catarrh  with  which  the  affection  begins  being  followed 
by  the  agglutination  of  epidermic  scales  which  are  thrown  off  in  the  form  of 
large  lamelte.  In  some  cases  the  scales  may  increase  in  quantity,  in  others, 
as  is  mentioned  under  Scabs,  they  may  become  massed  into  fatty  crusts  among 
the  hairs.  The  differential  diagnosis  of  eczema  has  been  set  out  in  the  articles 
on  the  primary  lesions.     The  secondary  lesions  in  this  affection  may  indeed 


SCALY     ERUPTIONS  657 


be  rather  a  hindrance  than  a  help  in  determining  its  true  nature,  and  in  doubtful 
cases  the  first  thing  to  do  is  to  remove  both  scales  and  crusts  in  order  that  the 
underlying  lesion  may  be  carefully  examined.  As  between  eczema  and  psoriasis, 
however,  just  as  between  eczema  and  seborrhoea,  the  scales  afford  guidance  in 
the  diagnosis.  While  in  psoriasis  the  lower  layers  of  scales  are  whitish  or 
silvery  and  hard,  in  eczema  they  are  yellowish,  dull  and  friable. 

In  this  affection,  psoriasis,  the  scale  has  distinct  diagnostic  value.  It  enters, 
indeed,  into  the  definition  of  the  disease  as  an  affection  of  the  skin,  charac- 
terized by  flat,  dry  patches  of  varying  extent,  covered 'with  whitish,  silver- 
grey,  or  asbestos-like  scales.  The  scaliness  may  vary  from  a  thin  film  to 
a  dense,  heaped-up  mass.  If  the  scales  are  removed,  a  smooth,  shining 
hyperjemic  surface  is  seen,  studded  with  spots  that  show  various  gradations 
of  colour,  from  a  deep  to  a  bright  red,  the  bright-red  points  being  the  tops  of 
inflamed  papillae.  The  eruption  appears  as  papules  of  pin-head  size,  at  first 
red,  but  becoming  white  as  the  scales  form.  Spreading  centrifugally,  the 
papules  form  patches,  generally  roundish  or  oval  when  small,  and  becoming 
more  irregular  as  they  grow  larger.  They  may  remain  stationary  for  a  long 
time,  and  slowly  disappear,  or,  continuing  to  spread,  may  become  confluent. 
While  the  disease  is  active  the  individual  patch  is  encircled  by  a  narrow  zone 
of  redness,  but  when  it  is  not  spreading  this  fades  away.  Sooner  or  later 
involution  takes  place,  and  the  redness  which  the  lesions  leave  behind  them 
soon  disappears,  though  in  protracted  cases  a  brown  stain  may  persist,  and 
in  rare  instances  there  may  be  superficial  atrophy.  In  distribution,  psoriasis 
is  almost  invariably  symmetrical.  Like  small-pox,  it  shows  a  marked  predilec- 
tion for  surfaces  that  are  exposed  to  friction.  Almost  alwaj^s  it  starts  on  the 
tips  of  the  elbows  and  the  fronts  of  the  knees.  After  the  extensor  aspects  of 
the  limbs,  its  favourite  site  is  the  hairy  scalp,  and  then  the  trunk,  especially 
over  the  lumbar  region.  In  typical  cases  the  clinical  picture — the  patches  with 
sharply  defined  border,  covered  with  hard,  shiny  scales  ;  the  hypersemic  surface 
beneath,  dotted  with  red  points  ;  the  distribution  as  just  described  ;  the  unim- 
paired health,  the  natural  complexion,  the  proneness  to  attack  blue-eyed  fair- 
haired  persons,  and  the  absence  of  exudation — scarcely  admit  of  misinterpreta- 
tion. In  all  these  particulars,  except  the  unimpaired  health,  psoriasis  differs 
from  eczema,  as  well  as  in  the  less  intense  and  less  constant  itching  by  which  it  is 
attended.  On  the  scalp,  while  psoriasis  usually  occurs  in  patches  and  ends 
abruptly  at  or  only  just  beyond  the  margin  of  the  hair,  seborrhoeic  eczema 
almost  invariably  extends  over  the  whole  surface,  and  often  involves  the  face 
and  the  neck.  Almost  always,  too,  psoriasis  spreads  upwards  from  its  sites  of 
election,  seborrhoeic  eczema  downwards  from  the  head.  In  very  chronic  forms 
of  eczema,  in  which  there  may  be  no  history  of  "  weeping,"  the  diagnosis 
from  psoriasis  may  be  difficult.  In  all  doubtful  instances,  gentle  scratching 
on  the  affected  surface  will  bring  out  the  silvery  scales,  if  the  case  is  one 
of  psoriasis. 

In  the  papular  stage  of  lichen  planus,  that  affection  may  in  some  cases 
be  mistaken  for  psoriasis.  In  lichen  planus,  however,  the  eruption  shows  a 
preference  for  the  flexor  aspects  of  the  wrists  and  knees  ;  it  consists  of  shining- 
smooth  papules,  while  scales  are  absent  ;  the  ground-tint,  so  to  speak,  is  bluish 
red  or  violet  ;  and  the  patches  are  formed  by  the  aggregation  of  a  number  of 
papules  instead  of  by  centrifugal  extension.  In  doubtful  cases  the  whole  body 
must  be  searched  for  the  typical  lesions  of  either  disease. 

Lupus  erythematosus  differs  from  psoriasis  in  that,  in  the  former  condition, 

the  scales    are    not   abundant,  the   edge  of   the   patch  is  more   elevated,   the 

cheeks  are  usually  attacked,  as  they  are   not  in   psoriasis,  and   there   are   the 

distinctive   plugs   in    the    orifices   of   the    sebaceous   ducts,  as  described  earlier 

D  42 


65  S  SCALY     ERUPTIOXS 


in  this  article.  Scarring,  too,  may  be  found  in  the  patch,  and  there  may  be 
atrophjr  of  the  ears. 

As  between  psoriasis  and  papular  syphilides,  the  diagnosis  is  given  under 
Papules.  The  heaped-up  crusts  of  the  condition  which  has  been  styled  psoriasis 
rupioides  can  be  distinguished  from  the  rupial  lesions  of  syphihs  by  the  base 
being  ulcerated  in  the  latter  disease  ;  but  s\-philis  mimics  everything,  and  cases 
sometimes  occur  in  which  it  can  onlj^  be  distinguished  even  from  so  distinctive 
an  affection  as  psoriasis  by  attention  to  the  history,  and  hy  the  discovery  of 
other  lesions,  the  presence  of  cachexia,  the  influence  of  iodides  and  mercury,  or 
bv  the  Wassermann  serum  test. 

In  pityriasis  rubra  the  whole  cutaneous  surface  is  always  inflamed  and 
reddened,  wdthout  infiltration  or  thickening,  but  accompanied  by  profuse  des- 
quamation {Plate  X),  branm^  on  the  head,  shed  in  larger  flakes  from  the  trunk, 
and  from  the  hands  and  feet  in  huge  scales.  Pit5Tiasis  rubra  may  occur  as  an 
independent  disease — an  extremeh^  rare  ev-ent — or  may  follow  in  the  wake  of 


ervthema  multiforme,  eczema,  psoriasis,  lichen  pIanuB7"dermaHtis  herpetitormis, 
and  certain  drug  eruptions.  Its  most  frequent  precursor  is  psoriasis.  The  con- 
stant and  profuse  desquamation,  the  papery  scales  and  sheets  in  which  the 
epidermis  is  shed,  are  important  diagnostic  signs  ;  others  are  the  vivid  redness 
of  the  eruption,  the  rapidity  with  which  it  is  diflused,  its  universahty,  the  serious 
impairment  of  health — sometimes  issuing  in  death — which  it  produces,  and  the 
frequent  absence  of  itching.  From  eczema  it  is  distinguished  hy  the  absence 
of  exudation  and  of  crusts  ;  from  psoriasis  b}'  its  rapid  spread  and  universal 
diffusion  ;  from  pemphigus  fohaceus  by  the  absence  of  loose  buUse  and  of  foul- 
smelling  discharge,  the  less  severe  general  symptoms,  and  the  greater  amena- 
bihtj^  to  treatment  ;  from  hchen  ruber  planus  by  the  absence  of  papules,  as 
well  as  by  its  rapid  extension  and  involvement  of  the  whole  area  of  the  body. 

The  essential  lesions  of  pityriasis  rosea  are  patches  or  circles,  very  slightly 
raised  and  thinly  covered  with  small  scales.  The  eruption  usually  first  shows 
itself  on  the  abdomen,  though  it  may  begin  on  the  chest,  the  face,  or  the  arms.  It 
spreads  less  rapidly  than  pityriasis  rubra,  but  in  two  or  three  weeks  the  trunk, 
the  face,  and  the  hmbs  may  be  covered,  and  though  occasionally  it  is  universal, 
it  seldom  extends  below  the  elbow  or  the  knee.  The  diagnosis  is  seldom  in 
doubt,  the  characteristic  "  herald  patch  "  with  which  the  rash  begins,  the  pale- 
red  tint,  the  sUght  elevation  of  the  patches,  the  minghng  of  maculate  and 
circinate  lesions,  the  shght  degree  of  scaHness,  and  the  spontaneous  involution, 
forming  a  distinctive  ensemble.  The  differences  it  presents  from  pityriasis  rubra 
have  been  indicated.  From  psoriasis  it  is  differentiated  by  its  less  inflammatory 
character,  the  more  rapid  onset,  the  slight  scaliness,  its  neglect  of  the  situations 
most  vulnerable  to  psoriasitic  attack,  and  the  absence  of  hypersemic  spots  on 
the  surface  beneath  the  scales.  From  seborrhoea  corporis,  by  the  dryness  of  the 
scales,  its  much  less  chronic  character,  the  lesions  disappearing  spontaneously 
in  a  few  weeks.  From  tinea  circinata,  by  the  large  number  and  wide  distribu- 
tion of  the  lesions,  and  the  absence  of  the  fungus  which  is  the  cause  of  cutaneous 
ringworm.  From  the  maculo-papular  sj-phihde,  b}-  the  absence  of  infiltration, 
the  lighter  colour,  the  fact  that  the  palms  of  the  hands  are  usually  spared,  and 
the  lack  of  concomitant  syphihtic  signs. 

Pityriasis  rubra  pilaris  may  appear  in  the  form  of  scaly  patches,  resembUng 
psoriasis,  on  the  palms  and  soles,  or  as  a  dry  eruption,  covered  with  eczematous- 
looking  crusts  ;  but  the  papule  which  soon  appears  is  a  more  characteristic 
lesion,  and  the  diagnosis  of  the  condition  from  psoriasis  and  other  affections 
will  be  found  under  Papules.  Malcolm   Morris. 


SCOTOMATA. — (See  Vision,  Defects  of.) 


PL  A  TE     X. 


PITYRIASIS       RUBRA 


^^^ 


From  "  Diseases  of  the  Skin" 

by  kind  permission  of  Sir  Alalcolm  JlforHs,  K.C.V.O. 


INDEX     OF     DIAGNOSIS 


SENSATION,     SOME    ABNORMALITIES     OF 


659 


SENSATION,  SOME  ABNORMALITIES  OF.— The  abnormalities  of  sensa- 
tion which  we  meet  with  in  disease  are  as  numerous  as  they  are  important  for 
the  purpose  of  diagnosis.  Under  Pain  in  the  Face  ;  Pain  in  the  Upper 
Extremity;  and  Pain  in  the  Lower  Extremity,  the  question  of  subjective 


I  Great  occipital,  poM.  branch 
{  of  second  cervical 
Auriclllo. 


divisions  of  spinal  nerve, 
of  Wrisberg 
Lateral  branches  of  intercostal 

Int  cutaneous  of  musculo-spiral 
neous  of  musculo-spiral 
cutaneous 
Internal  < 
-Iliac  branch  of  ilio-inguinal 
Second  lumbar 
Radial 
Ulnar 

Median 
Inf.  ha:innrrlioi<l.nl  .-ind 
.inperficial  perineal  of  piidit 
I'udendal  of  small  sciatic 

Inferior  gluteal 
ternal  cutaneous 


Posterior  tibial 


^'S'-  174- — 'J-"he   Distribution   of   Sensory   Nerves   in   the    Skin. 


pain  in  relationship  to  diagnosis  has  been  discussed,  and  in  the  second  of  these 
articles  some  reference  will  be  found  to  another  subjective  abnormality  of 
sensation,  to  which  the  term  "  acroparassthesia  "  is  applied. 


66o 


SENSATION,     SOME    ABNORMALITIES     OF 


In  the  present  paper  we  shall  have  to  deal  first  of  all  with  the  common  forms 
of  sensory  loss,  and  their  significance  in  clinical  work.  Wherever  sensory  loss 
occurs,  it  should  afford  some  assistance  in  forming  a  conclusion  as  to  the  site  of 
disease,  even  if  it  does  not  indicate  clearly  anything  with  regard  to  its  nature. 
In  order  that  the  sensory  loss  may  give  the  necessary  information  as  to  the 
site  of  disease,  it  is  absolutely  necessary  that  the  physician  should  ascertain  both 
the  limit  and  the  nature  of  the  loss.  He  will  be  able  to  judge  from  the  shape 
and  locality  of  the  anaesthetic  area,  whether  it  conforms  to  a  lesion  of  a  peripheral 
nerve,  a  spinal  root,  or  sonae  part  of  the  central  nervous  system.  An  analysis 
of  the  sensory  loss — that  is  to  say,  an  examination  directed  to  show  whether 
the  loss  is  uniform  to  all  forms  of  sensory  stinauli,  or  whether  it  is  limited  to 
one  or  two  forms  only — will  provide  additionaLiaionnation  tofThe^urpose  of 
diagnosing  the  situation  of  the  lesiojU"-"^ 

In  order  to  utilize  the  information  provided  by  the  shape  and  size  of  the  area 

of  anaesthesia,  it  is  necessary  to 
know  what  are  the  areas  on  the 
surface  of  the  body  which  corres- 
pond to  the  distribution  of  peri- 
pheral nerves  on  the  one  hand, 
and  of  spinal  segments  or  spinal 
roots  on  the  other.  The  accom- 
panying diagrams  (Fig.  174  and 
Plate  XI)  supply  this  information 
to  some  extent,  but  in  order  that 
it  ma}^  be  used  to  the  best  advan- 
tage, it  is  necessary  to  say  a  few 
words  about  various  forms  of 
sensory  loss  due  to  lesions  in 
different  parts  of  the  nervous 
system. 

Before  entering  upon  this  part 
of  the  subject,  we  may  interpose 
an  explanation  of  the  way  in 
which  we  propose  to  use  the  terms 
anaesthesia,  analgesia,  and  thermo- 
anassthesia. 

AncBsthesia  will  be  used  to 
denote  impairment  or  loss  of  the 
cutaneous  sensibility  to  cotton- 
wool touch,  and  it  is  important 
to  remember  that  parts  which 
are  hairless  should  be  chosen  when  an  accurate  examination  is  being  made. 

Analgesia  refers  to  impairment  or  loss  of  pain-sense,  the  adjective  "  superficial  " 
being  applied  when  the  surface  pain  produced  by  the  prick  of  a  pin  is  interfered 
with,  and  the  adjective  "  deep  "  when  the  pain  usually  associated  with  pinching 
or  squeezing  the  muscles  and  deeper  tissues  is  no  longer  appreciated. 

Thermo-ancssthesia  indicates  loss  of  appreciation  of  heat  and  cold  ;  but  as  we 
shall  see  later,  the  inability  to  distinguish  between  things  which  are  warm  and 
cool  is  not  always  associated  with  equal  loss  of  sensibility  in  distinguishing 
between  objects  which  are  ice-cold  and  really  hot. 

Disturbances  of  Sensation  in  Peripheral  Nerve  Lesions.— It  was  shown  by 
Head  and  Rivers  that  the  afferent  mechanism  of  the  peripheral  nervous  system 
consists  of  the  following  three  sub-systems  : — 

I.  Deep  Sensibility. — This  conveys  impulses  excited  by  pressure  and  by  all 


^'^g'/  175-  —  Peripheral  neuritis.  "Glove  and 
stocking  anaesthesia."  Cotton-wool  and  pinprick 
sensibility  impaired  or  lost  over  the  dotted  areas. 
This  is  associated  with  hyperalgesia  of  the  under- 
Ij'ing  muscles. 


SENSATION,     SOME     ABNORMALITIES     OF  66i 

movements  of  joints,  tendons,  and  muscles.  Painful  impulses  derived  from 
excessive  pressure  are  also  carried  by  this  sub-system.  By  its  means  a  healthy 
person  is  not  only  able  to  recognize  movements  of  joints,  but  also  the  locality 
of  the  stimulus  and  the  direction  of  the  movement.  The  fibres  which  conduct 
these  sensory  impulses  run  mainly  with  the  muscular  nerves,  and  are  not  destroyed 
by  division  of  the  sensory  nerv'es  to  the  skin. 

2.  Protopathic  Sensibility. — This  sub-system  responds  to  painful  cutaneous 
stimuli  (pin-pricks)  and  to  the  more  extreme  degrees  of  heat  and  cold.  The 
appreciation  of  these  stimuli  is  vague  and  inexact  as  to  the  locality  of  the  spot 
stimulated. 

3.  Epicritic  Sensibility. — To  this  sub-system  is  due  the  power  of  perceiving 
and  locating  light  touches  (cotton-wool),  of  discriminating  between  two  points 
applied  simultaneously  to  the  surface,  and  of  recognizing  the  finer  grades  of 
temperature  called  cool  and  warm. 

It  has  been  shown  that  when  a  peripheral  cutaneous  nerve  is  divided  the  area 
of  epicritic  loss  is  greater  than  that  of  protopathic  loss  ;  in  other  words,  there  is 
more  overlapping  of  protopathic  sensibility  than  of  epicritic  sensibility  between 
neighbouring  nerve  distributions.  Thus,  if  the  ulnar  nerve  is  divided  near 
the  wrist,  there  is  complete  loss  to 
touch,  superficial  pain,  heat,  and 
cold,  over  an  area  including  the  little 
linger  and  part  of  the  inner  edge  of 
the  palm  of  the  hand.  This  is  the 
area  of  epicritic  and  protopathic 
loss.  But  epicritic  loss  extends 
over  a  wide  area  which  includes 
half  the  ring  finger  and  more  of 
the  hand.  In  this  area  of  epicritic 
loss    pain     can    be    recognized    but 

cannot    be     localized    exactly,     while  f;^.  176.— Division  of  ulnar  nerve  at  the  wrist. 

light   touch    is   not    appreciated,    and  The   dark    area    represents    loss   of   epicritic    and 

^                                              i-ir                    J  protopathic    sensibility.       J  he    hne    indicates    the 

the    discrimination   between    cool   and  limits  of  epicritic  loss.     (After  Head  and  Shcry-en.) 

warm  is  absent. 

A  consideration  of  the  above  points  shows  how  important  it  is  to  define 
accurately  the  exact  nature  of  any  sensory  loss,  and  to  be  careful  that  the 
appreciation  of  pressure  is  not  mistaken  for  the  appreciation  of  light  touch. 
If  tactile  sensibility  is  tested  by  means  of  the  observer's  finger  or  by  the  head 
of  a  pin,  the  results  will  be  vitiated,  because  pressure  sensibility  is  at  once  brought 
into  action. 

Another  diagnostic  point  of  importance  depends  on  the  fact  that  protopathic 
sensibility  returns  some  months  before  epicritic  sensibility  in  the  process  of 
regeneration  after  the  division  of  a  peripheral  nerve.  During  the  stage  of 
protopathic  repair  there  is  often  a  considerable  degree  of  hyperalgesia  in  the 
affected  area  ;  that  is  to  say,  the  pain  produced  by  a  pin-prick  or  a  scratch  is 
out  of  all  proportion  to  the  nature  of  the  stimulus. 

So  far  we  have  dealt  with  the  disturbance  of  sensibility  produced  by  the 
disease  or  injury  of  a  single  nerve.  In  the  disease  known  as  peripheral  neuritis 
the  sensory  disturbances  are  very  characteristic,  and  consist  of  pain,  tingling, 
tenderness,  and  cutaneous  anaesthesia.  Spontaneous  pain  in  the  limbs  is  often 
complained  of,  but  more  important  is  the  intense  suffering  produced  by  move- 
ments, and  especially  by  handling  the  limbs  or  by  squeezing  the  muscles.  At 
the  same  time  cotton-wool  touch  is  often  unperceived  on  the  peripheral  parts 
of  the  limbs,  particularly  in  what  are  known  as  the  glove  and  stocking  areas. 
This  combination  of  deep  hyperalgesia  and  cutaneous  anaesthesia   constitutes 


662 


SEXSATIOX.     SOME    ABNORMALITIES     OF 


an  important  differential  sign  between  some  cases  of  peripheral  neuritis  and 
cases  of  tabes  dorsalis,  in  which  superficial  and  deep  analgesia  are  nearly  always 
associated. 

Disturbances  of  Sensation  in  Lesions  of  the  Cord. — Head  and  Thompson  have 
shown  that  the  inipulses~~of~4^he  three  peripheral  sub-systems — deep,  epicritic, 
and  protopatliic — combine  in  ne\v^-^oups  soon  after  they  enter  the  spinal  cord. 
Some  impulses  cross  to  the  opposite  si'de-immediately,  others  cross  after  running 
a  short  course  on  the  same  side,  and  other§--ascend  to  the  upper  extremity  of 
the  cord  entirely  on  the  side  of  their  entry .  ^^^i^his  rearrangement  mav  be 
summarized  briefly  thus  : — 

1.  Impulses  of  pain,  whether  excited  by  cutaneous  stimuli  or  by  excessi\'e 
pressure,  run  together  in  the  spinal  cord,  and  cross,  probably  soon,  to  the 
opposite  side. 

2.  Impulses  of  temperature   of    all  degrees   cross    to   the    opposite    side    and 
are   closely   associated,    but   not   inter- 
mingled,    -with     those     of    pain ;      the 
impulses   of    heat    are    also    separated 
from  those  of  cold. 

3.  Impulses  excited  by  light  touch 
and  by  pressure,  and  those  which  sub- 
serve their  localization,  accompany  each 
other,  cross  to  the  opposite  side,  prob- 
ably less  rapidly  than  those  of  pain  and 
temperature,  and  ascend  in  a  path 
which  is  distinct  from  that  of  the  latter. 

4.  Impulses  subserving  the  senses  of 
passive  position  and  movement  are 
associated  with  those  of  tactile  dis- 
crimination (compass  points)  in  their 
ascent  of  the  cord  on  the  same  side  as 
their  entrj^.  These  impulses  pass  up 
the  posterior  columns. 

The  accompanying  diagram  represents 
this  rearrangement  of  impulses  and 
their  course  in  the  spinal  cord  : — 


s  ■«  •§  " 

73      ~;    S    .0     § 


o"  -2  12  I  -^ 
s  b>  ft  ~  .g 


tl 


S3  -e    . 


{Pressure  and  its  localization. 

Deeo  J-P^«s«"''«  ^'="''- 

^'  i  Movements  of  muscles,  joints  and 
(  tendons,  Cheir  extent  and  directioiiT' 


(Tactile  Discrimination.- 


Epicritic.  -{Light  touch  and  its  localization. ' 

{Temperatures  {Ss'-M'C.)  

Tj     . .,•     {Temperatures  (fielow  20° and  above  is°C.)- 


Peripheral. 
(.Nerves) 

fig.  177. — Diagram  illustrating  the  course  of  the  sensory  impulses  passing  from  the  peripheral 
nerves  into  the  spinal  cord,     (from  the  author's  article  in  Osier's  ^/oilern  Medicine,  vol.  vii.) 


The  chief  points  of  practical  importance  in  clinical  work  to  be  deducted  from 
the  above  considerations  are  as  follows  :  In  the  first  place,  analgesia  resulting 
from  a  cord  lesion  always  includes  deep  as  well  as  superficial  pain,  and  so  differs 
from  the  analgesia  produced  by  a  peripheral  nerve  lesion  in  which,  as  we  have 


PLA  TE     XI. 

DIAGRAM       SHOWING       THE       RADICULAR       SENSORY      AREAS 
OF      THE       HUMAN       BODY. 


'—0234^ 


Copyright. 


By  D?-.   E.  Fa7-quhar  Buzzard. 


This  diagram  has  been  compiled  by  the  writer  from  a  study  of  similar  diagrams  published  by 
others,  and  modified  in  accordance  with  his  own  experience. 

Although  the  various  areas  depicted  in  the  diagram  are  essentially  Root  Areas,  the  information 
they  supply  can  be  used  clinically  for  the  purpose  of  localizing  both  radicular  and  intramedullary  lesions. 
It  must  be  remembered,  however,  that  the  deductions  in  the  one  case  are  different  from  those  in  the 
other.  If,  for  instance,  the  character  of  the  sensory  change  in  one  of  these  areas  is  of  the  peripheral 
type,  a  radicular  lesion  of  the  corresponding  segmental  level  may  be  diagnosed  ;  if,  on  the  other  hand, 
the  sensory  loss  is  of  the  central  type  in  a  particular  skin  area,  the  spinal  lesion  must  be  sought  at  a  level 
several  segments  higher  than  that  which  corresponds  to  the  sensory  area. 

For  practical  purposes  it  is  important  to  remember  that  the  uppermost  level  of  sensory  change  (not 
the  upper  level  of  total  analgesia)  should  be  compared  with  the  nearest  corresponding  line  on  this  diagram. 

If  employed  with  an  intelligent  appreciation  of  these  points  the  diagram  is  of  much  clinical 
importance,  but  it  should  not  be  exploited  blindly  as  a  mechanical  calculator.  Individual  variations 
alone  are  sufficient  to  demand  a  considerable  margin  of  error. 


INDEX     OF     DIAGNOSIS 


SENSATION.     SOME     ABNORMALITIES     OF 


663 


seen,  superficial  analgesia  may  be  associated  with  deep  hyperalgesia.      In  the 

second   place,    a    lesion    of    the    spinal    cord    may 

abolish  the  appreciation  of  thermal  stimuli,  but,  if 

it  does  so,  the   discrimination  between  all  degrees 

of  heat  and    cold   will   be   lost.     This  again  differs 

from  the  effect  of  some  peripheral  lesions.     In  the 

third  place,  a  lesion  of  the  posterior  columns  may 

produce  loss  of  the  sense  of  passive   position   and 

movement  without  any  loss  of  tactile,  painful,  or 

thermal    stimuli,    a    combination    which    does    not 

obtain    as    the    result   of    a    lesion    limited    to    the 

peripheral  nervous  system. 

In  all  diseases  or  injuries  of  the  spinal  cord,  the 
degree  of  sensory  loss  depends,  of  course,  upon  the 
severity  of  the  lesion.  On  the  other  hand,  the 
distribution  of  the  sensory  loss  is  of  the  greatest 
importance  for  the  diagnosis  of  the  level  of  the 
lesion.  The  distribution  must  be  mapped  out  care- 
full}^,  and  then  compared  with  the  accompanying 
diagram  {Plate  XI),  which  shows  the  sensory  areas 
corresponding  to  the  different  spinal  segments. 

In  a  case  of  myelitis,  for  instance,  it  may  be 
found  that  sensation  is  perfect  above  the  level  of 
the  umbilicus,  and  impaired  on  the  trunk  and  legs 
below  that  level  {Fig.  179).  We  shall  be  justified 
in  concluding  that  the  highest  point  of  the  disease 
corresponds  to  the  gth  dorsal  segment  of  the  cord. 
Take  another  example :    fracture   dislocation  of  the 

vertebrae  is  common  in  the  cervical  region,  and  may  crush  the  spinal  cord  at 
the  level  of  the  7th  cervical  segment.  The  resulting  sensor}'  loss  is  repre- 
sented in  the  accompanjdng  chart  {Fig.   180). 


Fig.  178. — Comminuted  frac- 
ture of  the  sacrum,  with  injury 
to  the  3rd,  4th,  and  5th  sacral 
roots.  Complete  loss  of  sensi- 
bility to  touch,  superficial  pain, 
heat  and  cold. 


/■Vy.  179.  —  Dorsal  myelitis  affecting  the  cord 
as  high  as  the  gth  dorsal  segment.  The  shaded 
parts  are  insensitive  to  touch,  deep  and  super- 
ficial pain,  and  all  degrees  of  temperature. 


Fig^.  180. — Fracture-dislocation  of  the  cervical 
spine.  The  shaded  area  represents  the  loss  of 
sensibility  to  touch,  pain,  heat  and  cold. 


664 


SENSATION,     SOME    ABNORMALITIES     OF 


In  testing  the  sensibility  of  the  skin,  it  is  ahvays  advisable  to  work  from  the 
anaesthetic  area  towards  the  normal,  and  to  note  not  only  complete  anaesthesia, 
but  all  modifications  of  sensation.  For  instance,  bordering  on  the  region  of 
complete  anaesthesia  there  ma}-  be  an  area  in  which  the  patient  is  able  to 
appreciate  a  touch  or  a  pin- prick,  but  in  which  he  describes  the  sensation 
produced  as  differing  from  the  natural  sensation  elicited  by  these  stimuli.  Such 
modifications  should  be  taken  into  account  in  diagnosing  the  level  of  the  lesion. 
As  a  result  of  disease  or  injury  of  one  side  oTTEhe--spinal__cord,  a  symptom- 
complex  called  Brown-Seqiiard  paralysis  is  met  with.  This  includes  loss  of 
sensibility  in  parts  of  the  body  on  the  opposite  side  to  that  of  the  lesion,  and  at 

a  lower  level.  The  sensor}^  loss,  is 
often  of  a  dissociative  tj^pe,  that  is 
to  say,  tactile  sensibihty  is  pre- 
served while  painful  and  thermal 
sensibility  is  lost.  Fig.  i8i  illus- 
trates the  sensor}-  loss  in  a  case  of 
this  kind. 

Syritigomyelia  and  hczmatomyelia 
are  other  conditions  in  which  dis- 
sociative anaesthesia  is  common  [Fig. 
182).  In  the  former  disease  thermo- 
anjesthesia  and  analgesia  are  usually 
found  first  in  the  upper  extremities 
and  thorax,  and  they  tend  to 
spread  all  over  the  body.  In  rare 
instances  thej-  commence  in  the 
lower  extremities  or  on  the  face. 
Their  distribution  is  nearly  always 
asymmetrical.  The  borders  of  the 
cutaneous  loss  are  not  sharp  but 
shaded  off,  and  correspond  to  the 
limits  of  spinal-root  areas.  On  the 
other  hand,  charts  sometimes  show 
regions  of  dissociative  anaesthesia 
which  correspond  lateralh'  to  one 
or  more  root  areas,  but  do  not 
cover  their  longitudinal  extent. 
For  instance,  the  sensory  loss  in 
one  hand  may  be  limited  above  by  a  line  encircling  the  forearm  so  as 
to  give  it  the  appearance  of  a  glove  distribution.  Similarly,  on  the  face  a 
central  area,  including  the  nose,  mouth,  and  eyes,  may  preserve  its  sensibility 
intact,  while  the  surrounding  regions  are  completel}^  insensiti^"e  to  painful  and 
thermal  stimuli.  Thermo-anaesthesia  and  analgesia  are  sometimes,  but  not 
always,  co-extensive.  Tactile  loss  also  occurs,  but  usually  supervenes  in  the 
later  stages  of  the  disease.  Subjective  sensations  may  form  the  initial  evidence 
of  the  disease,  and  may  be  thermal,  painful,  or  tactile.  Lancinating  pains  and 
cramps  are  described.  ]\Iore  curious  are  the  subjectiAe  sensations  of  drenching 
sweat  in  a  part  which  is  dry,  or  of  cold  in  a  part  which  is  quite  normal  in 
temperature. 

In  tabes  dorsalis  the  disturbances  of  sensation  are  numerous  and  charac- 
teristic. Lightning  and  dull  boring  pains,  tingling,  numbness,  girdle  sensations, 
and  \-arious  painful  crises  are  among  the  subjective  abnormalities.  Impairment 
or  loss  of  deep  and  superficial  pain  sensibility  in  various  parts  of  the  body  is  one 
of  the  earliest  and  most  important  phj-sical  signs  for  the  purpose  of  diagnosis. 


^ig^-  181. — Brown-Sequard  paralysis  due  to  an 
intra-meduUary  one-sided  lesion  of  the  lower  thoracic 
cord.  The  shaded  area  was  insensitive  to  deep  and 
.superficial  pain  and  to  all  degrees  ot  temperature, 
but  sensitive  to  touch.  The  sense  of  passive  move- 
ment and  position  and  tactile  discrimination  were 
disturbed  in  the  right  foot.  There  was  spastic 
paralysis  of  the  right  leg  only.  (After  Head  and 
'Jhovipson.) 


SENSATION,     SOME     ABNORMALITIES     OF 


66  = 


The  cutaneous  analgesia  is  generally  found  on  the  legs,  and  often  also  in  the 
root  areas  on  the  arms  and  thorax  corresponding  to  the  C  8  to  D  5  segments 
(see  Fig.  183).  Deep  analgesia  is 
nearly  always  present  in  the  calf 
muscles.  Superficial  nerves  such 
as  the  ulnar  may  often  be  found 
insensitive  to  rolling  or  pinching. 
Delayed  sensibility  is  another 
phenomenon  very  characteristic  of 
some  cases  of  tabes  dorsalis. 
Hyperassthesia  may  be  present, 
especially  in  bands  around  the 
abdomen,  when  gastric  or  intestinal 
crises  form  part  of  the  clinical 
picture.  Intolerance  of  hot  or  cold 
water  on  any  part  of  the  skin  is 
described  not  uncommonly  by 
patients  suffering  froru  severe  forms 
of  the  disease.  Allocheiria,  or  refer- 
ence of  a  sensory  stimulus  to  the 
opposite  side  of  the  body,  has  also 
been  observed. 

The  sense  of  position  and  move- 
ment is  nearly  always  disturbed  in 
locomotor  ataxy,   and   this    results 
.  in   varying  degrees  of  inco-ordina- 


/•'4'.  182.  —  Syringomyelia.  The  .shaded  parts 
show  the  areas  of  dissociative  anaesthesia,  i.e.,  of 
tliermo-ansesthesia  and  analgesia.  This  was  associ- 
ated with  atrophic  palsy  of  the  upper  extremities. 


tion     and     in     the    production     of 

Romberg's  sign.     Astereognosis,   or  the  inability  to  gauge  approximately  the 

size  and  shape  of  objects  placed 
in  the  patient's  hand,  is  another 
common  sensory  defect. 

In  disseminated  sclerosis,  sensory 
troubles  do  not  as  a  rule  constitute 
so  prominent  a  feature  as  do  the 
motor  disabilities,  but  subjective 
and  objective  changes  are  by  no 
means  uncommon.  Numbness  of 
one  limb  lasting  a  few  weeks  or 
months,  girdle  sensations,  and  even 
pains  of  a  neuralgic  type,  are 
sometimes  complained  of.  I  have 
known  transient  hemianaesthesia  to 
be  an  initial  symptom  in  one  case, 
and  astereognosis  with  loss  of 
sense  of  position  on  one  side,  to 
be  the  earliest  signs  of  disease  in 
two  or  three  cases.  From  the 
diagnostic  standpoint  these  are 
important  facts,  because  it  is  very 
tempting  to  assume,  erroneously, 
that  such  sensory  phenomena, 
occurring  alone  without  any  reflex 
or  motor  signs  of  organic  disease, 
are     hysterical     in    origin.      Thej' 


/•'i^.  1S3. —  Early  tabes  dor.salis.  The  dotted 
areas  represent  a  cliaracteristic  distribution  of  sensory 
disturbance.  The  loss  is  chiefly  to  painful  stimuli, 
and  the  superficial  analgesia  is  almost  always  associ- 
ated with  deep  analgesia. 


666 


SENSATION,     SOME     ABNORMALITIES     OF 


are    doubtless   due   to   patches  of  disease  in  the  neighbourhood  of  the  internal 
capsule. 

This  brings  us  to  the  consideration  of  the  Abnormalities  of  Sensation  resulting 
from  disease  of  the  Higher  Parts  of  the  Nervous  System. 

Hemiansesthesia  is  a  common  result  of  the  various  vascular  accidents 
responsible  for  apoplexy  and  hemiplegia.  It  may  be  present  with  or  without 
any  motor  paralysis  and  with  or  without  hemianopia  ;  sometimes  all  three 
phenomena  are  associated  in  the  case  of  severe  lesions  of  the  internal  capsule 
and  optic  radiations.  In  most  cases  of  apoplexy  hemiansesthesia  is  slight  and 
transient.  Tactile  and  pain  sensibility  may  be  impairedj  usually  more  so  on  the 
limbs  than  on  the  trunk,  and  more  especially  in  the  distal  portions  of  the  arm 
and  leg.  Even  when  touches  are  perceived,  they  are  localized  badly  by  the 
patient.  In  lesions  of  the  optic  thalamus  the  opposite  side  of  the  body  may  be 
the  site  of  a  curious  sensory  disturbance  which  consists  in  part  of  a  lowered 

sensibility  to  painful  stimuli  and  in 
part  of  a  great  exaggeration  of  the 
disagreeable  effects  produced  bj^ 
such  stimuli  when  they  are  per- 
ceived. For  instance,  the  patient 
may  fail  to  recognize  a  light  pin- 
prick so  well  on  the  affected  as  on 
the  sound  side,  but  a  scratch  may 
produce  an  intensely  painful  sensa- 
tion referred  to  a,  very  wide  area 
and  not  localized  to  the  spot 
stimulated.  In  such  cases  the 
patient  often  complains  also  of 
paroxysms  of  severe  pain  in  the 
affected  limbs. 

The  hemiancBSthesia  of  hysteria  is 
usually  far  more  complete  to  all 
forms  of  stimulation  than  any 
hemianaesthesia  due  to  organic  dis- 
ease of  the  brain.  The  hysterical 
patient  is  found  to  have  lost  taste, 
smell,  and  sometimes  even  hearing, 
on  the  anaesthetic  side.  The  visual 
defect,  instead  of  being  hemianopic 
as  in  the  organic  cases,  is  generally 
a  marked  contraction  of  the  visual 
especially  in  the  eye  corresponding 


184. — Thrombosis  of  left  posterior  inferior 
cerebellar  artery.  The  dotted  areas  show  the 
regions  of  dissociative  anaesthesia,  i.e.,  loss  of 
sensibility  to  pain  and  temperature  of  all  degrees. 


fields,  sometimes  amounting  to  blindness 
to  the  other  sensory  defects. 

Lesions  of  the  brain-stem  may  also  be  responsible  for  extensive  loss  of  sensation. 
For  instance,  thrombosis  of  the  posterior  inferior  cerebellar  artery  gives  rise 
to  a  localized  softening  on  one  side  of  the  medulla,  which  produces  thermo- 
anassthesia  and  analgesia  on  the  same  side  of  the  face,  and  on  the  trunk  and 
limbs  of  the  opposite  side.  This  sensory  disturbance  is  sometimes  comphcated 
by  homolateral  cerebellar  ataxy  and  cranial  nerve  palsies. 

So  far  we  have  dealt  chiefly  with  the  various  forms  of  lowered  sensibility,  and 
have  given  little  attention  to  perversions  of  sensation,  such  as  are  indicated  by 
the  terms  hypercssthesia  and  parcssthesia. 

Hypercssthesia  is  observed  in  cases  of  tabes  dorsalis  and  peripheral  nerve 
lesions  as  described  above,  but  it  is  also  met  with  in  other  conditions  of  organic 
as  well  as  functional  disease.      It  is  found,  for  instance,  in  root  areas  in  cases  of 


SKODA  IC     RESONANCE  667 


vertebral  and  intra  vertebral  disease.  In  spinal  caries  and  in  tumours  of  the 
spinal  meninges,  a  zone  of  hyperaesthesia  may  be  detected  just  above  the  area 
of  anaesthesia  produced  by  the  compression  of  the  cord,  or  it  may  precede  the 
appearance  of  compression  signs.  The  increased  sensibility  is  probably  caused 
by  pressure  on,  or  irritation  of,  the  posterior  root  fibres.  A  similar  phenomenon 
is  a  frequent  accompaniment  and  sequel  of  an  attack  of  herpes  zoster.  The 
shape  and  situation  of  such  hvperaesthetic  zones  afford  a  clue  to  the  site  of  the 
lesion.  Hyperjesthesia  as  well  as  parsesthesia  are  among  the  earliest  signs  of 
stibaciite  combined  degeneration  of  the  cord,  and  are  referred  b}^  the  patient  to 
peripheral  parts  of  his  four  extremities.  They  may  precede  by  many  weeks 
or  months  the  appearance  of  ataxic  or  spastic  paraplegia  and  definite  areas  of 
sensory  loss.  Similar  symptoms  are  also  complained  of  in  not  a  few  cases  of 
pernicious  anaemia  and  other  severe  blood  diseases,  probably  on  account  of 
scattered  degenerations  in  the  nervous  system  as  the  result  of  the  Anaemia  (q.v.). 

Neurasthenic  and  hysterical  states  are  responsible  for  hA'perjesthetic  areas 
which  have  no  relation  to  central  or  peripheral  innervation.  In  neurasthenia, 
especially  the  traumatic  variety,  the  patches  are  usually  found  on  and  around 
the  spine  and  over  the  scalp.  In  hA'sterical  conditions  similar  patches  may  be 
detected  in  the  mammary  and  ovarian  regions. 

HA-peraesthesia  in  connection  with  visceral  disease  has  been  referred  to  in 
other  articles,  such  as  those  on  Pain  in  the  Face;  Pain  in  the  Upper 
Extremity;  etc.  E.  Farqithar  Buzzard. 

SHIVERING  FITS.— (See  Rigors.) 

SHORTNESS  OF  BREATH.— (See  Breath,  Shortness  of.) 

SKIN  ERUPTIONS.— (See  Macules;  Papules;   Etc.) 

SKODAIC  RESONANCE.— WTien  there  is  a  basal  and  unilateral  pleuritic 
effusion  of  medium  degree,  it  may  often  be  noted  that  the  pitch  of  the  percussion 
note  over  the  upper  part  of  the  thorax  in  front  is  higher  on  that  side  of  the 
chest  on  which  the  effusion  is  than  on  the  other.  It  is  not  a  question  either 
of  impairment  of  resonance  or  of  hyper- resonance,  but  merely  of  pitch.  This 
higher  pitch  of  the  percussion  note  over  the  upper  lobe,  when  the  lower  lobe  is 
compressed  by  an  effusion,  is  named  "  Skodaic  resonance,"  after  the  observer 
who  first  drew  attention  to  it.  Its  importance  is  mainly  twofold  :  in  the 
first  place  it  does  not  indicate  disease  of  that  part  of  the  lung  which  affords 
the  sign — for  instance,  the  fact  that,  in  a  case  of  right-sided  effusion,  the  right 
upper  lobe  gives  a  higher-pitched  percussion  note  than  does  the  left  cannot  be 
taken  as  evidence  that  there  is  a  lesion,  perhaps  tuberculous,  at  the  right  apex  ; 
in  the  second  place,  it  is  erroneous  to  suppose  that  this  is  only  obtained  in  cases 
of  effusion ;  its  occurrence  cannot  be  taken  as  proof  that  dullness  at  the  base  is 
due  to  fluid  there.  It  is  true  that  pleural  effusion  gives  it  not  only  in  most  marked 
degree,  but  also  most  commonl^^ ;  nevertheless  it  may  also  be  observed  in  some 
cases  of  basal  pneumonia  without  effusion,  or  as  the  result  of  compression  of  a 
lower  lobe  by  such  causes  as  subdiaphragmatic  or  hepatic  abscess,  hepatic  masses 
such  as  carcinoma,  gumma  or  hydatid  cyst,  great  enlargements  of  the  spleen  such 
as  occur  in  splenomeduUarj^  leukaemia,  a  big  heart,  a  pericardial  effusion,  or  a 
mediastinal  or  pulmonary  new  growth. 

The  cause  of  Skodaic  resonance  has  never  been  quite  decided,  and  manv 
theories  have  been  propounded  about  it ;  clinically,  the  most  serviceable 
view  is  that  anything  that  lessens  the  degree  to  which  the  upper  lobe  is 
stretched,  yet  without  actually  compressing  it,  may  produce  a  rise  in  the 
pitch   of  its  percussion  note.     Bilateral  compression  of  the  bases  of  the  lungs 


668  SKODAIC     RESONANCE 

by  such  lesions  as  ascites,  presumably  causes  bilateral  Skodaic  resonance, 
but  this  is  difficult  to  determine,  because  the  latter  is  only  recognizable  when 
there  is  a  difference  of  pitch  between  the-lwa_sidea_ofthe  upper  part  of  the 
chest  in  front. 

Skodaic  resonance  over  an  upper  lobe  when  there  is  some  lesion  affecting^he 
lower  lobe  on  the  same  side,  should  not  be  confused  with  the  tympanic  note  that 
may  sometimes  be  heard  over  the  other  parts  of  the  thorax.  Stomach  tympany 
is  normally  heard  external  to  and  below  the  precordial  region  over  an  area 
known  as  Traube's  space,  which  is  bounded  above  by  the  precordial  dullness, 
behind  by  the  splenic  dullness,  and  below  by  the  rib  margin.  When  the 
stomach  is  dilated,  there  may  be  an  abnormal  extent  of  this  gastric  tympany 
in  the  thorax.  When  the  transverse  colon  is  distended  with  gas,  or  when 
it  is  pushed  upwards  by  something  intra-abdominal,  it  may  produce  abnormal 
areas  of  thoracic  tympany,  particularly  in  the  lower  sternal  region  or  on  either 
side  of  this. 

Such  conditions  can  scarcely  be  mistaken  for  Skodaic  resonance,  for  the  latter 
concerns  the  upper  part  of  an  upper  lobe  in  front,  and  is  not  a  definite  tympany, 
but  rather  a  moderate  rise  in  the  pitch  of  the  ordinarj^  percussion  note,  not  as 
a  rule  obvious  till  the  two  sides  are  contrasted.  Herbert  French. 

SLEEPLESSNESS.— (See   Insomnia.) 

SMELL,  ABNORMALITIES  OF. — Abnormalities  of  the  sense  of  smell  fall 
into  three  main  categories,  namely  : — (i)  Too  great  sensitiveness  to  smells  which 
actually  exist  ;  (2)  Deficient  sensitiveness  to  smells  which  actually  exist ;  (3)  Sub- 
jective sensations  of  smells  which  do  not  exist. 

1.  Too  great  sensitiveness  to  existing  smells  is  sometimes  a  nuisance  to  the 
individual,  but  is  very  seldom  a  sign  of  disease.  There  are  very  great  differences 
in  the  powers  of  perception  of  different  sensations  in  different  persons,  and  just 
as  some  can  appreciate  very  slight  differences  in  sounds  more  than  others,  so 
can  some  detect  smells  which  are  undiscernable  by  others.  This  is  natural 
idiosyncrasy. 

2.  Deficient  sensitiveness  to  actual  smells  is  often  but  the  obverse  of  the 
above,  and  no  sign  of  disease,  although  it  may  be  a  detriment  to  the  individual, 
especially  in  certain  commercial  pursuits  in  which  the  varying  qualities  of 
products  are  judged  partly  by  smell.  When  the  power  of  smell,  having  been 
normal,  becomes  deficient  or  totally  absent,  the  change  may  affect  one  nostril 
only,  or  both.  The  condition  may  be  transient  or  persistent.  The  commonest 
cause  of  transient  anosmia  is  acute  nasal  catarrh,  whether  the  result  of  an 
ordinary  co^ii,  or  of  other  affections  such  as  hay  fever  (coryza  e  feno),  oncoming 
measles,  or  the  effects  of  drugs  such  as  iodide  of  potassium  or  arsenic. 

Persistent  anosmia  may  be  due  to  : — 

(a).  Inability  to  get  air  freely,  or  at  all,  through  the  nostril,  as  the  result  of  : — 

Adenoids  '       Hypertrophic  rhinitis 

Polypi  Syphilis 

Dislocation   of    the  nasal  Necrosis  of  bones  in  the  nares 

septum  Occlusion  of  anterior  or   posterior 

Xasal  septal  spur  nares. 

{h).  Alteration  in  the  olfactory  mucous  membrane,  so  that  it  no  longer 
transmits  impulses  to  the  endings  of  the  olfactory  nerve,  although 
the  airway  is  free  : — 

Atrophic   rhinitis 

Paralysis  of  the  fifth  nerve,  leading  to  undue  dryness  of  the  mucosa. 


SNORING  669 


(c).  Abnormalities  of  the  olfactory  nerves. 
Congenital   absence 
Hydrocephalus 

Olfactory  neuritis,   either  the  result  of  overstimulation  locally  by 
strong  noxious  vapours,  ammonia,  or  snuff  ;  or  part  of  a  general 
peripheral   neuritis 
Post-influenzal  changes 
(d).  Cranial  lesions,  especially  haemorrhage,  thrombosis,  emboUsm,  softening, 
injury,  or  tumour  of  the  uncinate  gyrus,  which  is  the  centre  for  smell, 
(e).  General  nerve  diseases,  especially  : — 
General  paralysis  of  the  insane 
Locomotor  ataxy. 
(/).  Hysteria. 
There  is  httle  need  to  discuss  the  above  table  in  detail,  for  each  heading  speaks 
for  itself.     When  a  case  is  being  investigated,  the  history  is  very  important  ; 
it  is  next  necessary  to  examine  the  nose  carefully  through  a  speculum,  and  to 
test  the  air-way  through  each  nostril  ;   if  there  is  any  local  lesion,  it  will  generally 
become  obvious  at  once,  and  only  after  local  affections  have  been  excluded 
should  conditions  in  groups  c,  d,  e,  and  /  be  discussed.     Anosmia  will  seldom 
if  ever  be  a  prominent  symptom,  except  in  connection  with  local  affections  of 
the  nose  ;     when  due  to  any  other  cause,  there  will   nearly    always    be    some 
other  symptoms  which  will  attract  attention  more  than  the  anosmia  itself. 
3.  Subjective  sensations  of  smells   which    do   not  exist   externally   may   be 
due  to  : — 

(a).  Offensive   or  purulent  inflammations  of  the   nose   or  of   the    air-cells 
communicating    with   it,    especially  empyema    of    the    antrum    of 
Highmore,  or  of  a  frontal  sinus. 
ip).  Local    thickening    of    the    meninges,   tumour    of    the   brain,   or  inter- 
ference  with  the  vascular   supply,  causing  irritation    of   the   hippo- 
campal   region, 
(c).  An  aura  preceding  an  epileptic  seizure. 
{d).  Hysteria. 
[e).   Insanity. 
In  arriving  at  a  diagnosis,  it  is  chiefly  important  to  exclude  purulent  affec- 
tions discharging  into  the  nose  ;  if  it  is  possible  to  state  with  certainty  that  the 
abnormal  sensations  have  no  such  organic  basis,  it  is  not  difficult  as  a  rule  to 
decide  between  the  other  causes.     It  is  a  curious  fact  that  subjective  abnor- 
malities of  smell  are  apt  to  be  associated  with  delusional  insanity  concerning 
the  genital  organs,  in  which  the  prognosis  is  not  free  from  acute  dangers. 

Herbert  French. 

SNORING  may  be  a  very  troublesome  symptom  in  some  patients,  particularly 
to  those  who  have  to  sleep  in  the  same  room  with  them  ;  but  it  is  often  less  an 
indication  of  disease  than  merely  a  bad  habit.  Most  snorers  sleep  with  their 
mouths  open,  and  breathe  partly  through  the  nose  and  partly  through  the 
mouth  ;  but  it  is  possible  for  snoring  to  occur  with  the  mouth  completely  shut, 
and  nothing  the  matter  with  the  nasal  passages.  The  tendency  is  increased, 
however,  by  any  obstruction  of  the  nasal  airway,  so  that  particular  examination 
should  be  made  for  such  lesions  as  undue  smallness  of  the  nares  or  a  tendency 
for  the  soft  parts  of  the  nostrils  to  collapse  on  inspiration,  deflected  septiim, 
hypertrophic  rhinitis,  polypi,  adenoids,  acute  or  chronic  nasal  catarrh,  inflam- 
mation of  the  accessory  sinuses  or  of  the  pharyngeal^  tonsils,  or  even  a  fibro- 
sarcoma or  other  neoplasm  of  the  nasopharynx.  Herbert  French. 


670  SORE     THRO  A  T 


SORE   THROAT    may  be    due  to  one  or  other  of    many  different  causes 

1.  Affections  of  the  Tonsils  : — 

Quinsy. 

Acute  Tonsillitis. 

{a).  With  reddening  and  swelHng  only: 

Acute  inflammation  due  to  various  micro-organisms,  especially 
to  streptococci  ;  staphjdococci  ;  pneumococci  ;  diphtheria 
bacilU  ;  Hofmann's  bacilli  ;  Vincent's  spirilla  and  fusiform 
bacilli  ;  spirochceta  (treponema)  pallida  ;  micrococci  catar- 
rhales  ;  bacilli  influenzae  ;  tubercle  bacilli.  The  sore  throats 
of  scarlet  fever,  German  measles,  and  measles  are  probably 
not  due  to  specific  micro-organisms,  but  to  streptococci,  or 
others  of  the  bacteria  just  enumerated. 
[b).  With  redness,  swelling,  and  exudation  : 

Follicular  tonsillitis  due  to  streptococci,  etc.,  as  above. 
Diphtheria 
Vincent's  angina 
Syphilis, 
(c).  With  ulceration : 

Phlegmonous  tonsillitis  due  to  streptococci,  etc.,  as  above. 
Syphilis 

Vincent's  angina. 
Chronic  Affections  of  the  Tonsils  : — 

Recurrent  inflammation  often  associated  with  adenoids,  or  tonsillar 

hypertrophy,  especially  in  children 
Primary  or  secondary  syphilis 
Vincent's  angina 
Squamous-celled  carcinoma 
Sarcoma 
Gumma 
Tubercle. 

2.  Inflammation  of  the  Soft  Palate,  Uvula,  and  Fauces  : — 

Catarrh,   occurring  either  by  itself  or  associated  with   any  of   the 

varieties  of  tonsillitis  enumerated  above 
Gumma 

Squamous-celled  carcinoma 
Tubercle. 

3.  Affections  of  the  Pharynx  : — 

Acute  catarrhal  pharyngitis  due  to  any  of  the  micro-organisms  men- 
tioned under  the  heading  of  acute  tonsillitis 

Chronic  granular  pharyngitis  due  to  smoking  in  excess  ;  or  to  over-use, 
as  in  clergyman's,  costermonger's,  or  stockbroker's  sore  throat 

Squamous-celled  carcinoma  of  the  pharynx 

Post-pharyngeal  abscess 

Varicella 

Variola. 

4.  Laryngeal  Conditions,  especially  :— 

Acute  catarrhal  laryngitis   due  to   any  of  the  organisms  mentioned 

above. 
Tuberculous  laryngitis 
Syphilitic  laryngitis 
Carcinoma  laryngis 
Acute  perichondritis  of  the  arytenoid  cartilages. 


1 


SORE     THROAT  671 


5.  Sore  Throats  the  result  of  the  Swallowing  or  Inhalation  of  Irritants  : — 

Corrosives,  such  as  alkalies  or  strong  acids 
Ammonia  vapour 
Hot  steam. 

6.  Mumps. 

7.  Acute  and  Subacute  Adenitis  of  the  lymphatic  glands  in  the  neck. 

Notwithstanding  the  length  of  the  above  list  the  differential  diagnosis  of  a 
sore  throat  in  practice  is  not  difficult  as  a  rule.  Enquiry  into  the  history  and 
inspection  of  the  parts  locally  in  a  good  light  will  generally  serve  to  give  one  a 
very  shrewd  notion  of  the  nature  of  the  complaint.  The  chief  point  in  practice 
is  to  determine  as  soon  as  possible  whether  the  Klebs-Loffler  bacilli  of  diphtheria 
are  present  or  not,  for  it  has  been  established  that  there  is  no  kind  of  sore  throat 
which  can  be  recognized  clinically  as  non-diphtheritic.  It  is  important  that 
swabbings  should  be  taken  from  the  inflamed  parts  and  examined  by  a  bacterio- 
logist both  directly  in  films  stained  by  Neisser's  method,  and  by  means  of  cultures. 
Similar  bacteriological  investigations  will  serve  to  determine  which  of  the 
organisms  mentioned  above  is  responsible  for  an  acute  or  follicular  or  ulcerative 
sore  throat  other  than  diphtheritic,  it  being  borne  in  mind,  however,  that  the 
organism  should  be  found  in  fairly  pure  cultures  if  it  is  to  be  regarded  as  causative 
and  not  merely  as  a  secondary  or  even  casual  infection. 
I.  Affections  of  the  Tonsils. 

Quinsy  is  practically  always  an  asymmetrical  affection,  one  tonsil  being  very 
much  more  bulged  than  the  other  ;  the-  surface  is  reddened,  generally  without 
follicular  suppuration,  and  the  diagnosis  is  ultimately  confirmed  by  the  bursting 
of  the  abscess. 

The  presence  of  Klebs-Loffler  bacilli  in  association  with  a  sore  throat  may  be 
regarded  as  conclusive  proof  that  the  lesion  is  diphtheria,  even  though  there  may 
be  no  typical  diphtheritic  exudate.  Diphtheria  having  been  excluded,  the 
diagnosis  of  one  of  the  other  varieties  of  acute  tonsillitis  is  rendered  possible. 
The  frequency  with  which  acute  rheumatism  is  associated  with  recurrent  tonsil- 
litis, especially  in  young  people  between  the  ages  of  five  and  twenty,  should 
always  be  borne  in  mind  ;  the  patient  may  or  may  not  have  suffered  from  other 
effects  of  acute  rheumatism,  such  as  joint  pains,  endocarditis  (evidenced  by  the 
bruits),  pericarditis,  pleurisy,  erythema  nodosum,  chorea  ;  or  a  history  of  such 
rheumatic  affections  may  be  obtained  in  other  members  of  the  same  family. 
The  tonsillitis  is  benefited  by  sodium  salicylate,  but  by  no  means  to  the  same 
extent  as  are  the  joint  pains,  so  that  the  effect  of  treatment  is  not  by  itself 
conclusive  evidence  of  the  nature  of  the  complaint. 

When  acute  rheumatism  gives  rise  simultaneously  to  generalized  erythema 
and  to  tonsillitis,  there  will  be  very  considerable  difficulty  in  excluding  scarlet 
fever,  especially  if  there  has  been  considerable  nausea  or  actual  vomiting ; 
in  some  such  cases  the  diagnosis  will  be  one  of  opinion  only  ;  that  which  was 
regarded  at  first  as  acute  rheumatic  tonsillitis  and  erythema  may  prove  to  have 
been  scarlatina  after  all,  should  the  patient  presently  develop  acute  nephritis  ; 
the  occurrence  of  extensive  peeling  of  the  skin  is  not  conclusive  evidence  of 
scarlatinal  erythema  and  sore  throat.  If  the  patient  is  known  to  have  had 
scarlet  fever  formerly,  the  rheumatic  nature  of  the  case  is  more  likely. 

Follicular  tonsillitis  is  not  a  final  diagnosis,  for  it  may  be  due  to  various  different 
micro-organisms,  and  there  is  no  doubt  that  the  diphtheria  bacillus  may  produce 
that  which  to  inspection  presents  multiple  foci  of  pus  in  the  different  tonsillar 
,  crypts  formerly  regarded  as  characteristic  of  follicular  as  distinct  from  diph- 
theritic tonsillitis.  The  only  conclusive  proof  that  a  comparatively  simple 
follicular  tonsillitis  is  not  diphtheritic  is  bacteriological  examination.      If  clinical 


672  SORE     THROAT 


points  alone  have  to  be  relied  on,  one  would  say  that  the  higher  the  temperature, 
the  greater  the  constitutional  disturbances,  and  the  more  sudden  the  onset,  the 
more  likely  is  it  not  to  be  diphtheria. 

Vincent's  angina  has  been  differentiated  bacteriologically,  cases  of  this  kind 
having  formerly  been  regarded  either  as  diphtheria  or  as  follicular  tonsillitis. 
The  characteristic  micro-organisms  present  are  elongated  fusiform  bacilli  sym- 
biotic Avith  spirilla  {Plate  XII,  Fig.  M).  The  disease  is,  as  a  rule,  more 
resistant  to  treatment  than  are  other  forms  of  acute  sore  throat,  so  that  what 
has  originally  been  a  tonsillitis  with  exudation  presently  becomes  an  ulceration 
associated  with  remarkable  foetor  of  the  breath,  but  without  that  tendency 
to  fatal  termination  presented  by  most  other  varieties  of  acute  ulcerative  or 
phlegmonous  sore  throat.  The  disease  cannot  be  recognized  without  the  aid 
of  the  bacteriologist. 

Syphilis  may  cause  acute  soreness  of  the  throat  in  its  secondary  stages,  and 
unless  that  possibility  is  borne  in  mind,  one  may  diagnose  as  acute  simple  or  acute 
follicular  tonsillitis  that  which  is  really  syphilitic.  There  is  more  or  less  pyrexia 
at  the  same  time,  and  in  most  cases  there  will  be  tenderness  of  the  scalp  and  of 
the  bones,  together  with  the  well-known  roseolous  eruption  upon  the  skin  and  the 
"  snail-track  "  ulcers  upon  the  pharynx.  The  diagnosis  may  be  more  difficult 
in  women  than  in  men,  for  in  the  latter  the  remains  of  the  chancre  may  still  be 
obvious.  Wassermann's  serum  test  may  materially  assist  in  the  diagnosis  of 
doubtful  cases. 

Chronic  affections  of  the  tonsils  in  children  are  nearly  always  the  result  of 
recurrent  acute  attacks  of  non-diphtheritic  tonsillitis,  generally  in  association 
with  adenoids,  both  affections  arising  from  the  habit  of  mouth  breathing.  Inspec- 
tion of  the  bulging  hypertrophied  tonsils,  with  or  without  digital  examination  of 
the  posterior  nasal  fossse,  will  indicate  the  diagnosis.  In  an  older  person,  simple 
hypertrophy  from  a  recurrent  tonsillitis  becomes  progressively  less  common. 
Chronic  tonsillitis  in  a  young  adult  may  be  diphtheritic,  syphilitic,  or  due  to 
Vincent's  angina,  the  diagnosis  between  these  being  arrived  at  in  the  way 
described  above.  It  may  be  mentioned  that  in  very  rare  instances  an  actual 
chancre  appears  upon  one  tonsil,  giving  rise,  unless  secondary  symptoms  are 
present,  to  much  difficulty  in  diagnosis  until  the  case  has  been  watched.  Malignant 
disease  of  the  tonsils,  whether  squamous-celled  carcinoma,  or  sarcoma,  is  fortunately 
not  very  common  ;  when  it  does  develop,  its  comparatively  non-acute  course 
and  its  unilateral  distribution  Avith  progressive  ulceration  of  the  central  parts 
and  overgrowth  of  the  edges  of  the  neoplasm  will  point  to  the  diagnosis.  A 
gumma  of  the  tonsil  is  very  rare,  and  it  might  at  first  simulate  squamous-celled 
carcinoma  :  in  case  of  doubt  a  small  portion  of  the  suspicious  mass  might  be 
excised,  and  examined  microscopically  ;  or  if  operative  measures  were  not  to  be 
adopted  at  once,  potassium  iodide  might  be  administered,  and  the  lesion  would 
be  shown  to  be  gummatous  if  it  were  thereby  relieved  or  cured.  Tuberculous 
ulceration  of  the  tonsils  is  quite  uncommon,  practically  never  primary,  but 
secondary  to  extension  from  the  lungs,  and  nearly  always  preceded  by  both 
phthisis  and  tuberculosis  of  the  larynx.  The  diagnosis  will  be  indicated  by  the 
discovery  of  tubercle  bacilli  in  the  sputum,  though  it  should  not  be  forgotten 
that  carcinoma  or  gumma  might  affect  the  tonsils  in  a  person  Avho  had  phthisis. 

2.  Inflammation  of  the  Soft  Palate,  Uvula,  and  Fauces. 

This  may  be  seen  in  many  cases  of  common  cold  ;  in  association  with  acute 
rheumatism  ;  in  persons  Avho  have  recently  returned  to  tOAvn  from  a  holiday  in 
the  country  ;  in  patients  Avho  have  been  subjected  to  the  influence  of  motor-car 
dust  stirred  up  from  the  roads  after  the  latter  have  been  dry  for  about  three 
days — a  longer  period  of  dryness  seems  to  lead  to  relative  disinfection  of  the 
dust,  Avhilst  rain  keeps  the  dust  from  rising,  so  that  either  continuance  of  fine 


SORE     THRO  A  T  673 


weather  or  a  return  to  wet  leads  to  a  disappearance  of  the  sore  throats  ;  or 
in  those  who  are  subjected  to  the  influence  of  relatively  concentrated  microbes, 
as  in  the  air  of  old-fashioned  hospital  wards,  of  ill-ventilated  much-inhabited 
rooms,  of  sewers,  and  the  hke.  Often  a  rim  of  acute  reddening  is  to  be  seen 
all  along  the  edge  of  the  anterior  pillars  of  the  fauces,  and  affecting  much  of 
the  uvula  and  of  the  soft  palate,  producing,  as  a  rule,  but  little  pj^rexia,  though 
much  discomfort  in  swallowing,  and  a  raspy  feeling  on  the  back  of  the  mouth  on 
first  waking  in  the  morning.  This  inflammation  of  the  palate  and  fauces  may  or 
may  not  be  associated  with  tonsillitis,  pharyngitis,  or  laryngitis  ;  it  is  clearly 
microbial  ;  and  doubtless  more  than  one  of  the  varieties  of  bacteria  mentioned 
above  ma}^  produce  the  lesion.  The  diagnosis  of  the  fact  of  inflammation  is 
obvious  on  inspection  ;  that  of  the  nature  of  the  micro-organism  requires  skilled 
bacteriological  assistance. 

Gumma,  squanious-celled  carcinoma,  and  tuberculous  affections  of  the  fauces, 
soft  palate,  and  uvula  are  relatively  uncommon  ;  they  are  differentiated  in  the 
same  way  as  has  been  described  in  connection  with  tonsillitis. 

3.  Affections  of  the  Pharynx. 

Acute  pharyngitis  may  occur  by  itself,  or  in  association  with  acute  tonsillitis 
or  acute  larj-ngitis,  and  in  either  case  it  may  be  due  to  any  of  the  micro-organisms 
mentioned  above.  The  differential  diagnosis  of  the  micro-organisms  is  carried 
out  in  the  bacteriological  laboratory.  The  fact  of  acute  pharyngitis  is  deter- 
mined hy  careful  inspection  of  the  structures  at  the  back  of  the  mouth. 

Chronic  pharyngitis  is  generally  the  result  of  excessive  smoking,  or  of  the 
undue  use  of  the  voice,  in  which  latter  case  it  may  be  associated  with  hoarseness 
or  ready  tiring  of  the  voice,  as  in  those  who  have  to  declaim  loud  and  long — 
clergymen,  stockbrokers,  costermongers,  pubhc  orators,  and  others.  The  history 
will  generally  point  to  the  nature  of  such  a  case,  though  it  is  necessary  to 
examine  the  sputum  and  the  lungs  for  evidence  of  tuberculosis,  and  also  to  look 
for  signs  of  either  syphilis  or  new  growth,  in  order  to  exclude  these  possible 
alternatives. 

Post-pharyngeal  abscess  is  rather  a  cause  of  acute  dyspnoea  than  of  soreness  of 
the  throat  ;  it  is  almost  confined  to  infancy  ;  after  three  or  four  years  of  age 
the  disease  becomes  almost  unknown.  It  might  be  simulated  by  spinal  caries, 
in  which,  long  before  there  is  soreness  of  the  throat,  there  is  severe  pain  in  the 
cervical  region  of  the  spine,  especially  on  movement. 

Chicken-pox  and  small-pox  may  each  produce  its  characteristic  eruption  in 
the  mouth,  pharynx,  and  oesophagus,  and  thus  give  rise  to  sore  throat ;  but  the 
latter  symptom  will  never  be  present  by  itself,  and  the  presence  of  the  cutaneous 
papules,  vesicles,  or  pustules,  will  indicate  the  diagnosis,  especially  if  there  have 
been  other  similar  cases  in  the  neighbourhood. 

4.  Laryngeal  Conditions. 

Acute  laryngitis  may  be  due  to  the  same  micro-organisms  as  acute  tonsillitis; 
soreness  of  the  throat  is  generally  less  complained  of  than  is  huskiness,  or  weakness 
or  loss  of  voice.  The  nature  of  the  inflammation  is  determined  bacteriologically 
in -most  cases.  One  variety  of  acute  non-diphtheritic  laryngitis  that  merits 
special  mention  is  that  due  to  pyogenic  cocci- — pneumococci,  streptococci, 
staphylococci — which  in  a  few  cases,  in  addition  to  producing  acute  superficial 
inflammation,  also  lead  to  rapid  and  extreme  oedema  of  the  larynx,  with  death 
from  asphyxia  unless  tracheotomy  be  speedily  performed.  These  cases  have 
been  spoken  of  as  acute  suffocative  oedema  of  the  larj-nx. 

Tuberculous,  syphilitic,  and  carcinomatous  lesions  of  the  larynx  are  less  acute, 

though  they  may  have  relativel}^  acute  exacerbations  or  may  become  secondarily 

infected  with  pyogenic  cocci  ;  their  diagnosis  depends  partly  upon  larjTigoscopic 

inspection — ^tuberculosis   and    syphilis   being   bilateral,    whilst    new    growth   is 

15  43 


'  674  SORE     THRO  A  T 


generally  unilateral  ;  upon  examination  of  the  sputum  for  tubercle  bacilli,  and 
of  the  lungs  for  apical  physical  signs  of  phthisis  ;  upon  the  beneficial  influence 
of  potassium  iodide  and  mercury  ;  upon  Wassermann's  syphihtic  serum  test  ; 
upon  microscopic  examination  of  small  excised  portions  ;  or  upon  the  course  of 
the  disease. 

5.  Sore  Throats  the  Result  of  the  Swallowing  or  Inhalation  of  Irritants  and 
Corrosives,  are  diagnosed  as  a  rule  by  the  history  ;  enquiry  into  the  circumstances 
of  the  case  will  generally  suffice  to  indicate  that  some  irritant  has  been  taken,  or 
there  may  be  direct  evidence  of  it  in  the  form  of  eschars  on  the  hps  or  the  buccal 
mucosa  ;  there  may  be  vomiting  and  hsematemesis  ;  analysis  of  the  gastric 
contents  may  indicate  the  nature  of  the  poison  taken  ;  ammonia  may  be  detected 
by  the  smell. 

6,  7.  Mumps  and  Acute  Adenitis  of  the  Cervical  Lymphatic  Glands  maj^  each 
produce  marked  soreness  of  the  throat  in  addition  to  d3^sphagia,  stiffness, 
discomfort,  and  pain.  Mumps  is  not  difficult  to  diagnose  unless  its  possibiht}' 
is  forgotten,  in  which  case  it  might  be  mistaken  for  acute  oedema  of  the  neck 
or  other  similar  lesions.  The  way  in  which  the  sweUing  is  located  in  the  salivary 
glands,  starting  on  one  side  and  spreading  to  both,  is  often  pathognomonic. 
Cervical  adenitis  might  simulate  mumps,  but  careful  palpation  will  generallj'' 
enable  one  to  determine  that  the  swelling  is  not  in  the  salivary  but  in  the 
lymphatic  glands,  and  it  will  only  remain  to  decide  what  has  been  the  source  of 
the  infection.  This  will  probably  have  been  from  some  inflammatory,  ulcerative, 
or  malignant  focus  in  connection  with  the  shoulders,  neck,  head,  face,  lips, 
cheeks,  gums,  teeth,  tongue,  fauces,  uvula,  palate,  tonsUs,  pharynx,  or  nares  ; 
the  differential  diagnosis  will  be  based  upon  inspection  and  palpation  of  the  parts, 
together  with  bacteriologickl  examination. 

It  only  remains  to  add  that  scarlet  fever  is  at  the  present  time  so  at^^pical  that 
acute  cervical  adenitis  may  really  be  of  scarlatinal  origin  Avithout  any  scarlatini- 
form  rash  having  been  observed  upon  the  skin.  One  would  naturally  look  for 
evidence  of  desquaniation,  sore  throat,  bald  tongue,  albuminuria,  nephritis, 
perhaps  otitis  media  ;  but  there  is  no  doubt  that  some  cases  of  acute  cer\dcal 
adenitis  are  really  scarlatinal,  without  there  having  been  any  other  sign  of  this 
disease  except  pyrexia  and  sore  throat.  A  few  such  cases  prove  rapidly  fatal, 
and  they  have  recently  been  recorded  as  examples  of  acute  and  fatal  sore  throat 
corresponding  with  one  form  of  the  angina  maligna  of  the  eighteenth  century. 

Herbert  Fretich. 

SORES,  PENILE.— Sores  on  the  penis  may  be  present  on  the  thin  mucous 
covering  of  the  glans  or  prepuce,  or  on  the  cutaneous  surface  of  the  body  of 
the  penis  ;    they  are  more  common  in  the  former  situation. 

Ulceration  in  the  neighbourhood  of  the  glans  penis  may  be  due  to  : — 


5.  Epithelioma 

6.  Gummatous  ulceration 

7.  Tuberculous  ulceration. 


1.  Balanitis 

2.  Herpes  progenitalis 

3.  Soft  sore 

4.  Chancre 

I.  Balanitis. — If  inflammatory  processes  have  been  allowed  to  continue 
beneath  the  prepuce,  ulceration  and  excoriation  of  the  mucous  membrane 
covering  the  glans  penis  or  lining  the  prepuce,  will  occur.  The  surface  of  the 
glans  will  be  seen  to  be  denuded  of  epithelium,  and  the  process  will  be  accom- 
panied by  a  stinking,  purulent  discharge.  Multiple  shallow  ulcers  are  formed, 
rapidly  coalescing  and  causing  considerable  discomfort.  The  prepuce  often 
becomes  swollen  and  oedematous,  preventing  retraction,  so  that  a  condition  of 
phimosis  occurs.  In  this  condition  care  must  be  exercised  in  the  diagnosis  of 
3,  simple  balanitis  from  one  accompanying  acute  gonorrhceal  urethritis  or  an 


SORES,     PENILE  G75 


underlying  syphilitic  or  soft  chancre.  With  an  acute  urethritis,  there  will  be 
a  history  of  infection,  pain  along  the  course  of  the  urethra  during  micturition, 
and  other  symptoms,  such  as  chordee  ;  further,  the  intracellular  gonococcus 
may  be  identified  in  a  stained  smear  of  the  discharge  {Plate  XII,  Fig.  R). 

If  a  chancre  exist  under  the  swollen  phimosed  prepuce,  there  is  often  a 
tender  spot  about  the  corona  or  at  the  frsenum.  With  a  soft  sore,  consecutive 
sores  may  appear  about  the  orifice  of  the  prepuce,  whilst  the  inguinal  glands 
are  much  more  likely  to  be  inflamed  or  to  suppurate  than  in  a  simple  balanitis. 
A  syphilitic  chancre  obscured  by  a  phimosis  can  usually  be  felt  distinctly  under 
the  skin,  and  causes  a  comparatively  small  amount  of  discharge,  whilst  the 
inguinal  glands  become  enlarged  but  do  not  suppurate.  The  history  of  the 
date  of  infection,  and  the  subsequent  appearance  of  secondary  symptoms,  will 
materially  help  in  the  diagnosis. 

A  form  of  balanitis  which  is  frequently  very  obstinate  to  treatment  may  occur 
in  patients  the  subject  of  gout  or  diabetes  mellitus. 

2.  Herpes  Progenitalis. — Herpes  may  attack  the  genital  organs  as  part  of  a 
herpes  zoster  in  which  the  cutaneous  eruption  depends  upon  some  lesion  of  the 
central  nervous  system,  or  as  a  local  affection,  the  so-called  catarrhal  herpes. 
The  disease  begins  as  a  patch  of  erythema  on  the  inner  surface  of  the  prepuce 
or  on  the  glans  penis,  followed  by  the  appearance  of  vesicles  and  pustules  ; 
the  latter  become  rubbed  by  the  clothes,  and  form  small  ulcers.  Herpes  of 
the  genital  organs  tends  to  recur,  so  that  a  previous  history  of  a  similar  attack 
is  often  forthcoming.  If  it  arise  during  the  vesicular  stage,  no  difficulty  will 
be  met  with  in  the  diagnosis  ;  but  if  suppuration  has  followed,  it  must  be  diagnosed 
from  a  venereal  sore.  Soft  chancres  are  usually  deeper,  with  marked  edges  ; 
their  base  is  sloughing,  and  they  are  usually  accompanied  by  a  bubo,  which  is 
exceptional  with  herpes.  A  syphilitic  chancre  is  usually  single,  indurated 
and  raised,  and  is  accompanied  by  the  typical,  multiple,  discrete,  amygdaloid 
glands  in  the  inguinal  region.  It  should  be  remembered  that  syphilis  may 
become  inoculated  upon  a  herpetic  patch,  or  that  herpes  may  appear  in  an 
area  previously  inoculated  with  the  syphilitic  virus. 

3.  Soft  Sores  or  Chancroids  of  the  penis  occur  almost  invariably  from  infection 
during  sexual  connection.  The  incubation  period  is  short,  a  vesicle  occurs  in 
two  days,  and  this  rapidly  breaks  down  to  form  a  rounded  or  oval  ulcer  with 
sharply  defined  edges,  and  a  yellowish  sloughing  base.  The  ulcers  appear 
usually  on  the  mucous  surface  of  the  glans,  fraenum,  or  corona,  and  are  most 
often  multiple,  direct  inoculation  occurring  from  an  ulcer  to  the  contiguous 
part.  They  may  cause  rapid  destruction  of  tissue,  perforating  the  fragnum  or 
spreading  over  the  surface  of  the  glans. 

The  soft  sore  must  be  differentiated  from  others  occurring  on  the  glans,  and 
above  all  from  a  syphilitic  chancre.  At  the  same  time  it  must  be  remembered 
that  besides  the  infection  with  chancroid,  a  simultaneous  infection  with  syphilis 
may  have  taken  place,  so  that  a  soft  sore  may  ultimately  become  indurated  and 
assume  the  character  of  a  primary  syphilitic  lesion.  The  chancroids  are  multiple, 
are  accompanied  by  a  good  deal  of  thin,  purulent  discharge,  and  by  a  painful 
swelling  of  the  inguinal  glands,  usually  of  one  side,  which  have  a  marked  tendency 
to  suppurate.  On  the  other  hand,  a  syphilitic  chancre  is  single,  is  raised  and 
indurated,  has  littl-e  discharge,  and  is  accompanied  by  enlarged,  but  firm  and 
indolent,  glands  in  both  inguinal  regions  ;  the  incubation  period  of  a  syphilitic 
chancre  is  from  twenty-one  to  twenty-five  days. 

The  multiple  ulcerations  caused  by  herpes  are  more  superficial,  and  rarely 
cause  a  bubo. 

4.  Chancre — -the  initial  lesion  of  syphilis — generally  appears  on  the  penis,  and 
is  most   common  in  the  neighbourhood  of  the  fraenum  or  coronary  sulcus.     A 


676  SORES,     PENILE 


chancre  appears  about  twentj'-one  days  after  infection,  as  a  reddened  patch, 
which  becomes  raised  above  the  surface  of  the  mucous  membrane,  with  distinctly- 
indurated  margins.  The  central  part  breaks  down  into  an  ulcer,  discharging 
a  thin,  purulent  fluid,  and  at  the  same  time  the  inguinal  glands  of  both  sides 
become  palpable,  slightly  enlarged,  but  discrete,  and  with  no  tendency  to 
suppurate.  The  chancre  increases  but  slowly  in  size,  or  may  occasionally 
become  smaller  without  any  treatment,  and  after  a  further  lapse  of  from  four  to 
six  weeks  the  typical  secondary  symptoms  make  their  appearance ;  namety,  a 
roseolar  rash  on  the  chest,  abdomen,  face,  and  thighs,  general  adenitis,  and  a 
mucous  patch  about  the  faucial  pillars  and  tonsils. 

The  diagnosis  of  the  primary  lesion  of  syphilis  frequently  presents  no  diffi- 
culties, the  indurated  character  of  the  sore,  the  date  of  its  appearance  after 
infection,  and  the  presence  of  firm,  indurated  glands  in  the  inguinal  region, 
being  distinctive.  In  other  cases  the  character  of  the  sore  is  by  no  means  dis- 
tinctive, and  it  is  necessary  to  differentiate  it  from  other  lesions  of  the  penis. 
If  the  sore  be  syphilitic,  the  secondary  manifestations  of  the  disease  will  follow, 
provided  that  the  doubtful  ulcer  is  not  treated  as  a  chancre.  Thus,  in  any  case 
in  which  syphilis  is  suspected,  but  not  wholly  certain,  it  is  advisable  to  withhold 
any  specific  treatment  for  syphilis  until  such  time  as  secondary  symptoms 
appear,  so  that  a  patient  may  not  be  condemned  to  the  lengthy  process  of  treat- 
ment for  syphilis  until  the  diagnosis  is  absolutely  certain.  Wassermann's  serum 
reaction  may  also  be  tried,  and  the  Spirochceta  pallida  looked  for  in  scrapings 
from  the  affected  parts. 

A  chancre  may  be  simulated  by  an  inflamed  soft  sore,  especially  if  the  latter 
has  undergone  cauterization.  Soft  sores  are,  however,  frequently  multiple, 
appear  within  a  few  days  c  f  infection,  and  are  accompanied  by  a  painful  enlarge- 
ment of  the  inguinal  lymphatic  glands,  which  are  particularly  prone  to  suppurate. 
It  must  not  be  forgotten  that  a  double  infection  may  have  occurred,  so  that 
a  soft  sore  may  show  little  inclination  to  heal  or,  becoming  indurated,  may 
present  the  features  of  a  chancre  after  about  three  weeks,  and  later,  the  symptoms 
of  constitutional  syphilis. 

Epithelioma  of  the  penis  in  the  early  stage  may  be  confused  with  syphilitic 
chancre.  In  epithelioma  there  is  no  history  of  infection  ;  it  occurs  only  in 
elderly  patients,  and  there  is  frequently  a  greater  destruction  of  tissue  than  in 
syphilis.  The  inguinal  glands  are  not  enlarged  until  the  sore  has  been  present 
for  some  weeks,  and  there  are  no  secondary  lesions  such  as  the  faucial  ulceration 
and  cutaneous  rash.  If  any  doubt  exists,  a  small  piece  may  be  removed  from 
the  edge  of  the  ulcer  for  microscopical  examination. 

Perhaps  the  greatest  difficulty  in  the  diagnosis  of  a  chancre  is  experienced 
when  the  latter  is  hidden  beneath  an  inflamed  and  phimosed  prepuce.  There 
is  a  purulent  and  foul  discharge  from  beneath  the  prepuce,  which  may  be 
oedematous  and  swollen  ;  the  inguinal  glands  are  enlarged  from  the  associated 
sepsis,  either  with  a  simple  balanitis  or  from  subpreputial  ulceration.  If  a  chancre 
is  present,  it  can  frequently  be  felt  as  an  indurated  area  under  the  prepuce, 
whilst  if  it  has  been  present  for  some  time,  the  secondary  lesions  of  syphilis 
may  be  present.  If  any  doubt  exists  in  an  elderly  patient  whether  an  indurated 
subprepucial  area  be  an  early  epithelioma  or  a  syphilitic  sore,  the  prepuce  should 
be  split  up  along  the  dorsal  aspect  under  anaesthesia,  the  ulceration  inspected, 
and  a  small  piece  submitted  to  microscopical  examination  if  necessary,  without 
loss  of  time. 

5.  Epithelioma  (squamous-celled  carcinoma)  is  ths  most  common  form  of 
malignant  growth  of  the  penis.  It  arises  most  frequently  from  the  inner  aspect 
of  the  prepuce,  or  from  the  mucous  membrane  of  the  glans,  as  a  small,  raised 
ulcer,  with  friable,  irregular  edges.     Epithelioma  is  rarely  present  before  the 


SORES.     PERINEAL  677 


age  of  forty  years,  and  frequently  occurs  on  the  site  of  previous  ulceration  or 
long-standing  irritation.  An  epitheliomatous  ulcer  increases  gradually  in 
size,  in  spite  of  various  forms  of  treatment,  and  with  it  is  frequently  associated 
glandular  enlargement  in  the  inguinal  area.  At  first  the  glands  may  be  enlarged 
from  septic  infection,  but  later  from  malignant  infiltration. 

An  epitheliomatous  ulcer  raay  in  some  cases  be  confused  with  a  chancre  ;  but 
the  friable,  irregular  edges  of  the  former,  the  liability  to  bleed,  and  the  gradual 
progressive  increase  in  size  in  spite  of  treatment  in  an  elderly  patient,  should 
give  rise  to  grave  suspicion  of  malignant  disease.  The  microscopical  examination 
of  a  small  piece  removed  from  the  edge  of  the  ulcer  will  give  direct  evidence  ofr 
epithelioma. 

6.  Gummatous  Ulceration  of  the  penis  occasionally  occurs,  resulting  from  the 
disintegration  of  a  small  gumma  of  the  glans  or  prepuce,  frequently  in  the 
position  of  an  old  scar.  A  gumma  commences  as  a  small,  elevated  nodule, 
which,  if  left  untreated,  softens  and  discharges  its  contents,  leaving  an  ulcer 
bounded  by  thin  edges  and  with  a  yellowish,  sloughy  base.  A  gummatous 
ulcer  has  been  mistaken  for  a  primary  lesion  of  syphilis  ;  but  the  absence  of 
induration,  the  history  of  the  onset  and  of  a  previous  infection  with  syphilis, 
would  be  points  against  a  chancre.  A  second  infection  with  syphilis  is  by  no 
means  unknown,  but  it  is  very  rare  in  comparison  Avith  a  gummatous  ulceration. 
Occasionally  the  base  of  a  gummatous  ulcer  proliferates  into  a  papillary  tumour 
and  has  given  rise  to  a  suspicion  of  carcinoma  ;  the  diagnosis  will  be  confirmed 
by  the  behaA-iour  of  the  lesion  under  potassium  iodide,  when  a  tertiary  syphilitic 
affection  will  rapidly  clear  up. 

7.  Tuberculous  or  Lupoid  Ulceration  of  the  penis  is  rare,  and  is  usually  associ- 
ated with  advanced  tuberculous  infiltration  elsewhere.  Tuberculous  ulcers 
are  usually  shallow,  with  thin  overhanging  edges,  painful  and  multiple.  In 
rare  instances  the  infection  has  resulted  from  the  rite  of  infantile  circumcision 
by  the  Jewish  method.  r,  jj.  Jocelyn  Swan. 

SORES,  PERINEAL. — Ulceration  may  be  present  in  the  perineum  as  the 
result  of  : — • 

1.  Cutaneous  inflammations  and  3.   Prostatic  suppuration 

traumatism  I     4.  Syphilis 

2.  Urethral   fistulje  or  suppuration     1      5.  Epithelioma. 

1.  Cutaneous  Inflammation  and  Traumatism. — An  ulcer  in  the  perineum  may 
result  from  direct  injury  to  the  area,  or  from  inflammatory  infection  of  the 
sebaceous  or  hair  follicles  of  the  cutaneous  covering.  An  ulcer  from  these  causes 
may  be  placed  at  the  centre  or  to  one  side  of  the  perineum,  is  movable  on  the 
deeper  parts,  and  shows  no  tract  into  which  a  probe  can  be  passed,  indicating 
its  derivation  from  other  tissues.  In  women,  ulceration  of  the  perineal  area  may 
be  associated  with  gonorrhceal  or  septic  vaginal  discharge. 

2.  Urethral  Suppurations  or  Fistulae. — During  the  progress  of  an  acute  urethri- 
tis, a  glandular  follicle  frequently  becomes  infected.  The  suppurative  process 
leading  from  this  in  the  bulbous  urethra  may  extend  towards  the  perineum  and 
open  externally,  leaving  a  small  fistula  which  may  or  may  not  discharge  urine 
during  the  act  of  micturition.  In  a  similar  manner,  urinary  fistulse  may 
result  from  the  inflammatory  processes  behind  a  urethral  stricture,  and  in 
an  old-standing  case  it  is  not  uncommon  to  find  a  urinary  calculus  in  the 
dilated  portion  of  the  urethra  behind  the  stricture.  In  the  first  instance,  when 
the  urethral  suppuration  is  acute  and  an  abscess  bursts  in  the  perineum,  the 
diagnosis  will  be  quite  obvious,  and  the  ordinary  treatment  for  an  abscess,  in 
addition  to  that  of  the  acute  urethritis,  will  usually  suffice  to  cure  the  condition. 

If,  however,  the  perineal  wound  discharges  urine,  it  will  be  found  that  this 


678  SORES,     PERINEAL 


occurs  as  a  rule  only  during  the  act  of  micturition,  as  there  is  no  interference 
with  the  vesical  sphincter.  In  nearly  all  cases,  however,  it  will  be  found  that 
there  exists  a  stricture  of  the  urethra,  though  not  necessarily  one  of  sufficient 
degree  to  cause  any  severe  interference  with  micturition.  An  endoscopic 
examination  will  show  the  presence  of  a  urethral  stricture,  whilst  behind  it 
can  be  seen  frequently  the  sloughy  granulations  denoting  the  position  of  the 
internal  or  urethral  opening  of  the  fistula. 

Occasionally  it  may  be  found  that  urine  drains  frora  a  perineal  fistula  con- 
tinuously, and  not  only  during  the  act  of  micturition.  In  these  cases  there  is 
constant  soaking  of  the  perineal  skin,  and  frequently  excoriation.  That  urine 
should  leak  constantly  from  the  fistula  denotes  interference  with  the  vesical 
sphincter,  either  by  dilatation  behind  a  tight  urethral  stricture,  by  the  presence 
of  a  calculus  in  the  prostatic  or  membranous  urethra,  or  by  actual  division 
of  the  vesical  sphincter  following  some  operation,  such  as  perineal  prostatectomy 
or  perineal  lithotomy. 

3.  Diseases  of  the  Prostate. — An  abscess  or  tuberculous  focus  in  the  prostate 
may  occasionally  discharge  in  the  perineum,  and  remain  as  a  sinus. 

An  abscess  in  the  prostate  arises  practically  always  from  some  infection 
in  the  posterior  urethra,  from  venereal  causes,  or  after  septic  instrumentation. 
It  is  accompanied  by  urethral  discharge,  or  there  is  a  history  of  a  recent  infection, 
whilst  per  rectum  the  prostate  may  be  felt  to  be  inflamed  or  scarred  from  the 
shrinkage  of  the  abscess  cavity. 

That  a  tuberculous  cavity  in  the  prostate  should  open  in  the  perineum  implies 
that  there  is  advanced  tuberculous  disease,  so  that  little  difficulty  will  be  found 
in  arriving  at  a  diagnosis.  A  tuberculous  prostate  is  very  rarely  a  primary 
condition,  but  in  most  cases  is  secondary  to  disease  in  the  testis  or  bladder, 
so  that  an  examination  of  these  organs  will  in  nearly  all  cases  give  evidence  of 
tuberculous  disease  and  indicate  the  nature  of  the  perineal  fistula.  Palpation 
of  the  prostate  per  rectum  may  reveal  the  rounded  nodular  deposit  of  tubercle 
in  the  gland. 

4.  Syphilis  may  cause  ulceration  on  the  perineum  either  as  a  chancre  or  by 
mucous  tubercles.  A  chancre  on  the  perineum  is  rare.  It  forms  a  small  ulcer 
with  slightly  indurated  borders,  indolent  in  character,  and  accompanied  by 
slight  enlargement  of  the  inguinal  lymphatic  glands.  A  chancre  of  the  skin 
does  not  possess  the  usual  features  of  a  genital  chancre,  and  is  not  usually 
diagnosed  with  certainty  until  the  secondary  lesions  of  syphilis  become 
apparent  ;  but  an  ulcer  with  raised,  infiltrated  edges,  which  shows  no  tendency 
to  heal  under  aseptic  precautions,  should  always  give  rise  to  a  suspicion  of 
syphilis.  The  Spirochceta  pallida  may  be  looked  for,  and  Wassermann's  serum 
test  tried. 

Condylomata  may  be  present  about  the  perineum  in  association  with  active 
syphilis.  They  may  extend  from  the  anal  or  vulval  orifice,  and  form  oval  or 
rounded,  flat-topped,  sessile  masses,  covered  by  macerated,  grejdsh  epithelium, 
or  they  may  be  ulcerated  on  the  surface.  The  accompanying  signs  of  syphilis 
will  indicate  the  diagnosis. 

5.  Epitheliomatous  Ulceration  of  the  perineum  is  practically  only  seen  as  a 
direct  spread  of  a  growth  of  the  anus  or  vulval  area,  when  the  diagnosis  presents 
no  difficulty.  An  epithelioma  may  develop  in  the  scar  of  some  former  cutaneous 
affection,  in  which  case  an  ulceration  may  exist,  showing  the  usual  characteristics 
of  a  cutaneous  epithelioma,  namely,  gradual  progressive  increase  in  size,  raised, 
friable  edges,  and  tendency  to  slight  haemorrhages.  The  inguinal  glands  may 
be  enlarged  early  from  inflammatory  absorption,  or  later  by  infection  with 
malignant  disease.  In  case  of  doubt  a  fragment  may  be  removed  for  micro- 
scopical examination.  R.  H.  Jocelyn  Swan. 


SORES,     SCROTAL  679 


SORES,  SCROTAL. — Ulceration  of  the  scrotum  occurs  in  association  with  : — 

1.  Xew  growth  :  3.  Testicular  disease : 

Epithelioma  j  Inflammatory 

Papilloma  !  Tuberculous 

2.  Fistulae.  1  Syphilitic. 

!  4.  Suppurating  cysts. 

5.  Syphilis. 

1.  Epithelioma  of  the  Scrotum  is  the  most  common  form  of  ulceration  met  with 
in  this  region.  Although  commonly  known  as  "  chimney-sweep's  cancer,"  scrotal 
epithelioma  is  by  no  means  limited  to  this  avocation,  but  it  is  certainly  more 
common  in  men  engaged  in  work  in  which  they  are  exposed  to  much  irritation 
from  solid  particles  or  from  noxious  fumes.  Hence  the  disease  is  most  commonly 
seen  amongst  chimney-sweeps,  employees  in  gas-works,  paraffin  and  chemical 
works,  and  coal-mines.  The  disease  commonly  begins  as  a  small  subcutaneous 
nodule,  over  which  the  skin  is  thinned  and  adherent ;  the  nodule  slowly 
enlarges,  and  the  thinned  covering  gives  way,  to  form  an  ulcer  with  thickened, 
irregular  edges  and  with  a  tendency  to  bleed  on  slight  injur j^  The  ulcerated 
area  extends  both  radially  and  into  the  tissues  of  the  scrotum,  later  involving 
the  testes.  The  inguinal  lymphatic  glands  become  enlarged  soon  after  active 
ulceration  commences,  at  first  from  inflammatory  causes,  but  later  from 
maUgnant  infiltration. 

In  other  cases  a  scrotal  epithelioma  begins  in  a  wart  or  in  a  papilloma, 
which  may  have  been  present  for  some  years  with  only  slight  increase 
in  growth.  These  soft  papillomata  are  not  unusually  the  starting  -  point 
of  malignant  change,  when  they  become  more  vascular^  whilst  the  surface 
epithelium  becomes  thinned  and  easily  excoriated.  A  small  amount  of  foul 
discharge  is  present,  often  encrusted  into  a  scab,  which  on  removal  leaves 
an  ulcer  with  indurated,  everted  edges,  with  the  gradual  progress  of  a 
cutaneous  epithelioma. 

Thus  a  small  ulcer  on  the  scrotum,  especially  if  indurated  or  readily  caused 
to  bleed,  must  be  looked  upon  with  extreme  suspicion,  and  when  it  does  not 
improve  with  ordinary  antiseptic  medication,  should  be  widely  removed  with- 
out waiting  for  glandular  enlargement. 

Epithelioma  may  occur  in  the  scrotal  area  as  a  localized  recurrence  after 
removal  of  a  malignant  growth  of  the  penis  or  testicle.  The  knowledge  of 
the  previous  condition  for  which  operation  has  been  performed,  would  cause 
any  recurrent  ulceration  about  the  scar  to  be  regarded  with  extreme  suspicion 
of  malignant  disease. 

2.  FistuISB  may  occur  in  the  scrotum  and  cause  ulceration.  They  are  most 
common  in  association  with  tuberculous  or  s^'philitic  disease  of  the  testes  (see 
below),  but  occasionally  they  occur  from  urethral  extravasation,  or  the  burrow- 
ing from  rectal  suppuration.  An  abscess  may  form  and  open  through  the 
scrotal  skin  from  a  peri-urethral  abscess  accompanying  an  acute  urethritis  or 
formed  by  septic  infection  behind  a  urethral  stricture.  In  either  case  a 
small  amount  of  urine  may  leak  through  the  opening  during  micturition,  whilst 
the  history  of  urethral  discharge,  or  of  difficulty  in  micturition  and  other 
symptoms  of  stricture,  will  point  to  the  diagnosis. 

3.  Testicular  Disease. — In  some  cases  extension  of  disease  in  the  testicle  may 
involve  the  coverings  of  the  scrotum,  and  may  even  perforate  them  to  form  a 
scrotal  sore.  This  sequence  occasionally  occurs  with  :  (i)  A  testicular  abscess  ; 
(2)  Tuberculosis  of  the  testis  ;    (3)   Gumma  of  the  testis. 

A  testicular  abscess  is  somewhat  uncommon,  but  may  arise  from  direct  exten- 
sion from  the  urethra  via  the  vesiculse  seminales  and  vasa  deferentia  or  bv  a 


68o  SORES,     SCROTAL 


haematogenous  infection  during  the  course  of  a  specific  fever,  such  as  scarlet 
fever,  parotitis,  or  enterica.  It  may  also  follow  chronic  torsio  testis.  With 
urethral  disease,  the  primar)'  trouble  may  be  due  to  gonorrhoea,  or  more  fre- 
quently to  a  septic  urethritis  from  the  introduction  of  infected  instruments, 
and  is  thus  not  infrequent  in  cases  of  prostatic  enlargement  in  which  the  patient 
is  passing  his  own  catheter.  In  cases  in  which  the  infective  process  extends 
from  the  urethra,  the  epididymis  is  affected  first,  Avhilst  in  the  metastatic  cases 
the  body  of  the  testis  usually  shows  the  first  sign  of  enlargement.  These  acute 
inflammations  of  the  testis  occasionally  suppurate,  when  the  scrotal  tunics 
become  inflamed  and  adherent,  whilst  softening  occurs  later,  and  unless 
surgically  relieved,  the  abscess  opens  through  the  skin,  leaving  an  ulcer,  and  a 
sinus  discharging  pus. 

Tuberculosis  of  the  testicle  ma}-  occur  as  a  primar}'  disease  or  as  a  secondary 
deposit  in  association  with  tuberculosis  elsewhere  in  the  genito-urinarj-  tract. 
Testicular  tubercle  almost  always  begins  as  a  nodule  in  the  epidid}Tnis,  but 
in  the  later  progress  of  the  disease  may  extend  into  the  testicle  proper.  If 
the  tuberculous  nodule  progresses  rather  than  undergoes  cure,  the  scrotal  skin 
becomes  adherent,  thinned,  and  finally  perforated,  lea\-ing  a  shallow  ulcer  ■^•ith 
thin,  undermined  edges,  and  discharging  thin  pus.  Occasionally  the  necrotic 
tubules  of  the  epididymis  fungate  through  the  opening  in  the  scrotum,  appearing 
as  a  greyish,  sloughy  projection  from  the  cutaneous  opening — the  so-caUed 
"  hernia  testis." 

A  gumma  of  the  testis  causes  a  swelling  in  the  bod}'  of  the  testis  rather 
than  in  the  epididymis.  A  gumma  which  remains  unrecognized  or  un- 
treated may  soften  and  ulcerate  through  the  scrotal  skin  in  a  manner  similar 
to  tuberculous  disease,  leaving  a  clearly-defined  ulcerated  area  with  sharply- 
cut  margins,  and  a  wash-leather-like  slough}^  base.  The  gummatous  granu- 
lation tissue  may  fungate  through  the  scrotal  aperture,  forming  a  yellowish, 
necrotic  mass. 

The  diagnosis  of  these  three  conditions  may  produce  some  dif&culty  in  the 
earlier  stages  (see  Swellixg,  Scrotal),  but  in  the  advanced  stage  now 
under  consideration,  when  an  open  scrotal  sore  is  present,  the  diagnosis  is 
easier.  The  opening  of  a  testicular  abscess  on  the  scrotum  leaves  a  smaU  sinus 
discharging  pus  and  accompanied  by  a  general  enlargement  of  the  organ. 
Preceding  the  rupture  of  the  abscess  there  is  acute  pain  in  the  testicle,  with  rise 
of  temperature,  rigors,  and  general  signs  of  suppuration,  which  are  much 
diminished  as  soon  as  the  abscess  is  allowed  to  burst.  There  is  often  a 
urethral  discharge,  which,  however,  is  often  much  lessened  with  the  onset  of  the 
acute  epididj'mitis,  with  distinct  thickening  of  the  cord  and  aching  pain  in  the 
neighbourhood  of  the  external  abdominal  ring,  or  in  metastatic  cases  the 
abscess  occurs  during  the  progress  of  an  acute  fever.  The  general  history  is 
one  of  acute  pain  commencing  in  the  testicle,  with  rapid  and  extremely  tender 
swelling  of  the  organ,  followed  by  abscess-formation. 

In  tuberculosis  of  the  testis  the  progress  is  much  more  gradual.  A  nodule  may 
have  been  present  in  the  epididymis  for  some  time,  gradually  enlarging,  but 
causing  very  little  pain  ;  in  some  cases  a  nodule  may  have  been  present  for 
months  without  any  apparent  change,  and  then  it  maj'  enlarge  suddenly,  involve 
the  scrotal  tunics,  and  discharge  its  contents.  By  the  time  the  disease  has 
reached  this  stage,  it  is  probable  that  evidence  of  tuberculous  trouble  will  be 
found  in  other  organs,  particularly  the  other  testis,  prostate,  seminal  vesicle, 
or  bladder.  The  affected  testicle  usually  presents  several  nodules  in  the 
epididymis,  tender  on  pressure,  whilst  small  nodules  may  also  be  felt  in 
the  vas  deferens. 

The  opening  remaining  from  the  discharge  of  a  gummatous  orchitis  is  usually 


SORES.     SCROTAL  68i 


a  rounded  ulcer  with  sharply-cut  edges  and  yellowish  base.  The  whole  testis 
is  enlarged,  practically  painless,  and  gives  a  sensation  of  weight  in  the  organ. 
The  cord  is  not  thickened,  and  there  is  no  evidence  of  disease  in  the  other  testicle, 
prostate,  or  seminal  vesicles.  There  is  probably  a  history  of  syphihs,  and  other 
tertiary  s\^hilitic  lesions  may  be  present  elsewhere,  such  as  gummatous  peri- 
ostitis. Strong  evidence  of  the  s\^hilitic  nature  of  the  disease  is  often  obtained 
by  the  result  of  treatment  with  large  doses  of  potassium  iodide,  alone  or  in 
combination  with  mercury,  when  a  gumma  diminishes  in  size  with  marked 
rapiditv.  It  should  be  remarked,  however,  that,  as  in  two  cases  under  the 
^vriter's  care,  testes  which  are  subsequently  removed  and  found  to  contain 
large  gummata,  mav  show  no  improvement  before  operation,  even  under  large 
doses  of  iodides. 

A  Hernial  Protrusion  of  necrotic  Testicular  Tissue  may  be  present  either  ^vith 
tuberculous  disease  or  from  a  gumma.  In  tuberculosis  the  mass  is  grejdsh 
and  necrotic,  discharging  thin  pus,  and  there  wiU  be  sufficient  evidence  of 
tuberculous  disease  in  the  underlining  testis  and  other  genital  organs.  A 
distinctive  feature  of  the  gummatous  hernia  testis  is  found  in  the  appearance 
of  the  cutaneous  opening  ;  if  the  fungating  mass  be  pushed  aside,  the  opening 
in  the  scrotal  skin  will  be  seen  to  be  cleanly  cut  and  to  encircle  the  protruding 
tissue  tightlv.  The  fungating  hernia  testis  of  tubercle  or  syphilis  must  also  be 
diagnosed  from  other  conditions  producing  a  raised  tumour  on  the  scrotum. 
An  epithelioma  of  the  scrotum  has  raised  borders,  but  the  centre  is  excavated, 
and  there  is  rarely  anj'  enlargement  of  the  testis.  A  sloughing  papilloma  of 
the  scrotum  mav  more  nearly  reproduce  the  appearance,  but  the  tumour  and 
the  skin  are  freelv  movable  on  the  underlying  testis,  whilst  in  hernia  testis  the 
mass  is  easily  seen  to  be  connected  with  the  testicle,  and  the  tubular  structure 
of  the  latter  is  often  apparent  on  picking  up  a  smaU  fragment  of  the  fungating 
tumour. 

4.  Cysts  of  the  Scrotum. — As  an  exceptional  occurrence,  a  sebaceous  cyst  may 
develop  in  the  scrotal  skin,  suppurate,  and  leave  an  open  sore.  The  areas 
remaining  present  raised  borders,  and  are  easily  mistaken  for  an  early  epitheh- 
oma.  An  accurate  history  of  the  previous  swelHng  in  the  skin  is  of  little 
assistance  in  these  cases,  but  the  microscopical  examination  of  a  piece  removed 
from  the  margin  of  the  ulcer  will  readily  exclude  malignancy.  A  suppurating 
cyst  in  the  scrotum  is  more  uncommon  than  epithelioma. 

5.  Syphilis  of  the  Scrotum  may  be  present  either  as  a  primary  chancre  or 
as  a  mucous  tubercle.  A  primary  chancre  in  this  situation  is  by  no  means 
easy  to  recognize  unless  other  signs  of  sj'philis  are  present ;  but  the  presence 
of  a  cutaneous  sore  which  does  not  show  much  incUnation  to  heal  under 
non-mercurial  antiseptic  dressings  should  always  give  a  suspicion  of  syphilis. 
There  is  often  only  slight  induration  of  the  ulcer  compared  with  that  of  a 
penile  chancre,  but  the  edge  is  raised  and  of  a  rolled  appearance.  The 
inguinal  Ij-mphatic  glands  are  enlarged  and  discrete,  and  some  five  to  six 
weeks  after  the  commencement  of  the  ulcer  the  usual  secondan,-  s^-mptoms  of 
syphilis  become  manifest. 

JMucous  tubercles  may  be  present  on  the  scrotum,  usually  on  the  femoral 
aspect.  They  may  extend  directly  from  the  anal  area.  No  difi&culty  will  be 
met  with  in  the  diagnosis,  as  other  signs  of  s}-phiHs  are  obvious. 

R.  H.  Jocelvn  Swan. 

SPASMODIC  CONTRACTIONS.— (See  Contractions.) 


SPASMODIC  DYSPNffiA.— (See  Dyspncea.) 
SPASTICITY. — (See  Gait,  Abnormalities  of.) 


682  SPEECH,     ABNORMALITIES     OF 

SPEECH,  ABNORMALITIES  OF.— Speech  is  a  highly-specialized  function 
of  the  human  nerv'ous  system,  by  means  of  which  we  are  able,  more  easily  and 
more  clearly  than  by  any  other  means,  to  communicate  our  thoughts,  desires, 
commands,  etc.,  one  to  another.  Abnormalities  of  speech  are  numerous,  vary- 
ing from  complete  mutism  to  slight  defects  in  articulation,  and  dependent  on 
disturbances,  functional  or  organic,  in  some  part  of  the  complex  mechanism 
which  is  responsible  for  the  production  of  intelligible  language. 

This  article  is  intended  to  expose  the  broad  principles  by  which  various 
abnormalities  of  speech  can  be  detected  and  used  for  the  purposes  of  diagnosis  ; 
it  does  not  embrace  a  discus.sion  of  the  controversial  views  which  are  held  con- 
cerning their  exact  production. 

The  amount  of  investigation  required  for  making  a  diagnosis  in  cases  of  speech 
abnormality  must  vary  Avithin  wide  limits.  The  greatest  care  is  called  for  in 
the  examination  of  cases  of  aphasia  which  result  from  disturbances  in  the 
function  of  the  cerebral  speech  centres  or  their  dependent  paths  of  communica- 
tion. On  the  other  hand,  the  defective  articulation  of  a  patient  suffering  from 
cleft  palate  needs  only  a  comparatively  superficial  examination  in  order  to 
arrive  at  a  correct  diagnosis. 

It  will  be  convenient  to  consider  the  various  abnormalities  of  speech  under 
the  following  heads  :  (i)  Mental  defects  ;  (2)  Aphasia  ;  (3)  Deaf  mutism  ; 
(4)   Dysarthria  ;     (5)   Functional  disorders — stammering,  lalling,  idioglossia. 

1.  Mental  Defects. — The  acquirement  of  the  power  of  speech  may  be  delayed 
in  children  who  are  mentally  defective,  and  in  some  forms  of  idiocy  may  be 
suspended  altogether.  Before  making  a  diagnosis  of  mental  deficiency  in  a 
child  who  appears  to  be  dilatory  in  talking,  it  is  well  to  remember  that  the  age 
at  which  speech  is  acquired  is  very  variable,  and  that  the  delay  may  be  con- 
siderable where  no  mental  impairment  is  present.  In  such  cases  the  diagnosis 
m.ust  depend  on  a  consideration  of  other  points  in  the  child's  development. 
Inquirj^  should  be  made  as  to  whether  he  is  clean  in  his  habits,  whether  he  is 
destructive,  whether  he  pla^^s  with  toys  or  with  other  children  in  a  natural 
manner,  and  whether  he  displays  abnormally  bad  temper  or  irritability.  In 
some  cases  the  delay  in  speaking  may  be  due  to  a  defect  in  hearing  which  has 
been  unsuspected  by  the  parents.  This  point  is  especially  apt  to  arise  in  respect 
to  children  who  have  begun  to  talk  at  the  normal  age,  and  who  have  lost  what 
little  they  had  learned  of  the  art  in  the  sequel  of  some  acute  illness. 

In  adults,  loss  of  speech  may  be  due  to  many  forms  of  mental  deficiency  of  a 
temporary  or  permanent  nature.  A  familiar  example  of  temporary  loss  of 
speech  ma}^  be  the  result  of  that  degree  of  alcoholic  intoxication  to  which  the 
term  "  speechless  "  is  vulgarly  applied.  Similarly,  the  intoxication  of  the 
higher  mental  faculties  associated  with  organic  poisons,  such  as  those  of  pneu- 
monia or  tj'phoid  fever,  may  be  responsible  for  temporary  loss  of  speech.  Com- 
plete mutism  due  to  disease  of  the  higher  intellectual  centres  of  the  brain  is 
common  enough  in  various  forms  of  dementia,  and  is  proved  to  be  no  aphasic 
defect  by  the  sudden  and  complete  restoration  of  speech  which  may  take  place 
after  months  or  even  years  of  silence. 

The  speechlessness  of  a  melancholic  patient  or  of  one  who  is  suffering  from 
paralytic  dementia  is  further  differentiated  from  true  aphasia  by  the  fact  that 
the  latter  is  associated  with  attempts  at  communication,  while  the  former  is  not. 
On  the  other  hand,  it  must  be  remembered  that  general  paralysis  of  the  insane 
is  a  disease  in  which  temporary  aphasia  is  by  no  means  uncommon,  especially 
in  connection  with  the  transient  hemiplegia  following  "  congestive  "  attacks. 

2.  Aphasia. — A  definition  of  aphasia  is  difficult  to  supply  in  a  few  words. 
The  term  is  used  to  denote  that  loss  of  speech  which  does  not  depend  on  mental 
deficiency,  nor  upon  paralysis  of  the  motor  mechanism  of  articulation.     Such  a 


SPEECH,     ABNORMALITIES     OF 


negative  description  requires,  however,  some  modification,  because  aphasia  is 
frequently  associated  with  some  impairment  of  intelligence  resulting  from 
disturbance  of  internal  language.  Internal  language  plays  an  important  part 
in  all  intellectual  processes,  and  any  lesion  of  the  cerebral  centres  connected 
with  it  must  necessarily  interfere  with  the  higher  mental  activities.  This  is 
particularly  the  case  in  what  is  called  sensory  aphasia,  that  variety  which 
depends  upon  a  lesion  of  the  auditory  and  visual  word  centres  situated  in  the 
cortex  near  the  posterior  part  of  the  left  Sylvian  fissure  of  the  brain. 

In  right-handed  persons  the  chief  speech  centres  are  placed  in  the  left  cerebral 
hemisphere  {Fig.  185),  and  it  is  customary  to  consider  them  as  being  three  in 
number.  The  posterior  part  of  the  first  temporal  convolution  is  regarded  as  the 
area  in  which  the  auditory  memories  of  spoken  words  are  stored  and  recalled. 
It  plays  an  important  part  in  the  development  of  speech,  because  it  is  largely 
through  the  sense  of  hearing  that  the  child  first  learns  to  associate  objects  with 
their  names  and  expressions  with  their  meaning.  The  cortex  in  the  angular 
gyrus  has  a  similar  special  function  in  regard  to  the  storage  of  visual  word 
memories,  a  function  which  bears  the  same  relationship  to  written  language  as 


Cheiro-kinassthetic  centre 


Visual  word  centre 


— Left  cerebral  hemisphere,  with  speech  centres. 


the  auditory  word  centre  has  to  spoken  language.  These  two  portions  of  the 
cortex  constitute  the  sensory  speech  centres.  A  third  important  centre  is 
called  the  motor,  or,  better,  the  higher  kinsesthetic  centre,  and  this  is  located  in 
Broca's  area,  or  the  posterior  part  of  the  third  frontal  convolution.  In  this 
situation  are  stored  the  memories  of  afferent  impulses  excited  by  the  motor 
activities  employed  in  speech.  Unless  this  centre  is  intact,  the  conversion  of 
internal  into  external  language  is  imperfect  or  impossible.  In  the  opinion  of 
some  authorities,  there  is  a  similar  kinaesthetic  centre  in  the  posterior  part  of  the 
left  second  frontal  convolution,  which  plays  a  part  in  connection  with  written 
language  comparable  to  the  part  played  by  Broca's  area  in  relation  to  spoken 
language. 

With  these  physiological  and  anatomical  data  as  a  basis,  we  can  proceed  to 
consider  the  chief  varieties  of  aphasia  and  the  points  in  their  differential 
diagnosis.  Before  doing  so,  it  is  well  to  sound  a  note  of  warning  with  regard  to 
the  complications  which  are  constantly  being  met  with  by  the  clinician  in 
attempting  to  analyze  cases  of  aphasia.  In  the  first  place,  a  diagrammatic 
anatomical  definition  of  the  cerebral  centres  is  liable  to  give  a  wrong  impression. 


684  SPEECH,     ABNORMALITIES     OF 


These  centres  are  more  diffuse  in  their  function  than  they  appear  to  be  on  a  map 
of  the  brain,  and  they  are  much  more  interdependent  than  their  topography 
would  suggest.  Communicating  nervous  tracts  bind  them  together  in  such  a 
way  that  a  destructive  lesion  of  one  must  necessarily  upset  the  function  of 
another,  and  so  modify  profoundly  the  clinical  picture  of  any  particular  case. 
In  the  second  place,  it  must  not  be  forgotten  that  aphasia  is,  in  the  majority  of 
instances,  the  result  of  a  vascular  lesion,  and  that  all  the  centres  to  which  we 
have  referred  lie  in  the  area  supplied  by  one  artery — the  middle  cerebral  arter5^ 
Consequently  it  is  only  rational  to  expect  that,  even  when  the  main  brunt  of  a 
vascular  disturbance  falls  on  one  of  the  special  speech  centres,  the  other  centres 
may  also  suffer  more  or  less,  temporarily  or  permanently,  from  disturbances  of 
nutrition.  In  any  case  of  aphasia,  therefore,  we  may  have  to  be  satisfied  if  we 
can  arrive  at  a  conclusion  as  to  the  site  of  the  chief  defect,  without  being  able 
to  define  the  exact  limits  of  the  loss  or  impairment  of  cerebral  function.  In  the 
third  place,  due  allowance  must  be  made  for  the  recognized  fact  that  the  right 
cerebral  hemisphere  may  gradually  acquire  some  degree  of  speech  activity, 
especially  in  cases  of  aphasia  occurring  during  the  earlier  years  of  life,  and  may 
tend  to  replace  the  loss  caused  by  the  defective  action  of  the  left  hemisphere. 

Word-deafness  is  the  result  of  a  lesion  either  of  the  auditory  word  centre  in 
the  temporal  cortex,  or  of  one  which  isolates  that  centre  from  the  periphery  : 
that  is  to  say,  of  a  sub-cortical  lesion  cutting  off  the  centre  from  auditorj' 
im.pulses.  In  either  case  the  patient  who  is  word-deaf  is  unable  to  recognize 
the  meaning  of  spoken  language,  although  he  may  hear  perfectly  the  sounds 
by  which  it  is  conveyed.  In  the  course  of  examination  it  will  be  found  that  he 
fails  to  understand  anything  which  is  said  to  him,  and  that  he  does  not  obey 
simple  commands  so  long  as  they  are  not  accompanied  by  gestures  suggestive 
of  their  meaning.  If  the  visual  word  centre  has  not  been  affected  at  the  same 
time,  he  will  still  be  able  to  read  and  to  understand  what  is  written.  In  fact  he 
will  depend  upon  writing  and  reading  for  his  means  of  communication  with 
others.  The  amount  of  interference  with  spontaneous  speech  will  depend  upon 
whether  the  lesion  is  cortical  or  sub-cortical.  In  the  latter  case  the  integrity  of 
the  auditory  word  centre  preserves  internal  speech,  and  so  permits  the  patient 
to  speak  spontaneously  with  fluency  and  probably  with  accuracy,  and  his  power 
of  writing  will  be  equally  unimpaired.  When  the  cortical  centre  is  itself 
destroyed,  internal  language  is  thoroughly  disorganized,  and  although  a  certain 
amount  of  spontaneous  speech  may  be  uttered,  it  is  certain  to  be  more  or  less 
unintelligible.  According  to  the  extent  of  the  lesion,  it  will  vary  between  a 
speech  containing  inaccuracies  of  minor  importance,  and  one  which  is  a  jargon 
incapable  of  interpretation.  Characteristic  of  this  defect  is  the  fact  that  the 
patient  himself  does  not  appreciate  the  mistakes  he  makes.  His  written  language 
is  likely  to  be  more  accurate  and  more  intelligible  than  his  spoken  language, 
but  it  will  probably  not  reach  a  very  high  standard.  He  may  copy  with  accuracy, 
but  is  quite  unable  to  write  from  dictation.  Such  are  the  usual  chief  attributes 
of  word-deafness  in  its  pure  form.  Clinically,  word-deafness  is  usually  accom- 
panied by  word-blindness,  to  a  greater  or  less  extent. 

Word-blindness,  or  Alexia,  is  produced  by  a  lesion  of  the  left  angular  gyrus, 
and  may  or  may  not  be  accompanied  by  defective  vision.  As  in  the  case  of 
word-deafness,  it  may  result  from  a  cortical  or  from  a  sub-cortical  lesion,  and  it 
is  in  association  with  the  latter  class  of  case  that  Hemianopia  [q.v.)  is  most 
commonly  observed.  In  cortical  word-blindness  the  patient  is  unable  to  read, 
although  he  sees  the  letters  clearly  and  may  even  be  able  to  copy  them  in  the 
same  way  as  a  child  copies  letters  when  learning  the  alphabet.  Writing  conveys 
no  meaning  to  his  mind,  although  in  the  less  severe  cases  the  patient  may  still 
recognize  familiar  words,  such  as  his  name.     There  are,  in  fact,  varjdng  degrees 


SPEECH,     ABNORMALITIES     OF  685 

of  word-blindness,  some  of  which  are  difficult  to  understand  and  to  analyze. 
The  word-blind  patient  suiters  in  his  spontaneous  speech  to  a  greater  or  less 
extent  according  to  whether  he  uses  his  visual  or  his  auditory  memories  chiefly 
in  the  process  of  internal  language.  Should  he  be  a  "  visual  "  his  spontaneous 
speech  wall  suffer  much  more  than  if  he  is  an  "  auditive."  The  terms  "  visual  " 
and  "  auditive  "  are  used  to  distinguish  two  classes  of  persons,  the  first  depend- 
ing more  on  their  visual  m.emories  of  words,  and  the  second  more  on  their 
auditory  memories  of  words  in  the  course  of  reviving  them  for  the  purposes  of 
internal  thought  and  speech.  Spontaneous  writing  is  likely  to  be  completely 
lost,  but  writing  from  dictation  may  possibly  be  carried  out  with  more  or  less 
accuracy. 

In  word-blindness  due  to  a  sub-cortical  lesion,  although  hemianopia  is  almost 
certain  to  be  present,  spontaneous  speech  and  spontaneous  writing  are  perfectly 
preserved,  although  the  power  of  reading  and  the  power  of  copying  hand-written 
sentences  into  printed  capitals  is  entirely  in  abeyance. 

^Vhen  word-blindness  and  word-deafness  coexist,  the  condition  is  called 
sensory  aphasia,  and  is  one  to  which  some  authorities  believe  that  the  term 
aphasia  should  be  limited.  It  is,  however,  usual  to  describe  a  motor  aphasia 
which  may  be  dependent  upon  a  cortical  or  sub-cortical  lesion. 

Cortical  motor  aphasia  results  from  a  destructive  lesion  of  Broca's  area,  the 
part  of  the  cortex  which  stores  memories  of  the  afferent  impulses  excited  by 
speech,  and  in  which  such  memories  must  be  revived  if  spontaneous  speech  is 
to  be  carried  out  perfectly.  This  form  of  motor  aphasia  may  be  present  without 
any  paralysis,  but  it  is  usually  accompanied  by  some  disturbances  of  internal 
speech,  and  perhaps  even  by  some  defective  understanding  of  spoken  and 
written  language,  which,  however,  never  amounts  to  true  sensory  aphasia. 

IMuch  more  common  is  the  sub-cortical  motor  aphasia  which  is  due  to  a  lesion 
cutting  off  Broca's  cortical  area  from  the  motor  mechanism  connected  with 
articulation.  In  this  form  of  aphasia  the  intellectual  processes  and  internal 
language  may  be  perfectly  intact,  but  in  the  majority  of  cases  the  inability  to 
speak  is  associated  with  right  hemiplegia  in  right-handed  persons,  or  with  left 
hemiplegia  in  left-handed  indi\"iduals.  The  imperfect  speech  of  the  patient 
who  is  partly  aphasic  from  a  sub-cortical  motor  lesion  may  resemble  to  some 
extent  that  of  the  patient  who  is  word-deaf  ;  but  the  former  is  conscious  of  his 
mistakes  and  the  latter  is  not.  Sub-cortical  motor  aphasia  may  perhaps  be 
better  described  as  an  articulator}^  rather  than  a  speech  defect  :  as  an  anarthria 
rather  than  an  aphasia.  All  the  attributes  for  speech  are  preserved,  but  its 
emission  is  impossible. 

Agraphia  results  usually  from  a  lesion  of  the  visual  word-centre,  or  perhaps 
in  some  cases  from  a  lesion  of  the  posterior  part  of  the  left  second  frontal  con- 
volution. In  the  former  case  the  power  of  writing  may  be  lost,  although  there 
is  no  paratysis  of  the  arm  or  hand.  In  the  latter  case  the  agraphia  is  usually- 
associated  with  right  hemiplegia,  and  in  order  to  test  whether  the  power  of 
communicating  thoughts  by  written  language  is  preserved,  the  patient  must  be 
asked  to  use  the  left  hand  for  the  purpose.  There  is  some  doubt  as  to  whether 
pure  motor  agraphia  occurs,  and  some  doubt  as  to  the  lesion  upon  which  it  maj- 
depend.  I  have  had  experience  of  the  clinical  occurrence  of  pure  motor  agraphia 
without  being  able  to  correlate  the  phenomenon  with  its  anatomical  basis. 

We  have  now  considered  the  various  forms  of  aphasia  and  have  indicated 
their  points  of  distinction.  This  will  serve  as  a  basis  for  diagnosing  the  site  of 
the  lesion  responsible  for  the  speech  defect,  but  the  nature  of  the  lesion  must  be 
determined  from  other  considerations.  Vascular  lesions,  for  instance,  are 
usually  acute  in  their  onset,  sudden  in  the  case  of  embolism,  less  precipitate  as  a 
rule  in  cases  of  hcBmovrhage  or  throynbosis.     In  cerebral  tiimoitr  or  abscess  the  onset 


686  SPEECH,     ABNORMALITIES     OF 

of  symptoms  is  m.ore  gradual,  and  local  troubles  such  as  that  of  aphasia  are 
generally  accompanied  or  preceded  by  the  symptoms  of  increased  intracranial 
pressure  in  the  form  of  headache,  vomiting,  and  optic  neuritis.  But  aphasia 
is  not  always  the  result  of  a  gross  and  permanent  lesion.  Transitory  aphasia 
may  be  observed  in  the  sequel  of  epileptiform  convulsions,  or  may  be  in  itself 
an  epileptic  equivalent — a  form  of  petit  mal  in  an  epileptic  subject.  Temporary 
aphasia  occurs  also  in  connection  with  migraine,  and  I  have  known  it  to  occur 
at  intervals  during  a  period  of  thirty  or  forty  years  in  a  woman  who  was  perfectly 
healthy  in  every  respect,  and  who  showed  no  other  symptoms  suggestive  of 
either  epilepsy  or  migraine. 

4.  Dysarthria,  or  in  its  extreme  form  "  anarthria,"  is  the  term  used  to  describe 
defective  articulation  as  opposed  to  defective  speech.  Articulation  is  carried 
on  by  certain  muscles  of  the  larynx,  pharynx,  palate,  tongue,  and  lips  which 
are  innervated  by  the  bulbar  nuclei,  and  the  latter  are  set  into  action  by 
voluntary  impulses  coming  from,  the  motor  cortex  of  both  cerebral  hemi- 
spheres via  the  pyramidal  tracts.  The  articulatory  movements,  therefore,  are 
bilaterally  represented  in  the  brain,  and,  like  other  bilaterally  represented 
movements  of  the  body,  are  not  disorganized  by  unilateral  lesions  of  the 
pyramidal  system.  Thus,  in  cases  of  hemiplegia  without  aphasia,  there  is 
little  or  no  defect  in  articulation,  and  the  examination  of  such  a  patient  shows 
that  both  vocal  cords,  both  sides  of  the  palate,  and  the  tongue,  retain  their 
power  of  voluntary  movement  almost,  if  not  quite,  to  perfection. 

Suprabulbar  dysarthria  is  induced,  however,  in  cases  of  double  hemiplegia, 
when  the  fibres  from  both  hemispheres  to  the  bulbar  nuclei  are  interfered  with 
by  destructive  lesions.  When  a  right-sided  stroke  is  followed  by  a  left-sided 
stroke,  or  when  double  hemiplegia  results  from  a  lesion  in  the  pons,  dysarthria 
results.  In  such  cases  the  power  of  speech  may  be  perfect,  but  -the  ability  to 
articulate  naturally  and  clearly  is  disturbed.  The  patient  is  not  aphasic  but 
dysarthric.  Articulation  is  usually  slow,  spastic,  and  indistinct,  if  it  is  not 
altogether  unintelligible.  These  cases  are  differentiated  from  cases  of  dysarthria 
due  to  lesions  of  the  bulbar  nuclei  or  of  the  cranial  nerves,  not  only  by  the 
presence  of  other  hemiplegic  signs  in  the  limbs  and  trunk,  but  by  the  fact  that 
the  tongue  retains  its  shape,  nutrition,  and  normal  electrical  reactions,  and  the 
palate  its  natural  reflex.  This  condition  of  pseudo-bulbar  palsy,  as  it  is  sometimes 
called,  is  further  distinguished  by  facial  starchiness  or  spasticity,  and  by  the 
patient's  inability  to  control  the  expression  of  his  emotions. 

Dysarthria  of  similar  origin,  but  generally  of  less  degree,  may  be  observed  in 
cases  of  general  paralysis  of  the  insane,  in  cerebral  diplegia,  and  in  disseminated 
sclerosis.  In  the  latter  disease  the  terms  "  staccato  "  or  "  scanning  "  are  applied 
to  describe  the  articulatory  defect.  Some  cases  of  Friedreich's  ataxy  exhibit  a 
form  of  articulation  which  is  slow  and  jerky,  not  unlike  that  of  disseminated 
sclerosis.  Probably  some  degree  of  inco-ordination  enters  into  the  production 
of  this  peculiar  utterance.  In  all  these  diseases  the  diagnosis  of  the  condition 
depends  upon  the  presence  of  other  symptoms  and  physical  signs,  and  can 
rarely  be  deduced  from  the  articulation  alone. 

Dysarthria  also  arises  from  disease  of  the  bulbar  nuclei,  or  of  the  nerves 
arising  from  the  latter  which  supply  the  muscles  of  the  larynx,  pharynx,  tongue, 
and  lips.  In  true  bulbar  palsy,  which  is  a  disease  depending  on  a  slowly  pro- 
gressive degeneration  of  these  motor  nuclei,  articulatory  defects  are  often  among 
the  earliest  symptoms.  The  diagnosis  of  these  cases  is  based  on  the  fact  that 
the  symptoms  begin  insidiously  and  progress  gradually,  that  the  paresis  affects 
the  muscles  of  both  sides  more  or  less  symmetrically,  and  that  it  is  an  atrophic 
form  of  paralysis.  The  atrophy  is  best  seen  in  the  tongue  muscles,  and  is 
usually  associated  with  a  certain  amount  of  fibrillation,  and  with  diminution 


SPEECH,     ABNORMALITIES     OF  687 

of  their  electrical  excitability.  The  palatal  reflex  is  also  impaired,  and  an 
examination  of  the  vocal  cords  shows  that  they  too  are  the  seat  of  a  progressive 
palsy.  The  dysarthria  is  always  accompanied,  sooner  or  later,  by  some  degree 
of  dysphagia,  and  also  by  some  weakness  and  atrophjr  of  the  muscles  of 
mastication.  Atrophic  palsy  may  also  be  observed  in  the  small  muscles  of 
the  hands,  and  there  is  a  tendency  to  exaggeration  of  all  the  tendon  reflexes 
in  the  limbs. 

A  similar  clinical  picture  maj'  develop  in  cases  of  gross  disease  of  the  bulb, 
due  either  to  local  softening  or  hemorrhage,  or  in  rarer  cases  to  the  gradual 
growth  of  a  tumour  in  that  region.  Such  cases  can  be  differentiated  from  true 
bulbar  palsy,  partly  by  the  more  acute  onset  of  symptoms  in  the  case  of  the 
vascular  lesions,  and  partly  by  the  asymmetrical  distribution  of  the  muscular 
■atrophy  and  paresis  when  a  tumour  forms  the  basis  of  the  disease.  Gummatous 
meningitis  at  the  base  of  the  brain  may  involve  the  cranial  nerves  close  to  their 
«xit  from  the  bulb,  and  so  produce  a  dysarthria  of  a  somewhat  similar  character. 
When  tumours  or  meningitis  are  the  cause  of  the  dysarthria,  symptoms  of 
increased  intracranial  pressure  are  likely  to  be  observed. 

Another  form  of  bulbar  palsy  is  seen  in  cases  of  myasthenia  gravis.  In  this 
•condition  there  is  little  or  no  atrophy  of  the  articulatory  muscles,  although  some 
thinning  of  the  tongue  is  sometimes  observed.  The  distinguishing  characteristics 
of  this  dysarthria  are  first  of  all  its  marked  variability,  and  secondly  the  effect 
produced  by  fatigue.  A  myasthenic  patient  may  begin  a  conversation,  or  may 
begin  to  read  aloud  from  a  book,  without  showing  much  difficulty  in  his 
Titterance,  but,  as  he  progresses,  his  articulation  becomes  more  and  more  defective 
and  more  difficult  to  understand.  Usually  the  palate  fails  quickly,  and  a  nasal 
quality  is  given  to  the  voice.  If  he  is  asked  to  repeat  the  word  "  rub  "  many 
times,  the  terminal  "  b  "  becomes  an  "  m,"  and  he  ends  by  saying  "  rum  " 
instead  of  "  rub."  Most  cases  of  myasthenia  gravis  exhibit  similar  fatigue 
phenomena  in  relation  to  other  parts  of  the  musculature  (see  Fig.  83,  p.  261), 
and  in  particular  show  varying  degrees  of  ocular  palsy,  which,  like  the  dysarthria, 
is  at  one  time  more  marked  than  at  another,  and  which  is  much  influenced 
by  rest  and  exercise. 

Some  articulatory  defect  is  produced  in  cases  of  bilateral  peripheral  palsy  of 
the  palate,  which  most  often  results  from  the  effects  of  the  diphtheria  poison. 
The  voice  is  nasal,  and  the  pronunciation  of  certain  consonants  becomes 
impossible.  "  B  "  becomes  "  m,"  "  d  "  becomes  "  n,"  and  "  k  "  sounds  like 
"  ng." 

Bilateral  facial  palsy  interferes  with  that  part  of  articulation  which  depends 
^ipon  the  labial  muscles,  and  so  renders  speech  indistinct,  although  not 
unintelligible.  Facial  palsy  of  this  kind  is  met  with  in  some  cases  of  peripheral 
neuritis  and  also  in  some  cases  of  myopathy,  especially  that  form  to  which  the 
name  Landouzy-Dejerine  is  applied. 

Unilateral  bulbar  palsy  may  exist  without  much  interference  with  articulation 
or  phonation.  There  may  be  considerable  palsy  of  one  vocal  cord  due  to  a 
lesion  of  one  recurrent  laryngeal  nerve,  without  a  recognizable  alteration  in  the 
character  of  the  voice.  A  bilateral  laryngeal  palsy,  when  complete,  leads  to 
aphonia.  Similarly,  unilateral  palsy  of  the  palate  or  of  one-half  of  the  tongue 
may  exist  without  articulatory  defect,  especially  after  the  patient  has  become 
accustomed  to  the  altered  conditions. 

5.  Functional  Disorders  of  Speech. — In  cases  of  hj^steria,  a  functional  aphonia 
is  by  no  means  uncommon,  and  in  many  cases  can  only  be  distinguished  from 
aphonia  due  to  organic  disease  by  an  examination  of  the  larynx.  Hysterical 
•aphonia  may  be  complete  ;  in  other  cases  the  voice  is  reduced  to  a  whisper,  and 
yet  the  patient  is  able  to  adduct  the  cords  properly  in  coughing.     This  is  often 


SPEECH,     ABNORMALITIES     OF 


a  recurrent  malady^  and  the  suddenness  of  its  onset,  as  well  as  the  suddenness 
with  which  it  is  often  cured,  are  peculiar  characteristics. 

Stammering  is  another  type  of  functional  dysarthria  and  presents  a  large 
variety  of  forms.  There  is  little  difficulty  in  their  recognition,  because  in  all 
cases  when  once  the  articulatory  flow  is  established  the  utterance  is  perfectly 
normal.  The  difficulty  generally  arises  either  in  commencing  a  word  or'  a 
sentence,  or  in  other  cases  the  trouble  is  evoked  only  in  connection  with  the 
production  of  certain  consonants.  Some  of  the  cases  depend  on  an  initial  spasm 
of  the  articulatory  muscles,  and  others  upon  an  inco-ordination  between  the 
action  of  the  respiratory  muscles  and  those  which  have  to  do  with  phonation 
and  articulation.  The  complete  absence  of  any  physical  signs  of  disease,  and 
the  history  of  the  case,  make  the  diagnosis  easy.  On  the  other  hand,  stammering 
is  occasionally  an  early  symptora  of  progressive  degenerative  conditions  of  the 
central  nervous  system,  especially  of  general  paralysis  of  the  insane. 

The  term  "  lalling  "  is  applied  to  a  defective  form  of  articulation  chiefly  met 
with  in  persons  who  are  more  or  less  mentally  feeble.  It  is  characterized  by 
what  appears  to  be  an  imperfect  pronunciation  of  certain  consonants.  In 
more  severe  cases  one  consonant  is  consistently  replaced  by  another,  such  as 
"  r  "  by  "  w."  These  mistakes  in  pronunciation  are  common  enough  in  normal 
children  when  learning  to  speak,  but  the  endurance  of  the  defect  after  the  learn- 
ing age  is  passed  generally  indicates  some  permanent  mental  deficiency.  A 
temporary  perversion  of  speech  is  occasionally  seen  in  children  before  they 
learn  the  proper  use  of  language.  They  may  talk  glibly  and  fluently  in  a  language 
which  they  appear  to  understand  themselves  but  which  is  unintelligible  to  their 
neighbours.  In  this  condition,  to  which  the  term  "  idioglossia  "  is  generally 
given,  the  prognosis  may  be  regarded  as  favourable.  e.  Farquhar  Buzzard. 

SPLEEN,   ENLARGEMENT  OF   THE. 

The  Physical  Signs  of  Enlargement  of  the  Spleen. — If  the  organ  is  only  shghtly 
or  moderately  enlarged,  there  is  no  alteration  in  the  size  or  shape  of  the  abdomen  ; 
if  it  is  considerably  or  enormously  enlarged,  the  abdomen  may  be  much  dis- 
tended, and  at  a  first  glance  this  distention  may  appear  to  be  uniform,  as 
though  due  to  ascites.  Closer  inspection  may  show  that  it  is  by  no  means 
uniform,  there  being  distinct  bulging  of  the  left  side,  especially  in  the  left 
hypochondrium,  the  left  lumbar,  and  the  left  half  of  the  umbilical  regions. 
The  inner  border  may  be  tilted  forward  in  some  cases,  so  that  a  distinct  edge 
or  ridge  may  be  seen  pushing  the  abdominal  wall  forward,  this  ridge  running 
downwards  and  inwards  from  the  left  costal  margin  near  the  anterior  axillary 
fine  towards  the  umbihcus  ;  in  a  few  cases  a  distinct  notch  can  be  seen  in 
this  edge  or  ridge.  When  the  patient  takes  a  deep  breath,  the  prominence 
may  be  seen  to  move  distinctly  downwards,  though  occasionally  the  spleen 
may  be  so  enormously  enlarged  that  its  lower  end  becomes  impacted  in  the 
pelvis,  when  no  downward  movement  is  possible. 

Palpation  is  the  best  means  of  detecting  splenic  enlargement.  If  the  organ 
is  but  little  enlarged,  it  may  not  be  felt  until  the  observer,  standing  upon  the  left- 
hand  side  of  the  recumbent  patient,  and  supporting  the  lower  left  ribs  posteriorly 
with  his  right  hand,  steadily  but  firmly  presses  the  fingers  of  his  left  hand  under 
the  left  costal  margin  just  in  front  of  the  anterior  axillary  line  ;  when  the  patient 
now  takes  a  deep  breath,  a  definite  sense  of  increased  resistance  may  reveal 
splenic  enlargement  when  the  organ  is  comparatively  soft,  as  in  many  cases  of 
typhoid  fever  for  example,  or  a  hard  mass  with  a  distinct  edge  may  be  felt  in 
more  obvious  cases.  When  the  enlargement  is  moderate  or  ccgisiderable,  the 
splenic  tumour  will  be  felt  coming  down  from  beneath  the  left  ribs  close  behind 
the  abdominal  wall  ;  and  unless  there  is  a  very  large  liver  at  the  same  time,  or 


SPLEEN,     ENLARGEMENT     OF     THE 


some  other  cause  preventing  the  viscus  from  following  its  natural  direction  as 
it  enlarges,  it  tends  to  reach  and  ultimately  cross  the  middle  line  at  or  just  below 
the  level  of  the  umbilicus.  It  is  generall}^  smooth  and  firm,  and  the  character- 
istic notch  or  notches  can  be  felt  in  its  anterior  border.  Except  in  those  rare 
cases  in  which  the  whole  spleen  is  dislocated,  it  will  not  be  possible  to  insert  a 
hand  between  it  and  the  left  costal  margin,  or  to  define  its  upper  limit  by  palpa- 
tion. The  lower  pole  can  be  felt  readily  moving  decidedly  downwards  on  inspira- 
tion, unless  the  enlargement  is  very  great.  On  bimanual  palpation,  the  loin  is 
flaccid  and  not  filled  out  as  it  would  be  by  a  renal  tumour,  and  the  mass  cannot 
be  pushed  back  into  the  loin  so  as  to  be  felt  by  the  posterior  hand  as  readily 
as  it  is  by  the  hand  on  the  anterior  abdominal  wall. 

Percussion  yields  a  dull  note  over  the  mass,  the  dullness  being  directly  con- 
tinuous with  an  increased  area  of  dullness  in  the  thorax  extending  upwards  as 
high  as  the  seventh  rib  in  the  mid-axillary  line,  the  sixth  rib  in  the  nipple  line, 
or  even  higher,  and  including  the  ordinary  area  of  splenic  impairment  of  resonance 
behind.  Percussion  of  the  left  loin  will  generally  elicit  resonance  here,  indicating 
that  the  colon  is  not  displaced  as  it  would  have  been  by  a  renal  tumour  ;  no 
intestines  can  be  felt  or  percussed  over  the  front  of  the  spleen. 

Auscultation  seldom  affords  much  evidence  of  value  in  these  cases,  but  some- 
times when  the  splenic  enlargement  is  associated  with  local  peritonitis,  as  in 
cases  of  infarction  for  example,  a  loud  rub  may  be  heard  over  the  mass  ;  and 
sometimes,  especially  if  the  enlargement  is  associated  with  venous  engorgement, 
a  well-marked  continuous  humming  bruit  may  be  heard. 

Distinction  between  an  Enlarged  Spleen  and  other  Tumours  which  may 
simulate  it.  An  enlarged  spleen  has  to  be  distinguished  from  other  tumours 
which  may  arise  in  the  left  hypochondriac  region,  especially  from  : — (i)  Kidney 
tumours  or  perinephric  inflammation  or  abscess  ;  (2)  Suprarenal  tumours  ;  (3) 
Carcinoma  of  the  splenic  flexure  of  the  colon  ;  (4)  Pancreatic  tumours,  especi- 
ally cyst  or  carcinoma  ;  (5)  Malignant  growth  of  the  stomach  ;  (6)  Ovarian 
tumour  ;    (7)  Tuberculous  peritonitis  ;    (8)  Fsecal  accumulation  in  the  colon. 

Distinction  from  a  Renal  Tumour.  —  It  may  be  difficult  to  distinguish  an 
enlarged  spleen  from  a  kidney  in  some  cases.  Both  conditions  may  cause  local 
prominence  or  bulging  of  the  left  side  of  the  abdomen  ;  in  the  case  of  splenic 
enlargement  the  bulging  is  more  forward  and  inward,  whereas  in  a  kidney  enlarge- 
ment, the  loin  is  more  likely  to  be  bulged.  No  distinct  edge  or  notch  can  be  seen 
or  felt  in  the  case  of  the  majority  of  renal  enlargements,  a  most  important  point, 
the  significance  of  which  cannot  be  over-estimated.  Either  tumour  may  move 
downwards  when  the  patient  takes  a  deep  breath  ;  but  the  spleen,  being  in  closer 
contact  with  the  under  surface  of  the  diaphragm,  moves  the  more  markedly  of 
the  two.  A  renal  tumour,  being  more  deeply  situated  in  the  abdomen,  seldom 
approximates  closely  to  the  anterior  abdominal  wall  unless  the  enlargement  is 
very  great,  in  which  case  the  loin  will  be  filled  out  and  feel  very  firm  and  resistant 
on  bimanual  examination.  A  renal  tumour  generally  slopes  away  as  it  approaches 
the  ribs,  so  that  it  is  less  difficult  to  get  one's  hand  between  its  upper  pole  and 
the  costal  margin  than  is  the  case  with  the  undislocated  spleen.  The  colon  may 
be  seen  or  felt  over  the  anterior  surface  of  a  renal  tumour,  which  is  never  the 
case  with  splenic  enlargement  ;  and  percussion  may  yield  a  resonant  note  in 
front,  or  in  t3^pical  cases  a  vertical  band  of  colonic  resonance  down  the  centre 
of  an  otherwise  dull  mass,  the  loin  posteriorly  being  dull ;  whereas  with  a  splenic 
tumour  the  loin  is  generally  resonant,  and  the  anterior  aspect  of  the  mass  quite 
dull.  The  presence  of  a  local  bruit  or  rub  would  make  renal  tumour  unlikely. 
The  occurrence  of  Hematuria  [q.v.),  Pyuria  (q.v.),  or  Albuminuria  {q-v.), 
would  suggest  renal  enlargement,  whilst  the  conditions  of  the  blood  might  be 
such  as  to  suggest  splenic. 

D  44 


690  SPLEEN,     ENLARGEMENT     OF     THE 

Notwithstanding  all  these  points,  to  distinguish  between  splenic  and  renal 
masses  is  sometimes  by  no  means  easy  ;  and  it  is  only  by  paying  careful  attention 
to  the  history  and  to  the  patient's  own  sensations,  as  well  as  to  the  physical 
signs,  and  to  the  changes  in  the  blood  and  urine,  that  a  correct  diagnosis  can  be 
made. 

Malignant  Disease  of  the  Left  Siipravenal  Gland  may  cause  a  large  mass  which 
is  sometimes  particularly  difficult  to  distinguish,  either  from  a  splenic  or  from  a 
renal  enlargement.  Owing  to  the  close  proximity  of  the  suprarenal  capsule  to 
the  kidney,  and  the  liability  of  the  latter  to  become  infiltrated  hy  growth  of  the 
former,  the  physical  signs  of  a  suprarenal  are  practically  the  same  as  those  of 
a  renal  tumour,  except  that  it  may  be  more  difficiilt  to  pass  the  hand  between 
the  mass  and  the  costal  margin.  Hsematuria  and  other  urinary  changes  may 
result  from  spread  of  the  disease  to  the  kidney  ;  affection  of  one  suprarenal 
gland  alone  does  not  produce  Addison's  disease,  and  it  may  be  impossible  to 
arrive  at  a  correct  diagnosis  Avithout  laparotomy. 

A  peculiar  affection  of  children  deserves  special  mention  :  at  a  comparatively 
early  age  there  may  be  an  abnormal  development  of  the  pubic  and  axillary  hair 
and  of  the  genital  organs  (see  Figs.  125,  126,  pp.  453,  454),  with  premature 
puberty,  associated  Avith  overgrowth  of  suprarenal  rests  in  the  kidney,  the 
resultant  tumour  being  spoken  of  as  a  hypernephroma. 

Carcinoma  of  the  Splenic  Flexure  of  the  colon  is  usually  annular,  giving  rise 
to  no  definite  tumour,  but  rather  to  symptoms  of  chronic,  followed  by  acute, 
intestinal  obstruction.  Occasionally,  however,  the  growth  may  be  more 
voluminous,  or  it  may  have  caused  leakage  and  inflammatory  matting  from 
local  perforation  through  or  above  the  growth,  with  the  result  that  a  fairh'  large 
tumour  may  be  felt  in  and  below^  the  left  hypochondriura.  This  mass  is  generally 
resonant  to  percussion,  has  no  well-defined  edge  or  notch,  and  maj^  vary  some- 
what in  position  from  day  to  A&y  :  it  will  usually  be  associated  with  intestinal 
symptoms,  especialljr  constipation  alternating  wath  diarrhoea,  and  the  passage 
of  mucus,  and  occasionally  blood,  per  rectum.  Sometimes  there  are  obvious 
secondary  deposits  in  the  liver  or  in  the  left  supraclavicular  glands. 

Pancreatic  Tumours  are  usuallj^  situated  more  in  the  median  hne  of  the  abdomen 
than  is  a  spleen,  between  the  ensiform  cartilage  and  the  umbihcus  ;  sometimes, 
however,  a  very  large  cyst,  such  as  may  nearly  fill  the  abdominal  cavit}',  may 
cause  considerable  difficulty  in  the  diagnosis.  One  very  important  point  is 
that  no  definite  edge  and  no  notch  can  be  felt.  The  stomach  generally  lies  in 
front  of  a  pancreatic  cyst  ;  or,  if  the  latter  pushes  its  way  forward  so  as  to 
displace  the  stomach  upwards  and  the  transverse  colon  downwards,  it  may  be 
possible  to  define  its  relationship  to  the  stomach  by  inflating  the  latter  with 
gas.  A  splenic  tumour  rarely  extends  to  the  right  of  the  middle  line  unless 
the  enlargement  is  great,  and  then  it  crosses  at  or  below  the  umbilicus,  Avhereas 
a  pancreatic  cyst  reaches  across  to  the  right  of  the  middle  line  above  the  navel. 
Pancreatic  new  growth  has  a  similar  position ;  but  the  outline  of  the  mass,  if 
any  can  be  felt  at  all,  is  more  nodular  ;  there  will  generallj'  be  jaundice  and  a 
palpable  gall-bladder,  and  the  urine  may  yield  Cammidge's  pancreatic  reaction. 

Malignant  Growth  of  the  Stomach  may  be  mistaken  for  enlargement  of  the 
spleen,  and  even  suggest  splenomedullarj^  leukaemia;  this  is  especially  so  w-ith 
gastric  sarcoma,  which,  though  very  much  rarer  than  carcinoma,  is  more  likeh'  to 
involve  the  whole  of  the  stomach  and  give  rise  to  a  very  large  tumour  occupying 
chiefly  the  upper  part  of  the  left  side  of  the  abdomen.  The  following  changes 
will  serve  to  distinguish  a  gastric  new  growth  from  enlargement  of  the  spleen  : 
the  mass  is  apt  to  shift  its  position  during  the  course  of  an  examination  or  from 
day  to  day  ;  it  does  not  present  a  well-defined  edge  with  definite  notch  or  notches  ; 
it  may  extend  a  considerable  distance  to  the  right  of  the  middle  line,  although 


SPLEEN,     ENLARGEMENT     OF     THE  691 

its  lower  limit  may  not  be  below  the  level  of  the  umbilicus  ;  it  is  Hkely  to  be 
resonant  in  front,  though  the  percussion  note  over  it  may  be  impaired  ;  there 
may  be  anaemia  and  leucocytosis,  but  the  blood-changes  would  not  be  character- 
istic of  any  positive  blood  disease  ;  the  taking  of  food  may  cause  an  increase 
in  the  gastric  pain  ;  vomiting  will  generally  be  a  prominent  symptom  ;  the 
vomit  may  contain  blood,  obvious  or  occult  ;  free  hydrochloric  acid  may  be 
deficient  or  absent  ;  sarcinse  ventriculi  may  be  found  {Fig,  92,  p.  267)  ;  and 
there  may  be  secondary  deposits,  especially  in  the  liver  or  in  the  left  supra- 
clavicular glands. 

Ovarian  Tumours  have  been  mistaken  for  enlargement  of  the  spleen,  and  vice 
versa,  the  differential  diagnosis  being  particularly  difficult  in  cases  in  which  the 
spleen  has  become  dislocated,  or  is  so  large  as  to  reach  down  as  far  as  the  uterus. 
The  organ  has  sometimes  been  found  so  dislocated  as  to  lie  wholly  within  the 
pelvis.  The  differential  diagnosis  depends  in  most  cases  on  the  following  points  : 
an  ovarian  tumour  rarely  extends  upwards  to  such  an  extent  that  its  upper  limit 
comes  into  actual  contact  with  the  left  costal  margin,  so  that  the  hand  cannot 
be  placed  between  it  and  the  ribs  ;  it  does  not  move  much  downwards  during 
deep  inspiration  ;  it  extends  upwards  from  the  pelvis,  whence  it  may  be  felt 
definitely  to  arise,  the  lower  part  of  the  abdomen  being  more  prominent  than 
the  upper ;  it  is  usually  more  globular  than  a  splenic  tumour,  and  has  no  sharp, 
well-defined  edge  with  notches  in  it,  even  when  covered  with  projecting 
bosses  of  simple  or  malignant  new  growth  ;  it  usually  extends  more  to  the  right 
"  of  the  middle  line  than  an  enlarged  spleen  ;  and  it  is  more  apt  to  transmit 
aortic  pulsations  ;  a  vaginal  examination  may  determine  that  the  mass  is 
attached  to  one  or  other  of  the  broad  ligaments,  and  that  the  cervix  and  the 
body  of  the  uterus  are  drawn  upwards  ;  there  will  probably  be  no  distinctive 
blood-changes,  but  very  likely  amenorrhoea. 

Tuberculous  Peritonitis  may  cause  various  abdominal  tumours  (see  Ascites), 
and  sometimes  gives  rise  to  a  mass  occupjdng  the  left  hypochondriac  region, 
the  result  of  matting  together  of  the  intestines,  thickening  of  the  omentum,  or 
thickening  and  infiltration  of  the  peritoneum  attached  to  the  abdominal  wall 
here.  The  tumour  does  not  generally  extend  close  up  under  the  ribs  so  that 
the  hand  may  be  placed  between  it  and  the  costal  margin,  and  although  it  may 
feel  somewhat  rounded,  with  a  more  or  less  well-defined  edge,  there  is  no  definite 
notch  to  be  felt  ;  sometimes,  however,  when  there  are  two,  three,  or  more  separate 
masses  united  together,  a  notch  may  be  simulated  to  some  extent.  The  mass 
itself  may  be  dull,  but  there  is  generally  resonance  between  it  and  the  normal 
splenic  dullness.  Ascites  {q.v.)  is  often  present,  and  there  may  be  palpable 
lumps  in  other  parts  of  the  abdomen,  or  perhaps  redness  and  oedema  of  the 
abdominal  wall,  or  a  purulent  or  faecal  discharge  frona  the  umbilicus.  There 
may  be  signs  of  tuberculosis  elsewhere,  for  instance  in  joints,  or  lymphatic 
glands.  Calmette's  or  von  Pirquet's  tuberculin  reactions  may  be  positive. 
The  patient  will  generally  be  young,  and  have  consumed  unsterilized  cow's  milk. 
Pyrexia  may  be  present  or  absent,  either  with  tuberculous  peritonitis  or  with 
splenic  affections,  so  that  its  occurrence  does  not  assist  the  diagnosis  much, 
except  perhaps,  that  if  the  chart  exhibits  marked  evening  pyrexia,  with  a  sub- 
normal temperature  in  the  morning,  it  is  an  additional  argument  in  favour  of 
tubercle  in  a  young  subject.  The  reverse  type  of  pyrexia — morning  rise  and 
evening  fall — has  been  spoken  of  as  characteristic  of  tubercle,  but  it  is  seldom 
met  with. 

FcBcal  Accumulation  in  the  Splenic  Flexure  or  adjacent  parts  of  the  transverse 
or  descending  colon  may  be  mistaken  for  an  enlargement  of  the  spleen  upon  a 
first  examination  ;  but  this  source  of  error  is  usually  removed  when  the  patient 
is  re-examined  after  an  abundant  action  of  the  bowels  has  taken  place.     The 


692 


SPLEEX,     EXLARGEMEKT     OF     THE 


Splenomegalic  polycj-thaemia 
Splenom  egalic  cirrtiosis 
Splenic  ansemia 
Pseudo-leuksemia  infantum. 


condition  is  found  most  frequenth"  in  women  if  the  age  is  not  great,  or  in  elderlj' 
people  of  either  sex.  There  is  generally  a  history  of  severe  obstipation,  and 
possibly  attacks  of  temporary,-  obstruction.  The  mass  is  generally  irregular, 
more  or  less  cyhndrical,  and  in  thin  persons  it  ma^-  be  possible  actually  to  alter 
its  shape  bj^  manipiilation  with  the  hand.  The  best  test  of  the  condition,  how- 
ever, is  the  effect  of  copious  enemata  upon  the  mass. 

Hcsmatonia  due  to  Leakage  from  an  Abdominal  Aneurysm  is  by  no  means 
al'w"a3's  easily  recognized,  and  it  ma^'  be  mistaken  for  an  enlargement  either 
of  the  spleen  or  of  the  kidney,  unless  the  aneurysm  itself  can  be  felt  pulsa- 
ting ;  or  unless  there  is  a  history  of  an  acute  exacerbation  of  intra-abdominal 
pain,  accompanied  b}-  blanching  due  to  the  amount  of  blood  lost  from  the 
leaking  aneurysm. 

Causes    of    Splenic    Enlargement. 

Ha\'ing  concluded  that  the  spleen  is  enlarged,  the  next  step  is  to  decide  the 
cause  of  the  enlargement.  There  are  various  ways  in  which  the  different  causes 
may  be  classified,  but  from  a  diagnostic  point  of  view  the  following  is 
ser%'iceable  : — 

I.  Chronic  Enlargement  of  the  Spleen, 
(a).    Very  great  enlargement  : 

Splenomedullan,'  leuksEmia 
L^-mphatic  leukaemia 
ISIixed  leukaemia 
Chronic  malaria 
Kala-azar  ^ 

(fe).  Moderate  enlargement. — All  conditions  mentioned  in  group  [a)  will  at 
some  stage  exhibit  a  spleen  that  has  not  yet  become  enormous  ;  and  besides 
these,  chronic  and  moderate  enlargement  of  the  spleen  may  be  exhibited  in 
cases  of  : — ■ 

Pernicious  anemia  Thrombosis  of  the  portal  vein 

Rickets  Pressure    on    the    portal    vein    by 

Congenital  s\'philis  enlarged    hTiiphatic    glands    or 

Hodgkin's  disease  by  adjacent  tumour  of  the  gall- 

Cirrhosis  of  the  hver  bladder,  hver,  pancreas,  stomach, 

Lardaceous  disease  etc. 

II.  Acute  Enlargement  of  the  Spleen,  the  enlargement  as  a  rule  being  slight, 
(a).  Acute  infective  fevers  : 

Especiall}' — 

Tj^hoid  fever  1  IMalaria 

Parathyphoid  fever  Erysipelas 

Relapsing  fever  1  Septicaemia. 

Less  often  in — 

Pneimionia  I  Tj-phus  fever 

Diphtheria  Influenza 

Scarlet  fever  General  tuberculosis. 

Small-pox 
(6) .  Embolism,  especiallj^  in  cases  of  f  ungating  endocarditis.  "^   '^^'^-e^' 
{c).  Injury. 

(d).  Strangulation  b}*  twisting  of  the  pedicle. 

It  will  be  noted  that  no  mention  is  made  of  abscess,  gumma,  carcinoma 
(whether  primarj'-  or  secondary),  sarcoma  (primary  or  secondary),  or  hydatid 
cyst  of  the  spleen,  for  these  are  all  so  exceedingly  rare  that  it  is  \er3-  unlikely 


J^       /^'O--^^'"^-^ 


SPLEEN,     ENLARGEMENT     OF     THE  693 

they  will  be  met  with.  It  will  also  be  noted  that  no  mention  is  made  of 
backward  pressure,  whether  due  to  chronic  valvular  disease  of  the  heart  with 
failing  compensation,  or  to  obstruction  to  the  inferior  vena  cava  above  the 
hepatic  veins,  such  as  may  result  from  thrombosis  or  from  pressure  upon  the 
veins  by  mediastinal  fibrosis  or  new  growth.  These  conditions  are  purposely 
omitted,  for  it  is  quite  exceptional  for  ordinary  backward  j5ressure  to  produce 
enlargement  of  the  spleen.  So  true  is  this,  that  in  a  case  of  chronic  valvular 
heart-disease  with  failing  compensation,  the  existence  of  a  definitely  palpable 
spleen  is  evidence  of  there  being  more  than  rnere  mechanical  tieart-failure — 
probably  superposed  fungating  endocarditis  The  chief  exceptions  to  this 
occur  in  chil'dhood,  where  the  spleen  becomes  more  easijy  palpable  than  in 
adults,  so  that  with  heart-failure  in  a  child  enlargement'  of  the  spleen  is  less 
good  evidence  of  fungating  endocarditis  than  it  is  in  a  grown-up  person. 

I. — Chronic    Enlargement   of  the  Spleen. 

(«).  Chronic  and  very  great  Enlargement  of  the  Spleen. — When  the  spleen 
is  so  large  as  to  occupy  half  the  abdomen  or  more,  the  diagnosis  is  generally 
very  easy.  The  largest  of  all  spleens  are  those  due  to  splenomedullary 
leukcBmia.  The  first  step  is  to  make  a  full  examination  of  the  blood,  including 
particularly  total  and  difi:erential  leucocj^te  counts.  If  there  is  an  extreme 
degree  of  leucocytosis,  up  to  anything  between  50,000  and  and  1,500,000  per 
c.mm.  for  example,  the  diagnosis  is  almost  certainly  leukaemia,  and  if  in  the 
differential  leucocyte  count  there  are  from  20  per  cent  to  50  per  cent  of  myelo- 
cytes, it  is  of  the  splenomedullary  type,  whilst  if  the  small  lymphocytes  amount 
to  00  per  cent  or  more,  the  disease  is  of  the  lymphatic  form,  in  which  the 
lymphatic  glands  are  almost  certain  to  be  enlarged  as  well  as  the  spleen  ;  in 
some  cases  of  lymphatic  leukasmia  it  may  be  scarcely  enlarged  at  all,  but  in 
others  it  may  be  almost  if  not  quite  as  large  as  in  the  splenomedullary  type  of 
the  disease.  For  mixed  leukaemia,  see  Anemia.  In  the  absence  of  any  marked 
leucocytosis,  or  of  characteristic  differential  leucocyte  counts  (see  also  Anaemia), 
the  diagnosis  of  the  nature  of  a  very  large  spleen  will  depend  in  the  first  place 
upon  whether  there  has  or  has  not  been  residence  in  a  malarial  region — the  fen 
districts  of  Great  Britain,  the  tropics,  or  certain  parts  of  Europe,  particularly 
Italy.  The  ague-cake  spleen  of  the  fens  is  now  very  rare  ;  it  is  more  often  found 
in  chronic  cases  of  tropical  malaria,  when  the  history  may  indicate  its  nature, 
and  if  the  patient  is  having  febrile  attacks,  the  parasites  {Plate  XII,  Figs.  A, 
B,  C,  D,  E)  may  be  found  in  the  blood.  Recent  investigations  have  shown 
that  some,  at  least,  of  the  enlarged  spleens  formerly  attributed  to  malaria, 
are  due  to  other  infections.  One  of  these  has  been  clearly  differentiated  from 
the  rest,  namely  Kala-azar,  which  occurs  in  India,  particularly  in  Assam,  in 
Africa,  and  in  Sicily,  and  is  diagnosed  chiefly  by  the  discovery  of  the  Leishman- 
Donovan  bodies  in  the  fluid  obtained  b}^  splenic  puncture  {Plate  XII,  Fig.  H) . 

Splenomegalic  polycythcBmia  is  a  rare  affection  of  adults,  characterized  by 
more  or  less  cyanosis  and  s^^mptoms  which  might  suggest  a  cardiac  lesion, 
together  with  more  or  less  enlargement  of  the  spleen,  and  polycythaemia  amount- 
ing perhaps  to  six,  seven,  or  even  ten  million  red  corpuscles  per  c.mm.  The 
diagnosis  is  arrived  at  when  polycythaemia  and  enlargement  of  the  spleen 
occur  in  the  absence  of  any  definite  cause. 

Splenomegalic  cirrhosis  is  an  affection  of  children  and  young  adults,  in  whom 
there  are  likely  to  be  more  or  less  jaundice,  ansemia,  lack  of  development,  and 
ultimately  ascites,  as  well  as  considerable  enlargement  of  the  spleen.  There  is 
a  tendency  for  this  maladj^  to  affect  more  than  one  member  of  a  family,  and 
this  sometimes  gives  the  clue  to  the  diagnosis.  When  death  ultimately  ensues, 
in  addition  to  the  great  enlargement  of  the  spleen,  these  cases  exhibit  more  or 


694 


SPLEEN,     ENLARGEMENT     OF     THE 


less  fibrosis  or  cirrhosis  of  the  Uver,  and  sometimes  the  hver  is  indistinguishable 
from  that  of  ordinary  alcoholic  cirrhosis.  What  relationship  this  malady  has 
to  ordinary  alcoholic  cirrhosis  of  the  liver  on  the  one  hand,  and  to  splenic  anaemia 
or  Banti's  disease  upon  the  other,  is  not  clear  ;  but  owing  to  the  enlargement  of 
the  spleen,  it  is  differentiated  as  splenomegalic  cirrhosis.  Haemorrhages,  par- 
ticularly haematemesis,  are  not  infrequent  in  this  as  in  other  forms  of  cirrhosis 
of  the  liver.  The  blood-changes  are  merely  those  of  a  simple  chlorotic  anaemia. 
The  diagnosis  is  afforded  chiefly  by  the  age  of  the  patient,  by  the  size  of  the 
spleen,  and  by  the  absence  of  any  positive  blood-changes,  particularly  if  more 
than  one  member  of  the  family  is  affected  in  the  same  way.  The  patient  often 
lives  for  a  number  of  years,  and  is  able  to  work  in  spite  of  the  complaint,  until 
ascites  supervenes.     The  fingers  may  be  clubbed. 

Splenic    ancBmia  has   been    discussed    under   Anemia    (q.v.).     The   spleen  is 

not  as  a  rule  very  greatly 
enlarged,  though  sometimes 
it  may  be  [Fig.  i86).  The 
blood  -  changes  are  simply 
those  of  progressive  and 
severe  anaemia  of  a  chlorotic 
type  ;  even  though  there  may 
really  be  a  disease  meriting 
the  distinctive  term,  "  splenic 
anemia,"  not  a  few  cases 
diagnosed  as  such  on  account 
of  the  co-existence  of  splenic 
enlargement  with  simple 
anaemia,  ultimately  turn  out 
to  be  cirrhosis  of  the  liver. 
When  that  which  is  really 
cirrhosis  of  the  liver  is  dia- 
gnosed in  its  early  stages  as 
splenic  anaemia,  the  condition 
is  termed  Banti's  disease. 

Pseiido-leiikcBmia  infanium 
(voN  Jaksch's  Disease)  is, 
apart  from  true  leukaemia, 
almost  the  only  cause  of  verj' 
great  enlargement  of  the 
spleen  in  young  children 
{Fig.  2,  p.  42).  It  is  dia- 
gnosed by  the  severity  of  the 
anaemia,  which  is  of  the  in- 
determinate chlorotic  type  without  great  leucocytosis,  but  with  all  the  changes 
that  are  to  be  expected  in  any  severe  ansemia  (pp.  27,  28)  developing  in  an 
infant  of  a  year  old  or  less,  running  a  chronic  course,  but  sometimes  resulting 
in  complete  recovery. 

(b).  Chronic  Enlargement  of  the  Spleen,  the  enlargement  being  of  moderate  size. 
It  is  clear  that  conditions  which  may  sometimes  produce  great  enlargement 
of  the  spleen  must  go  through  a  phase  in  which  the  spleen  is  not  yet  enormous, 
and  at  this  stage  all  those  diseases  that  have  just  been  discussed  will  come  into 
the  present  group.  The  remarks  already  made  need  not  be  repeated  here, 
however,  for  the  diagnosis  at  the  stage  in  which  the  spleen  is  yet  only 
moderately  big  is  arrived  at  in  the  way  already  described.  A  blood-count 
is    essential    in    order    to    exclude   or   diagnose   splenomeduUary    leukaemia    or 


/''ig:  186. — Splenic  anaemia  :  photograph  showing  the 
outline  of  the  spleen.  There  was  .severe  chlorotic  ana;mia 
without  leucocytosis;  the  patient  died,  and  at  the  autopsy 
there  was  no  cirrhosis  of  the  liver. 


SPLEEN,     ENLARGEMENT     OF     THE  695 

lymphatic  leukaemia  ;  parasites  may  be  discovered  to  account  for  malaria  or 
kala-azar  ;    and  so  on. 

The  spleen  is  palpable  in  a  considerable  proportion  of  cases  of  pernicious 
ancBmia,  but  it  is  seldom  greatly  enlarged,  and  the  diagnosis  is  arrived  at  by 
finding  the  blood-changes  described  under  Anemia.  In  none  of  the  other 
diseases  mentioned  in  the  hst  above  are  the  blood-changes  themselves  patho- 
gnomonic. 

The  spleen  of  a  small  child  is  very  often  just  palpable  without  there  being 
any  disease  at  all  ;  if  it  is  more  decidedly  enlarged,  the  first  suspicion  will  be 
that  it  is  due  to  rickets  or  congenital  syphilis.  The  bony  changes,  quadrate 
head,  beaded  ribs,  large  epiphyses,  exaggerated  curves  of  the  long  bones, 
particularly  of  the  legs,  delay  in  the  closure  of  the  fontanelles,  and  the 
pot-belly,  will  suggest  rickets  ;  it  should  be  added,  however,  that  owing  to  the 
eversion  of  the  lower  ribs  along  a  line  corresponding  with  the  attachment 
of  the  diaphragm,  and  known  as  Harrison's  sulcus,  the  spleen  often  becomes 
unduly  palpable  in  rickety  children  without  being  necessarily  enlarged.  Con- 
genital syphilis  may  be  suggested  by  a  knowledge  of  the  family  history,  by  the 
occurrence  of  snuffles,  of  specific  skin  eruptions,  and  so  forth  ;  but  in  many 
cases  the  diagnosis  will  be  one  of  surmise  only,  unless  it  can  be  confirmed  by 
the  specific  serum  reaction  of  Wassermann.  Pseudo-leukcDtnia  infantum  has 
already  been  discussed  above  ;  by  some  observers  it  has  been  regarded  as  in 
some  way  associated  either  with  rickets,  with  congenital  syphilis,  or  both  ;  but 
the  most  recent  view  seems  to  be  that  it  is  due  to  some  cause  other  than  these, 
though  its  nature  is  not  yet  known. 

Hodgkin's  Disease,  when  it  is  typical,  is  associated  with  considerable  and 
progressive  Lymphatic  Gland  Enlargement  [q.v.),  especially  those  of  the 
neck,  and  later  those  of  the  axillae  and  groins,  thorax  and  abdomen,  together  with 
moderate  but  seldom  very  great  enlargement  of  the  spleen  ;  without  any  anaemia 
to  begin  with,  but  later  with  a  progressive  and  ultimately  severe  anaemia  of  the 
chlorotic  type,  with  all  the  changes  mentioned  on  pp.  27,  28  ;  without  leuco- 
cytosis,  and  with  nothing  characteristic  about  the  differential  leucocyte  count, 
except  that  an  occasional  basophile  cell  or  myelocyte  may  be  seen.  Hodgkin 
himself  laid  particular  stress  upon  the  changes  in  the  spleen  in  this  disease,  but 
there  can  be  little  doubt  that  there  are  cases  of  a  precisely  similar  nature  in 
which  there  is  much  lymphatic  glandular  enlargement  without  enlargement  of 
the  spleen.  An  attempt  is  sometimes  made  to  distinguish  this  type  from  that 
with  splenic  enlargement,  by  styling  it  lymphadenoma  ;  but  where  lymphadenoma 
ends  and  Hodgkin's  disease  begins,  and  vice  versa,  is  by  no  means  settled.  It 
would  seem  much  more  likely  that  there  is  every  degree  of  acuteness  and  severity 
between  extremes  that  are  wide  apart,  those  cases  which  have  lymphatic  glandular 
enlargement  and  a  rapidly  fatal  ending  without  leucocytosis  as  their  most 
prominent  feature  being  styled  lymphosarcoma  ;  similar  cases  with  the  addition 
of  enlargement  of  the  spleen,  but  a  fairly  rapid  fatal  ending,  being  termed  acute 
Hodgkin's  disease  ;  others  again,  with  enlargement  of  the  glands  without  enlarge- 
ment of  the  spleen  and  with  rather  greater  duration,  being  termed  Ijmiph- 
adenoma  ;  whilst  precisely  similar  cases  with  enlargement  of  both  spleen  and 
glands,  and  a  duration  of  anything  between  several  months  and  several  years, 
are  termed  ordinary  Hodgkin's  disease.  One  very  important  point  to  be 
realized  about  this  disease  is,  that  the  blood-changes  in  it  are  not  pathogno- 
monic even  when  they  are  severe. 

Cirrhosis  of  the  Liver,  by  the  time  it  has  ended  fatalty,  is  nearly  always 
associated  with  a  spleen  that  is  bigger  than  normal  as  judged  by  post-mortem 
weights.  Clinically,  however,  this  enlargement  can  be  made  out  only  in  a 
small  proportion  of  the  cases,  and  even  in   these   the   enlargement  is   seldom 


696  SPLEEN,     ENLARGEMENT     OF     THE 

great.  When,  however,  there  is  doubt  as  to  the  diagnosis,  and  cirrhosis  of  the 
hver  seems  to  be  a  possible  cause  for  other  symptoms,  such  as  H^matemesis 
{q-v.),  Ascites  (q.v.),  Jaundice  [q.v.),  the  presence  of  chronic  but  not  very  great 
enlargement  of  the  spleen,  without  affection  of  the  lymphatic  glands  and  without 
pathognomonic  blood-changes,  is  an  additional  argument  in  favour  of  the 
diagnosis.  Splenic  enlargement  is  a  very  prominent  and  relatively  early  feature 
in  a  few  cases,  on  the  other  hand,  as  in  the  splenomegalic  cirrhosis  of  children 
and  young  adults  ;  whilst  in  some  older  patients,  long  before  the  hepatic 
changes  themselves  attract  attention,  the  case  may  come  under  observation 
for  anaemia,  with  or  without  haemorrhage  such  as  purpura,  epistaxis,  haemat- 
emesis,  or  the  passage  of  blood  per  rectum  ;  and  a  considerable  enlargement 
of  the  spleen  may  be  found.  The  blood-changes  may  be  merely  chlorotic,  and 
in  the  absence  of  other  definite  signs  or  symptoms,  the  diagnosis  of  Sjjlenic 
anaemia,  that  is  to  say  of  simple  anaemia  associated  with  an  enlarged  spleen, 
may  be  made  ;  many  such  cases  ultimately  turn  out  to  be  examples  of  cirrhosis 
of  the  liver — Banti's  disease. 

Lardaceous  Disease. — A  lardaceous  spleen  is  not  always  enlarged,  but  is 
frequently  big  enough  to  be  palpable,  and  the  liver  is  gen@i;ally  enlarged  at  the 
same  time.     Lardaceous  disease  of  the  spleen  is  met  with  in  two  forms  :  (i)  the 


^   DESCRI'PTION    OF    PLATE    XIL 

A,  Malaria,  early  ring  form;  B,  Malaria,  ordinary  ring  form;  C,  Malaria,  mature 
tertian ;  D,  Malaria,  tertian,  ready  to  sporulate ;  E,  Malaria,  crescentic ;  F,  Filaria 
embryo ;  G,  Trypanosoma  Gambiense ;  H,  Leishman-Donovan  bodies,  obtained  by 
splenic  puncture ;  /,  Spirochaeta  Obermeieri  of  relapsing  fever ;  /,  Spirochaeta  pallida 
of  syphilis;  K,  Tubercle  bacilli  and  pus  cells;  L,  Diphtheria  bacilli;  M,  Vincent's 
angina,  Spirilla  and  Fusiform  bacilli;  N,  Meningococci  within  a  leucocyte;  O,  Pneumo- 
cocci  and  pus  cells ;  P,  Staphylococci  and  pus  cells ;  Q,  Streptococci  and  pus  cells ; 
R,   Gonococci,  in  and  outside  of  pus  cells;  S,  Actinomyces;   T,  Tetanus  bacilli. 

(The  ittagnification  of  V  and  S  is  7!iuck  less  than  is  thai  of  tJie  remainder;    the  relative 
magnifications  are  indicated  hy  the  relative  sizes  of  the  white  corpiiscles.) 


sago  spleen,  in  which  the  changes  involve  the  Malpighian  bodies  mainly ;  and 
(2)  the  diffuse  waxy  spleen,  in  which  the  blood-vessels,  sinuses,  and  trabeculae 
are  universally  affected.  It  is  a  condition  which  results  from  long-continued 
suppuration,  discharging  sinuses  from  empyema  or  spinal  caries,  purulent 
cavities  in  phthisis  or  bronchiectasis,  or  from  tertiary  syphilis.  If  considerable 
enlargement  of  the  spleen  is  associated  with  any  of  these  conditions,  it  is  most 
probably  due  to  lardaceous  disease.  There  is  generally  diarrhoea  on  account  of 
affection  of  the  intestines ;  and  pohmria  and  albuminuria  owing  to  renal  changes. 
The  patient  is  weak,  frail-looking,  and  bloodless.  Blood-counts  exclude  leukaemia, 
and  indicate  more  or  less  severe  anaemia  of  the  chlorotic  type.  The  disease  is 
very  much  less  common  than  formerly,  and  for  the  most  part  it  is  diagnosed  by 
reason  of  there  being  obvious  cause  for  it,  especially  prolonged  suppuration  or 
tertiary  syphilis. 

Thrombosis  of  the  Portal  Vein  as  a  cause  for  splenic  enlargement  can  seldom 
be  more  than  guessed  at  (see  Ascites). 

Pressure  on  the  Portal  Vein  by  enlarged  lymphatic  glands  or  by  adjacent 
tumours,  will  almost  certainly  be  associated  with  obstruction  to  the  bile-duct 
at  the  same  time,  so  that  there  will  be  jaundice,  and  probably  also  ascites,  in 
addition  to  any  splenic  enlargement ;  the  latter  in  any  case  will  not  be  more 
than  slight  or  moderate. 


SPLEEN,     ENLARGEMENT     OF     THE  697 


II. — Acute   Enlargement   of    the    Spleen. 

Acute  Infectious  Fevers. 

Typhoid  Fever  is  the  best  known  febrile  disease  in  which  moderate  enlargement 
of  the  spleen  occurs.  The  organ  is  usually  soft,  so  that  in  many  cases  only  an 
increased  .sense  of  resistance  can  be  determined  on  palpating  close  under  the 
left  ribs.  The  enlargement  may  be  so  slight  that  the  organ  may  only  be  felt 
when  the  patient  takes  a  deep  breath,  so  as  to  push  it  down  from  under  the 
ribs  ;  or  it  may  be  so  big  that  its  lower  border. reaches  down  to  the  level  of  the 
umbilicus.  If,  in  a  case  of  obscure  fever  in  which  a  continued  pyrexia  is  associated 
(especially  during  the  first  ten  days)  with  a  relatively  slow  pulse-rate,  the  spleen 
is  found  to  be  enlarged,  the  diagnosis  of  typhoid  fever  is  very  likely,  especially 
if  there  is  a  history  of  a  gradual  onset  with  a  feeling  of  anorexia  and  lassitude, 
accompanied  by  headache  and  sometimes  with  attacks  of  epistaxis,  a  gradual 
rise  of  temperature  which,  if  it  has  been  observed  from  the  first,  is  seen  to  go  up 
about  two  degrees  every  night,  with  a  fall  of  one  degree  the  following  morning, 
until  step  by  step  it  reaches  103°  F.  or  104°  F.,  or  even  higher  ;  and  perhaps  no 
definite  abnormal  physical  signs  whatever  except  as  regards  the  spleen,  or  a  few 
rhonchi  in  the  chest.  The  characteristic  rash  does  not  appear  until  the  sixth 
day  or  later,  when  it  comes  out  on  the  abdomen  as  a  rule,  sometimes  also  upon 
the  chest  and  back,  in  the  form  of  small,  rosy-red,  flattened  papules  which  fade 
on  pressure,  come  out  in  successive  crops,  and  are  seldom  present  to  the  extent 
of  more  than  half-a-dozen  or  a  dozen  at  a  time.  Widal's  agglutinating  serum 
reaction  should  ultimately  be  positive  in  a  dilution  of  i  in  200  in  half  an  hour,  but 
it  is  generally  the  second  week  before  this  test  is  positive.  Earlier  confirmation 
of  the  nature  of  the  fever  may  be  obtained  by  the  blood-count,  there  being  no 
leucocytosis — indeed,  sometimes  Leucopenia  (q.v.) — whilst,  unlike  many  febrile 
illnesses,  typhoid  fever  produces  a  relative  increase,  not  in  the  polymorpho- 
nuclear cells,  but  in  the  small  lymphocytes.  Such  blood-changes  are  in  them- 
selves almost  pathognomonic,  and  they  are  obtainable  before  Widal's  reaction 
is  to  be  expected,  though  the  latter  is  the  ultimate  test  of  the  fever.  When 
neither  blood-count  nor  serum-test  is  possible,  the  diagnosis  may  not  be  cleared 
up  until  the  third  week  or  later,  when  sloughs  from  Peyer's  patches  can  be  dis- 
covered in  the  stools.  The  ratio  of  the  pulse-rate  and  temperature  is  of  very 
considerable  value  in  the  diagnosis,  for  in  the  majority  of  cases  the  pulse-ratio 
is  very  low  ;  for  instance,  with  a  temperature  of  104°  F.,  the  pulse-rate  may  be 
only  85  or  90  per  minute,  when  the  physiological  ratio  for  this  temperature  is 
120.  Pneumonia  in  its  earlier  stages  may  also  produce  a  low  pulse-ratio;  but 
the  respiration-ratio  is  here  increased,  which  is  not  the  case  in  typhoid  fever. 
The  following  figures  illustrate  these  points  : — 

T.  P.  R. 

Physiological  ratio  . .  .  .  104°  F.  125  32 

Typhoid  fever  . .  .  .  104°  F.  90  30 

Pneumonia         .  .  .  .  .  .  104°  F.  100  40 

Paratyphoid  Fever  is  closely  related  to  typhoid  fever,  the  clinical  symptoms 
being  very  similar  ;  the  importance  of  distinguishing  between  the  two  lies 
chiefly  in  the  carrying  out  of  Widal's  agglutinating  serum  reaction.  It  some- 
times happens  that  in  a  case  which,  from  a  clinical  point  of  view,  is  almost  certainly 
typhoid  fever,  the  serum  will  not  cause  clumping  of  Eberth's  typhoid  bacilli ; 
and  so  far  as  the  bacteriological  test  goes,  the  diagnosis  might  remain  altogether 
obscure  unless  the  serum  were  also  tested  against  the  Bacillus  paratyphosus  A 
and  the  Bacillus  paratyphosus  B.  In  a  certain  proportion  of  cases,  clumping 
will  be  obtained  with  one  or  other  of  these,  the  diagnosis  of  paratyphoid  fever 
being  based  upon  bacteriological  rather  than  upon  clinical  conditions.  The 
spleen  is  enlarged  in  paratyphoid  fever  to  about  the  same  extent  as  in  typhoid. 


698  SPLEEN,     ENLARGEMENT     OF     THE 

Relapsing  Fever  is  associated  with  considerable  enlargement  of  the  spleen. 
The  disease  is  contagious,  but  nowada}^s  rare,  developing  only  under  conditions 
of  filth  and  famine.  It  is  characterized  by  an  acute  onset,  with  chills,  pains  in 
the  back,  and  a  sudden  rise  of  temperature.  The  latter  remains  high,  for  six 
or  seven  days,  and  then  falls  by  crisis.  For  about  a  week  the  temperature 
remains  normal,  and  then  it  rises  again  as  before,  several  such  remissions  and 
relapses  succeeding  each  other  and  being  pathognomonic  of  the  disease.  The 
pulse  is  rapid,  and  there  is  profuse  sweating.  Enlargement  of  the  spleen  is 
detected  early.  It  is  most  conclusively  distinguished  from  other  diseases  by 
examination  of  blood-films  in  which  the  Spirochcsta  obermeieri  [Plate  XII, 
Fig.  I),  will  be  found. 

Malaria. — Apart  from  the  chronic  enlargement  of  the  spleen  due  to  recurrent 
attacks  of  malaria,  the  spleen  becomes  enlarged  and  soft  as  the  result  of  active 
hyperaemia  during  acute  attacks.  Even  when  no  splenic  enlargement  can  be 
detected  in  the  intervals,  during  the  paroxysms  the  viscus  can  usually  be  felt 
projecting  below  the  costal  margin,  presenting  a  soft  and  indefinite  lower  border. 
When  the  patient  has  more  or  less  chronic  enlargement  of  the  spleen  as  the 
result  of  preceding  attacks,  each  acute  febrile  paroxysm  is  associated  as  a  rule 
with  an  additional  swelling  which  passes  off  after  the  attack.  For  the  characters 
of  the  fever,  see  pp.  34,  35.  The  nature  of  the  malady  will  be  suggested  by 
geographical  considerations,  or  by  the  influence  of  quinine ;  but  the  only 
conclusive  proof  of  its  nature  is  the  discovery  in  stained  blood-films  of  the 
malaria  parasites  [Plate  XII,  Figs.  A,  B,  C,  D).  There  is  often  marked 
anaemia,  especially  in  cases  of  recurrent  malaria,  the  red  corpuscles  and  haemo- 
globin becoming  reduced  as  in  chlorosis  ;  the  leucocytes  are  also  diminished, 
and  the  differential  leucocyte  count  shows  a  relative  increase  in  the  large  hyaline 
lymphocytes  up  to  even  15  or  20  per  cent. 

Erysipelas  is  often  associated  with  a  moderate  degree  of  enlargement  of  the 
spleen  ;  but  the  fever,  rigors  [Fig.  166,  p.  614),  and  slightly-raised  red  spreading 
infection  of  the  skin  are  sufficiently  characteristic  to  indicate  the  diagnosis. 

Septiccemia  may  be  less  easj^  to  diagnose  unless  there  is  some  obvious  source 
of  sepsis  in  the  first  instance,  such  as  infection  of  the  uterus  after  childbirth, 
sepsis  in  connection  with  the  general  peritoneal  cavity,  joints,  wounds,  and  so 
forth.  The  chief  difficulty  arises  in  those  cases  in  which  the  source  of  the  sepsis 
is  not  obvious,  being  due  to  absorption  from  such  lesions  as  pyorrhoea  alveolaris, 
whitlows,  acne,  or  other  conrparatively  small  superficial  affections  ;  or  to  deep- 
seated  suppuration,  such  as  a  hidden  empyema,  infective  pylephlebitis,  infective 
cholangitis,  pyosalpinx,  and  so  forth.  In  some  cases  of  chronic  or  subacute 
septicaemia,  enlargement  of  the  spleen  may  be  considerable,  and  the  diagnosis 
of  infective  endocarditis  will  very  likely  suggest  itself.  Whether  or  not  the 
heart  valves  are  affected  in  these  cases,  the  ultimate  diagnosis  will  depend  upon 
discovery  of  infective  organisms  in  cultures  obtained  by  venesection. 

Diphtheria,  Pneumonia,  Scarlet  Fever,  and  Small-pox  seldom  give  rise  to  any 
very  prominent  splenic  enlargement,  and  the  only  importance  of  it  is,  that  in 
the  early  stages  of  the  malady,  detection  of  a  spleen  that  is  just  palpable  may 
temporarily  arouse  a  suspicion  that  the  patient  may  be  suffering  from  tj^phoid 
fever.  The  course  of  the  disease,  bacteriological  examination  by  swabbings 
from  the  throat,  the  physical  signs  in  the  lungs,  and  characters  of  the  sputum 
and  the  skin  rash,  will  serve  to  point  to  the  correct  diagnosis  in  each  case. 

Typhus  Fever  is  fortunately  very  rare  now,  although  there  are  small  out- 
breaks of  it  in  the  poorer  parts  of  large  cities  from  time  to  time  ;  the 
spleen  becomes  soft  and  moderately  enlarged,  but  less  constantly  so  than  in 
typhoid  fever.  The  disease  sets  in  more  acutely  than  enteric,  with  chills,  early 
prostration,  and  a  high  temperature  which  ends  by  less  marked  lysis  than  does 


SPLEEN,     ENLARGEMENT     OF     THE  699 

that  of  typhoid  fever  ;  and  sometimes  almost  by  crisis  at  the  end  of  the  second 
■vveek.  The  rash  differs  from  that  of  typhoid  fever,  in  that  it  appears  on  the 
fifth  day,  and  consists  of  petechise  and  of  dark  red  groups  of  subcutaneons 
macules,  in  addition  to  rosy- red  papules  on  the  surface.  Nervous  symptoms 
become  very  marked,  especially  at  the  end  of  the  iirst  week,  the  so-called  typhoid 
state  being  an  expression  used  to  denote,  not  the  condition  that  occurs  in  typhoid 
fever,  but  that  which  develops  in  typhus.  There  may  be  severe  vomiting,  and 
retention  of  urine,  important  s^-mptoms  that  are  rare  in  t3'phoid  fever.  There 
should  be  no  positive  Widal's  reaction,  and  no  sloughs  in  the  stools. 

Influenza  is  a  diagnosis  which  should  never  be  made  unless  with  very  good 
■cause,  for  many  febrile  illnesses  in  which  the  real  cause  escapes  recognition 
receive  the  label  influenza.  It  is  easiest  to  diagnose  correctly  in  times  of  severe 
•epidemic,  and  then  slight  enlargement  of  the  spleen  may  occur  in  a  few  cases. 
This  in  itself  is  not  important  if  influenza  can  be  diagnosed  with  certainty  on 
■other  grounds  ;  but  until  the  nature  of  the  fever  becomes  obvious,  it  is  important 
in  that  it  may  suggest  tj'phoid  when  none  exists.  The  sudden  onset,  the  extreme 
prostration,  the  high  pulse-rate  as  well  as  temperature,  the  initial  chill,  the 
profuse  sweating  which  comes  on  when  the  patient  begins  to  improve,  and  the 
fall  of  the  temperature  after  an  illness  lasting  from  twenty-four  hours  to  three 
or  four  days  or  a  week,  would  all  point  to  influenza.  It  may,  however,  be  im- 
possible to  distinguish  influenza  from  typhoid  fever  until  the  course  of  the 
pyrexia  has  been  watched.  It  is  worthy  of  note  that  in  influenza  as  well  as 
typhoid,  there  is  no  leucocytosis. 

General  Tuberculosis  may  also  simulate  typhoid  fever  in  certain  cases,  and 
enlargement  of  the  spleen  may  result  from  the  developnrent  of  tubercles  in  it. 
When  cerebral  symptoms  predominate,  the  diagnosis  is  relatively  easy  ;  the 
headache  may  be  equally  severe  in  both,  but  with  tuberculous  meningitis  there 
is  more  vomiting  and  more  retraction  of  the  head,  whilst  it  is  probable  that 
optic  neuritis,  and  perhaps  choroidal  tubercles,  can  be  detected.  Widal's  test 
will  remain  persistently  negative  ;  there  will  be  no  rosy  rash,  probably  no 
leucocytosis,  and  no  sloughs  will  be  found  in  the  stools.  In  some  cases,  however, 
general  tuberculosis  produces  a  clinical  picture  that  may  be  very  difficult  to 
distinguish  from  typhoid  fever.     Lumbar  puncture  may  decide  the  diagnosis. 

Embolism. — Fungating  endocarditis  is  nearly  always  associated  with  palpable 
■enlargement  of  the  .spleen,  and  sometimes  the  organ  attains  a  considerable  size. 
As  stated  above,  ordinary  heart-disease  with  failure  of  compensation  does  not 
give  rise  to  splenic  enlargement  that  can  be  recognized  clinically,  except  per- 
haps in  children,  notwithstanding  the  fact  that  one  might  have  expected  the 
backward  pressure  to  cause  the  spleen  to  be  big  by  being  dilated  with  blood. 
Except  in  children,  enlargement  of  the  spleen  in  a  heart  case  should  always 
arouse  serious  suspicion  of  infective  endocarditis.  The  enlargement  may  be  due 
to  embohsm  and  infarction,  in  which  case  there  may  have  been  a  history  of  acute 
pain  low  down  on  the  left  side  of  the  chest,  accompanied  by  a  definite  rub  due 
to  perisplenitis  over  the  infarct.  The  splenic  enlargement  in  some  cases,  how- 
ever, is  due  less  to  actual  infarction  than  to  the  general  toxaemia  ;  even  when 
there  has  been  an  infarct  it  is  not  always  easy  to  be  sure  of  it.  Fungating  endo- 
carditis sometimes  develops  without  there  being  any  bruit  at  all ;  the  diagnosis 
is  then  exceedingly  difficult  unless  the  patient  suffers  from  multiple  emboli — 
cerebral,  renal,  intestinal,  splenic,  peripheral.  Sometimes  such  an  embolus  may 
be  followed  bj'  the  development  of  an  acute  aneurysm — femoral,  popliteal, 
cerebral,  and  so  forth.  A  cerebral  embolism  of  this  kind  has  sometimes  resulted 
in  sudden  transient  coma  and  hemiplegia  ;  the  patient  has  seemed  to  be  re- 
covering ;  then  in  a  day  or  two  has  relapsed  into  coma  again,  and  died,  the 
cause  of  the  relapse  and  fatal  ending  being  the  de\'elopment  of  an  acute  cerebral 


700  SPLEEN,     ENLARGEMENT     OF     THE 

aneurysm  at  the  site  of  the  embolus,  rupture  of  this  aneurysm,  and  death  from 
the  resultant  hssmorrhage.  Progressive  aneemia  of  the  chlorotic  type,  without 
much  leucocytosis,  is  another  feature  of  these  cases.  The  diagnosis  must  always 
be  difficult  when  there  is  no  cardiac  bruit ;  whilst,  when  there  is  a  bruit,  the 
difficult}'  is  to  determine  whether  the  patient  is  suffering  merely  from  mechanical 
heart-failure,  or  from  fungating  endocarditis  superposed  upon  the  chronic  heart 
lesions  (pp.  38,   39). 

Thrombotic  infarction  may  cause  acute  splenic  enlargement  in  almost  any 
of  the  blood  diseases,  particularly  in  lymphadenoma  and  leukaemia. 

Neither  Injury  nor  Strangulation  of  the  spleen  by  its  becoming  twisted  upon  its 
own  hilum  is  a  very  common  event,  and  the  latter  is  nearly  always  the  result 
of  injury.  A  blow  in  the  splenic  region  may  be  such  as  to  cause  a  rupture 
in  the  pulp  of  the  spleen  without  bursting  its  capsule,  and  without  obviously 
injuring  the  chest  wall  or  the  abdomen.  The  bleeding  that  occurs  within  the 
capsule  of  the  spleen  itself  causes  very  great  pain  in  the  part  and  enlarge- 
ment of  the  organ  ;  the  diagnosis  can  seldom  be  more  than  guessed  at  unless 
laparotomy  is  performed.  Strangulation  of  the  spleen  seldom  occurs  if  the 
organ  is  in  its  natural  position  ;  but  when  there  has  been  previous  dislocation, 
an  abdominal  injury,  or  sometimes  a  sudden  spontaneous  effort,  has  led  to  its 
becoming  twisted  on  its  own  hilum,  the  symptoms  being  such  as  to  suggest 
an  acute  intra-abdominal  condition  requiring  immediate  laparotomy,  but 
seldom  pointing  to  the  actual  diagnosis  until  the  laparotomy  has  been 
performed.  Herbert  French. 

SPONGY  GUMS.— (See  Bleeding  Gums.) 

SPUTA  vary  enormously  as  to  their  amount,  consistence,  colour,  and  so 
forth ;  but  by  far  the  most  important  point  about  them  in  diagnosis  is  the 
determination  of  whether  they  contain  tubercle  bacilli  or  not.  There  is  no 
particular  variety  of  sputum  which  can  be  said  to  be  characteristic  of  pulmonary 
tuberculosis  to  the  naked  eye,  although  much  stress  is  generally  laid  upon  the 
fact  that  phthisis  with  cavitation  produces  a  nummular  sputum — that  is  to  say, 
sputum  of  which  the  individual  portions  expectorated  tend,  not  to  coalesce 
but  to  flatten  out  as  separate  round  portions,  if  they  are  spat  on  to  a  flat,  dry 
surface  ;  if  expectorated  into  antiseptic  fluid,  they  remain  as  more  or  less 
globular,  separate  masses.  As  a  matter  of  fact,  however,  ordinary  bronchitis 
may  produce  sputum  possessing  a  typical  appearance  of  nummularity,  and 
it  is  most  unwise  to  rely  on  the  naked-eye  appearances  of  sputum  for  any 
diagnosis  except  that  of  lobar  pneumonia,  when  it  may  be  typically  viscid 
and  rusty.  It  is  in  almost  all  cases  essential  to  make  films  of  the  sputum, 
and  to  stain  these  for  tubercle  bacilli  by  the  Ziehl-Neelsen  method  with 
carbol-fuchsin. 

The  carbol-fuchsin  solution  is  made  up  of  i  gr.  of  fuchsin,  10  c.c.  of  absolute  alcohol, 
and  100  c.c.  of  5  per  cent  solution  of  carbolic  acid  in  distilled  water.  The  slide  is  covered 
by  the  stain  in  a  suitable  receiver,  and  held  over  a  small  Bunsen  burner  or  spirit  flame 
until  the  fluid  steams  briskly  but  does  not  actually  boil.  After  immersion  in  this  for 
five  minutes  at  least,  and  it  does  not  much  matter  if  for  longer,  the  excess  of  stain 
is  poured  off,  the  film  washed  in  water,  the  excess  of  the  latter  drained  off,  and  the  slide 
immersed  in  25  per  cent  sulphuric  acid  for  about  half  a  minute  ;  it  is  then  transferred 
to  water  again,  and  recovers  more  or  less  of  the  red  tint  of  the  fuchsin  ;  if  too  little  of 
this  has  been  discharged,  the  slide  is  returned  to  the  sulphuric  acid  for  another  period, 
and  so  on  ;  when  well  decolorized,  only  the  thickest  parts  of  the  film  retain  obvious 
red  ;  it  is  then  counterstained  by  five  minutes'  immersion  in  carbol-methylene  blue, 
the  excess  of  this  stain  being  washed  off  with  water,  the  film  dried  in  the  air,  and 
either  mounted  in  Canada  balsam  or  else  examined  directly  through  cedar-wood  oil ; 
the  tubercle  bacilli  (Plate  XII,  Fig.  K)  show  up  as  bright  red  rods  in  a  blue  field  under 
the  oil-immersion  lens. 


SPUTA 


701 


The  presence  of  acid-fast  bacilli  in  an  ordinary  sputum  film  is  ver}^  nearly 
proof  positive  of  tuberculosis  of  the  lung,  the  only  source  of  fallacy  being  the 
possibility  of  non-pathogenic  acid-fast  bacilli  being  derived  from  the  mouth. 
It  is  very  unlikely  that  this  source  of  fallacy  will  persist  from  day  to  day, 
especially  if  care  be  taken  to  make  the  films  from  the  interior  of  the  sputum 
pellets.  It  should  be  remembered,  of  course,  that  the  absence  of  tubercle  bacilh, 
or  rather  their  non-detection,  is  no  proof  of  the  absence  of  pulmonary  phthisis, 
and  if  there  is  doubt,  successive  sputa  should  be  tested  in  the  same  way.  It 
should  also  be  remembered  that  a  lesion  which  may  have  been  tuberculous 
originally,  may  in  time  lose  its  tuberculous  character,  the  tubercle  bacilli  may 
die  out,  though  the  cavities  produced  by  them  still  persist  and  become  occupied 
by  pyogenic  organisms  and  their  products.  Many  of  the  symptoms  of  phthisis 
itself  are  not  due  to  tubercle  bacilli  directly,  but  rather  to  secondary  infection 
by  streptococci,  staphylococci,  pneumococci,  and  so  forth  ;  and  the  degree 
of  this  secondary  infection  may  be  gauged  from  the  films  at  the  same  time  as 
one  looks  for  tubercle  bacilli. 

It  is  also  important  to  reahze  that  a  person  may  expectorate  sputum  containing 
tubercle  bacilh  in  abundance  every  day  for  months,  and  yet  may  have  precisely 
as  much  lung  tissue  left  by  the  end  of  that  time  as  at  the  beginning  ;  this  is 
due  to  the  fact  that  when  cavities  have  been 
produced  they  are  lined  by  granulation  tissue, 
and  it  is  possible  for  the  discharge  from  the 
surface  of  these  granulations  to  produce  a 
continuous  supply  of  sputum  without  the 
erosion  of  the  lung  tissue  progressing.  One 
sees  a  precisely  similar  state  of  affairs  in 
cases  of  some  skin  ulcers,  which  may  discharge 
abundantly  and  yet  remain  much  the  same 
size  for  months  at  a  time.  The  best  evidence 
of  lung  destruction  is  afforded  by  the  dis- 
covery of  elastic  fibres  {Fig.  187)  in  the 
sputum  ;  if  these  are  present  there  must  be 
something  which  is  eroding  the  lung  tissue, 
and  if  tubercle  bacilli  are  present  at  the  same 
time,  the  two  together  indicate  advancing 
phthisis.  The  elastic  fibres  may  be  obvious 
when    ordinary    sputum    is    examined    fresh 

after  it  has  been  pressed  out  between  cover-slip  and  slide,  but  oftener  they 
are  more  easily  detected  when  a  quantity  of  sputum  has  been  boiled  with 
strong  caustic  soda  to  destroy  pus  cells,  mucus,  and  so  forth,  leaving  the  very 
resistant  elastic  fibres  unaffected.  Tubercle  bacilli  are  also  very  resistant  to 
the  effect  of  strong  alkali,  and  when  they  are  suspected  to  be  present  but  cannot 
be  found  without  in  some  way  concentrating  them,  it  is  a  useful  plan  to  boil 
the  sputum  with  an  equal  amount  of  5  per  cent  caustic  potash,  to  dilute  the 
result  with  water,  to  centrifugalize  it  well,  and  make  films  from  the  deposit. 
There  are  various  other  methods  of  obtaining  concentrated  bacilli  from  the 
sputum,  but  this  is  one  of  the  simplest.  It  should  be  borne  in  mind  that 
tubercle  bacilli  may  be  found  even  when  the  sputum  is  exceedingly  small  in 
amount  and  apparently  insignificant  and  mucoid. 
For  sputa  containing  blood,  see  Hemoptysis. 

Viscid,  rusty  Sputum  is  almost  pathognomonic  of  pneumonia.  As  a  rule  the 
diagnosis  of  lobar  pneumonia  is  fairly  clear  owing  to  the  sudden  onset  of  an 
acute  pulmonary  complaint  associated  with  fine  crepitations  confined  to  one  or 
more  lobes,  followed  by  dullness,  with  bronchial  breathing,  bronchophonj-,  and 


Fig.  187. — Elastic  fibres  from  sputum. 
The  lower  figure  is  less  magnified  than 
the  upper,  and  shows  alveolar  arrange- 
ment of  the  fibres.  (From  French's 
Medical  Laboratory  Methods.) 


702 


SPUTA 


pectoriloquy  without  rales  ;  these  being  succeeded  by  redux  crepitations,  with 
a  diminution  in  the  bronchophonjr,  pectoriloquy,  and  bronchial  breathing  until 
normal  voice  and  breath  sounds  are  restored.  The  patient's  temperature,  after 
maintaining  a  high  level  such  as  103°  F.  or  104°  F.  for  from  five  to  ten  or  more 
daj's — usually  about  seven — falls  by  crisis  {Fig.  188).  The  respiration  rate  is 
very  rapid — for  example,  40  per  minute — during  the  height  of  the  fever,  and  the 
skin  is  flushed,  dry,  pungent  before  the  crisis,  moist  from  profuse  perspiration 
after  it.  The  diagnosis  is  much  more  difficult  in  some  cases,  however  ;  there  are 
not  a  few  patients  in  whom  the  consolidation  is  deep-seated,  so  that  it  does  not 
come  to  the  surface  at  all,  and  lobar  pneumonia  has  to  be  diagnosed  when  there 
are  no  abnormal  physical  signs  to  be  detected  in  either  side  of  the  chest.  In 
such  cases  the  general  symptoms  may  suggest  the  diagnosis,  and  the  sticky, 
viscid  sputum,  the  colour  of  which  is  generally  that  of  iron  rust — but  which 
may  be  any  of  the  colours  that  a  bruise  may  have,  from  bright-red  or  brown 
to  greenish-brown,  greenish,  j^ellowish,  or  even  bluish-yellow — confirms  it  even 
when  the  lung  signs  remain  normal.     The  viscidity  of  the  sputum  in  these  cases 


J^2^.  1S8. — Temperature  chart  of  an  ordinary  case  of  lobar  pneumonia,  showing  a  crisis  on  the 
seventh  day  of  the  illness,  and  a  slight  post-critical  rise  on  the  following  daj'. 


is  of  as  much  importance  as  the  colour.  Films  of  it  usually  contain  numbers 
of  pneumococci  (Plate  XII,  Fig.  O)  ;  in  exceptional  instances  pneumo-bacilli. 
When  lobar  pneumonia  is  due  to  the  influenza  bacillus,  the  sputum  has  not  the 
viscid,  rusty  character  as  a  rule,  but  is  more  like  that  of  ordinary  muco-purulent 
bronchitis.  The  presence  of  large  numbers  of  pneumococci,  however,  or  of  any 
other  micro-organism  than  the  tubercle  bacillus,  is  by  itself  no  proof  that  this  is 
the  cause  of  the  lung  lesion,  for  even  in  the  sputum  of  perfectly  normal  persons, 
pneumococci  and  other  bacteria  are  frequently  abundant.  It  is  quite  possible 
for  a  patient  who  is  dying  of  general  miliary  tuberculosis  of  the  lung  to  have  no 
tubercle  bacilli  in  the  sputum,  but  an  abundance  of  capsulated  pneumococci 
which  may  readily,  when  they  are  discovered,  lead  to  an  erroneous  diagnosis. 

Influenza  bacilli  are  exceedingly  small ;  but  it  is  important  that  they  should 
be  looked  for,  both  directly  and  by  cultural  methods,  in  all  cases  thought  to  be 
influenzal,  before  this  diagnosis  is  regarded  as  established  :  even  when  influenza 
bacilli  are  found,  there  is  still  the  possibility  that  they  may  be  an  intercurrent 
infection  in  some  other  malady ;  but  it  is  so  tempting  to  think  of  influenza  when 
no  other  obvious  cause  for  a  febrile  illness  can  be  discovered,  that  it  should  not 
be  diagnosed  until  influenza  bacilli  have  been  shown  to  be  present. 


SPUTA  703 

Abundance  of  Foul  Sputum,  especially  when  expectorated  much  at  a  time  at 
comparatively  long  intervals,  is  sometimes  by  itself  a  striking  symptom,  and 
it  suggests  that  the  patient  is  suffering  from  one  or  other  of  the  following  : — 


Bronchiectasis 

Phthisis  with  cavitation 

Foetid  bronchitis 


An  empyema  ruptured  into  the 

lung 
Gangrene  of  the  lung. 


It  is  sometimes  very  easy  to  distinguish  between  these  ;  with  fibroid  lung 
and  bronchiectasis  the  patient  is  likely  to  have  had  symptoms  periodically  for 
a  long  while  ;  there  will  generally  be  marked  Clubbing  of  the  Fingers  [q.v.)  ;. 
the  abnormal  physical  signs  are  confined  to  one  lung  as  a  rule,  and  especially 
to  the  lower  lobe,  with  displacement  of  the  heart  towards  that  side  ;  there  will 
be  deficiency  of  movement,  resonance,  and  vesicular  murmur  in  the  affected 
lower  lobe,  together  with  either  absence  of  voice  sounds  and  of  rales,  or  scattered 
foci  of  crackling  rales,  especially  when  the  patient  coughs,  with  bronchophony, 
pectoriloquy,  and  bronchial  breathing.  If,  on  the  other  hand,  the  abundant 
and  foul  sputum  is  associated  with  abnormal  physical  signs  in  both  lungs,  and 
if  the  upper  lobes  are  obviously  more  affected  than  the  lower,  if  the  patient 
has  a  strong  tuberculous  family  history,  and  if  tubercle  bacilli  are  either  now 
present  in  the  sputum,  or  are  known  to  have  been  present  formerly, — the 
diagnosis  of  chronic  phthisis  with  extensive  cavitation  and  secondary  infection  of 
the  cavities  with  pyogenic  organisms  is  obvious. 

Foetid  bronchitis  is  always  a  dangerous  diagnosis  to  make,  and  the  probability 
is  that  many  cases  so  diagnosed  have  been  examples  either  of  deep-seated 
bronchiectasis,  of  phthisis  with  cavitation  and  secondary  pyococcic  infection,. 
or  of  empyema  ruptured  into  the  lung.  The  latter  is  generally  associated  with 
hardly  any  abnormal  physical  signs,  because  if  the  original  empyema  had  given 
rise  to  its  ordinary  physical  signs,  it  would  have  been  diagnosed  and  relieved 
by  operation  ;  an  empyema  may  develop  either  between  the  lobes,  or  between 
the  pericardium  and  the  lung,  or  between  the  diaphragm  and  the  lung,  in  such 
a  way  as  to  leave  normal  lung  tissue  all  round  the  surface  next  the  chest  wall, 
so  that  the  usual  evidence  of  pus  in  the  chest  is  entirely  wanting.  Even  if 
abnormal  physical  signs  are  produced  when  the  pus  is  kept  in  an  abnormal 
position  in  this  way,  the  needle  may  have  to  pass  through  so  much  tissue  before 
the  empyema  cavity  is  entered,  that  the  pus  cannot  be  located  :  in  either  of 
these  cases  the  empyema  will,  in  the  course  of  time,  tend  to  ulcerate  its  way- 
through  the  pleura  and  lead  to  the  expectoration  of  large  quantities  of  foul 
sputum  at  intervals  as  the  empyema  cavity  re-fills.  The  diagnosis  depends 
largely  upon  the  exclusion  of  other  causes  of  abundant  foul  expectoration,  and 
perhaps  upon  the  history  of  a  preceding  illness  predisposing  to  empyema,  for 
example,  lobar  pneumonia. 

Gangrene  of  the  lung  may  be  simulated  to  some  extent  by  bronchiectasis  or 
by  empyema  rupturing  into  the  lung ;  but  generally  speaking  nothing  but 
gangrene  will  produce  so  much  stench.  Foul  though  the  sputum  in  bad 
bronchiectasis  may  become,  it  seldom  approaches  the  awful  foetor  of  pulmonary 
gangrene.  The  history,  moreover,  is  acute  ;  there  may  be  some  obvious  cause 
for  gangrene,  particularly  lobar  pneumonia  in  a  patient  debilitated  from  some 
other  cause,  such  as  diabetes,  or  inhalation  of  foul  particles  after  immersion 
in  a  dirty  river,  or  as  the  result  of  disease  of  the  mouth,  throat,  or  oesophagus,, 
or  septic  embolism  of  the  lung  from  lateral  sinus  thrombosis,  and  so  forth.  If 
any  doubt  remains  as  to  whether  the  lung  tissue  is  being  destroyed  or  not, 
elastic  fibres  can  be  sought  for,  their  presence  at  once  distinguishing  between 
bronchiectasis  or  deep-seated  empyema  on  the  one  hand  and  gangrene  on  the 
other. 


704 


SPUTA 


When  a  large  quantity  of  pus  is  expectorated  through  the  lung  in  a  person 
who,  having  been  in  the  tropics  and  having  possibly  suffered  from  dysentery,  has 
since  had  symptoms  pointing  to  hepatic  trouble,  the  possibility  that  an  amoebic 
abscess  of  the  liver  may  have  opened  its  way  through  the  diaphragm  into  the 
lung  will  immediately  occur  to  one,  especially  if  the  expectorated  pus  is  tinged 
the  colour  of  anchovy  sauce.  It  might  be  thought  that  the  Aniceba  coli  would 
be  found  in  it ;  but  this  is  not  the  case,  for  this  protozoon  is  not  present  in  the 
pus  of  a  hepatic  abscess,  but  only  in  the  granulations  of  the  abscess  wall.  The 
sputum  in  these  cases  is  not  foul  as  a  rule. 

The  other  abnormal  features  that  may  be  exhibited  by  sputum  are  relatively 
uncommon,  and  are  of  diagnostic  significance  only  in  exceptional  cases.  The 
serous,  mucoid,  muco-purulent,  or  purulent  sputum  of  the  various  stages  of 
acute  and  chronic  bronchitis  may  arouse  a  doubt  as  to  whether  the  patient 
has  not  a  tuberculous  focus  ;  repeated  examination  will  fail  to  reveal  either 
tubercle  bacilli  or  elastic  fibres,  but  it  is  to  be  remembered  that  a  considerable 
minority  of  phthisical  subjects  seem  not  to  expectorate  the  bacilli.  Black 
sputum  is  common  in  those  who  live  in  smoky  atmospheres,  particularly  in 
towns,  colliery  districts,  and  manufacturing  centres.  Other  changes  in  colour 
may  be  due  to  haemoptysis,  pneumonia,  or  hepatic  abscess,  which  are  all 
discussed  above  ;  sometimes  infection  by  the  Bacillus  pyocyaneus  may  produce 
greenish  or  bluish  sputa  which  may  alarm  the  patient,  but  which  need  not  have 
any  serious  import. 

Curschmann's  spirals  (p.  179)  and  Charcot-Leyden  crystals  (p.  117)  have  been 
discussed  elsewhere. 

Casts  of  the  bronchial  tubes  are  met  with  in  very  exceptional  cases,  and  they 
are  of  two  main  types — namely,  diphtheritic,  and  non-diphtheritic.  The 
distinction  depends  on  bacteriological  examination  ;  histologically  they  consist 
of  ill-defined  exudate  containing  cells  irregularly  embedded  in  it.  Non- 
diphtheritic  casts  are  due  to  plastic  or  fibrinous  bronchitis,  a  very  rare  disease 
of  which  the  sputum  is  the  diagnostic  point.  Two  other  rare  causes  for  the 
expectoration  of  casts  of  the  bronchi  are  lobar  pneumonia,  and  the  inhalation 
of  blood  from  some  other  part  of  the  lung  in  a  case  of  hsemoptysis,  and  its 
subsequent  expectoration  after  it  has  clotted. 

Now  and  again  a  cretaceous  pellet  or  a  small  caseous  mass  may  be  found  in 
the  sputum  of  a  patient  who  either  has  pulmonary  phthisis,  as  evidenced  by 
the  abnormal  apical  physical  signs,  and  by  the  detection  of  elastic  fibres  as  well 
as  tubercle  bacilli  in  the  sputum,  or  in  children  as  the  result  of  the  ulceration 
of  a  caseous  bronchial  gland  into  the  trachea  or  a  main  bronchus,  and  then 
expectoration  of  its  caseous  or  cretaceous  contents. 

Another  rarity  which  has  occasionally  been  found  in  the  sputum  is  a  recogniz- 
able particle  of  new  growth,  the  detection  of  which  may  be  of  material  assistance 
in  diagnosis. 

Chemical  analyses  are  relied  on  by  some  observers  in  distinguishing  tuberculous 
from  non-tuberculous  sputum,  it  being  stated  that  expectoration  containing 
coagulable  proteid  is  more  likely  to  be  the  result  of  tuberculous  infection  than 
is  sputum  which  does  not  coagulate  with  heat.  This  distinction,  however, 
is  not  universally  accepted,  and  microscopical  examination  for  tubercle  bacilli 
is  certainly  a  more  reliable  test  in  the  great  majority  of  cases. 

The  rarer  bacteria  and  moulds  that  may  be  detected  in  the  sputum  by  special 
bacteriological  methods  generally  require  very  special  investigation,  including 
cultural  tests  by  skilled  bacteriologists  :  one  need  not,  therefore,  enter  into 
details  here,  though  it  may  be  well  to  enumerate  certain  micro-organisms  which 
may  be   pathogenic   in   the   lung  in   comparatively  rare   instances — B.  mallei, 


STERILITY 


705 


generally  amongst  workers  in  stables  or  otherwise  in  connection  with  horses  ; 
Aspergillus  flav.us,  A.  niger,  A.  funiigatus,  generally  amongst  those  who  have 
to  do  with  the  artificial  feeding  of  pigeons  and  other  birds  ;  Actinomyces 
or  the  ray  fungus,  in  those  who  have  had  to  do  with  barley  in  some  way  or 
another,  or,  as  has  recently  been  demonstrated,  in  those  who  are  in  the  habit 
of  holding  cotton  in  their  mouths,  such  as  tailors  and  seamstresses.  Besides 
these  pathogenic  micro-organisms,  not  a  few  others  which  are  not  actually 
pathogenic  are  to  be  recognized  in  the  sputum  when  it  has  become  secondarily 
infected  in  chronic  cases.  Penicillium  glaucum,  for  instance,  or  Oidiuni  albicans  ; 
yeast  and  other  moulds  ;  Micrococcus  tetragenus  ;  or  Oidium  tropicale,  a  micro- 
organism similar  to  but  culturally  different  from  Oidium  albicans,  which  has 
recently  been  reported  to  be  a  cause  of  lung  lesions  both  in  Europeans  and 
natives  in  Ceylon,  the  symptoms  suggesting  phthisis,  but  the  latter  being 
excluded  by  the  persistent  absence  of  tubercle  bacilli  from  the  sputum  and  by 
the  absence  of  reaction  to  tuberculin. 

Whooping-cough  is  sometimes  difficult  to  distinguish  from  other  colds  and 
from  bronchitis,  and  if  the  recent  statements  to  the  effect  that  it  is  due  to  a 
minute  bacillus  prove  true,  bacteriological  examination  of  the  sputum  may  be 
of  use  in  diagnosing  this  condition  in  doubtful  cases. 

The  lung  fluke,  Paragonimus  Westermani,  which  causes  haemoptysis  in  Corea, 
Japan,  and  parts  of  China,  is  to  be  diagnosed  by  the  discovery  of  its  oval, 
capsulated  eggs  in  the  sputum.  Herbert  French. 

SQUINT.— (See  Strabismus.) 

STAMMERING. — (See  Speech,  Abnormalities  of.) 

STERILITY. — The  differential  diagnosis  of  the  causes  of  sterihty  is  often  a 
matter  of  great  difficulty,  and  although  there  are  many  well-defined  conditions 
which  give  rise  to  it,  we  are  bound  to  admit  that  there  are  numbers  of  cases  in 
which  no  definite  cause  can  be  found.  Further,  we  must  not  overlook  the  fact 
that  the  husband  is  responsible  for  a  sterile  marriage  in  one-fourth  to  one-third 
of  the  cases.  This  is  a  fact  shown  by  many  observers,  and  too  often  forgotten 
when  investigating  cases.  Therefore,  we  must  not  consider  a  case  to  be  complete 
unless  the  husband  and  his  semen  have  been  investigated.  Many  a  woman  has 
her  married  hfe  made  miserable,  and  is  taken  from  doctor  to  doctor  on  account 
of  sterility,  when  the  husband  really  is  to  blame.  The  causes  of  sterility  are 
shown  in  the  table  on  the  next  page. 

From  a  study  of  this  table,  it  is  clear  that  some  of  the  causes  of  sterility  are 
primary,  whilst  others  are  secondary.  Thus  absence  of  the  uterus  or  infantile 
uterus  means  primary  sterility,  whilst  hyperinvolution,  carcinoma  of  the  cervix, 
etc.,  may  occur  in  women  who  have  had  children,  and  only  secondarily  become 
sterile  on  account  of  these  lesions.  Further,  some  of  these  causes  are  common, 
or  may  be  remedied  ;  others,  on  the  other  hand,  are  rare  or  absolutely  incurable. 
Diagnosis  is  therefore  of  great  importance,  for  it  is  far  better  to  discover  and 
remedy  a  defect  early  in  married  hfe,  than  to  wait  until  the  best  years  are 
soured  and  embittered  by  the  longing  for  a  child.  Unfortunately,  many  patients, 
from  various  motives,  put  off  the  investigation  too  long. 

Congenital  Lesions. — Some  of  the  congenital  lesions  are  diagnosed  easily,  such 
as  closure  of  the  hymen,  absence  of  the  vagina,  or  closure  of  the  cervix,  whilst 
absence  of  the  essential  organs  often  requires  an  anaesthetic  in  order  that  a 
bimanual  examination  may  be  made  satisfactorily.  The  infantile  uterus  and 
small  adult  type  are  very  difficult  to  differentiate  ;  but  it  may  be  remembered 
that  in  the  former  the  body  forms  only  one-third  of  the  total  length  of  the  organ, 
whilst  in  the  latter  it  forms  two-thirds,  both  t}^es  of  uterus  being  small  in  the 
D  45 


706 


STERILITY 


antero-posterior  and  lateral  dimensions,  and  only  slightly  shortened  in  the 
vertical.  Of  all  the  congenital  lesions,  the  "  cochleate  "  uterus  of  Pozzi  is  the 
commonest  cause  of  sterihty,  and  is  the  most  hopeful  as  regards  treatment. 
The  uterus  is  felt  to  be  unusually  curved  anterior^,  has  a  long  conical  cervix,  and 
a  small  external  os.  In  such  an  extemall}'  malfonned  uterus  as  this,  it  is  possible 
that  the  internal  structure  is  abnormal ;  the  endometrium,  perhaps,  is  unduly 
thin  and  fibrous,  the  muscle  layers  badh'  developed.  The  hypothetical  change 
in  the  endometrium  maj"  be  the  essential  cause  of  sterihtj^  :  hence  curettage 
for  its  complete  removal  forms  an  essential  part  of  the  treatment.  The  pecuhar 
shape  and  cur^'ature  have  long  been  considered  a  possible  cause,  preventing  the 
entrance  of  spermatozoa  into  the  cavit}'.  Pseudo-hermaphroditism  usually  shows 
itself  by  shortness  of  the  vagina,  elongation  of  the  chtoris,  and  the  presence  of 
glandular  masses  in  the  groins,  which  are  almost  alwaj'-s  testes,  proving  that 
the  subjects  of  it  are  reaU^'  undeveloped  males. 


Lesioxs  of  the  Generative  Organs. 


General  Conditions. 


Congenital  Lesions — 
Absence  of  uterus,  tubes, 

ovaries 
Closure  of  hj-men,  vagina, 

cervix 
Pseudo-hermaphroditism 
Infantile  uterus 
Small     adult     tj'pe     of 

uterus 
'■'  Cochleate  "  uterus 
Displacements 
H\-pothetical  changes  in 

endometrium. 


Acquired  Lesions — 
Dyspareunia 
Vaginismus 
Salpingo-oophoritis 
Uterine  fibroids 
Endometritis 
Cervical  catarrh 
Polypi 

Carcinoma  of  cervix 
Carcinoma  of  fundus 
Ovarian  tumours 
Acquired  atresia  of  vagina 

cervix 
Genital  fistulae 
H^^erinvolution 
Frequent  astringent 

douches 
Deficient  ovarian 

activit)'. 

In  the  male. 
Azoospermia 
Ohgospermia 
Necrospermia. 


Old  age 

Obesity 

Anaemia 

Kutritional  disturbances 

Incompatibihty 

Absence  of  sexual 

feeling. 


Acquired  Lesions. — The  difierential  diagnosis  of  the  acquired  lesions  can  only 
be  made  by  complete  examination  of  the  patient  by  inspection,  bimanual  examina- 
tion, and  the  use  of  the  microscope  to  elucidate  doubtful  growths.  Dyspareunia 
as  a  cause  is  dealt  with  in  the  article  under  this  head.  Hyperinvolution  requires 
just  a  word  to  itself,  as  it  is  an  interesting  and  easily  diagnosed  condition.  It 
occurs  alwa^'S  after  a  labour,  and  strictly  means  a  continuance  and  progressive 
increase  of  the  normal  lactation  atrophy  of  the  uterus.  The  uterus  is  felt  to  be 
very  small  bimanuallv,  and  the  sound  ma\-  pass  onl^^  ij  inches  in  a  marked 
case.     It  is  always  associated  with  incurable  amenorrhoea. 

Deficient  ovarian  activity,  whereby  the  Graafian  folhcles  do  not  ripen  or  rupture, 
is  not  to  be  diagnosed  bj'  any  of  the  ordinary  methods  we  can  employ,  and  it  is 
doubtful  whether  a  microscopic  examination  of  the  ovaries  themselves  Avould 


STERTOR 


707 


reveal  the  true  condition.  It  is  supposed  to  be  associated  with  scanty  nnenstrua- 
tion  or  amenorrhoea  for  which  no  other  definite  cause  can  be  found.  Absence 
of  ovarian  activity  must  be  the  true  cause  in  the  general  conditions,  which  are 
outwardly  shown  by  obesity,  ancemia,  and  disturbances  of  nutrition  ;  and  it  is  a 
fact  that  some  women  have  not  conceived  as  long  as  they  remain  too  fat,  whilst 
loss  of  weight  has  in  some  cases  been  followed  by  conception.  Incompatibility 
between  husband  and  wife  sexually  is  an  ill-defined  condition,  which,  however, 
is  fully  believed  to  be  a  cause  of  sterilitj'.  It  is  almost  incapable  of  proof,  for 
in  the  case  of  a  sterile  widow  who  remarries  and  conceives  for  the  first  time. 
we  have  no  proof  that  the  former  husband  was  capable  of  procreation.  Absence 
of  sexual  feeling  or  the  sexual  orgasm,  too,  is  not  always  a  cause  of  sterility, 
for  conception  has  occurred  in  women  who  are  absolutely  devoid  of  these  feehngs. 
On  the  other  hand,  most  authors  quote  the  case  of  a  woman  who  conceived  as 
a  result  of  the  only  coitus  at  which  an  orgasm  was  experienced.  The  influence 
of  age  on  child-bearing  must  never  be  forgotten,  the  liability  to  conceive  falling 
rapidly  every  year  over  thirty. 

Sterility  of  the  Male. — Finally,  the  examination  of  the  husband  and  his 
seminal  fluid  should  never  be  omitted  unless  there  is  some  quite  well-defined 
cause  to  be  found  in  the  wife.  Assuming  that  the  penis  and  testes  are  present, 
and  that  erections  render  the  sexual  act  possible,  the  seminal  fluid  must  be 
examined  carefully. 

The  fluid  should  be  collected  in  a  condom  by  means  of  a  normal  coitus,  and 
should  be  examined  within  twelve  hours.  It  must  be  spread  on  a  shde 
and  examined  with  a  high  power  of  the  microscope.  There  may  be  no 
spermatozoa  present  at  all,  the  condition  known  as  azoospermia,  in  which  case 
the  husband  is  incapable  of  procreation.  There  may  be  but  few  spermatozoa, 
and  those  exhibiting  only  feeble  powers  of  movement  :  oligospermia.  There 
maybe  plenty  of  spermatozoa  present,  but  quite  devoid  of  motility  :  necrospermia. 
It  is  unnecessary  in  this  article  to  enter  into  the  causes  of  these  conditions.  They 
are  usually  incurable,  and  consequently  further  investigation  is  unnecessary. 

Thos.  G.  Stevens . 

STERTOR  is  really  another  word  for  snoring ;  but  it  is  commonly  restricted 
to  the  heavy,  snoring  sound  accompanying  inspiration,  produced  not  in  the  nose 
but  by  vibrations  of  the  soft  palate,  generally  when  the  patient  is  in  a  state  of 
profound  unconsciousness.  It  differs  from  stridor  in  that  the  latter  is  produced 
in  the  larynx.  If,  as  is  generally  the  case,  the  patient  is  comatose,  the  presence 
or  absence  of  stertor  helps  little  in  the  diagnosis,  which  is  discussed  under  the 
heading  Coma.  Sometimes,  however,  without  being  comatose,  the  patient  may 
have  stertor  during  sleep,  when  he  is  suffering  from  any  of  the  following  : — • 


Paralysis  of  the  soft  palate 
Post-pharyngeal  abscess. 


Adenoids 

Hypertrophied  tonsils 

Quinsy 

The  stertor  in  these  cases  is  closely  akin  to  snoring.  The  differential  diagnosis 
generally  becomes  manifest  when  the  interior  of  the  mouth  and  pharynx  are 
examined.  Possibly  the  condition  most  likely  to  be  overlooked  is  post- 
pharyngeal abscess,  but  this  should  not  be  mistaken  for  anything  else  if  a  digital 
examination  of  the  back  of  the  mouth  is  made  ;  moreover,  except  when  due  to 
tuberculous  caries  of  the  cervical  vertebrae,  it  is  commonest  in  infants  and  quite 
small  children,  becoming  rarer  with  each  year  of  life.  Herbert  French. 

STIFF  NECK. — This  occurs  in  a  number  of  diseases  entirely  different  in 
character,  and  its  significance  may  be  either  grave  or  trivial.  It  is  rarely  that 
stiffness  is  the  only  symptom,  but  it  may  be  the  first  thing  complained  of,  or 
it  may  be  a  complication  arising  in  the  course  of  a  disease. 


yoS  STIFF     NECK 


It  is  not  right  to  assume  that  the  trouble  is  trivial,  or  vaguely  to  designate 
it  as  "  rheumatic,"  without  a  thorough  investigation.  It  is  necessary  first  to 
enquire  into  the  history  of  the  duration  of  the  illness,  when  it  may  become  obvious 
that  it  follows,  say,  an  injury,  or  has  arisen  during  the  course  of  some  disease 
and  is  not  primary.  Next  examine  the  patient  with  the  head  and  shoulders 
bared,  and  see  whether  there  is  any  swelling  or  abnormality  present,  also  the 
extent  of  possible  movement,  and  whether  or  not  it  is  the  movement  that  causes 
pain  ;  and  if  possible  locate  the  seat  of  the  pain.  Many  further  investigations 
may  be  necessary,  e.g.,  examination  of  "the  throat  for  tonsillitis,  the  ear  for 
suppurative  otitis  media,  etc.,  according  to  the  circumstances  of  the  case. 

Exposure  to  Cold  or  Sleeping  in  a  Cramped  Position  may  give  rise  to  a  transient 
stiff  neck,  which  is  associated  with  no  other  symptoms.  There  is  generally 
a  distinct  history  of  the  patient  waking  up  in  the  morning  with  a  stiff  neck,  and 
the  diagnosis  is  made  by  exclusion.  It  is  well  not  to  confound  these  with 
cases  of  rheumatoid  arthritis. 

Inflammation  of  the  Lymphatic  Glands  and  the  cellular  tissues  of  the  neck. 
Any  inflammatory  focus  in  the  neck  may  cause  stiffness,  whether  it  be  a  boil 
or  carbuncle,  or  an  enlarged  gland  arising  from  a  carious  tooth,  an  inflamed 
tonsil,  pediculosis  capitis,  or  other  similar  cause.  There  is  no  spasm  or  rigidit}' 
of  the  muscles  here,  the  neck  can  be  moved  quite  well ;  but  it  hurts  to  do  so, 
and  therefore  it  is  held  stiffly.  The  diagnosis  is  made  easy,  for  the  signs  of 
inflammation  will  be  obvious. 

Torticollis  or  Wry-neck  is  due  to  contraction  of  the  sternomastoid  muscle 
on  one  side,  usually  the  result  of  an  injury  to  the  muscle  caused  by  pulling  on 
the  aftercoming  head  in  breech  presentations.  The  muscle  stands  out  as  a 
tight  band  in  the  neck,  and  its  contraction  leads  to  a  characteristic  deformity. 
The  head  is  pulled  down  towards  the  affected  side,  and  the  face  and  chin  are 
tilted  towards  the  opposite  shoulder.  The  movements  of  the  head  are  necessarily 
restricted  owing  to  the  shortening  of  the  one  muscle,  and  in  long-standing 
cases  this  leads  to  a  marked  asymmetry  of  the  face.  The  consequences  are  not 
limited  to  the  head  and  neck,  for  the  spine  shares  in  the  general  obliquity,  and 
shows  marked  lateral  curvature  in  old  cases. 

Spasmodic  Torticollis  is  an  unusual  form  due  to  spasms  of  the  sternomastoid 
and  other  muscles  of  the  neck.  The  spasms  are  intermittent,  coming  on 
suddenly  with  great  pain,  the  affected  muscles  relaxing  after  a  variable  time. 

Cervical  Caries. — The  greatest  care  must  be  taken  not  to  confound  muscular 
rigidity  with  tuberculous  disease  of  the  cervical  vertebree.  In  the  latter,  pain 
and  rigidity  are  among  the  earliest  signs  ;  the  pain  is  increased  by  the  least 
movement,  and  the  child — for  it  is  generally  a  child  that  is  affected — takes  the 
greatest  precaution  to  avoid  any  movement,  even  holding  the  head  between 
the  two  hands.  The  position  of  the  head  varies  ;  it  is  most  often  held  very 
stiff  and  straight,  the  natural  backward  curve  of  the  neck  being  lost.  In  the 
late  stages  there  may  be  an  angular  or  lateral  curve.  The  distaste  for  move- 
ment is  very  well  brought  out  when  the  patient  is  asked  to  look  round — the 
eyes  only  are  moved,  or  the  whole  body  is  rotated.  Bearing  the  possibility  of 
this  condition  in  mind,  there  is  not  much  difficulty  in  diagnosis,  but  in  doubtful 
cases  a  skiagram  should  be  taken. 

Infective  Arthritis  of  the  Cervical  Vertebrce. — Following  infective  diseases  such 
as  scarlet  fever,  diphtheria  and  tonsilhtis,  especially  in  children,  there  may 
ensue  a  very  chronic  form  of  suppurative  arthritis  affecting  one  or  several  of 
the  cervical  vertebrae,  and  going  on  sometimes  to  complete  bony  ankylosis. 

Spondylitis  Deformans  causes  fixation  of  the  neck,  though  the  movements  of 
nodding  '  yes  '  and  '  no  '  remain  ;  the  nature  of  the  case  is  at  once  indicated, 
however,  by  the  fixation  of  the  other  regions  of  the  spinal  column  also. 


STRIDOR  709 


Injuries  to  the  Neck. — A  stiff  neck  may  arise  from  some  slight  injury,  such 
as  a  blow  or  a  sudden  twist.     This  will  be  clear  from  the  history. 

Severe  injuries  involving  fracture  or  dislocation  are  almost  always  fatal  : 
if  not  immediately,  then  in  a  few  days.  A  rare  injury  that  may  not  be  fatal 
is  unilateral  dislocation  of  one  of  the  cervical  vertebrae.  This  may  result  from 
a  fall  on  to  the  head.  From  the  start,  there  is  great  pain  and  stiffness  in  the 
neck,  the  head  being  fixed  immovably  and  turned  to  the  opposite  side  to  that 
of  the  displacement. 

Burns. — A  self-evident  cause  of  stiffness  is  the  cicatricial  contraction  following 
a  burn  on  the  neck. 

Stiffness  and  retraction  of  the  head  are  important  indications  of  meningitis, 
but  they  are  by  no  means  constant ;  when  present  they  are  generally  accompanied 
by  other  well-marked  signs  of  meningitis. 

Stiffness  of  the  neck  is  one  of  the  earliest  signs  of  tetanus  ;  it  is  rarely  the 
only  one,  however.  The  trouble  soon  spreads  to  the  jaw,  causing  trismus. 
The  patient  looks  very  ill,  and  there  is  almost  always  some  wound  which  is 
sufficient  to  indicate  the  cause  of  the  illness.  Geo.  E.  Gask. 

STRABISMUS. — Squints  may  be  classified,  according  to  their  direction,  into 
convergent,  divergent,  or  attitudinal ;  according  to  their  cause,  into  paralytic 
and  non-paralytic  (concomitant). 

The  diagnosis  between  paralytic  and  non-paralytic  strabismus  is,  as  a  rule, 
easy.  In  a  paralytic  strabismus  the  convergence  or  divergence  of  the  two  eyes 
is  not  constant  in  amount  in  all  directions,  as  the  farther  the  eyes  are  moved 
over  in  the  direction  of  the  action  of  the  paralyzed  muscle  the  greater  will  be 
the  deviation  from  parallelism.  In  a  concomitant  squint  the  eyes  always  bear 
the  same  relative  position  to  each  other  in  whatever  direction  they  are  turned. 

The  diagnosis  of  the  cause  of  a  paralytic  strabismus,  which  is  associated  with 
Diplopia,  is  discussed  under  that  heading  {q.v.).  The  causes  of  concomitant 
strabismus  are  usually — Error  of  refraction  ;  Failure  of  binocular  vision  ;  Defective 
vision  in  one  eye  ;  or  the  association  of  one  or  more  of  these  conditions.  The 
cause  cannot  be  determined  accurately  without  a  careful  examination  of  the 
ocular  refraction  under  a  mydriatic.  In  general  terms  it  may  be  stated  that 
convergent  squints  are,  as  a  rule,  due  to  hypermetropia,  and  divergent  squints 
to  myopia.  Herbert  L.  Eason. 

STRANGURY. — (See  Micturition,  Abnormalities  of.) 

STRIDOR  is  a  term  used  to  denote  a  harsh,  vibrating  noise  produced  as  the 
air  passes  in  or  out  of  a  partially  obstructed  larynx  or  trachea.  It  may  be  due 
to  many  different  causes,  which  may  be  classified  as  follows  : — 

1.  Partial  Obstruction  Inside  the  Larynx  or  Trachea : — 

Mucus  or  muco-pus 

Foreign  body 

Caseous  gland  rupturing  into  trachea. 

2.  Affections  of  the  Wall  of  the  Larynx  or  Trachea  : — 

Diphtheria 

Acute  oedema  due  to — 

Bright's  disease 

Potassium  iodide 

Acute  streptococcal  laryngitis 

Acute  pneumococcal  laryngitis 

Acute  staphylococcal  laryngitis 


yio 


STRIDOR 


Secondary  infection  in  cases  of  tuberculous  ulceration 
^,  ,,  „  syphilitic  ulceration 

J,  J,  „  malignant  ulceration 

J,  „  „  traumatic  ulceration 

,,  J,  „  post-typhoidal  ulceration 

Stenosis  after  tracheotomy  or  cut  throat 

Epithelioma  of  the  vocal  cords 

Fibroma  of  the  vocal  cords 

Epithelioma  of  the  trachea 

Syphilitic  stenosis. 

3.  Swellings  Outside  Compressing  the  Larynx  or  Trachea  :— 

Enlargement  of  the  thyroid  gland 

Enlargement  of  the  thymus  gland 

Thoracic  aneurysm 

Mediastinal  new  growth 

Post-pharyngeal  abscess 

Epithelioma  of  the  oesophagus  invading  the  trachea 

Malignant  glands  in  the  neck 

Epitheliomatous  glands  in  the  neck. 

4.  Bilateral  Abductor  Paralysis  of  the  Vocal  Cords,  generally  due  to  syphilitic 
degeneration  of  the  vagal-nuclear  nerve  cells. 

Distinction  is  sometimes  drawn  between  inspiratory  and  expiratory  stridor, 
and  stridor  which  is  both  inspiratory  and  expiratory  ;  but  in  practice  such  a 
distinction  is  not  helpful.  The  main  value  of  stridor  as  a  symptom  is  that  it 
indicates  stenosis  of  the  main  air-passages  by  one  or  other  of  the  above  causes, 
except  in  those  rare  cases  in  which  it  is  functional  :  hysterical  stridor  ceases 
during  sleep,  is  nearly  always  confined  to  the  female  sex,  as  a  rule  between  the 
ages  of  fifteen  and  thirty,  and  is  often  associated  with  other  functional  nervous 
symptoms,  such  as  globus  hystericus  and  functional  aphonia.  Stridor  should 
never  be  diagnosed  as  functional,  however,  until  every  possible  organic  cause 
has  been  excluded.  The  differential  diagnosis  of  the  causes  of  obstruction  to 
the  main  air-passages  will  be  found  discussed  on  page  464.  Herbert  French. 

STUPOR.— (See  Coma.) 

STUTTERING. — (See  Speech,  Abnormalities  of.) 

SUCCUSSION  SOUNDS Succussion  sounds  may  be  heard  when  a  part  that 

contains  any  considerable  bulk  of  both  fluid  and  gas  is  shaken,  whilst  the  ear  or 
the  stethoscope  is  applied  over  the  part.  Sometimes  the  sounds  are  so  loud 
that  they  can  be  heard  at  a  considerable  distance  from  the  patient.  A  very 
good  example  of  succussion  sound  is  often  afforded  by  the  normal  stomach  after 
a  quantity  of  fluid  has  just  been  swallowed.  It  is  a  mistake  to  suppose  that 
gastric  succussion  sounds  are  evidence  of  abnormality  ;  they  merely  prove 
that  the  viscus  contains  fluid  and  gas  at  the  same  time  ;  the  gas  may  be  due  to 
fermentation,  but  it  is  often  nothing  but  air  that  has  been  swallowed  during 
drinking.  The  chief  value  of  gastric  succussion  sounds  is  that,  according  to  the 
position  in  the  abdomen  at  which  they  can  be  heard,  they  afford  some  clue  as  to 
the  position,  and  perhaps  as  to  the  size,  of  the  stomach.  They  should  not  be 
heard  lower  than  the  umbilicus  ;  if  they  are,  the  stomach  is  either  displaced 
downwards,  or  dilated,  or  both. 

Another  variety  of  succussion  sounds  may  sometimes  be  heard  in  the  chest, 
especially  in  cases  of  hydropneumothorax  ;  when  the  patient  deliberately 
oscillates  his  trunk  to  and  fro,  and  then  stops,  the  fluid  and  air  can  be  heard 


SUCCUSSION     SOUNDS  711 

making  noises  like  those  produced  when  a  partly-filled  barrel  is  moved  about. 
Sometimes  the  fluid  splashes  up  on  to  the  collapsed  lung  and  then  drips  off 
again  into  the  pool  at  the  bottom  of  the  pleural  cavity,  each  drop  echoing  in 
the  cavity  and  producing  a  metallic  clink  like  a  bruit  d'airain  or  coin  sound. 
Similar  succussion  sounds  may  be  produced  by  a  pyopneumothorax  or  a 
haemopneumothorax,  the  difference  between  these  being  decided,  as  a  rule,  by 
exploratory  needling. 

Succussion  sounds  other  than  those  due  to  the  stomach,  or  to  gas  and  fluid 
in  the  pleural  cavity,  are  uncommon,  but  the  following  is  a  list  of  the  chief 
possible  causes  : — 

1.  Causes  of  Succussion  Sounds  in  the  Thorax  : — 
{a)   Hydropneumothorax 

{b)  Pyopneumothorax 

(c)  Haemopneumothorax 

(d)  Diaphragmatic  hernia 

(e)  Subdiaphragmatic  abscess  communicating  with  stomach  or  duodenum, 

and  so  containing  air  and  pus  ;  or  else  infected  with  the  Bacillus  coli 

commimis,  and  containing  gas  and  pus 
(/)    Hydropneumopericardium 
(§■)   Pyopneumopericardium 
{h)  A  huge  phthisical  cavity  beneath  a  thin  chest  wall. 

2.  Causes  of  Succussion  Sounds  in  the  Abdomen  : — 
{a)  The  normal  stomach 

(&)   Dilatation  of  the  stomach 

(c)    Enormous  dilatation  of  the  csecum 

{d)   Enormous  dilatation  of  the  sigmoid  colon 

(e)   Enormous  dilatation  of  some  other  part  of  the  colon 

(/)  Pneumoperitoneum,  due  to  :  (i)  Perforated  gastric  ulcer  ;  (ii)  Perforated 
duodenal  ulcer  ;  (iii)  Perforated  typhoid  ulcer  of  the  intestine  ; 
(iv)  Perforated  tuberculous  ulcer  of  the  intestine  ;  (v)  Perforated 
malignant  ulcer  of  the  colon  ;  (vi)  Production  of  gas  by  the  Bacillus 
coli  communis,  either  in  a  local  abscess  (e.g.,  appendicular  or  subdia- 
phragmatic) or  in  the  general  peritoneum 

(g)   Subdiaphragmatic  abscess  communicating  with  the  interior  of    stomach 

{h)  Air  and  urine  in  the  bladder  (see  Pneumaturia) 

{i)  Infection  of  an  ovarian  cyst  or  other  collection  of  fluid  by  a  gas- 
producing  micro-organism. 

I.   Succussion  Sounds  in  the  Chest The  diagnosis  is  not  as  a  rule  difficult. 

It  is  very  rare  indeed  for  a  phthisical  cavity  to  give  succussion  sounds  ;  but  should 
it  do  so,  the  phenomenon  would  be  apical  rather  than  basal,  and  thus  distinguish- 
able from  most  cases  of  hydro-  or  pyo-pneumothorax.  It  is  possible  for  the 
latter  to  be  apical,  however,  if  old  adhesions  prevent  the  parietal  and  visceral 
layers  of  pleura  from  separating  in  the  lower  part  of  the  chest,  and  then,  if 
tubercle  bacilli  were  found  in  the  sputum,  it  would  become  a  matter  of  opinion  as 
to  whether  the  sounds  were  produced  in  the  pleural  cavity  or  in  a  huge  vomica. 
Hydro-  and  pyo-pericardium  are  very  rare,  and  they  are  at  once  distinguished 
by  the  extraordinary  churning  sounds  made  by  the  heart  beating  within  the 
mixture  of  air  and  fluid.  Survival  is  improbable.  The  cause  is  generally 
either  an  epithelioma  of  the  oesophagus  opening  the  pericardium  from  behind, 
a  foreign  body,  such  as  a  tooth-plate,  ulcerating  through  from  the  oesophagus, 
or  else  the  opening  of  an  air-containing  subdiaphragmatic  abscess  through  the 
diaphragm  into  the  pericardium,  or  infection  of  the  pericardial  sac  by  a  gas- 
producing  organism  such  as  the  Bacillus  coli  communis. 


712  SUCCUSSION     SOUNDS 

It  may  be  important  to  know  that  a  subdiaphragmatic  abscess  containing  air, 
owing  to  communication  with  a  hole  in  a  gastric  or  duodenal  ulcer,  sometimes 
pushes  the  diaphragm  up  so  high  that  the  condition  may  be  mistaken  for  hydro- 
or  pyo-pneumothorax  when  it  is  really  subdiaphragmatic  ;  it  may  be  possible 
to  distinguish  the  two  by  knowing  that  the  trouble  began  with  gastric  ulceration  ; 
on  the  other  hand^  it  may  be  impossible  to  tell  which  it  is  untU  an  operation  is 
performed  and  the  position  of  the  diaphragm  ascertained.  When  the  trouble 
is  subdiaphragmatic,  the  tendency  is  to  displace  the  heart  upwards  rather  than 
towards  the  opposite  side  of  the  chest,  whereas  the  contrary  is  true  of  pneumo- 
thorax. The  ;ir-rays  may  be  of  use  in  deciding  whether  the  diaphragm  is  above 
or  below  the  gas-containing  cavity. 

Diaphragmatic  hernia  is  very  rare  ;  it  may  be  congenital,  or  it  may  be  the 
result  of  severe  injur}^  to  the  abdomen  and  chest.  In  neither  case  are  the  patient's 
prospects  of  survival  good.  The  exact  diagnosis  may  not  be  arrived  at  without 
operation  or  post-mortem  examination  ;  if  the  stomach  is  herniated  into  the 
thorax,  however,  the  effects  of  eating  and  drinking  upon  the  physical  signs  may 
point  to  the  diagnosis,  or  the  x-Ta.ys  may  be  used  to  demonstrate  the  gastric 
shadow  after  the  administration  of  large  doses  of  bismuth  oxycarbonate  by  the 
mouth.  In  most  cases  of  hydropneumothorax  there  is  little  difficulty  as  to  the 
diagnosis  of  the  condition  itself  ;  it  may  be  less  easy  to  decide  what  the  hydro- 
pneumothorax is  due  to.  The  onset  has  generally  been  sudden,  with  acute 
pain  in  the  affected  side  of  the  chest,  cyanosis,  and  dyspnoea,  and  by  far  the 
commonest  cause  is  phthisis.  The  sputum  should  be  examined  carefully  for 
tubercle  bacilli.  In  some  instances  an  injury  may  have  been  the  immediate 
cause,  but  injury  will  very  seldom  produce  hydropneumothorax  unless  there  was 
already  a  tuberculous  or  other  lesion  in  the  lung  at  the  time  of  the  accident. 
Hydropneumothorax  may  result  temporarily  after  paracentesis  thoracis. 

If  there  has  been  bleeding  at  the  same  time,  hcBmopneumothorax  may  be  found. 
Either  a  hydro-  or  a  haemo-pneumothorax  may  become  infected  with  pj^ogenetic 
organisms  and  converted  into  a  pyopneumothorax,  in  which  case  the  patient 
will  be  more  gravely  ill,  with  pjnrexia,  cachexia,  and  perhaps  rigors.  The 
diagnosis  will  be  confirmed  by  needling  the  chest.  Pyopneumothorax  is  apt  to 
escape  detection,  however,  because  it  arises  when  the  patient  is  too  ill  to  be 
shaken — in  cases  of  gangrene  of  the  lung  for  instance,  resulting  perhaps  from 
lobar  pneumonia,  obstruction  of  a  bronchus  by  a  foreign  body  or  a  new  growth, 
or  the  breaking  down  of  an  infective  bronchopneumonia  or  pulmonary  infarct. 
Generally  speaking,  indeed,  one  may  say  that  the  existence  of  well-marked 
succussion  sounds  in  the  pleural  cavit^^  of  a  patient  who  has  sufficient  vigour 
to  shake  his  own  body  to  and  fro  indicates  hydropneumothorax  of  phthisical 
origin. 

2.  Succussion   Sounds   in   the  Abdomen The  first  point  in  the  differentia 

diagnosis  of  succussion  sounds  in  the  abdomen  is  to  decide  whether  the  sounds 
are  gastric  or  not.  Generally  this  is  obvious  ;  if  there  is  doubt,  the  effect  of 
putting  more  gas  or  more  fluid  into  the  stomach  by  taking  a  seidlitz  powder  in 
two  halves,  or  by  drinking  a  quantitj^  of  water,  will  usually  so  change  the 
character  and  distribution  of  the  sounds  if  they  are  gastric,  that  little  doubt 
wUl  remain  ;  or  the  ;ir-rays  and  bismuth  method  of  demarcating  the  stomach 
xaz-j  be  employed.  As  has  been  mentioned,  the  existence  of  gastric  succussion 
is  no  proof  of  gastrectasis  ;  if,  however,  the  succussion  sounds  are  audible  over 
a  larger  area  than  the  normal  stomach  should  occup}?^,  they  afford  valuable 
evidence  of  gastrectasis,  and  the  next  step  will  be  to  determine  the  cause  of 
the  latter.  Dilatation  of  the  stomach  has  three  main  causes,  namely,  atony, 
non-malignant  pjdoric  obstruction,  especially  by  a  healed  simple  ulcer,  and 
mahgnant  pjdoric  obstruction  by  primary  gastric  carcinoma. 


SUCCUSSION     SOUNDS  713 

The  presence  of  visible  peristaltic  waves,  or  the  occurrence  of  vomiting,  will 
exclude  simple  atony,  which  can  never  be  diagnosed  with  certainty  until  it  is 
known  that  there  is  no  pyloric  obstruction.  The  latter  will  be  indicated  by  the 
periodicity  of  the  vomiting  ;  by  the  abundance  of  the  fluid  vomited  being  greater 
than  the  amount  taken  at  the  last  meal  ;  by  the  presence  in  it  of  particles  of 
food  eaten  a  day  or  more  previously — ham,  for  instance,  vomited  on  Tuesday 
when  last  partaken  of  on  Sunday  ; — by  the  visible  peristaltic  waves  correspond- 
ing with  the  stomach  ;  and  by  the  presence  of  sarcinae  in  the  vomit  (see 
Fig.  92,  p.  267). 

There  may  also  be  evidence  of  delay  in  the  absorption  of  substances  that  are 
not  dissolved  until  they  reach  the  pancreatic  juice  in  the  duodenum,  tested  for 
instance  by  giving  methylene  blue  in  keratin-coated  capsules,  and  observing 
when  the  urine  first  begins  to  be  blue.  Keratin  is  not  dissolved  by  gastric  juice, 
but  is  by  pancreatic  ;  if  there  is  no  evidence  of  pancreatic  disease,  delay  of  more 
than  one  to  two  hours  in  the  first  sign  of  blueness  of  the  urine,  after  giving  the 
capsules,  indicates  marked  delay  in  their  transit  from  stomach  to  duodenum. 

It  is  often  a  matter  of  extreme  difficulty  to  decide  whether  pyloric  stenosis  is 
simple  or  malignant,  though  upon  the  whole  the  shorter  the  history  the  older 
the  patient,  and  the  more  definite  the  pyloric  thickening  or  lump  the  more 
likely  is  the  lesion  to  be  carcinomatous.  The  latter  may  occur  in  quite  young 
subjects,  however,  even  between  20  and  30;  and  a  long  history  does  not  exclude 
carcinoma,  since  some  cases  of  simple  ulcer  ultimately  become  malignant.  Even 
when  laparatomy  is  performed  for  the  relief  of  the  condition,  its  nature  may 
not  be  obvious  ;  sometimes,  indeed,  post-mortem  examination  has  failed  to  decide 
whether  the  stenosed  pylorus  was  carcinomatous  or  not,  until  microscopical 
examinations  have  been  made.  It  has  been  stated  that  if  the  gastric  juice  after 
a  test  meal  contains  a  normal  amount  of  HCl,  the  diagnosis  is  unlikely  to  be 
carcinoma,  and  vice  versa ;   but  even  this  general  rule  has  many  exceptions. 

The  diagnosis  of  pyloric  stenosis  due  to  other  causes  than  healed  ulcer  or  a 
carcinoma  is  seldom  possible  without  a  laparotomy  ;  occasionally  such  out-of- 
the-way  things  as  a  calcified  retroperitoneal  cyst  adherent  to  the  pylorus  and 
thought  to  have  been  a  carcinoma  pylori  may  be  found. 

If  there  are  well-marked  abdominal  succussion  sounds  that  can  definitely  be 
shown  not  to  be  gastric,  there  are  generally  other  well-marked  signs  and  sym- 
ptoms which  materially  assist  the  diagnosis. 

Succussion  sounds  in  the  general  peritoneal  cavity  are  excessively  rare,  for 
even  though  this  cavity  should  contain  both  gas  and  fluid,  for  instance  after 
perforation  of  a  typhoid  ulcer,  the  coils  of  bowel  prevent  the  sounds  from 
being  readily  produced.  The  list  of  causes  given  above  indicates  the  conditions 
that  may  be  present.  It  would  clearly  be  next  to  impossible  to  diagnose  most 
of  them  unless  the  previous  state  of  the  patient  was  accurately  known,  or 
unless  exploratory  laparotomy  was  resorted  to.  It  is  important  to  remember 
that  the  Bacillus  coli  communis  produces  gas,  so  that  intra-abdominal  abscesses, 
appendicular  and  otherwise,  are  not  infrequently  resonant.  The  occurrence, 
however,  of  marked  non-gastric  succussion  sounds  in  the  abdomen  of  a  patient 
who  is  not  acutely  ill  will  generally  arouse  a  suspicion  that  there  is  distention 
with  gas  and  fluid  of  some  part  of  the  large  bowel,  especially  the  caecum  or 
the  sigmoid  colon.  This  distention  will  generally  be  the  result  either  of  chronic 
constipation  (see  p.  140)  or  of  some  cause  of  intestinal  stenosis. 

In  some  cases  that  were  formerly  described  as  idiopathic  dilatation  of  the 
colon,  but  which  are  now  regarded  as  chronic  volvulus  of  the  sigmoid  colon,  the 
result  of  persistent  constipation,  the  sigmoid  dilatation  may  be  so  extreme  that 
this  part  of  the  intestine  bulges  up  as  far  as  the  diaphragm  (Hirschsprung's 
disease,  see  Fig.  40,  p.  148,  and  Fig.  122,  p. 432  )  ;   the  occurrence  of  succussion 


7l4  SWEATING,     ABNORMALITIES     OF 

sounds  in  such  a  dilated  colon  might  readily  lead  to  the  erroneous  diagnosis  of 
gastrectasis ;  the  pear-shaped  outline  of  the  dilated  viscus,  and  the  fact  that 
it  is  known  to  have  come  upwards  from  the  pelvis,  may  indicate  the  true 
nature  of  the  case,  but  sometimes  the  fact  that  succussion  sounds  are  colonic 
and  not  gastric,  can  only  be  determined  by  giving  large  doses  of  bismuth  by 
the  mouth  and  then  outlining  the  stomach  by  the  dark  shadow  cast  by  the 
bismuth  under  the  ;ir-rays.  Herbert  French. 

SUPPRESSION  OF  URINE.— (See  Anuria.) 

SWEATING,  ABNORMALITIES  OF.  —  The  functional  disorders  of  the 
sweat-glands,  sudamen  {miliaria)  and  hidrocystoma,  sue  dealt  with  from  the 
diagnostic  point  of  view  in  the  article  on  Vesicles.  The  other  abnormalities 
require  but  the  briefest  notice  in  a  work  on  diagnosis,  for  it  is  hardly  possible 
to  confuse  them  with  each  other  or  with  any  other  conditions.  In  hyperidrosis 
the  secretion  of  sweat  is  excessive,  either  over  the  whole  skin  or  in  some  particular 
region,  e.g.,  the  palms  and  soles,  and  especially  covered  parts  furnished  with 
large  sweat-glands,  such  as  the  axillae  and  genital  regions.  Occasionally  hyper- 
idrosis is  limited  to  the  area  of  distribution  of  a  particular  nerve — the  fifth,  for 
example.  In  some  cases  a  peculiar  pink  tint  of  the  inner  side  of  the  palm  and 
the  ball  of  the  little  finger  and  thumb  has  been  noticed.  In  rare  instances 
hyperidrosis  in  delicate  children  is  associated  with  granulosis  rubra  nasi,  a  condi- 
tion in  which  the  skin  of  the  nose  becomes  intensely  red,  and  is  dotted  over  with 
minute  deep-red  specks  and  papules,  the  papules  gradually  developing  into 
pustules  which  soon  dry  up.  The  cells  around  the  sweat-ducts  are  infiltrated, 
and  both  ducts  and  coils,  and  also  the  blood-vessels  and  the  lymphatic  spaces  of 
the  corium,  are  dilated.  This  complication  is  distinguishable  from  rosacea  by 
the  age  of  the  patient  and  the  absence  of  telangiectases  and  of  change  in  the 
sebaceous  glands  ;  from  eczema,  by  the  absence  of  vesiculation  and  weeping, 
and  its  obduracy  to  local  treatment  ;  from  lupus  erythematosus,  by  the  absence 
of  scales  ;  and  from  lupus  vulgaris,  by  the  absence  of  apple- jelly  nodules.  The 
night  sweats  of  phthisis,  and  those  associated  with  rickets  and  with  infantile 
scurvy  (Barlow's  disease),  are  not,  as  a  rule,  difficult  to  attribute  to  their  cause. 

In  anidrosis  the  secretion  may  be  merely  diminished  or  totally  suppressed, 
and  either  the  whole  skin,  or  only  some  particular  area,  may  be  affected.  The 
abnormality  is  rarely  idiopathic,  but  is  usually  associated  with  ichthyosis, 
psoriasis,  eczema,  sclerodermia,  with  disordered  innervation,  belladonna  poison- 
ing, or  with  malnutrition.  Apart  from  the  dryness  there  is  no  symptom 
except  a  sense  of  fullness  and  tension  on  exposure  to  heat. 

Bromidrosis,  or  foul-smelling  sweat,  sometimes  associated  with  hyperidrosis, 
may  occur  in  connection  with  such  general  affections  as  acute  rheumatism, 
uraemia,  and  scurvy,  or  following  a  serious  illness  like  pneumonia,  or  may  be 
idiopathic.  Occasionally  generalized,  it  is  much  more  frequently  limited  to 
particular  parts,  such  as  the  feet,  the  axillae,  and  the  perineum.  The  foul  smell 
is  due  to  the  growth  of  the  Bacillus  fcetidus  upon  the  sweat  after  exudation. 

In  chromidrosis  both  sweat  and  sebum  may  be  coloured,  generally  some  shade 
of  blue,  but  occasionally  red,  green,  yellow,  violet,  and  even  black.  The  pigment- 
ation is  usually  localized,  the  most  frequent  situations  being  the  eyelids,  cheeks, 
forehead,  and  side  of  the  nose ;  but  occasionally  the  whole  of  the  face  and  large 
parts  of  the  trunk  and  limbs,  and  especially  the  axillae  and  groins,  are  affected. 
The  condition  is  probably  a  neurosis,  but  it  may  be  due  to  the  ingestion  of  copper 
(green  sweat),  or  of  iron  (blue  sweat),  or  to  the  action  of  cocci  or  the  Bacillus 
pyocyaneus  upon  the  sweat  after  secretion.  The  chief  point  in  diagnosis  is  the 
exclusion  of  imposture. 


SWELLING,     ABDOMINAL  715 

Hcematidyosis,  or  bloody  sweat,  generally  limited  to  particular  parts,  the 
face,  hands,  feet,  navel,  etc.,  may  be  a  form  of  so-called  vicarious  menstruation, 
or  an  expression  of  emotional  stress  in  highly-strung  persons.  Uridrosis,  in 
which  urinary  constituents  are  present  in  the  sweat  in  abnormal  quantity,  is 
not  an  idiopathic  affection,  but  an  accompaniment  of  such  grave  conditions  as 
cholera  and  uraemia.  It  is  quite  unmistakable  ;  the  sweat  has  a  urinous  odour, 
and  white  crystals  will  be  seen  on  the  skin.  Malcolm  Morris. 

SWELLING,  ABDOMINAL. — These  may  be  acute  or  chronic,  general  or  local, 
and  caused  by  abdominal  accumulations  that  are  mainly  either  gaseous,  fluid,  or 
solid.  The  position,  physical  consistency,  and  duration  of  abdominal  swellings  are 
their  three  outstanding  clinical  features,  and  it  is  on  these  that  their  classifica- 
tion for  purposes  of  diagnosis  should  be  based. 

CLASSIFICATION. 
I. — Swellings  in  the  Abdominal  Wall. 

II. — General  Abdominal  Swellings  : — 

A.  Mainly  gaseous — 

Surgical  emphysema  |  Meteorism  [q.v.) 

B.  Mainly  fluid — • 

Ascites  {q.v.)  |  Abnormal  distention  of   hollow 

Large  cystic  tumours  j  viscera 

C.  Mainly  solid — 

Obesity  (q.v.)  |         ..New  growths 

Constipation  {q.v.)  \  ^if      Hydatid  disease- 

Inflammatory  deposits  '    I 

III. — Local  Abdominal  Swellings  : — 

A.  Due  to  general  causes — 


Encysted  ascites 
Tuberculous  peritonitis 
Hydatid  disease 


Subphrenic  abscess 
Phantom  tumours 
Enteroptosis 


B.   The  regional  Diagnosis  of  Local  Abdominal  Swellings. 

I. — Swellings  in  the  Abdominal  Wall. 

Swellings  that  are  situated  in  the  abdominal  wall  itself  can  be  recognized  by 
their  superficial  position  ;  by  the  fact  that  they  adhere  to  the  skin,  muscles,, 
or  fascia  of  the  abdominal  wall ;  or  by  the  discovery  that  they  do  not  follow 
the  movements  of  the  viscera  immediately  underlying  the  wall  of  the  abdomen, 
and  therefore  must  be  superficial  to  them.  But  it  may  be  impossible  to  dis- 
tinguish between  a  fatty  tumour  in  the  deeper  part  of  the  wall,  for  example, 
and  a  fatty  omental  mass  that  has  become  adherent  to  the  parietal  peritoneum, 
and  so  has  practically  incorporated  itself  with  the  abdominal  wall. 

Inflammatory  swelling  of  the  wall  may  occur  by  infection  from  without  or,, 
less  often,  from  within.  Thus  a  liver  abscess  may  cause  extensive  redness  and 
swelling  in  the  right  hypochondriac  region  ;  infiltration  of  the  abdominal  wall 
is  often  met  with  in  operations  for  appendicular  abscess.  In  acute  cases  of 
Hodgkin's  disease  and  lymphosarcoma,  tumours  suggesting  a  subacute  inflam- 
matory process  may  occur  in  the  abdominal  wall ;  but  they  are  really  localized 
lymphadenomatous  or  sarcomatous  deposits,  not  due  to  infection,  and  are 
associated  with  glandular  enlargements  in  other  parts  of  the  body  and  with 
anaemia.  Inflammatory  swelling  about  the  umbilicus  is  not  rare  in  newly-born 
infants,  and  is  due  to  the  entrance  of  infection  by  way  of  the  cord  ;  in  stout 


71 6  SWELLIXG,     ABDOMINAL 

uncleanly  adults  the  umbilical  fossa  may  be  the  seat  of  intertrigo,  which  becomes 
painful,  sweUs,  and  suppurates,  in  consequence  of  infection  from  without.  But 
a  far  more  serious  umbiUcal  inflammation  may  occur  in  patients,  usually 
children,  with  tuberculous  peritonitis  ;  a  tuberculous  mass  in  connection  with  the 
round  hgament  may  break  down,  perforate  at  the  umbihcus,  set  up  a  chronic 
discharge  there,  and  ultimately  a  faecal  umbilical  fistula  may  be  established. 
In  rare  cases  a  subdiaphragmatic  or  perigastric  abscess  may  cause  inflammatory 
thickening  of  the  round  ligament  and  umbilicus. 

(Edema  of  the  abdominal  wall  may  be  either  local  or  general   (see  GEdema). 

Tumours  of  the  abdominal  wall,  excluding  those  due  to  inflammation,  are 
rare  except  in  certain  situations.  Lipomata  and  fibro-lipomata  maj^  occur  in  an}' 
part  of  it,  and  in  the  inguinal  or  femoral  rings  closely  imitate  omental  hernias. 
Herni(B  are  commoner,  particularly  at  the  umbihcus  and  in  the  groins,  and 
there  is  httle  likehhood  that  a  definite  hernial  protrusion  in  any  part  of  the 
abdominal  wall  will  be  overlooked  ;  but  minute  hernias  into  the  abdominal 
wall,  such  as  may  occur  along  the  linea  alba,  especially  above  the  umbilicus, 
at  the  femoral  or  inguinal  rings,  or  along  the  hneee  semilunares,  may  sufiice  to 
produce  complete  intestinal  obstruction  and  yet  be  small  enough  to  demand 
ver\'  careful  palpation  for  their  discovery. 

In  malignant  disease  of  the  stomach,  pylorus,  or  region  of  the  portal  fissure 
generally,  small  secondary  nodules  may  appear  quite  earh^  at  the  umbilicus 
or  in  the  round  hgament  just  above  it ;  and  this  may  occur  before  the  primarj' 
tumour  has  given  rise  to  any  definite  signs  or  symptoms. 

II. — General  Abdominal  Swelling. 

A.  Mainly  Gaseous,  —  In  certain  cases  of  extensive  surgical  emphysema  the 
fascial  planes  of  the  abdominal  wall  are  invaded  and  dissected  out  by  gas,  which 
imparts  to  them  a  highl}-  characteristic  feathery,  crepitant,  and  crackling  feeling 
on  palpation.  The  gas  may  have  entered  from  wounds  in  the  neck,  thorax, 
or  trachea,  or  it  may  have  been  generated  by  gas-producing  microbes  in  any 
abscess  or  focus  of  inflammation  in  the  trunk  or  viscera,  and  have  made  its  way 
thence  into  the  abdominal  wall. 

Distention  of  the  intestines  with  gas  is  an  event  so  common  as  to  be  famihar 
to  all ;  its  diagnosis  is  discussed  under  ]\Ieteorism  {q.v.).  In  this  condition  the 
whole  of  the  abdomen,  or  in  special  cases  some  part  of  it  only,  is  distended,  and 
on  percussion  gives  a  highly  resonant  or  tympanitic  note.  It  often  happens 
that  the  outhnes  of  the  gas-distended  viscera  can  be  seen  on  the  abdominal 
wall,  particularly  when  it  is  looked  at  in  an  obhque  illumination.  The 
increased  size  of  the  inflated  intestine  is  apt  to  produce  displacement  of  the 
other  viscera  ;  the  dome  of  the  diaphragm  is  pushed  up  into  the  chest,  carrying 
the  heart  with  it  and  shifting  the  apex-beat  upwards  ;  the  liver  is  similarly 
pushed  up,  and  in  addition  it  is  often  caused  to  rotate  round  a  transverse  axis, 
its  lower  anterior  edge  ascending  and  its  lower  posterior  edge  descending,  with 
the  result  that  the  area  of  liver-dullness  in  front  is  much  reduced,  or  even 
lost  altogether.  But  it  is  only  a  little  reduced  in  the  mid-axillary  line,  so  long  as 
the  gas  remains  in  the  intestine ;  and  if  the  liver-dullness  in  the  mid-axillary 
line  disappears,  the  diagnosis  of  free  gas  in  the  peritoneal  cavity  is  to  be  made. 

B.  Mainly  Fluid. — The  diagnosis  of  the  various  causes  producing  accumula- 
tions of  fluid  in  the  peritoneal  cavity  is  given  under  the  heading  Ascites  (q.v.). 
Whatever  its  cause,  ascites  is  usually  not  difficult  to  diagnose  when  the  amount 
of  fluid  present  is  as  much  as  three  pints  or  more  ;  smaller  quantities  produce 
no  very  definite  phj^sical  signs.  Ascitic  fluid,  when  free,  always  tends  to 
gravitate  into  the  most  dependent  parts  of  the  abdominal  cavit}-,  causing 
localized  bulging,   dullness  on   percussion,  and    transmitting    a   characteristic 


SWELLING.     ABDOMINAL  717 

fluid  thrill  when  percussed  and  palpated  at  the  same  time.  When  present  in 
moderate  amount,  it  occupies  the  flanks  while  the  patient  lies  on  his  back  ;  the 
intestines  are  floated  upwards,  and  produce  a  tympanitic  or  resonant  area 
about  and  above  the  umbilicus.  When  present  in  large  amount — three  or  four 
gallons — it  may  make  the  whole  of  the  abdomen  dull  on  percussion,  probably 
because  the  mesentery  is  not  long  enough  to  allow  the  gas-containing  intestine 
to  reach  the  anterior  abdominal  wall  and  make  it  resonant. 

It  may  be  impossible  to  diagnose  ascites  in  an  adult  when  less  than  about 
three  pints  are  present ;  the  fluid  appears  to  spread  itself  about  the  abdomen 
and  pelvis,  and  to  occupy  the  interstices  between  the  viscera,  without  producing 
any  unmistakable  signs  of  its  presence.  Such  small  amounts  of  fluid  may  be 
detected  if  the  patient  is  placed  in  the  knee-elbow  position,  when  the  most 
dependent  part  of  the  abdomen  will  become  dull  on  percussion  ;  they  may 
also  be  diagnosed  in  women  by  vaginal  examination,  when  the  weight  and 
resistance  of  the  fluid  can  be  felt  in  Douglas's  pouch.  It  is  said  that  they  can 
be  diagnosed  in  males  by  pressing  a  finger  upwards  and  outwards  in  the  inguinal 
canal,  and  percussing  the  abdominal  wall  above  it,  the  patient  standing  upright, 
when  a  fluid  thrill  will  be  communicated  to  the  finger.  If  a  moderate  amount 
is  present — one  or  two  gallons — and  the  abdominal  wall  is  markedly  oedematous, 
the  diagnosis  of  ascites  may  again  be  impossible,  while  it  may  be  difficult  also 
if  the  abdominal  wall  is  very  fat.  If  peritoneal  adhesions  are  present,  the  ascitic 
fluid  may  become  encysted  or  loculated,  and  be  difiicult  of  diagnosis  because  it 
simulates  other  cystic  or  semi-solid  growths  occurring  in  the  abdomen. 

There  are  but  few  abdominal  swellings  that  simulate  ascites.  Unusually 
large  and  mobile  cysts  of  the  ovary,  mesentery,  omentum,  peritoneum,  or  liver 
do  so  most  often,  and  in  a  few  cases  large  soft  retroperitoneal  lipomata  (which 
may  occur  even  in  emaciated  patients)  have  been  taken  for  ascites.  The 
distinguishing  characteristic  of  ascitic  fluid  is  the  readiness  with  which  it  changes 
its  position  in  accordance  with  changes  in  the  patient's  posture  and  in  obedience 
to  gravity.  Ovarian  and  other  cystic  growths  in  the  abdomen  hardly  ever 
exhibit  such  complete  mobility,  and  tend  rather  to  swing  over  mainly  to  the 
one  or  the  other  side  of  the  abdomen  about  some  more  or  less  fixed  point — the 
pedicle  of  the  cyst — as  the  patient  turns  from  one  side  to  the  other  on  the  couch. 
An  ovarian  cyst  should  arise  out  of  the  pelvis,  and  it  is  usually  possible  to  demon- 
strate its  connection  with  the  uterine  adnexa.  But  every  gynaecologist  must 
have  met  with  cases  of  simple  ascites  operated  upon  for  ovarian  or  parovarian 
cyst,  and  with  cases  of  cyst  treated  by  paracentesis,  in  the  belief  that  the  con- 
dition was  one  of  ascites.  In  instances  that  are  fortunately  rare,  the  mistake  has 
been  made  of  regarding  some  viscus  abnormally  distended  with  fluid  as  ascitic 
fluid,  and  of  treating  it,  as  such,  by  paracentesis.  This  has  most  often  happened 
to  the  bladder  {Fig.  191,  p.  730),  which  should  always  be  emptied  (either  naturally 
or  by  the  catheter)  before  the  abdomen  is  tapped ;  to  a  greatly  dilated 
stomach  full  of  fluidr  [Fig.  190,  p.  728) ;  to  the  intestines  when  distended  with  fluid 
faeces  in  enteritis  or  chronic  obstruction  ;  to  the  gall-bladder  in  cholelithiasis ; 
to  the  uterus  in  pregnancy  alone,  or  in  pregnancy  combined  with  hydramnios. 

The  effusion  of  blood  into  the  peritoneal  cavity,  or  hcBnioperitoneum,  occurring 
after  a  fall  or  after  the  abdomen  has  been  crushed  or  has  received  a  blow,  may 
cause  a  slight  movable  dullness  in  the  flanks  exactly  like  that  of  ascites  ;  but 
the  patient  will  be  blanched  and  anaemic  from  loss  of  blood,  with  rapid  small 
pulse  and  sighing  respiration,  and  there  will  be  a  history  of  the  recent  accident. 
The  blood  comes  from  some  ruptured  viscus,  often  the  liver  or  spleen,  and  the 
diagnosis  is  not  usually  difficult.  The  accumulation  of  pus  in  the  peritoneal 
cavity,  or  pyoperitoneum,  is  a  part  of  acute  peritonitis  of  local  origin,  and  may 
also  occur  in  pneumococcic   or   tuberculous   peritonitis  ;    it   is   associated  with 


71 8  SWELLING.     ABDOMINAL 

many  other  signs  and  symptoms — ^pain,  fever,  vomiting,  constipation,  wasting, 
and  others — that  are  foreign  to  ascites.  In  rare  instances  the  abdomen  may 
become  distended  vnth  bile,  choleperitoneum  resulting  ;  usually  the  bile  is  infected 
and  sets  up  acute  peritonitis,  but  if  it  is  sterile  the  s^-mptoms  are  slight,  jaundice 
is  absent,  and  the  signs  point  only  to  ascites. 

C.  Mainly  Solid. — In  Obesity  {q.v.)  the  abdomen  may  swell  either  in  con- 
sequence of  the  deposit  of  fat  in  the  abdominal  wall  itself,  or  as  the  result 
of  fatt\-  deposits  behind  the  peritoneum  generally,  in  the  mesenterj^,  in  the 
omentum  and  appendices  epiploicae.  In  ver\-  fat  patients  it  is  rarely  possible 
to  diagnose  the  exact  nature  of  an  intra-abdominal  mass  by  the  usual  methods 
of  palpation  and  percussion,  and  without  having  recourse  to  exploratory?  laparo- 
tom}',  because  the  abdominal  waUs  are  so  thick.  The  frequency  with  which 
inconveniently  large  fatty  accumulations  occur  in  the  abdomens  of  such  persons 
must  not  be  forgotten  when  the  diagnosis  of  some  vaguelj'-felt  tumour  Avithin 
the  abdomen  has  to  be  considered. 

In  the  severer  and  more  chronic  cases  of  Constipation  (q.v.),  abdominal 
distention  may  result  from  the  accumulation  of  faeces  in  the  large  intestine, 
particularh'  when  dilatation  of  the  colon,  whether  idiopathic  or  secondary,  is 
present.  The  scj-bala  can  usually  be  felt  quite  distinctly,  perhaps  soft  and  plastic 
in  the  region  of  the  ascending  colon,  usuall}-  hard  and  nodular  in  the  descending 
sigmoid  and  colon.  Idiopathic  dilatation  of  the  colon  seems  to  be  congenital, 
and  is  associated  -with  much  hypertrophy  of  the  colon  [Fig.  122,  p.  432)  ;  it 
is  known  as  Hirschsprung' s  disease.  The  child,  obstinatelj'  constipated  at  all 
times,  has  periodical  dyspeptic  attacks,  in  which  the  distended  abdomen  becomes 
even  larger  ;  the  bowels  may  not  be  open  for  manj?  days  or  even  several  weeks 
together,  while  manj-  pounds  of  scybala  accumulate  in  the  colon  and  sigmoid, 
which  come  to  occupj*  the  whole  of  the  front  of  the  abdomen.  Forcible  colonic 
peristalsis  is  usually  visible  on  the  surface  of  the  abdomen.  Llalnutrition  and 
chronic  impairment  of  health  result,  and  the  patients  usually  die  young,  with 
emaciation  or  s}-mptoms  of  intestinal  obstruction.  Yet  no  obstruction  is  found 
to  exist  post  mortem  ;  possibly  there  is  a  congenital  abnormal  kinking  causing 
intermittent  obstruction  at  the  point  where  the  sigmoid  joins  the  rectum.  The 
diagnosis  is  easy  if  the  dilatation  and  hypertrophy  of  the  colon  are  once  seen. 
In  older  patients  a  vers"  similar  dilatation  and  hypertrophy  of  the  colon  may  come 
on  as  the  result  of  chronic  obstruction  about  the  lower  end  of  the  large  intestine. 
(See  Vomiting.)  As  much  as  47  lb.  weight  of  faeces  may  accumulate  in  the 
intestines  of  such  patients  as  these. 

In  rare  cases  of  chronic  peritonitis,  particularlj?  when  it  is  tuberculous,  semi- 
sohd  inflammatory  7nasses  ma.j  bring  about  a  general  swelling  of  the  abdomen  ; 
the  diagnosis  is  discussed  below.  General  swelhng  of  the  abdomen  may  occur 
in  malignant  disease  of  the  peritoneum,  the  so-called  malignant  peritonitis,  due 
in  part  to  the  groAvth  of  numerous  secondarj-  malignant  nodules,  in  part  to 
a  concomitant  ascites.  The  symptoms  are  often  vague  at  first — loss  of  weight, 
strength,  appetite,  with  indefinite  abdominal  disorders.  The  abdomen  enlarges, 
and  if  there  is  not  much  ascites  the  secondary'  deposits  can  be  felt  obscurely 
through  the  abdominal  wall.  Occasionalh?  they  can  be  palpated  in  the  ab- 
dominal wall  itself  near  the  umbilicus,  or  in  the  round  ligament  above  it,  or  the 
urachus  below.  As  the  case  progresses,  emaciation  becomes  marked,  the  skin 
loses  its  elasticity  and  often  develops  a  diffuse  brownish  pigmentation  ;  bedsores 
are  not  rare.  The  primar}'  growth  Taay  be  in  any  of  the  thoracic,  abdominal, 
or  pelvic  organs,  or  in  the  mamma  or  testis.  If  any  primary  growth  can  be 
made  out,  the  diagnosis  will  not  be  difficult,  especialty  if  glandular  enlargements 
are  found  in  the  groins  or  axillae,  if  the  ascitic  fluid  is  haemorrhagic,  and  if  it 
is  found  to  contain  multinuclear  endothelial  cells,  and  cells  with  atj'pical  mitotic 


SWELLING.     ABDOMINAL  719 

figures.  Tuberculous  peritonitis  can  be  excluded  by  means  of  the  tuberculin 
test  and  by  the  result  of  injecting  several  c.c.  of  the  ascitic  fluid  into  guinea-pigs. 
Hydatid  disease  of  the  peritoneum  runs  a  slower  course  than  malignant  peri- 
tonitis, and  echinococcal  cysts  may  be  found  in  the  ascitic  fluid  if  it  is  tapped. 
General  abdominal  swelling  may  occur  when  multiple  cysts  representing  the 
bladder  stage  of  Tcsnia  echinococcus  develop  all  over  its  surface.  As  a  rule, 
these  are  secondary  after  the  rupture  (accidental  or  by  paracentesis)  of  a  primary 
cyst  in  the  liver,  and  are  very  numerous.  They  cause  a  slowly  progressive 
enlargement  of  the  abdomen,  which  appears  to  be  filled  with  a  solid  or  semi-solid 
mass  ;  if  the  individual  cysts  are  large,  they  can  be  seen  outlined  on  the  ab- 
dominal surface,  and  can  be  felt.  They  are  freely  movable,  and  do  not  appear 
to  be  connected  with  any  of  the  viscera  in  particular  ;  they  do  not,  as  a  rule, 
give  the  hj'datid  thrill  on  percussion.  Peritoneal  hydatid  disease  is  extremely 
rare,  excepting  in  countries  (Iceland,  Australia)  where  the  inhabitants  live  very 
closely  in  company  with  dogs  that  are  the  hosts  of  Tcenia  echinococms. 
Eosinophilia  may  bs  found,  and  when  the  cysts  are  living  and  active  the 
patient's  blood-serum  may  give  a  specific  hydatid  precipitin  reaction,  though 
the  absence  of  both  this  and  eosinophilia  does  not  exclude  hydatid  disease. 

III. — Local  Abdomixal  Swelling. 

A.  Due  to  General  Causes. — It  often  happens  that  the  causes  which  produce 
general  swelling  of  the  abdomen  fail  to  do  so  in  particular  cases,  and  give  rise 
only  to  a  local  swelling.  Thus  in  encysted  ascites,  left  behind  after  an  acute 
diffuse  peritonitis,  or  accompanying  a  chronic  peritonitis,  an  accumulation  of 
fluid  bounded  by  fibrinous  or  fibrous  adhesions  between  the  adjacent  viscera 
may  be  found  in  any  part  of  the  peritoneal  cavity,  but  most  often  in  the 
flanks  and  about  the  pelvis.  If  a  good  history  of  the  case  can  be  obtained,  the 
diagnosis  of  the  nature  of  such  a  cyst  will  at  least  be  suggested  ;  the  phvsical 
signs  will  be  those  of  a  fixed  cystic  or  semi-solid  tumour,  and  the  diagnosis  will 
often  be  obscure  until  laparotomy  has  been  performed. 

Abdominal  swellings  of  the  most  various  size  and  position  may  occur  in 
tuberculous  peritonitis.  Many  of  them  are  composed  of  the  infiltrated  and 
roUed-up  omentum,  others  of  enlarged  and  tuberculous  mesenteric  glands, 
others  of  doughy  masses  of  adherent  intestine  and  fibrin.  The  amount  of  ascitic 
fluid  varies  widely  in  different  cases.  When  there  is  much,  and  the  patient  is 
an  adult,  the  diagnosis  of  cirrhosis  of  the  liver  is  likely  to  be  made  ;  when  the 
peritonitis  is  dry  (the  so-called  obliterative  form),  the  abdominal  cavity  may 
be  smaller  than  normal,  and  occupied  by  a  doughy,  rather  tender  mass  that 
presents  areas  of  resonance  alternating  with  areas  that  are  dull  on  percussion. 
The  physical  signs  here  will  naturally  vary  from  day  to  day  according  to  the 
amount  and  position  of  flatus  in  the  intestine.  The  symptoms  of  tuberculous 
peritonitis  are  very  variable  ;  as  a  rule  the  patient  is  thin,  ansmic,  seriously 
ill,  with  a  drawn  aspect ;  abdominal  pain  and  tenderness  are  usually  observed, 
nausea  and  constipation  with  chronic  intestinal  obstruction  are  frequent.  If 
there  is  ulceration  of  the  large  intestine,  diarrhoea  occurs,  and  blood  may  be 
passed  in  the  motions.  The  discovery  of  signs  of  tuberculosis  in  some  other 
part  of  the  body,  or  of  a  family  history  of  tuberculosis  if  the  patient  is  a  child, 
are  strong  arguments  for  regarding  a  case  with  signs  like  those  described  above 
as  tuberculous. 

In  patients  who  have  swallowed  the  ova  of  Tcsnia  echinococcus,  single  or 
multiple  hydatid  cysts  may  occur  in  any  part  of  the  abdominal  cavity.  Usually 
they  are  single,  and  the  large  majority  of  them  occur  in  the  liver,  because  the 
six-hooked  embryo  into  which  the  swallowed  ovum  develops,  travels  by  way  of 
the  vascular  svstem  and  starts  from  the  alimentarv  canal.     Having  reached  the 


720  SWELLING,     ABDOMINAL 

liver,  or  in  rarer  cases  the  spleen,  omentum,  mesentery,  or  peritoneum,  the 
embryo  or  proscolex  develops  a  laminated  chitinous  envelope  and  forms  what  is 
called  a  hydatid  or  echinococcal  cyst.  The  cyst  grows  slowly,  and  is  spherical 
except  in  so  far  as  it  is  moulded  by  the  pressure  of  adjacent  structures.  It 
contains  a  clear  saline  fluid,  in  which  may  be  found  booklets  (-Fig'.  6,  p.  57),  like 
those  on  the  head  of  the  adult  worm  or  scolex  that  infests  the  intestine  of  the 
dog,  brood-capsules  bearing  external  and  internal  scolices,  and  secondary  cysts 
or  bladders  that  are  completely  detached  from  the  walls  of  the  primary  or  parent 
cyst.  Until  it  has  become  large  enough  to  cause  mechanical  obstruction  and 
pressure-symptoms,  the  single  hydatid  cyst  gives  rise  to  little  pain  or  complaint. 
It  then  produces  a  bulging  of  the  overlying  abdominal  wall ;  on  palpation  it 
can  be  felt  as  a  smooth  rounded  and  more  or  less  tense  tumour,  sometimes 
elastic.  On  percussion,  the  cyst  is  dull,  and  if  it  is  of  a  certain  degree  of  tenseness 
it  may  yield  the  hydatid  thrill — just  as  any  other  cyst  may.  Hydatid  cysts 
in  the  mesentery,  omentum,  or  peritoneum  are  often  multiple,  and  may  be  felt 
as  scattered,  rounded  tumours  ;  otherwise  their  physical  signs,  and  the  scanty 
symptoms  to  which  they  give  rise,  are  like  those  of  the  single  hydatid  bladder. 
The  diagnosis  of  hydatid  disease  is  often  easy,  particularly  when  it  occurs  in 
persons  who  have  lived  in  Iceland,  Australia,  or  South  America,  and  who  present 
the  marked  physical  signs  and  the  comparative  absence  of  symptoms  indicated 
above.  In  other  cases,  exploratory  laparotomy  may  be  necessary  before  the 
diagnosis  can  be  established  ;  exploratory  puncture  of  any  cystic  tumour  in 
the  abdomen  cannot  be  advised.  Eosinophilia  is  sometimes  observed  in  hydatid 
disease,  but  not  always  ;  hence  its  absence  does  not  exclude  that  condition. 
A  specific  serum  reaction  is  reported  by  some  observers. 

In  consequence  of  bacterial  infection  spreading  towards  the  peritoneum 
from  within  or  from  without,  any  part  of  the  abdomen  may  swell  from  the 
formation  of  an  abscess.  Several  forms  of  abdominal  abscess  are  more  or  less 
localized,  and  these  are  considered  below  (see  B)  ;  others  present  more  general- 
ized abdominal  signs  and  symptoms,  and  will  for  that  reason  be  considered 
here.  A  subphrenic  abscess  is  any  abscess  in  contact  with  the  under  surface  of 
the  diaphragm  except  those  situated  in  the  liver  or  in  the  spleen.  It  is  intra- 
peritoneal in  more  than  half  the  instances  ;  it  contains  gas  in  about  half  the 
cases.  The  simple  or  non-gaseous  abscesses  are  generally  the  result  of  appendi- 
citis or  of  suppuration  in  the  liver,  and  so  are  usually  on  the  right  side  of  the 
body  ;  less  often  they  are  secondary  to  gastric  or  duodenal  ulcer,  or  to  suppura- 
tion spreading  from  the  pancreas,  kidney,  Fallopian  tubes,  spleen,  or  thorax. 
They  are  deep-seated,  and  tend  to  produce  abdominal  swelling,  with  signs  and 
symptoms  that  are  indefinite.  The  onset  is  insidious,  often  consisting  in  nothing 
more  than  failure  to  recover  from  the  primary  disorder — appendicitis,  hepatic 
abscess — after  it  has  been  surgically  treated  ;  the  patient  remains  seriously 
ill,  with  fever  and  quick  pulse,  leucocytosis,  and  often  a  septic  aspect.  If  the 
abscess  is  at  the  back,  the  signs  may  point  to  pleurisy  or  pleural  effusion,  with 
the  appropriate  pain  and  friction  sounds.  If  it  pushes  forwards,  the  hypo- 
chondrium  and  epigastrium  may  bulge  in  front  and  become  tender.  The  dia- 
gnosis of  subphrenic  abscess  may  be  very  difficult  when  there  is  no  obvious 
antecedent  to  suggest  its  occurrence,  especially  if  the  abscess  is  behind  and 
below  the  liver,  and  is  complicated  by  pleurisy  or  empyema.  If  it  is  above 
the  liver,  it  may  be  very  difficult  to  say  whether  the  pus  is  inside  the  liver  or 
outside  it,  or,  indeed,  both  ;  enlargement  of  the  liver  downwards  is  in  favour 
of  intrahepatic  abscess.  Examination  with  the  ;ir-rays  is  often  of  great  assist- 
ance ;  but  often  it  is  necessary  to  give  the  patient  a  general  anaesthetic  and 
insert  a  4-in.  exploring  needle  successively  into  the  intercostal  spaces  (tenth 
to  sixth)  in  the  scapular  and  mid-axillary  lines  (Barnard).     It  must  be  thrust 


SWELLING,     ABDOMINAL 


in  deeply.  As  viewed  by  the  ;ir-rays  the  diaphragm  is  depressed  by  empyema 
or  pleural  effusion,  elevated  by  subphrenic  abscess,  and  immobilized  by  either. 

The  etiology,  signs,  and  symptoms  of  a  subdiaphragmatic  abscess  that  con- 
tains gas,  or  subphrenic  pyopneumothorax,  are  different  from  those  of  simple 
subphrenic  abscesses.  The  gas-containing  abscess  is  commoner  in  females 
than  in  males,  and  is  usually  due  to  the  perforation  of  a  gastric  ulcer,  less  often 
to  perforation  of  a  duodenal  ulcer  or  to  appendicitis  ;  in  rare  instances  it  is 
secondary  to  a  suppurating  hydatid  cyst  or  to  an  ulcer  of  the  colon.  It  is  usually 
on  the  left  side.  The  onset  is  generally  sudden,  with  the  acute  abdominal 
pain  and  collapse  often  seen  when  a  gastric  ulcer  perforates  ;  but  both  the  ulcer 
and  its  perforation  may  be  latent,  and  nothing  more  than  a  history  of  chronic 
dyspepsia  may  be  obtainable.  The  abdomen  soon  becomes  distended  ;  hectic 
fever,  with  rigors,  rapid  pulse,  marked  leucocytosis,  and  shortness  of  breath, 
are  the  symptoms  likely  to  appear.  The  physical  signs,  on  the  whole,  resemble 
those  of  Pneumothorax  [q.v.)  ;  the  diaphragm  is  pushed  up  into  the  thorax, 
and  the  gas  in  the  abscess-cavity  below  it  causes  the  signs  of  pneumothorax  to 
develop  in  the  upper  part  of  the  abdominal  cavity  and  the  lower  part  of  the 
thorax.  The  picture  is  complicated  by  the  fact  that  the  inflammatory  process 
habitually  spreads  through  the  diaphragm,  so  that  the  signs  due  to  pleurisy, 
with  or  without  effusion,  are  added.  The  diagnosis  has  to  be  made  between 
this  condition  and  true  pneumothorax.  The  points  that  serve  to  distinguish 
the  two  are,  that  in  pneumothorax  the  gas  seems  to  occupy  the  whole  of  one 
side  of  the  thorax,  the  heart  is  pushed  or  pulled  over  to  the  sound  side,  and  the 
physical  signs  are  limited  to  the  thorax  ;  whereas  in  subphrenic  pyopneumo- 
thorax the  signs  occur  at  the  base  of  one  or  both  lungs  but  not  at  the  apex, 
the  heart  is  displaced  upwards  but  not  to  either  side,  and  the  upper  part  of 
the  abdominal  cavity  is  involved  as  well  as  the  thorax.  Examination  with 
the  ;v-rays  is  of  the  greatest  service,  for  it  shows  that  the  gas-containing  cavity 
is  below  the  diaphragm  and  not  above  it  ;  the  readiness  with  which  the  level 
of  the  fluid  in  the  abscess  changes  as  the  patient  alters  his  position  can  also  be 
noted,  and  proves  that  the  abscess-cavity  contains  gas  as  well  as  fluid. 

The  abdomen  is  not  infrequently  the  seat  of  phantom  tumours.  These  are 
felt  as  fixed  and  more  or  less  rounded  smooth  swellings,  either  in  or  immediately 
underneath  the  abdominal  wall ;  they  are  dull  on  percussion,  and  may  be  tender 
on  palpation.  The}^  are  caused  by  involuntary  contractions  of  the  muscles  in 
the  area  in  which  they  occur  ;  they  persist  when  the  patient's  attention  is 
distracted,  and  also  during  sleep,  but  disappear  under  the  influence  of  a  general 
anaesthetic.  Phantom  tumours  are  commoner  in  women  than  in  men,  and  in  the 
neurotic  or  hysterical  than  in  the  normal,  more  stolid  adult.  They  often  persist 
for  long  periods,  but  may  vanish  when  the  patient  believes  that  they  have 
been  cured.  A  phantom  tumour  in  the  region  of  the  liver  may  be  taken  as 
evidence  of  cholecystitis,  hepatic  abscess,  or  gumma  ;  in  the  left  hj'pochondrium 
for  a  gastric  carcinoma  adherent  to  the  abdominal  wall ;  in  the  appendix  region 
for  an  appendicular  abscess  ;  above  the  pubes,  a  phantom  tumour  ma}^  resemble 
the  gravid  uterus,  and  lead  to  the  diagnosis  of  pregnancy  [pseudocyesis). 

In  enteroptosis  (Glenard's  disease),  or  downward  displacement  of  abdominal 
viscera,  any  or  all  of  the  organs  may  slip  away  from  their  normal  position  and 
attachments  (Fig.  39,  p.  147,  and  Fig.  41,  p.  149).  The  diagnosis  must  be 
made  by  the  discovery  that  one  or  more  of  the  viscera  is  out  of  place,  and  is 
also  abnormally  mobile. 

B.  The    Regional  Diagnosis  of    Local    Abdominal   Swellings.  —  For   clinical 

purposes  the  abdomen  may  be  subdivided  into   nine  areas  or  regions,  by  two 

vertical  lines  drawn  through  the  middle  of  Poupart's  ligaments,  and  by  two 

horizontal  lines,  one  of  which  passes  through  the  lowest  points  of  the  tenth 

D  46 


722 


SWELLING,     ABDOMINAL 


ribs  (the  subcostal  line),  the  other  being  drawn  at  the  level  of  the  highest  points 
of  the  iliac  crests  or  through  the  tubercles  on  the  outer  edges  of  the  iliac 
bones  about  two  inches  behind  the  anterior  superior  iliac  spines.  These  areas 
are  shown  in  Fig.  189;  the  structures  and  viscera,  or  portions  of  viscera,  they 
commonly  contain,  are  given  in  the  table  below  : — 


The  Normal  Contents  of   the  Abdominal    Regions. 


I.  Right  Hjrpochondriac 

2.  Epigastric 

3.  Left  Hypochondriac 

Liver 

Liver 

Liver 

Gall-bladder 

Stomach  and  pvlorus 

Stomach 

Hepatic  flexure  of  colon 

Transverse  colon 

Splenic  flexure  of  colon 

Right  kidney 

Omentum 

Spleen 

Pancreas 

Pancreas 

Duodenum 

Left  kidney 

Kidnevs 

Suprarenal  capsules 

Spleen 

Lymphatic  glands 

4.  Right  Lumbar 

5.  Umbilical 

6.  Left  Lumbar 

Riedel's  lobe  of  the  liver 

Stomach 

Descending  colon 

Ascending  colon 

Transverse  colon 

Small  intestine 

Small  intestine 

Omentum 

Left  kidney 

Right  kidney 

Urachus 

Small  intestine 

Duodenum 

Kidneys 

Lymphatic  glands 

Aorta 

7.  Right  Inguinal 

8.  Hjrpogastric 

g.  Left  Inguinal 

Caecum 

Small  intestine 

Sigmoid  flexure  of  colon 

Appendix 

Caecum,  sigmoid,  and 

ap- 

Lj^mphatic  glands 

Lymphatic  glands 

pendix 
Distended  bladder 

Urachus                        [nexa 

Enlarged  uterus   and 

ad- 

The  abdominal  swellings  that  may  be  felt  in  and  about  these  nine  regions 
will  now  be  considered  seriatim,  excluding  the  tumours  situated  in  the  abdominal 
wall  itself  that  have  been  described  under  heading  I.  above. 


I.   Right  Hypochondriac  Region. 

(a).  The  superficial  part  of  this  area  is  mostly  occupied  b}^  the  liver  and  gall- 
bladder, and  the  majority  of  the  tumours  in  it  are  connected  with  one  or  other 
of  them.  Swellings  in  the  liver,  such  as  gumma,  new  growth,  abscess,  hydatid 
or  other  cysts,  can  be  felt  as  more  or  less  rounded  masses  interrupting  the 
normally  smooth  and  impalpable  surface  of  the  liver  ;  they  move  up  and  down 
with  the  liver  on  respiration,  lie  in  front  of  or  above  the  colon,  and  are  very 
rarely  fixed  by  adhesions  to  the  abdominal  wall.  If  multiple,  they  are  in  all 
probabilit}'  secondary  malignant  deposits,  when  they  often  have  an  indented  or 
umbilicated  surface.  It  may  be  difficult  to  distinguish,  by  touch  alone,  between 
the  hobnail  liver  of  hepatic  cirrhosis  and  the  liver  nodulated  by  malignant 
disease.     It  may  be  very  difficult  to  distinguish  between  an  abscess  or  cyst  in 


SWELLING,     ABDOMINAL 


723 


the  liver  itself,  and  an  abscess  or  cyst  situated  just  outside  it — a  pancreatic  cyst 
pressing  the  liver  forwards,  for  example,  or  a  subphrenic  abscess ;  if  the  tumour 
is  in  the  liver,  general  enlargement  of  that  organ  is  usually  present  (see  Liver, 
Enlargements  of  the).  To  regard  the  firm  and  rounded  swelling  produced 
by  the  upper  segment  of  the  right  rectus  abdominis  muscle  as  evidence  of  tumour, 
enlargement,  or  induration  of  the  liver,  is  a  mistake  easily  and  frequently  made. 

(b).  Disease  of  the  gall-bladder  may  make  that  viscus  palpable  ;  cholecystitis, 
cholelithiasis,  and  new  growth  are  the 
most  likely  to  occur.  The  gall-bladder 
may  be  felt  as  a  rounded  tense  mass 
when  distended,  and  may  be  recognized 
by  the  fact  that  it  is  separated  from  the 
liver  by  a  sulcus ;  gall-stones  are  occasion- 
ally to  be  felt  within  it.  (See  Gall- 
bladder Enlargement.) 

(c).  Tumours  in  connection  with  the 
hepatic  flexure  of  the  colon,  excluding 
scybala,  are  rare.  Scybala  may  be  recog- 
nized by  their  general  shape,  the  fact  that 
they  tend  to  move  onwards  towards  the 
rectum,  and  most  of  all  by  the  ease  with 
which  they  can  be  moulded  or  indented, 
as  they  lie  in  the  intestine,  by  the  pressure 
of  the  fingers  ;  such  tumours  are  dispersed 
by  a  purgative.  In  rare  instances  malig- 
nant disease  or  tuberculosis  of  the  colon 
may  produce  a  palpable  tumour  here ; 
and  so  may  the  process  of  intussusception 
(see  4  (6)  below).  The  diagnosis  must  rest 
upon  the  previous  history  and  the  course 
of  the  disease. 

[d).  Tumours  of  the  kidney  and  supra- 
renal gland  rarely  present  themselves  in 
this  region  of  the  abdomen  (see  4  [d)  below). 


Fig,  189. — The  regions  of  the  abdomen 
For  the  significance  of  the  numerals,  see  the 
table  on  opposite  page. 


2.  Epigastric  Region. 

{a).  Abnormal  lobes  in  the  liver,  tumours  in  either  of  its  lobes  or  in  its  falciform 
or  round  ligaments,  may  be  felt  here  (see  i  {a)  above). 

(b).  The  normal  stomach  occupies  a  large  part  of  this  region,  and  comes  to 
the  surface  in  its  left-hand  part.  In  thin  people  and  children  the  curvatures 
of  the  organ  when  it  is  full  may  often  be  seen  dimly  outlined  in  the  epigastrium 
under  normal  circumstances,  the  lower  curvature  habitually,  the  upper  less 
often,  and  the  gastric  succussion-splash  can  often  be  elicited  here  in  healthy 
persons  as  well  as  in  those  with  dilatation  of  the  stomach.  If  an  epigastric 
splash  is  obtained,  it  is  usually  gastric  in  origin,  but  may  be  colonic.  In  dilata- 
tion of  the  stomach  due  to  obstruction  at  the  pylorus  (caused  in  infants  by  spasm 
or  hypertrophy  of  the  pylorus,  in  adults  by  malignant  or  cicatricial  stenosis), 
waves  of  peristalsis  travelling  from  left  to  right  may  be  seen  in  the  epigastrium. 
Similar  waves,  but  travelling  from  right  to  left,  occur  in  the  colon  of  patients 
with  obstruction  in  the  rectum  or  sigmoid  (see  below).  Tumours  of  the  stomach, 
usually  carcinomatous,  rarely  sarcomatous,  or  due  to  inflammatory  deposits 
round  a  gastric  ulcer,  may  sometimes  be  felt  here,  particularly  when  the  patient 
takes  a  deep  breath  and  drives  the  abdominal  viscera  down  from  out  the  cover 


724  SWELLING,     ABDOMINAL 

of  the  diaphragmatic  dome  ;  this  manoeuvre  is  particularly  useful  in  the  case  of 
the  pylorus — it  must  not  be  forgotten  that  the  normal  pylorus  can  sometimes 
be  felt  in  an  infant,  child,  or  thin  adult,  as  a  rounded  finger-like  mass  deep  in 
the  right  side  of  the  epigastrium.  The  connection  of  a  gastric  tumour  with  the 
stomach  can  often  be  made  out  more  clearly  if  that  organ  is  inflated  with  gas  ; 
or  by  the  method,  little  used  in  this  country,  of  gastrodiaphany. 

(c).  The  transverse  colon  goes  across  the  lower  part  of  the  epigastrium  in  some 
cases,  more  usually  across  the  upper  part  of  the  umbilical  area.  Its  sacculations 
and  peristalsis  are  often  outlined  on  the  abdominal  walls  of  pot-bellied  rickety 
children  or  of  thin  adults,  particularly  when  they  are  flatulent  or  constipated. 
In  acute  or  chronic  obstruction  the  peristalsis  becomes  much  more  marked,  as 
it  does  in  the  rare  idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease, 
(see  par.  C,  p.  718)  of  5^oung  children.  Tumours  of  the  transverse  colon  are  very 
rare,  except  the  common  occurrence  of  scybala  in  it — see  i  (c)  ;  a  few  cases  of 
chronic  hyperplastic  tuberculosis  of  this  part  of  the  colon  have  been  recorded, 
with  great  diffuse  thickening  of  its  wall  and  stenosis  of  its  lumen. 

(d).  Swellings  in  connection  with  the  omentum  lie  below  the  colon  and  in 
immediate  relation  with  the  anterior  abdominal  wall,  in  front  of  the  mass  of 
small  intestine.  In  tuberculous  peritonitis  it  often  forms  an  irregular  rope  or 
mass  composed  of  inflammatory  tissue,  cheesy  tubercle,  or  encysted  exudate, 
that  may  lie  in  the  epigastrium,  or  extend  into  any  of  the  regions  of  the  abdomen 
— when  the  diagnosis  of  malignant  disease  of  the  intestine  or  some  other  viscus 
may  possibly  be  made.  Similar  nodular  enlargement  and  deforruity  of  the 
omentum  is  common  in  chronic  peritonitis  of  any  sort  ;  and  it  may  become 
the  seat  of  an  abscess  in  cases  of  perforated  gastric  ulcer.  Cysts  of  the  omentum, 
single  or  multiple,  are  not  very  rare,  and  are  often  inflammatory  in  origin. 
Occurring  in  the  epigastrium,  tuberculous  or  inflammatory  masses  of  omentum 
are  readily  diagnosed  ;  they  often  adhere  freely  to  the  anterior  abdominal  wall 
as  well  as  to  the  neighbouring  viscera. 

{e).  Swellings  derived  from  the  pancreas  push  forwards  from  the  depths  of 
the  abdomiinal  cavity  towards  the  epigastric  and  the  upper  part  of  the  umbilical 
areas,  and,  whilst  small,  present  themselves  as  deeply-seated  vaguely-felt  masses 
on  palpation.  They  have  the  stomach,  or  the  stomach  and  colon,  in  front  of 
them,  and  are  fixed  to  the  posterior  abdominal  wall  ;  they  are  usually  made 
out  best  by  examination  under  an  anaesthetic ;  they  move  little  on  respiration, 
and  often  transmit  from  the  adjacent  aorta  a  non-expansile  pulsation.  They  are 
separated  from  the  liver  and  from  the  spleen  by  areas  of  resonance.  These 
swellings  may  be  carcinomatous,  in  which  case  wasting,  anaemia,  and  jaundice 
are  likely  to  be  observed,  with  death  in  a  few  months'  time  ;  or  due  to  chronic 
pancreatitis,  when  the  course  of  the  disease  will  be  slower  and  there  will  be  more 
epigastric  tenderness  and  pain,  with  clayey  stools  and  perhaps  intermittent 
jaundice  and  glycosuria.  In  acute  pancreatitis  the  swollen  pancreas  has  only 
exceptionally  been  palpated  before  laparotomy  ;  the  main  symptoms  are  acute 
epigastric  pain,  vomiting,  constipation,  fever,  and  proneness  to  collapse,  and 
are  such  as  to  tempt  the  surgeon  to  immediate  laparotomy. 

Pancreatic  cysts,  so-called,  are  often  cysts  not  in  the  pancreas  but  in  its 
neighbourhood,  and  therefore  better  called  peripancreatic  cysts.  Pancreatic 
cysts  proper  are  single  or  multiple  retention-cysts,  usually  the  result  of  chronic 
pancreatitis  ;  they  form  deeply-seated,  smooth,  rounded  tumours,  possibly 
giving  a  feeling  of  fluctuation.  At  first  they  occupy  the  lower  epigastric  or 
hypochondriac  regions  ;  but  if  they  enlarge  much  they  may  fill  the  whole  upper 
part  of  the  abdomen,  or  extend  down  to  the  pubic  symphysis  or  fianks.  The 
symptoms  of  chronic  pancreatic  disease  should  be  present — chronic  indigestion, 
the  passage  of  pale  and  bulky  stools,  glycosuria,  perhaps  jaundice  from  time  to 


SWELLING,     ABDOMINAL  725 


time  if  pancreatic  calculus  is  present.  Peripancreatic  or  retroperitoneal  cysts, 
due  to  accumulations  in  the  lesser  sac  of  the  peritoneum,  or  to  growths  originating 
in  residues  of  the  Wolffian  body  behind  the  peritoneum,  may  produce  apparently 
identical  cysts  ;  the  evidences  of  chronic  pancreatic  disease  should  be  absent 
in  these  cases,  but  the  diagnosis  may  be  impossible  until  laparotomy  has  been 
performed.  Cammidge's  urinary  reaction  (see  p.  115)  is  said  to  be  of  assistance 
in  diagnosing  these  cases. 

(/).  Swellings  in  connection  with  the  duodenum  are  felt  in  the  right  side  of 
the  epigastric  and  umbilical  areas,  and  are  usually  due  to  primary  malignant 
disease.  In  many  cases  they  escape  palpation  because  they  are  so  deeply  placed, 
and  they  usually  have  to  be  diagnosed  from  such  conditions  as  cancer  of  the 
stomach,  pylorus,  pancreas,  bile-ducts,  and  portal  fissure  generally,  not  by 
their  physical  signs  but  by  the  general  symptoms  and  progress  of  the  disease. 
A  growth  in  the  first  part  of  the  duodenum  produces  symptoms  like  those  of 
cancer  of  the  pylorus — wasting,  ansemia,  progressive  dilatation  of  the  stomach 
with  visible  peristalsis,  attacks  of  copious  vomiting,  and  occasional  hsematemesis 
perhaps  ;  the  motions  contain  bile,  but  the  vomit  does  not  ;  jaundice  is  absent 
unless  secondary  growths  appear  in  the  portal  fissure.  Malignant  disease  of 
the  second  part  of  the  duodenum,  in  or  involving  the  biliary  papilla,  soon 
produces  obstructive  jaundice  and  distention  of  the  gall-bladder,  and  often 
leads  to  suppurative  cholangitis,  when  ulceration  has  destroyed  the  growth 
and  removed  the  obstruction,  whereas  a  cancer  in  the  head  of  the  pancreas  or 
bile-ducts  produces  a  steady  jaundice  and  is  not  followed  by  suppuration  in 
the  bile-passages.  Cancer  in  the  third  part  of  the  duodenum  or  below  the 
bile  papilla  produces  duodenal  stenosis,  with  dilatation  of  the  duodenum  and 
stomach  and  frequent  vomiting ;  but  in  this  case  the  vomit  is  habitually  bilious 
and  contains  the  pancreatic  ferments.  If  there  is  no  stenosis,  the  bilious 
vomiting  will  be  less,  and  the  case  may  be  indistinguishable  from  one  of  cancer 
of  the  stomach.  In  most  of  these  cases  the  exact  diagnosis  is  more  often  made 
post  mortem  than  ante  mortem. 

(§■).  Swellings  in  connection  with  the  kidneys  and  suprarenal  capsules  occur 
in  the  epigastrium  only  after  they  have  reached  a  considerable  size.  They 
rise  up  out  of  the  loin  and  flanks,  and  their  diagnosis  is  considered  below  (see 
4  id)  ).  ^ 

(h).  Enlargement  of  the  spleen  may  bring  its  blunt  anterior  end  or  its  notched 
upper  edge  into  the  epigastric  area.  The  splenic  swelling  lies  always  in  contact 
with  the  anterior  wall  of  the  abdomen,  with  the  stomach  above  and  behind  it 
(see  3  {d),  and  Spleen,  Enlargement  of  the). 

(i).  In  every  region  of  the  abdomen  there  is  a  plentiful  supply  of  lymphatic 
glands,  and  any  of  these  may  become  enlarged  and  palpable  in  cases  of  Hodgkin's 
disease,  chronic  peritonitis,  tuberculous  peritonitis,  or  malignant  disease.  The 
enlarged  glands  are  felt  as  nodulated  chains  or  masses,  usually  hard  and  rounded, 
but  softer  and  even  cystic  if  their  contents  caseate  or  break  down  into  pus  ; 
they  may  also  calcify,  when  they  become  hard  and  stony.  The  enlarged  glands 
that  will  be  felt  in  the  epigastric  area  are  those  connected  with  the  stomach, 
liver,  and  mesentery  ;  the  diagnosis  must  be  made  on  general  and  anatomical 
lines  (see  Lymphatic  Gland  Enlargement). 

3.  Left  Hypochondriac  Region. 

(a).  An  abnormally  lobulated  liver  may  make  a  superficial  tumour  in  this 
area  continuous  with  the  main  mass  of  the  liver  in  the  epigastric  region.  In 
the  same  way,  a  tumour  in  the  left  lobe  of  the  liver  may  project  superficially 
into  the  left  hypochondrium. 


726  SWELLING,     ABDOMINAL 

(&).  Part  of  the  stomach  lies  in  this  region  normally  ;  the  diagnosis  of  gastric 
swellings  has  been  considered  above  (see  2  (5)  ).  A  gastric  tumour  may  often  be 
differentiated  from  a  tumour  of  the  adjoining  spleen  by  the  fact  that  while  the 
spleen  is  anchored  at  its  hilum,  and  so  is  capable  of  but  little  movement,  the 
stomach  is  highly  mobile,  changing  its  position  with  the  position  of  the  patient, 
and  also  in  accordance  with  its  fullness  and  distention. 

(c).  The  diagnosis  of  a  tumour  of  the  splenic  flexure  of  the  colon — scybalous, 
tuberculous,  or  malignant — is  considered  above  (see  i  (c)  and  2'(c) ). 

{d).  The  normal  spleen  is  not  palpable  per  abdomen.  The  first  degrees  of  its 
enlargement  are  best  detected  when  the  patient  is  lying  down  and  has  his 
abdominal  wall  relaxed.  The  observer  stands  on  his  left  side  and  palpates 
the  left  hj^pochondrium  by  hooking  his  fingers  over  the  costal  margin  about 
the  eighth  or  ninth  costal  cartilages  ;  the  fingers  are  tucked  in  under  the  ribs 
as  the  patient  inspires  deeply,  their  pressure  being  relaxed  as  he  expires.  The 
lower  pole  of  the  moderately  enlarged  spleen  can  then  be  felt  as  a  rounded  mass 
just  touching  the  finger-tips  at  the  end  of  inspiration.  As  it  progressively 
enlarges,  the  spleen  passes  on  towards  or  a  little  below  the  umbilicus,  and  then 
towards  the  right  anterior  superior  spine  of  the  ilium.  The  diagnosis  of  the 
various  causes  of  its  enlargement  are  discussed  under  Spleen,  Enlargement 
OF  THE.  It  is  usually  to  be  recognized  by  the  fact  that  it  comes  down  from 
under  the  left  costal  margin  in  direct  contact  with  the  anterior  abdominal  wall, 
descends  on  inspiration,  has  a  smooth  surface,  and  a  notched  upper  and  inner 
margin.  In  exceptional  cases,  however,  the  enlarged  spleen  seems  to  adopt 
a  more  compact  and  cubical  form  in  place  of  its  usual  elongated  prismatic 
shape,  and  also  to  lie  back  in  the  loin  and  left  lumbar  region  instead  of 
occupjdng  the  anterior  and  upper  part  of  the  abdominal  cavity.  When  this 
is  the  case,  it  will  simulate  a  tumour  of  the  left  kidney  or  suprarenal  body, 
and  unless  the  blood  and  leucocyte  count  give  a  definite  lead,  the  diagnosis 
may  be  settled  only  by  a  laparotomy.  Conversely,  a  spleen-shaped  hyper- 
nephroma or  suprarenal  tumour,  or  a  calculous  and  cystic  kidney,  may  easily 
be  mistaken  in  an  anemic  patient  for  an  enlarged  spleen,  unless  the  possibility 
of  the  error  be  kept  in  mind  (see  6  (a)  below). 

(e).  Tumours  of  the  pancreas  and  retroperitoneal  cysts  may  project  into  the 
left  hypochondrium  (see  2  (e)  above). 

(/).  Tumours  of  the  left  kidney  and  suprarenal  body  rarely  appear  in  the 
left  hypochondrium  unless  they  are  very  large  (see  6  (c)  below).  They  have  the 
stomach  or  the  stomach  and  colon  in  front  of  them,  and  so  are  variably 
resonant  on  percussion — according  to  the  amount  of  gas  in  those  viscera, — and 
are  also  less  distinctly  palpable  than  tumours  arising  from  the  spleen,  stomach, 
colon,  or  omentum,  that  may  be  felt  in  the  same  situation. 

4.   Right  Lumbar'^Region^ 

{a).  When  the  liver  is  abnormally  lobulated,  either  congenitally  or  as  the  result 
of  tight  lacing,  a  thin  flange  of  liver-tissue,  known  as  Riedel's  lobe,  may  be  met 
with  as  a  superficial  tumour,  continuous  with  the  liver  above  it,  in  this  region. 
Sometimes  it  is  freely  movable,  and  then  may  be  mistaken  for  a  movable  kidney 
or  for  a  dilated  gall-bladder. 

{b).  The  ascending  colon  can  usually  be  palpated  and  rolled  under  the  fingers 
as  a  tube-like  structure  at  the  confines  of  this  and  the  umbilical  region  ;  when 
empty  and  contracted  it  may  feel  almost  rod-like.  Its  contents  are  usually 
fluid,  but  it  may  contain  semi-solid  or  solid  fscal  masses  that  can  be  moulded 
by  pressure,  in  constipated  patients.  In  patients  with  obstruction  lower  down, 
it  may  be  distended — up  to  18  in.  in  circumference — and  show  sacculation  and 


SWELLING.     ABDOMINAL  727 

visible  peristalsis.  It  may  become  much  thickened  with  inflammatory  tissue, 
or  even  come  to  lie  in  an  abscess  of  its  own  production,  in  pericolitis,  perityphlitis, 
typhlitis,  appendicitis,  and  hyperplastic  tuberculosis  of  the  colon,  forming  a 
thickened  and  tender  mass  immediately  under  the  abdominal  wall  ;  the  patient 
will  be  more  or  less  acutely  ill,  with  local  pain  and  tenderness,  constipation, 
often  vomiting.  In  the  more  chronic  of  these  cases,  the  diagnosis  of  malignant 
disease  of  the  colon  will  often  be  suggested. 

General  thickening  of  the  ascending  colon,  with  tenderness  and  characteristic 
mucous  or  blood-streaked  stools,  is  common  in  muco-membranous  colitis,  in 
dysentery,  and  in  ulcerative  colitis.  The  first  of  these  is  met  with  in  nervous 
constipated  women  ;  dysentery,  amoebic  or  bacterial,  is  caught  abroad, 
and  is  commoner  in  men  than  women  ;  while  ulcerative  colitis,  whether  it 
be  dysenteric  or  no,  is  a  severe  and  progressive  painful  diarrhoea,  often 
associated  with  vomiting  and  irregular  fever,  that  commonly  leads  to 
emaciation  and  death  from  exhaustion  or  intestinal  haemorrhage  in  a  few 
weeks  or  months. 

The  ascending  colon  can  be  felt  as  a  sausage-shaped  tumour  in  acute,  subacute, 
and  chronic  ileocsecal  and  ileocolic  intussusception  :  at  first  in  the  right  flank, 
then  extending  across  the  abdomen  above  the  umbilicus,  and  finally  down  the 
left  flank  and  into  the  pelvis.  The  chief  symptoms  are  spasmodic  abdominal 
pain,  vomiting,  the  passage  of  blood  and  mucus  by  the  rectum,  and  tenesmus  ; 
the  palpability  and  consistency  of  the  elongated  tumour  vary  according  to 
the  degree  of  muscular  spasm  in  it. 

(c).  The  small  intestine  is  but  rarely  the  cause  of  abdominal  swelling  in  this 
region,  excepting  when  it  becomes  the  seat  of  enteric  intussusception  (see  {b) 
above). 

{d).  Tumours  in  connection  with  the  Hght  kidney  and  suprarenal  body  usually 
make  their  first  appearance  deep  down  in  this  region,  having  the  ascending 
colon  and  small  intestine  in  front  of  them.  They  can  be  lifted  forwards  en 
masse  from  behind  by  a  hand  placed  at  the  back  of  the  loin.  For  their 
diagnosis  see  Kidney,  Enlargement  of. 

The  lower  pole  of  the  right  kidney  can  be  felt  in  normal  persons  on  deep 
abdominal  palpation  ;  but  when  the  kidney  is  abnormally  mobile,  the  whole  of 
it  may  be  felt,  and  in  rare  cases  it  may  be  found  in  any  of  the  adjoining  abdominal 
areas.  The  shape  and  consistency  of  the  movable  kidney  are  characteristic, 
and  the  patient  complains  of  a  peculiar  sickening  sensation  when  it  is  grasped 
bimanually  and  squeezed  ;  in  the  lesser  degrees  of  mobility  it  disappears  readily 
into  its  normal  position  under  cover  of  the  diaphragm,  and  ceases  to  be 
palpable  until  the  patient  drives  it  down  again  by  a  deep  inspiration.  As 
regards  its  diagnosis,  the  movable  right  kidney  will  hardly  be  mistaken  for 
anything  else  in  this  region  ;  on  the  other  hand,  Riedel's  lobe  of  the  liver,  the 
enlarged  gall-bladder,  faecal  accumulations  or  a  cancer  of  the  ascending  colon, 
and  omental  masses,  have  all  been  mistaken  for  it,  although  they  are  all 
superficial  to  the  kidney,  and  lie  in  contact  with  the  anterior  abdominal  wall. 
Other  wandering  tumours,  e.g.,  of  the  ovary.  Fallopian  tube,  mesentery,  hydatid 
disease,  may  give  rise  to  the  same  error  if  reniform. 

5.  The    Umbilical  Region. 

(a).  In  recent  years  examination  with  the  ;if-rays  after  a  bismuth-meal  has 
shown  that  the  stomach  is  a  far  more  mobile  organ  under  normal  circumstances 
than  was  previously  supposed,  and  that  in  health  its  lower  margin  often 
descends  even  below  the  level  of  the  umbilicus.  But  if  much  of  the 
stomach  habitually  occupies  the   umbilical   region,   it   is   probable  that    it    is 


72  S 


SWELLING,     ABDOMINAL 


dilated  to  a  pathological  degree,  either  from  atony  or  from  pyloric  obstruction 
{Fig.  190). 

(b).  Tumours  in  connection  with  the  transverse  colon  have  been  considered 
under  the  headings  i  (c)  and  4  {h)  above. 

(c).  Tumours  in  connection  with  the  omentum  are  common  in  this  region  : 
those  arising  from  the  small  intestine  are  rare.  Both  are  superficial,  and  their 
diagnosis  has  been  given  above  (see  2  (d)  ). 

{d).  Abdominal  swellings  in  connection  with  the  urachns,  which  runs  from 
the  umbilicus  to  the  bladder,  are  considered  below  (see  8  (c)  ). 

{e).  Swellings  arising  from  the 
duodenum,  kidneys,  suprarenals, 
pancreas,  and  mesentery,  may  all 
present  themselves  in  the  deeper 
parts  of  the  umbilical  region, 
nsually  as  more  or  less  fixed 
masses  arising  from  or  connected 
with  some  definite  part  of  the 
posterior  wall  of  the  abdomen. 
Their  diagnosis  will  depend 
mainly  upon  the  success  with 
which  the  origin  and  connections 
of  the  tumour  can  be  made  out  ; 
if  the  patient  is  fat,  or  if  relaxa- 
tion of  the  abdomen  cannot  be 
obtained,  palpation  while  a 
general  anaesthetic  is  given  may 
be  desirable.  Consideration  must 
also  be  given  to  any  general 
sj^mptoms  the  patient  may 
present — such  as  may  point  to 
renal  calculus,  hydronephrosis, 
pancreatitis,  for  example. 

(/).  The  aorta  bifurcates  half 
an  inch  below  and  just  to  the 
left  of  the  umbilicus.  In  thin, 
nervous,  and  excited  patients, 
particularly  young  women,  great 
pulsation  of  the  aorta  can  often 
be  felt  in  the  umbilical  and  lower 
epigastric  areas,  and  may  lead  to 
the  wrong  diagnosis  of  abdominal 
aneurysm.  Careful  examination  will  almost  always  show  that  this  pulsation  is 
no  more  than  a  throbbing,  an  up-and-down  movement  as  the  patient  lies,  and 
that  a  lateral  expansile  pulsation  is  lacking.  Aneurysm  of  the  abdominal 
aorta  is  very  rare  ;  it  is  seen  in  patients  who  have  had  syphilis,  and  is 
commoner  in  men  than  in  women.  The  aneurysmal  sac  is  distinctly  larger 
than  the  normal  aorta,  and  presents  the  diagnostic  expansile  lateral  pulsation, 
when  grasped  between  the  fingers,  that  is  met  with  in  no  other  condition. 
These  abdominal  aneurysms  often  leak  into  the  retroperitoneal  tissues  ;  and 
large  irregular  clots  of  blood,  weighing  several  pounds  and  of  the  most  varied 
extent  and  distribution,  may  form  gradually  in  the  flanks,  pelvis,  and  back  of 
the  abdomen  generally,  causing  the  patient  great  pain  and  rendering  him 
anaemic  and  breathless.  The  abdominal  aneurysm  also  causes  pain  and  stiffness 
in  the  back  by  eroding  the  bodies  of  the  vertebrae  upon  which  it  presses. 


Fig.  190. — Idiopathic  dilatation  of  the  stomach.  The 
organ  post  mortem  almost  filled  the  abdominal  ca\  ity. 
— Introduction  to  Surgery  (Rutherford  Morison). 


SWELLING,     ABDOMINAL  729 

6.   Left  Lumbar  Region. 

(a).  The  enlarged  spleen  (see  3  (d)  above)  may  intrude  into  this  area  ;  it  forms 
a  firm  mass,  dull  on  percussion,  and  is  in  contact  with  the  abdominal  wall, 
driving  the  splenic  flexure  of  the  colon  inwards  or  downwards  before  it.  The 
spleen,  when  enlarged,  comes  down  into  the  abdomen  in  front  of  all  the  other 
structures  in  the  left  side,  and  its  abdominal  dullness  is  continuous  with  its 
thoracic  dullness,  which  extends  back  and  up  into  the  axilla  along  the  line  of 
the  ninth  or  tenth  ribs.  Tumours  of  the  stomach,  omentum,  suprarenal,  kidney, 
or  descending  colon,  may  all  be  in  contact  with  the  anterior  abdominal  wall, 
and  though  usually  nodular  and  irregular,  may  present  a  smooth  and  spleen-like 
surface  on  palpation.  They  may  be  distinguished  from  the  enlarged  spleen  by 
the  fact  that  they  produce  no  such  typical  area  of  thoracic  dullness  in  continuity 
with  the  dullness  of  abdominal  tumour  ;  while  the  renal  and  suprarenal  tumours 
may  in  addition  be  shown  to  occupy  the  back  of  the  loin,  so  that  they  can  be 
tilted  forwards  by  the  fingers  placed  behind  just  outside  the  edge  of  the  erector 
spinas  muscles,  and  so  pushed  against  the  other  hand,  which  is  placed  on  the 
anterior  surface  of  the  loin.  A  suprarenal  tumour  may  be  associated  with 
sexual  precocity  (see  Figs.  125,  126,  pp.  453,  454). 

(&).  The  diagnosis  of  tumours  of  the  small  intestine,  kidney,  and  suprarenal 
gland  in  this  region  has  been  given  sufficiently  already  (see  4  [d)  and  6  (a)  ). 

7.    Right  Inguinal  Region  and  Right  Iliac   Fossa. 

Abdominal  swellings  in  the  right  inguinal  region  are  rarely  confined  to  it, 
and  usually  extend  into  the  outer  part  of  the  hypogastric  region,  occupying 
what  may  be  described  somewhat  indefinitely  as  the  right  iliac  fossa. 

{a).  New  growths,  inflammatory  thickenings,  and  abscesses  in  connection 
with  the  ccBCum  and  appendix  may  all  extend  into  this  region  of  the  abdomen, 
giving  rise  to  more  or  less  acute  and  severe  abdominal  symptoms — pain,  fever, 
vomiting,  constipation,  with  a  tumour  in  the  right  iliac  fossa.  The  physical 
signs  are  very  variable,  depending  on  the  extent  and  acuteness  of  the  process, 
the  degree  to  which  the  abdominal  wall  can  be  relaxed,  the  exact  position  of 
the  tumour — an  abscess  to  the  inner  side  of  and  behind  the  caecum  and  appendix 
may  lie  too  deeply  to  be  felt  per  abdomen.  The  rare  condition  of  sarcoma  or 
lymphosarcoma  of  the  caecum  may  be  associated  with  fever  ;  the  tumour  is 
soft,  and  the  diagnosis  of  some  chronic  inflammatory  condition  will  probably 
be  made.  A  csecal  carcinoma  is  usually  a  harder  mass  and  of  slower  growth  ; 
it  tends  to  constrict  the  bowel,  with  the  result  that  faecal  accumulation  occurs 
behind  it,  and  so  the  new  growth  may  be  overlooked  when  the  hard  mass  of 
impacted  fsces  is  discovered.  The  diagnosis  of  appendicular  abscess  has  been 
made  in  patients  with  movable  right  kidney  during  a  Dietl's  crisis  ;  fever  is 
usually  absent  in  the  latter  ;  careful  examination  will  generally  show  that  the 
tumour  in  the  right  iliac  fossa  is  an  enlarged  and  movable  kidney,  and  a  history 
pointing  to  intermittent  hydronephrosis,  with  polyuria  after  the  acute  attacks, 
should  be  obtainable.  Inflammation  of  the  right  ovary  or  tube,  or  ovarian 
neuralgia  occurring  with  the  catamenia,  may  all  give  rise  to  symptoms  in  nervous 
patients  that  closely  simulate  those  of  appendicitis  ;  and  if  scybala  are  present 
in  the  csecum,  and  are  vaguely  felt  as  a  tumour  through  the  rigid  abdominal 
wall,  the  mistaken  diagnosis  of  appendicitis  may  easily  be  made  ;  but  as  a  rule 
pelvic  symptoms  and  signs  will  be  found,  and  pain  be  felt  in  the  pelvic  region 
and  the  lower  part  of  the  back  ;  the  diagnosis  will  be  cleared  up  by  a  vaginal 
or  rectal  examination — which,  indeed,  should  never  be  omitted  when  there  is 
any  doubt  as  to  the  exact  causation  of  an  inflammatory  swelling  in  the  iliac 
fossa — and  by  the  previous  history  of  the  case., 


73° 


5  WELLING,     A  BDOMIXA  L 


[b).  Inflammator}-  swellings  and  abscesses  in  the  right  iliac  fossa  may  arise 
in  connection  with  psoas  abscess,  abscess  originating  in  the  sacro-iliac  joint,  hip- 
jomt,  or  ilium,  and  from  the  swelHng  or  breaking  down  of  lymphatic  glands  (the 
external  iliac)  infected  from  some  perhaps  trivial  wound  in  the  leg  or  perineum. 
The  symptoms  of  bom^  disease  about  the  hip  or  the  pelvic  girdle  will  be  present  ; 
the  leg  will  be  held  more  or  less  stiffly-  in  some  abnormal  attitude  of  flexion  and 
inversion  to  relieve  the  pain,  and  movement  of  the  leg  will  be  painful.  Unless 
local  peritonitis  is  present,  there  will  be  none  of  the  special  svmptoms  that  point 
to  appendicular  or  ceecal  disease. 

8.  Hypogastric  Region. 

{a).  In  rare  instances,  tumours  arising  in  the  small  intestine,  and  more  often 
the  sausage-like  swelling  of  an  enteric  intussusception,  may  be  felt  in  the  hypo- 
gastric area  (see  4  (fe) ).     Tumours  extending  into 
it  from  the  iHac  fossas  are  described  under  head- 
ings 7  above  and  9  below. 

(&).  In  infants,  the  bladder  reaches  half  way  to 
the  umbilicus  when  moderately  full,  and  does  not 
fall  below  the  pubic  symphysis  when  empty. 
In  the  adult,  the  distended  bladder  is  a  common 
hypogastric  swelling,  particulars^  in  females  with 
retroverted  gravid  uterus  or  in  males  of  about 
sixty  with  enlargement  of  the  prostate  ;  it  may 
reach  up  as  an  ovoid  elastic  mass  arising  from 
the  front  of  the  pelvis  almost  to  the  umbilicus 
under  conditions  that  are  in  no  way  pathological, 
as  well  as  when  the  retention  is  due  to  some 
pathological  cause.  Such  a  distended  bladder 
{Fig.  191)  has  been  tapped  as  ascites,  operated  upon 
as  ovarian  or  urachal  cyst,  and  diagnosed  as  the 
pregnant  uterus  :  mistakes  that  are  not  likel}^  to 
occur  if  these  possibilities  be  remembered,  and 
are  put  out  of  court  by  micturition  or  the  use  of 
a  catheter  before  the  diagnosis  is  made. 

(c).  The  urachus  is  a  fibrous  cord  running  in 
front  of  the  peritoneum  from  the  top  of  the 
bladder  to  the  umbilicus,  in  the  middle  line  ;  it 
represents  the  obliterated  distal  part  of  the  intra- 
abdominal portion  of  the  foetal  allantois.  It 
sometimes  becomes  the  seat  of  cyst-formation, 
more  often  in  women  than  in  men.  The  urachal 
cyst  is  a  rounded  tumour  lying  between  the 
umbilicus  and  pubes,  soft  or  firm  according  to 
the  tension  of  its  contents  ;  it  may  produce  hj'po- 
gastric  pain.  It  must  be  distinguished  from 
encysted  tuberculous  peritonitis,  from  ovarian 
cystadenoma,  and  from  the  distended  bladder. 

{d).  Abdominal  swellings  arising  from  the  uterus, 
ovaries,  tubes,  and  uterine  ligaments  may  all  rise  up 
out  of  the  pelvis  and  present  themselves  as  swellings 
in  this  region,  and,  as  they  grow  larger,  may  spread  into  the  whole  or  any  part  of 
the  abdomen.  While  they  are  comparatively  small  and  manifestly  connected 
with  some  intrapelvic  organ,  their  origin  is  not  difficult  to  determine  ;  their 
diagnosis  is  considered  under  Swelling,  Pelvic.      But  when  they  have  grown 


J^ig^.  191. — Idiopathic  dilatation 
of  the  bladder.  The  physical 
signs  were  those  of  a  cj'stic 
tumour  occupying  the  lower  part 
of  the  abdomen. — Inirociiiciioji  to 
Surgery  (Rutherford  IMorison). 


SWELLING,     AXILLARY  731 

up  into  the  abdomen,  or  have  acquired  a  long  pedicle,  or  have  become  iixed  by 
adhesions  to  some  distant  part  of  the  abdominal  wall  or  to  some  other  viscus, 
perhaps  causing  it  to  become  inflamed  and  impairing  its  functional  activity, 
these  pelvic  tumours  may  give  rise  to  signs  and  symptoms  suggesting  any  disease 
rather  than  one  that  is  pelvic,  and  the  true  diagnosis  may  be  very  difficult  to 
make.    The  possibilitv  of  pregnancy  in  the  female  should  always  be  remembered. 

9.  Left  Inguinal  Region  and  Left  Iliac  Fossa  (see  7  above). 

(a).  The  sigmoid  flexure  of  the  colon  can  be  felt  normally  as  a  tube-like  cord 
passing  from  the  left  lumbar  region  down  into  the  pelvis,  and  rolled  under  the 
fingers.  It  very  frequently  contains  hard  ovoid  scybalous  masses.  In  rare 
instances  it  ma^^  be  uniformlj^  thickened  and  tender  in  consequence  of  chronic 
inflammation,  tuberculous  or  otherwise.  It  is  occasionally  the  seat  of  cancerous 
new  growth,  when  the  patient  will  complain  of  chronic  intestinal  obstruction, 
\vith  cachexia,  tenesmus,  and  the  passage  of  blood-stained  stools,  phenomena 
that  may  also  be  met  with  in  hyperplastic  or  stenotic  tuberculosis  of  the  sigmoid. 

[b).  The  left  iliac  fossa  may  be  the  seat  of  abscess  or  inflammations  similar 
to  those  described  under  7  (5)  above.  In  addition,  suppuration  around  an 
exaggerated  colonic  diverticulum,  with  symptoms  not  unlike  those  of  appendi- 
citis on  the  wrong  side,  has  been  known  to  occur  ;  such  a  condition  has  been 
spoken  of  as  acute  diverticulitis  of  the  colon.  A.  J.  J  ex  Blake. 

SWELLING,  AXILLARY. — SweUing  in  the  axilla  is  due  in  the  great  majority 
of  cases  to  enlargement,  from  one  cause  or  other,  of  the  lymphatic  glands  ;  an 
abscess,  either  acute  or  chronic,  is  also  of  frequent  occurrence.  An}'  other  form 
of  tumour  is  distinctly  rare. 

In  examining  a  case,  therefore,  these  two  causes  should  be  uppermost  in  the 
mind,  and  indeed,  on  inspection  only,  the  diagnosis  may  be  obvious,  e.g.  : — - 

Acute  Abscess  may  be  recognized  at  once  by  the  well-marked  signs  of 
local  inflammation  and  the  general  febrile  disturbances.  There  is  one  form  of 
acute  abscess  that  may  not  be  obvious,  namely,  one  situated  in  the  upper 
part  of  the  axilla  and  covered  by  the  pectoral  muscles.  On  account  of  the 
distance  of  the  abscess  from  the  surface,  the  local  signs  of  inflammation  may 
not  be  great,  though  the  general  signs  are  marked.  There  will  be  great  dis- 
incUnation  to  move  the  arm  on  account  of  pain,  and  there  is  usually  some  cause, 
such  as  a  whitlow  on  the  finger,  to  account  for  the  trouble.  It  must  be  remem- 
bered, however,  that  the  abscess  may  be  "  residual  "  ;  that  is  to  saj^,  the  original 
source  of  infection,  such  as  the  whitlow,  may  have  healed  completely  two, 
three,  or  even  more  weeks  before  the  axillary  abscess  declares  itself. 

Chronic  or  Tuberculous  Abscess  forms  a  single  fluctuating  swelling  which, 
if  large,  may  extend  upwards  under  the  pectoralis  major.  Owing  to  the  fact 
that  few,  if  any,  of  the  local  signs  of  inflammation  may  be  present,  difficulty 
arises  in  distinguishing  this  form  of  abscess  from  a  soft  lipoma.  The  duration 
and  the  rapidity  of  growth  of  the  swelling  are  a  good  guide,  for  though  the 
duration  of  a  chronic  abscess  may  run  into  months,  it  does  not  exist  for  years 
as  does  a  lipoma. 

Enlargement  of  the  Lymphatic  Glands. — Next,  supposing  that  examination 
proves  that  the  swelling  is  not  an  abscess,  attention  should  be  directed  to  ascer- 
tain whether  it  is  glandular,  and  it  is  therefore  necessary  to  recall  the  anatomical 
position  of  the  glands.  The  axillary  lymphatic  glands  are  ten  to  twelve  in 
number,  and  are  arranged  in  three  sets.  One  chain  surrounds  the  axillary 
vessels  and  receives  the  lymphatics  from  the  arm  ;  a  small  chain  runs  along  the 
lower  border  of  the  pectoralis  major  as  far  as  the  mammarv  gland,  receiving 
the  lymphatics  from  the  front  of  the  chest  and  the  breast  ;    the  third  chain  is 


732  SWELLING,     AXILLARY 

placed  along  the  lower  margin  of  the  posterior  wall  to  receive  lymphatics  from 
the  integuments  of  the  back. 

If  the  glands  are  affected  in  anj-  way,  all  need  not  necessarily  be  enlarged, 
but  it  would  be  extremely  unusual  if  onh^  one  were  picked  out,  and  commonly 
two  or  three,  or  one  entire  group  are  found  enlarged.  Therefore,  axillary 
swellings  due  to  glandular  enlargement  are  almost  always  multiple,  and  are 
situated  in  that  part  of  the  axilla  where  glands  are  normally  present.  This 
may  not  be  quite  accurate  when  much  inflammation  has  occurred  around  the 
glands  and  they  are  matted  together,  as  happens  with  tuberculous  infection  ; 
but  even  then  the  mass  may  be  felt  to  be  made  up  of  many  glands. 

For  the  differential  diagnosis  of  glandular  swellings,  see  Lymphatic  Gland 
Enlargement. 

Primary  Tumours  of  the  Axilla  are  distinctly  rare. 

Lipoma  is  the  most  common.  It  ma}^  attain  a  large  size  in  this  situation, 
and  extend  up  under  the  pectoral  muscles.  It  should  be  diagnosed  by  its  long 
historj^,  slow  growth,  definite  outline,  and  free  mobility.  When  very  soft,  the 
tumour  may  give  the  feeling  of  fluctuation,  and  so  be  mistaken  for  a  chronic 
tuberculous  abscess. 

Cystic  Hygroma  of  the  axilla  is  wexy  rare.  It  is  usually  congenital.  It  forms 
a  soft,  fluctuating,  painless  swelling,  which  sometimes  grows  rapidly.  It  may 
easily  be  mistaken  for  a  lipoma. 

Primary  Malignant  Tumours  may  arise,  but  are  of  extreme  rarity. 

Aneurysm  of  the  Axillary  Artery  does  occur,  but  is  uncommon.  It  is  easily 
recognized,  because  it  is  comparatively  superficial  and  it  gives  an  expansile 
pulsation,  synchronous  with  the  heart's  beat  ;  the  veins  of  the  forearm  may 
be  distended  on  account  of  pressure  on  the  axillary  vein,  and  the  radial  pulse 
on  the  affected  side  is  diminished  in  size  and  delaj^ed.  There  may  be  a  definite 
history  of  local  injurj^,  or  in  cases  of  apparenth'  spontaneous  aneurysm,  there 
maA'-  be  signs  or  symptoms  of  fungating  endocarditis.  George  E.  Gask. 

SWELLING,  FEMORAL. — By  the  femoral  region  is  meant  Scarpa's  triangle. 
It  is  ver}-  easy  to  define  on  paper  what  is  a  femoral  swelling,  but  in  a  fat  patient 
it  may  be  very  difficult.  The  two  great  landmarks  which,  with  care,  can  always 
be  made  out,  however  fat  the  patient,  are  the  spine  of  the  pubes  and  the  anterior 
superior  spine  of  the  ilium  ;  a  line  joining  these  two  points  and  curving  slightly 
downwards  separates  the  inguinal  from  the  femoral  region,  and  indicates 
Poupart's  ligament.  Mistakes  are  often  made,  especially  in  fat  people,  because 
a  horizontal  crease  in  the  thigh  which  lies  below — sometimes  as  much  as  two 
inches  below — is  mistaken  for  the  ligament. 

The  first  point  in  making  the  diagnosis  is  to  decide  definitely  that  the  swelling 
is  femoral,  and  then  to  decide  its  nature. 

It  may  be  obvious  at  once  what  the  swelling  is :  for  instance,  a  well-marked 
acute  abscess,  with  redness  and  oedema  of  the  skin  and  an  undoubted  source 
of  infection,  such  as  a  sore  toe  ;  or,  a  rare  occurrence,  an  aneurysm  of  the 
femoral  arter\-,  showing  marked  expansile  pulsation. 

Supposing,  however,  the  signs  are  not  so  clear,  the  various  conditions  may  be 
classed  broadly  under  two  heads  :  (i)  Swellings  that  are  reducible  and  give  an 
impulse  on  coughing  ;  (2)  Swellings  that  are  irreducible  and  do  not  give  an  impulse 
on  coughing. 

Reducible  Swellings  with  an  Impulse  are:  (a)  Femoral  hernia  —  reducible; 
(6)  Saphena  varix  ;    (c)  Psoas  abscess. 

All  these  three  conditions  give  an  impulse  on  coughing ;  they  all  are,  or  may 
be,  reducible  on  pressure ;  they  all  may  disappear  on  lying  down  and  reappear 
on  standing.     How  then  is  one  to  distinguish  between  them  ? 


SWELLING,     FEMORAL  733 


[a).  Femoral  Hernia  (reducible). — The  sex  of  the  patient  is  no  real  guide,  for 
though  it  is  more  common  to  find  a  femoral  hernia  in  a  woman  than  in  a  man, 
this  is  not  sufficient  to  base  the  diagnosis  on.  Below  the  age  of  puberty  it  is 
very  rarely  found  in  either  sex.  A  femoral  hernia  leaves  the  abdomen  through 
the  femoral  canal,  and  turns  directly  forward,  forming  a  tumour  in  the  upper 
and  inner  part  of  the  femoral  region.  Then,  following  the  line  of  least  resistance, 
it  turns  upwards,  extending  often  above  Poupart's  ligament,  thus  simulating 
an  inguinal  hernia.  More  rarely,  the  hernia  extends  downwards  along  the 
femoral  vessels.  The  course  of  the  hernia  must  be  re;niembered  in  attempting 
to  discover  whether  the  swelling  is  reducible.  If  the  hernia  is  large  and  contains 
intestine,  it  will  be  resonant,  and  a  gurgling  noise  may  be  heard  on  reduction, 
which  distinguishes  it  at  once  from  all  other  femoral  swellings.  If  the  hernia 
is  reduced  and  the  finger  held  over  the  femoral  aperture,  the  hernia  will 
be  felt  projected  quite  forcibly  against  the  finger  when  the  patient  is  asked 
to  cough. 

If  a  swelling  is  complained  of,  and  none  is  found  even  on  standing  and  straining, 
it  is  suggestive  of  femoral  hernia,  with  only  occasional  descent,  and  the  patient 
should  be  examined  at  another  time  after  exercise. 

(b).  Saphena  Varix  is  a  localized  dilatation  of  the  saphenous  vein  at  the 
saphenous  opening,  immediately  before  it  joins  the  femoral  vein.  It  may  easily 
be  confounded  with  a  femoral  hernia,  for  it  forms  a  swelling  in  the  ordinary 
position  of  a  femoral  hernia,  it  disappears  on  lying  down,  reappears  on  standing, 
and  gives  an  impulse  on  coughing.  A  little  care,  however,  should  suffice  to 
distinguish  the  two.  The  impulse  is  quite  different — in  a  saphena  varix  it  is 
more  in  the  nature  of  a  thrill  such  as  may  be  felt  in  a  varicocele  or  in  big  varicose 
veins  in  the  leg.  If,  while  the  patient  is  standing,  a  finger  is  pressed  on  the 
swelling,  it  collapses,  and  as  the  finger  is  withdrawn  the  swelling  follows, 
regaining  its  shape  like  an  air-ball,  whereas  a  hernia  comes  out  with  a  pop. 
A  saphena  varix  is  almost  always  associated  with  varicose  veins  in  the  leg, 
though,  owing  to  the  persistence  of  valves,  none  may  show  between  the  knee 
and  Scarpa's  triangle. 

(c).  Psoas  Abscess. — The  need  to  differentiate  between  this  and  the  two  con- 
ditions above  mentioned  only  exists  when  the  abscess  has  extended  from  the  iliac 
region,  has  passed  under  Poupart's  ligament  and  the  femoral  vessels,  and  is 
pointing  in  the  inner  part  of  Scarpa's  triangle.  As  before,  there  is  an  impulse  on 
coughing  and  the  swelling  is  reducible  ;  but  another  swelling  is  to  be  found 
above  Poupart's  ligament,  and  fluctuation  is  to  be  obtained  between  the  two. 
Conclusive  proof  can  be  found  by  an  examination  of  the  back.  This  should 
be  made  with  the  patient  standing  and  the  whole  length  of  the  back  and  the 
hips  exposed.  An  undoubted  angular  kyphotic  curve  may  be  seen  at  once, 
or,  if  that  is  not  present,  there  may  be  marked  rigidity  and  impaired  movement, 
denoting  some  disease  on  the  anterior  surfaces  of  the  bodies  of  the  vertebrae. 

Irreducible  Swellings  without  Impulse  :  (a)  Femoral  hernia  —  irreducible  ; 
ib)  Lymphatic  glands — inflammatory  or  malignant ;  (c)  Primary  tumours — 
lipoma,  fibroma,  sarcoma  ;    {d)    Ectopic  testis. 

(a).  Femoral  Hernia. — The  irreducibility  may  be  accounted  for  in  four 
ways  :  (i)  Strangulation  ;  (ii)  A  piece  of  omentum  adherent  to  and  plugging 
the  neck  ;  (iii)  An  empty  sac,  but  a  mass  of  extraperitoneal  fat  round  the  sac  ; 
(iv)   A  hydrocele  ot  the  sac. 

If  strangulation  has  occurred,  there  will  be  the  signs  of  intestinal  obstruction, 
viz.,  vomiting  and  constipation.  It  must  be  remembered  that  the  swelling 
may  be  but  a  small  one,  and  when  the  patient  is  very  fat  it  may  be  missed. 

It  is  usual  to  find  around  the  sac  of  a  femoral  hernia  a  quantity  of  extra- 
peritoneal fat,  even  in  a  thin  person,  and   it  is  quite  impossible  to  say  without 


734  SWELLING,     FEMORAL 

dissection  whether  the  sweUing  is  due  to  a  plug  of  omentum  inside  the  sac  or 
to  a  collection  of  fat  outside  it. 

A  hydrocele  may  be  formed  as  a  result  of  a  long-standing  hernia  into  which 
there  has  been  no  descent  of  bowel  or  omentum,  and  in  which  the  communication 
with  the  general  peritoneal  cavity  has  become  constricted  or  closed.  The  sac 
then  may  become  cystic  and  filled  with  fluid.  The  feeling  of  fluctuation  can 
now  be  obtained  in  the  swelhng,  though  it  is  often  only  on  dissection  that  the 
exact  nature  of  the  condition  is  revealed. 

It  is  to  be  noticed  that  in  all  cases  of  hernia  the  swelling  is  single,  and  that 
though  it  may  be  movable  in  some  directions,  it  is  always  tied  down  by  its  neck 
to  the  aperture  of  the  femoral  canal. 

(b).  Enlarged  Glands  may  be:  (i)  Inflammatory;  (ii)  Mahgnant — secondary. 

Inflammatory  Glands. — -The  glands  may  be  acutely  inflamed  as  the  result  of 
an  infection  from  some  part  of  the  limb  ;  all  the  signs  of  inflammation  and 
perhaps  abscess  may  be  present,  and  the  diagnosis  is  obvious.  Chronically 
inflamed  glands  are  very  different,  and  it  may  be  exceedingly  hard  to  differentiate 
them  frora  a  small  irreducible  femoral  hernia.  The  whole  limb  is  to  be  examined 
to  see  whether  there  is  any  possible  source  of  infection,  and  the  whole  patient 
to  see  whether  there  is  a  general  enlargement  of  the  glands,  as  in  lymphadenoma. 
The  chief  distinguishing  feature  between  the  two  conditions  is  that  femoral 
hernia  forms  only  one  swelling,  whilst  it  is  very  rare  for  only  one  gland  in 
its  group  to  be  picked  out  by  an  infecting  agent,  and  not  the  others.  There- 
fore, if  there  is  more  than  one  swelling  the  chances  are  that  these  are  glands. 
Perchance  both  conditions  are  present,  a  femoral  hernia  and  enlarged  glands  : 
a  very  difficult  combination  unless  the  femoral  hernia  happens  to  be  reducible 
or  gives  an  impulse  on  coughing.  In  such  a  case  an  attempt  should  be  made 
to  feel  the  neck  of  the  sac  running  up  to  the  femoral  canal. 

Malignant  Glands. — To  account  for  these  there  will  be  a  primary  growth  in 
5ome  part  of  the  limb,  e.g.,  a  melanotic  sarcoma  or  an  epithelioma  of  the  skin 
or  penis,  or  a  sarcoma  of  bone. 

(c).  Primary  New  Growths  are  rare  in  this  situation.  They  may  be  lipoma, 
fibroma,  or  sarcoma.  The  innocent  tumours  are  noted  for  their  free  mobihty 
in  all  directions.  A  primary  sarcoma  is  diagnosed  rather  by  exclusion  and  by 
its  malignant  characteristics. 

{d).  Ectopic  Testis. — One  of  the  places  into  which  a  testis  may  be  drawn  abnor- 
mally is  Scarpa's  triangle,  which  it  reaches  by  passing  over  Poupart's  ligament. 
The  facts  that  the  swelling  has  the  shape  of  the  testis,  though  generally  smaller 
than  normal,  and  that  the  corresponding  half  of  the  scrotum  is  empty,  make 
the  diagnosis  easy. 

Mention  may  be  made  here  of  those  swellings  which  are  neither  truly  femoral 
nor  truly  inguinal,  but  betwixt  and  between,  and  bulge  Poupart's  ligament 
forwards.  They  are  generally  deep,  and  on  that  account  obscure.  They  may 
be  due  to  : — 

1.  Distention  of  the  hip  joint,  as  in  tuberculous  disease  of  the  hip. 

2.  Distention  of  the  bursa  between  the  tendon  of  the  ilio-psoas  muscle  and 
the  capsule  of  the  hip  joint.  If  large,  the  swelling  may  be  quadrilateral  in 
shape,  and  owing  to  its  sensitiveness  to  pressure  the  leg  is  kept  in  the  position 
of  greatest  ease,  i.e.,  slightly  flexed,  abducted,  and  externally  rotated.  It  is 
often  difficult  to  distinguish  from  psoas  abscess  or  from  distention  of  the 
hip  joint,  with  which,  indeed,  it  often  communicates.  Diagnosis  may  be  aided 
by  puncturing  the  swelling  with  an  aspirating  needle. 

3.  Osteophytic  outgrowths  from  the  acetabulum  in  osteo-arthritis  of  the 
hip  joint. 

4.  A  parametric  abscess.  George  E.  Cask. 


SWELLING     IN     THE     LEFT     ILIAC     FOSSA  735 

SWELLING  IN  THE  ILIAC  FOSSA  (LEFT).— For  general  method  of  examina- 
tion, compare  Swelling  in  the  Iliac  Fossa  (Right). 

Swellings  connected  with  Structures  normally  present  in  the  Left  Iliac  Fossa. 

The  Sigmoid  Flexure  cannot  be  felt  normally.  It  becomes  palpable  as  a 
cylindrical  swelling  if  distended  with  faeces  or  thickened,  as  it  may  be,  in  chronic 
ulcerative  colitis  and  congenital  dilatation  of  the  colon. 

Carcinoma  of  the  Sigmoid. — Next  to  the  rectum,  the  sigmoid  colon  is  the  most 
common  seat  of  cancer  in  the  bowel.  If  of  the  scirrhous  or  ring  type,  no  lump 
may  be  felt,  and  the  condition  may  not  be  discovered  until  intestinal  obstruction 
has  supervened.  When  infiltrating  the  bowel  widely,  and  especially  when  the 
tumour  is  undergoing  colloid  degeneration,  a  swelling  forms  which  is  most 
evident  on  bimanual  examination,  after  the  bowels  have  been  well  cleared  by 
cnemata.  -  If  a  lump  can  be  felt  in  the  sigmoid  flexure  of  a  middle-aged  patient, 
the  strong  probability  is  that  it  is  a  carcinoma,  and  whether  there  are  other 
clinical  signs  or  not,  the  diagnosis  should  be  made  sure  by  actual  inspection  of 
the  swelling  by  means  of  the  sigmoidoscope,  or  even  through  an  abdominal 
incision. 

Enlarged  Lymphatic  Glands. — The  glands  forming  a  chain  round  the  external 
iliac  vessels  may  be  swollen  as  the  result  of  pyogenic  infection,  which  has  spread 
up  through  the  femoral  lymphatics  or  from  secondar}^  deposit  of  some  malignant 
growth  starting  either  in  the  leg,  the  external  genitals,  or  the  pelvis.  The 
enlargement  is  seldom  very  great ;   the  source  of  infection  is  usually  obvious. 

Aneurysm  of  the  external  Iliac  Artery  is  very  rare.  It  is  recognized  at  once  by 
its  expansile  pulsations. 

Swellings  connected  with  Structures  not  normally  present  in  the  Left  Iliac 
Fossa. — These  may  be :  Swellings  coming  down  from  above,  extending  upwards 
from  the  pelvis,  or  pushing  forward  from  behind. 

Swellings  coming  down  from  above. — The  Spleen,  if  much  enlarged,  may  reach 
even  as  far  as  the  left  iUac  fossa.  It  is  recognized  by  its  rounded  margin,  and 
the  notch  on  the  inner  edge.  (See  Spleen,  Enlargement  of  the.)  A  kidney, 
if  freely  movable,  may  be  displaced  as  far  as  the  pelvis  ;  on  rare  occasions  it 
becomes  fixed  there  by  inflammation. 

For  swellings  extending  up  from  the  pelvis  and  those  pushing  up  from 
behind,  compare  article  on  Swelling  in  the  Iliac  Fossa  (Right)  ;  they  are 
the  same  on  each  side.  Geove  E.  Gask. 

SWELLING   IN  THE   ILIAC    FOSSA  (RIGHT) It  is  not  always  easy  to  say 

whether  there  is  or  is  not  a  definite  swelling  in  the  right  ihac  fossa,  for  it  may  be 
only  small  and  deep,  or  be  masked  by  abdominal  rigidity  or  fat.  In  aU  cases  a 
careful  inspection  of  the  abdomen  is  first  to  be  made,  the  patient  h-ing  on  the 
back  with  the  whole  of  the  abdomen  and  the  lower  thorax  exposed.  Most 
mistakes  result  from  want  of  a  complete  examination,  which  cannot  be  made 
through  a  tiny  gap  in  the  clothes.  Before  even  touching  the  abdomen,  much 
may  be  made  out  by  the  use  of  the  eyes,  and  the  points  to  observe  are  : — 

1.  The  presence  or  absence  of  an  obvious  tumour. 

2.  WTiether  the  abdominal  muscles  move  freely. 

3.  The  conformation,  etc.,  of  the  tumour,  should  one  be  present,  and  whether 
it  moves  on  respiration. 

Palpation  is  then  to  be  employed,  and  this  method  ^\ill  go  a  long  wav  to  eluci- 
date the  complaint,  for  it  wiU.  at  once  be  recognized  whether  there  is  a  well- 
defined  swelling,  such  as  a  carcinoma  of  the  caecum  ;  or  an  indefinite  sweUing, 
such  as  is  common  in  appendicitis. 

It  must  be  remembered  that  distention  with  wind  may  cause  a  considerable 
swelling,  as  will  also  an  accumulation  of  faeces  ;  but  any  doubt  existing  mav 


736  SWELLING     IN     THE     RIGHT     ILIAC     FOSSA 

readily  be  cleared  up  by  the  administration  of  an  enema.  If  the  swelling  persists, 
the  questions  that  arise  are  :  is  it  connected  with  one  of  the  structures  normally 
present  in  the  right  iliac  fossa,  e.g.  the  ceecum,  appendix,  or  mesentery,  or  is  it 
springing  from  the  bone  ;  or,  again,  is  it  arising  from  some  organ  invading  this 
space  ;  for  instance,  one  of  the  pelvic  viscera,  or  some  structure  displaced  down- 
wards, as  the  gall-bladder,  stomach,  or  kidney  ? 

A. — Swellings  Connected  with  Structures  Normally  Present 
IN  THE  Right  Iliac  Fossa. 

The  Appendix. — Appendicitis  is  so  common  that  it  is  put  first.  Most  well- 
marked  attacks  of  appendicitis  are  associated  at  some  period  with  a  swelling, 
though  in  the  acutest  and  gravest  forms  the  latter  may  be  absent.  The  appendix 
itself,  even  if  swollen  and  thickened,  can  rarely  be  felt  by  palpating  the  abdomen, 
and  the  swelling  may  be  due  to  one  of  two  causes — paralytic  distention  of  the 
caecum,  or  the  formation  of  an  abscess. 

The  chief  indications  of  appendicitis  are  :  pain,  tenderness,  and  swelling  in 
the  right  iliac  fossa,  associated  with  a  furred  tongue,  vomiting,  constipation,  an 
increase  of  the  pulse-rate,  and  a  rise  of  temperature.  Usually  there  is  also 
diminished  muscular  movement  in  the  lower  part,  or  it  may  be  over  the  whole, 
of  the  abdomen.  Any  movement  is  painful,  and  in  order  to  relax  the  tension 
the  patient  lies  with  the  right  leg  drawn  up.  A  rectal  examination  should  be 
made,  for  a  bulging  abscess  may  be  felt  by  this  route.  Micturition  is 
frequently  abnormal,  with  a  tendency  to  be  either  painful  or  unduly  frequent. 
A  leucocyte  count  is  of  great  service,  for  in  almost  every  case  of  acute  appendi- 
citis the  number  of  white  cells  is  increased. 

Tuberculosis  of  the  Caecum  or  of  the  Lymphatic  Glands  in  the  neighbourhood  of 
the  CfBCum. — This  is  not  nearly  so  common  as  appendicitis,  but  is  not  so  rare 
as  is  often  imagined,  and  when  it  does  occur  it  is  frequently  mistaken  for 
appendicitis  ;  it  may  be  only  after  the  abdomen  has  been  opened  that  the 
mistake  is  discovered.  The  glands  become  enlarged  and  painful,  and  there 
may  be  some  local  peritonitis  over  them  which  makes  the  diagnosis  very  difficult. 
Usually  there  is  some  other  tuberculous  focus  about  the  patient,  especially  in 
the  lungs,  which  should  be  examined  with  particular  care,  the  A^-rays  and 
sputum  analyses  not  being  omitted  in  cases  of  doubt.  If  doubt  exists  recourse 
may  be  had  to  a  diagnostic  injection  of  Koch's  old  tuberculin,  and  the  opsonic 
index  may  be  taken  both  before  and  after  abdominal  massage.  Von  Pirquet's 
test  is  not  very  trustworthy. 

Actinomycosis  starting  in  the  cscum  and  appendix  is  another  inflammatory 
condition  which  may  cause  a  swelling  and  give  the  signs  of  a  chronic  abscess. 
The  diagnosis  can  only  be  made  with  certainty  by  an  incision,  and  the  finding  in 
the  pus  of  the  characteristic  yellowish  granules  (occasionally  black — the  gun- 
powder variety),  and  the  recognition  under  the  microscope  that  these  granules 
are  formed  of  a  Gram-staining  streptothrix  {Plate  XII,  Fig.  S). 

Carcinoma  of  the  Csecum  gives  rise  to  a  swelling  which  occasions  few  symptoms, 
unless  the  passage  of  faeces  is  affected  and  intestinal  obstruction  results.  It  is 
important,  however,  from  the  point  of  view  of  treatment  that  an  early  diagnosis 
be  made.  The  presence  of  a  non-inflammatory  swelling  of  long  standing  in  the 
right  iliac  fossa,  with  a  history  of  wasting,  is  very  suggestive  of  a  carcinoma,  and 
early  recourse  should  be  had  to  the  only  sure  diagnostic  method,  namely,  laparo- 
tomy.     Very  rarely  is  there  passage  of  blood  or  mucus  by  the  bowel  to  help  one. 

Intussusception  usually  occurs  in  children,  especially  during  the  latter  half 
of  the  first  year  of  life,  and  its  presence  is  indicated  by  the  signs  of  intestinal 
obstruction,  namely,  vomiting  and  constipation,  and  by  the  passage  of  blood 
and  mucus  by  the  rectum.     The  intussuscepted  portion  may  be  palpable,  and 


SWELLING,     INGUINAL  737 


in  some  cases  it  lies  in  the  right  ihac  fossa,  though  more  frequently  in  the 
right  h^-pochondrium.  Chronic  intussusception  may  also  cause  a  swelling  which 
generally  baffles  diagnosis,  and  is  commonly  mistaken  for  an  enlarged  kidney. 

B. — Swellings  Connected  with  Structures  not  Xormally  Present 
IN  THE  Right  Iliac  Fossa. 

These  may  be  :  Swelhngs  coming  down  from  above,  swellings  extending 
upwards  from  the  pelvis,  or  swelhngs  pushing  forward  from  behind. 

Swellings  coining  down  from  above. 

The  liver,  an  enlarged  or  abnormal  lobe  of  the  hver — Riedel's  lobe — is  some- 
times very  deceptive.  The  facts  that  there  are  few  symptoms,  that  the  mass 
moves  on  respiration  and  is  continuous  with  the  hver,  and  that  there  is  no  inter- 
vening area  of  resonance  between  it  and  the  hver,  should  assist  the  diagnosis  ;  but 
cases  are  not  infrequently  mistaken  for  enlargement  of  the  gall  bladder.  A 
suppurating  gall-bladder  has  been  opened  in  the  right  ihac  fossa  under  the  mis- 
taken diagnosis  of  appendix  abscess,  for  there  is  often  no  jaundice  in  these  cases. 
Laparotomy  may  be  the  only  means  of  certain  diagnosis. 

Carcinoma  of  the  Stomach — with  extreme  distention  of  the  stomach.  It  is  a 
surprising  fact  that  the  stomach  may  be  so  distended  as  to  enable  the  pylorus 
to  he  in  the  right  ihac  fossa.  The  history'  of  copious  vomiting,  the  wasting, 
and  the  distention  of  the  stomach,  make  the  diagnosis  easy. 

Swellings  extending  upwards  from  the  Pelvis — and  attached  to  the  uterus 
and  its  appendages.  Usualh'  these  can  be  felt  dipping  into  the  pelvis  ;  vaginal 
and  rectal  examinations  will  assist  the  diagnosis  ;  and  there  are  sjTnptoms,  such 
as  disturbances  of  menstruation,  indicating  their  nature.  Such  swellings  might 
be  a  large  fibroid  of  the  titerus,  a  laterallj^-placed  ovarian  cyst,  pregnancy ,  or 
an  abscess  extending  from  the  broad  hgament. 

It  happens  not  infrequently  that  there  may  be  difficulty  in  determining 
between  an  inflamed  appendix  and  an  enlarged  and  tender  ovary,  particularly 
when  the  attacks  of  pain  are  coincident  with  the  menstrual  periods.  These 
generally  turn  out  to  be  due  to  the  appendix,  though  both  may  be  implicated, 
the  appenchx  having  become  adherent  to  the  ovarj^  or  tube. 

Pyosalpinx  is  easily  confused  with  appendix  abscess  ;  the  fact  that  it  is 
associated  with  vaginal  discharge,  or  is  subsequent  to  parturition,  puts  one 
on  the  right  track.     Vaginal  examination  is  essential  in  these  cases. 

Swellings  pushing  forward  from  behind. 

These  may  be  solid,  such  as  sarcoma  or  chondroma  of  the  pelvic  bones.  Here 
the  tumour  will  be  immovable  apart  from  the  pelvis,  and  a  skiagram  makes 
the  condition  clear.  If  the  sweUing  is  fluid  it  may  depend  on  suppurative 
osteomyelitis  of  the  ihum  ;  or  on  a  tuberculous  affection  of  the  ihum,  either 
primary,  or  secondary  to  hip-joint  disease;  or  on  tuberculosis,  necrosis  or 
suppuration  of  the  lumbar  vertebrcB. 

If  the  sweUing  cannot  be  attributed  to  any  of  the  causes  mentioned  above, 
it  is  to  be  remembered  that  a  wandering  organ,  such  as  a  spleen  or  kidney,  may 
find  its  way  into  the  right  iliac  fossa.  Geor°e  E.  Gask. 

SWELLING,  INGUINAL.  —  A  variety  of  sweUings  may  appear  in  the  groin, 
and  be  verj'  difficult  to  differentiate.  The  following  are  some  of  the  most 
important: — (i)  Enlarged  glands  :  {a)  inguinal;  (b)  femoral;  (c)  ihac. 
(2)  Abscess,  acute  or  chronic.  (3)  Hernia  :  {a)  inguinal  ;  {b)  femoral  ; 
(c)  obturator.  (4)  Retained  testicle.  (5)  Hydrocele.  (6)  Tumours  of  the  cord  or 
round  ligament.  (7)  Aneicrysm  and  other  vascular  swellings.  (S)  New  growths. 
(g)  Distended  psoas  bursa  and  other  cysts. 

I.  Enlarged  Glands. — There  are  two  chief  groups  of  glands  in  the  groin.  The 
D  47 


738  SIVELLIXG,     IXGUIXAL 

most  commonly  affected  are  the  inguinal,  which  lie  in  the  subcutaneous  tissues 
about  Poupart's  ligament,  and  drain  the  external  genitals,  the  anus,  the 
umbilicus,  the  lower  parts  of  the  abdomen  and  back,  the  buttock  and  the  upper 
third  of  the  thigh.  The  femoral  glands  rest  below  the  saphenous  opening  and 
drain  the  lower  limb  below  the  upper  third  of  the  thigh.  It  must  be  remem- 
bered, however,  that  the  lymphatic  drainage  is  somewhat  erratic,  so  that  a  sore 
toe  may  sometimes  induce  enlargement  of  an  inguinal  gland  onlj-.  The  iliac 
glands  drain  the  inguinal  and  femoral  set,  and  consequently  often  enlarge 
secondarilj'  to  these  ;  but  they  also  communicate  freely  with  the  abdominal 
lymphatics  and  maj-  become  infected  from  them. 

Enlarged  glands  in  the  groin  are  nearly  always  mvdtiple.  and  usually  sub- 
cutaneous, so  that  they  are  easy  to  recognize  as  glands  ;  but  a  sohtarj-  one 
adherent  to  the  saphenous  opening  ma}'  be  almost  impossible  to  distinguish 
from  an  irreducible  omental  femoral  hernia  or  a  hydrocele  of  a  hernia  sac. 

The  ihac  glands  just  above  Poupart's  hgament  are  more  difficult  to  palpate, 
because  thej'  lie  deep  to  the  abdominal  muscles,  but  their  enlargement  is 
generally  secondary  to  disease  of  the  superficial  glands,  and  this  often  gives 
the  key  to  the  diagnosis  of  an  obscure  swelling  in  this  region. 

Some  Causes  of  Enlargement  of  the  Groin  Glands. — (a)  Mechanical  or  chemical 
irritation  ;  ih)  Septic  infection,  for  instance,  from  genital  sores  or  from  sores  on 
the  toes  or  legs  ;  (c)  Tubercle  ;  {d)  S}.'phihs  ;  (e)  Other  specific  diseases,  such 
as  rubella  and  bubonic  plague  ;  (/)  Lj-mphadenoma  ;  (g)  Lj-mphatic  leukaemia ; 
[h)  MaUgnant  diseases  :   secondary'  carcinoma  ;    secondary  or  primary  sarcoma. 

(a).  The  glands  become  shghtly  enlarged  and  tender  as  a  result  of  the 
tnecha.nical  irritation  of  a  truss,  and  more  frequently  the  bites  of  parasites  such 
as  the  Pediculus  pubis.  The  glands  generally  remain  movable,  and  they  rarely 
suppurate. 

(fe).  Septic  infection  may  follow  insect  bites  ;  but  more  commonly  a  septic 
sore  or  recent  scar  can  be  discovered  upon  examination  of  the  area  drained  by 
the  glands.  Septic  glands  either  soon  subside  or  cease  to  be  tender  after  the 
removal  of  the  source  of  infection,  or  they  enlarge  rapidh^,  become  adherent,  and 
suppurate  within  three  or  four  weeks  of  their  first  enlargement. 

(c).  This,  and  the  amount  of  inflammation  of  the  skin  over  them,  distinguishes 
septic  from  tuberculous  glands  which  do  not  suppurate  for  some  months,  and 
then  with  but  little  inflammatory  reaction.  Epitheliomatous  glands  may 
suppurate  towards  the  end. 

{d).  The  true  syphilitic  gland,  is  hard,  movable,  and  onlj- moderately  enlarged, 
and  the  existence  of  the  indurated  chancre  usually  makes  the  diagnosis  easy. 
The  SpirochcBta  pallida  maj-  be  detected,  or  Wassermann's  serum  test  maj' 
be  positive  ;   but  a  negative  reaction  is  not  conclusive. 

It  must  not  be  forgotten  that,  as  an  apparently  soft  sore  (septic)  may  later 
become  hard  and  definitel}*  syphihtic,  therefore  suppuration  of  a  bubo  does  not 
disprove  syphihtic  infection.  Instances  of  mixed  infection  by  sepsis  and  SA'philis 
are  fairh^  common. 

(/).  In  lymphad,enoma  the  groin  glands  are  rareh'  affected  alone,  and  the 
smooth,  soft  enlargement  of  many  glands  without  signs  of  inflammation, 
associated  with  increasing  anaemia  and  intermittent  p\Texia,  makes  the  diagnosis 
fairlj'  easy.     The  spleen  ma}'  be  affected  at  the  same  time. 

{g).  Blood  examination  will  give  pathognomonic  results  in  cases  of  h'mphatic 
leukaemia. 

(h).  Malignant  disease  of  the  groin  glands  is  nearly  always  epithehomatous, 
and  secondary  to  a  primary  epithelioma  of  the  skin  or  mucous  membrane  in 
the  area  drained  by  the  glands.  The  primary  growth,  especially  at  the  anus, 
may  be  very  small,  and  the  patient  may  be  unaware  of  its  existence.     The  other 


SWELLING,     INGUINAL  739 

main  points  in  distinguishing  epitheliomatous  glands  are  their  exceeding 
hardness  ;  their  progressive  but  slow  growth  ;  their  early  adhesion  to  the  deep 
fascia  and  skin  ;  and  the  amount  of  pain  which  they  give  rise  to  without  signs 
of  inflammation.  Late  in  the  disease  they  may  suppurate  or  slough,  with  severe 
haemorrhage. 

Sarcoma  of  the  groin  glands  is  rare  ;  it  may  be  primary  or  secondary.  Usually, 
these  are  not  the  only  glands  affected.  They  grow  with  great  rapidity  and  remain 
smooth  and  fairly  soft  until  they  attain  a  great  size,  when  they  may  fungate 
through  the  skin.  They  are  distinguished  from  lymphadenoma  by  their  very 
rapid  growth  and  the  absence  of  pallor  until  late  in  the  disease.  Melanotic 
growths  of  the  skin  give  rise  to  rapidly  growing  smooth  glands,  whose  pigment 
may  be  visible  through  the  skin.  The  primary  growth  or  ulceration  in  connec- 
tion with  the  skin,  particularly  of  a  toe,  may  not  show  pigmentation,  and  its 
serious  import  may  thus  be  overlooked. 

2.  Abscess. — [a.)  Acute.  The  only  common  cause  of  acute  abscess  in  the 
gxoin  is  suppuration  of  the  glands,  and  a  search  must  always  be  made  for  a 
primary  source  of  infection,  especially  about  the  genitals.  A  hernia  may 
occasionally  suppurate,  and  an  appendicular  abscess  may  point  just  above 
Poupart's  ligament  ;  but  there  is  then  a  history  of  the  characteristic  symptoms 
of  appendicitis,  and  the  pus  when  released  has  the  suggestive  smell  of  the 
products  of  the  Bacillus  coli  communis.  Both  tuberculous  and  epitheliomatous 
glands  may  become  acutely  inflamed  and  suppurate. 

{b).  Chronic  abscess  here  may  be  due  to  caries  of  the  sacro-iliac  joint  or  to  hip 
disease,  or  it  may  arise  from  tuberculosis  of  the  superficial  or  deep  glands. 
Psoas  abscess,  due  to  caries  of  the  spine,  is  distinguished  by  fluctuation  from 
the  loin  to  the  groin,  and  often  bimanually,  above  and  below  Poupart's  ligament, 
external  to  the  femoral  vessels.  There  is  also  some  tenderness  and  rigidity, 
and  often  deformity  of  the  lumbar  or  lumbo-dorsal  spine.  Iliac  abscess  does 
not  extend  up  into  the  loin,  and  is  placed  further  out  than  psoas  abscess.  More- 
over, there  may  be  pain  and  tenderness  over  the  sacro-iliac  joint,  and  a  limping 
gait.  In  hip  disease,  especially  in  children,  the  floor  of  the  acetabulum  may 
give  way,  and  an  abscess  may  thus  enter  the  true  pelvis,  whence  it  often  ascends 
and  becomes  palpable  above  Poupart's  ligament.  The  diagnosis  of  the  cause 
is  easy  from  the  well-marked  signs  of  hip  disease. 

3.  Hernia. — In  examining  swellings  in  the  groin,  hernia  must  always  be 
considered.  Three  chief  varieties  occur  here  :  inguinal,  femoral,  and  very  rarely 
obturator  hernia.  A  hernia  gives  an  impulse  on  coughing,  but  so  do  psoas 
abscess,  psoas  bursa,  and  a  saphena  varix.  All  these  may  also  be  reducible 
like  a  hernia.  A  psoas  abscess  presenting  below  Poupart's  ligament  has  been 
mistaken  for  a  femoral  hernia  ;  but  it  is  distinguished  by  its  position — external 
instead  of  internal  to  the  femoral  vessels.  Moreover,  it  is  dull  on  percussion, 
whereas  a  hernia  is  resonant  except  when  it  contains  omentum  alone.  Psoas 
bursa  is  also  placed  outside  the  vessels.  A  saphena  varix  has  often  been 
mistaken  for  femoral  hernia  ;  but  it  can  be  easily  distinguished  from  the  latter 
because  it  returns  after  complete  reduction,  even  though  the  finger  is  kept 
pressed  against  the  femoral  canal.  It  is  not  always  easy  to  distinguish  the 
three  hernias  which  occur  in  the  groin,  but  close  attention  to  the  following  points 
usually  leads  to  a  correct  diagnosis.  An  inguinal  hernia  is  both  seen  and  felt 
to  be  above  the  fold  of  the  groin  and  above  Poupart's  ligament  ;  whereas  a 
femoral  hernia  is  seen  and  felt  to  be  below  the  fold  of  the  groin  and  below  Poupart's 
ligament.  It  is  to  be  remembered  that  when  a  femoral  hernia  becomes  very 
large  and  loculated,  it  generally  extends  upwards  and  inwards  over  Poupart's 
ligament.  Still,  the  bulk  of  it  remains  below  the  fold  of  the  groin  in  the  upper 
and  inner  part  of  the  thigh.     An  inguinal  hernia  often  extends  into  the  scrotum 


740  SWELLING,     INGUINAL 

or  labium  ;  a  femoral  hernia  never  does  this.  The  neck  of  an  inguino-scrotal 
hernia  is  above  and  internal  to  the  spine  of  the  pubis,  whereas  the  neck  of  a 
femoral  hernia  is  below  and  external  to  this  bony  prominence.  Inguinal  hernia 
is  most  easily  reduced  by  pressure  directed  upwards,  backwards,  and  outwards, 
whereas  a  large  femoral  hernia  is  most  easily  reduced  by  pressure  directed  at 
first  backwards  and  downwards,  and  then  directly  upwards.  In  difficult  cases 
it  is  a  good  plan  to  reduce  the  hernia,  then  to  get  the  patient  to  stand  up,  while 
the  surgeon  makes  firm  pressure  over  the  internal  ring  and  asks  the  patient  to 
cough.  A  femoral  hernia  may  then  come  down,  but  not  an  inguinal.  Similarly, 
pressure  can  be  made  on  the  femoral  canal  ;  this  prevents  the  return  of  a  femoral 
hernia,  so  that  if  it  now  comes  down  it  is  inguinal.  In  this  connection  it  may 
be  well  to  remember  that  femoral  hernia  is  rare  in  naales,  and  also  in  all  females 
under  maturity.  The  prevalent  belief  that  femoral  hernia  is  more  common  than 
inguinal  in  grown-up  women  is  wrong,  the  latter  being  more  common  at  all 
ages  and  in  both  sexes.  It  is  excessively  difficult  to  differentiate  between  an 
irreducible  femoral  hernia  containing  omentum  and  an  enlarged  gland  at  the 
saphenous  opening  or  in  the  femoral  canal.  A  hydrocele  of  a  hernial  sac  gives 
rise  to  the  same  difficulty,  and  sometimes  an  exploration  becomes  necessary  on 
account  of  the  danger  of  overlooking  femoral  hernia,  and  the  risk  of  strangulation. 

The  diagnosis  between  femoral  and  obturator  hernia  is  not  very  difficult  ; 
it  is  far  more  common  to  overlook  an  obturator  hernia  altogether.  When  an 
external  swelling  is  caused  by  an  obturator  hernia,  it  is  placed  further  inwards, 
and  it  is  more  vague  than  a  femoral  hernia.  Moreover,  there  is  pain  shooting 
along  the  inner  side  of  the  thigh,  and  generally  the  signs  and  symptoms  of 
strangulation.  Further,  a  tender  swelling  can  be  felt  at  the  obturator  foramen 
upon  vaginal  or  rectal  examination. 

The  two  chief  varieties  of  inguinal  hernia,  the  oblique  and  the  direct,  are 
usually  distinguished  quite  easily.  Direct  hernia  is  rare,  and  is  more  globular 
in  shape  than  the  indirect  or  oblique  hernia  ;  the  spermatic  cord  is  antero- 
external  to  it,  and  postero-internal  to  the  ordinary  oblique  hernia.  Direct 
hernia  is  placed  a  little  further  in  and  higher  up  than  the  oblique.  It  is 
generally  much  more  easily  reduced,  but  returns  again  with  striking  abruptness 
when  the  patient  coughs.  It  rarely  travels  into  the  scrotum,  and  it  is  uncommon 
before  the  age  of  thirty.  There  is  often  a  history  of  sudden  onset  after  some 
violent  straining  effort. 

4.  Retained  Testicle. — The  most  important  points  in  the  diagnosis  of  this 
condition  are  the  absence  of  the  organ  from  its  proper  place,  and  the  presence 
of  a  swelling  about  the  inguinal  canal.  Occasionally,  the  testicle  may  be  mal- 
descended,  or  after  leaving  the  external  ring  may  have  found  its  way  into 
the  upper  and  inner  part  of  the  thigh,  where  it  simulates  a  femoral  hernia,  or 
into  the  perineum.  The  swelling  in  the  groin  may  give  the  characteristic 
testicular  sensation,  or  the  condition  may  be  associated  with  attacks  of  pain 
which  have  been  mistaken  for  appendicitis  or  intestinal  colic.  It  is  practically 
always  accompanied  by  actual  or  potential  hernia  into  the  tunica  vaginalis, 
which  is  in  direct  communication  with  the  abdominal  cavity. 

5.  Hydrocele. — The  neck  of  the  sac  of  either  a  femoral  or  an  inguinal  hernia 
may  become  obstructed,  and  a  hydrocele  of  the  sac  may  then  develop.  This 
may  become  inflamed  and  give  rise  to  considerable  difficulty  in  diagnosis. 
Strangulated  or  irreducible  omental  hernia  may  be  simulated,  and  sometimes 
an  exploration  is  the  only  way  of  settling  the  diagnosis.  It  is  more  easily 
distinguished  from  strangulated  hernia  containing  bowel,  because  it  is  dull  on 
percussion,  and  the  bowels  are  not  obstructed.  An  encysted  hydrocele  of  the 
cord  occupying  the  inguinal  canal  is  sometimes  difficult  to  distinguish  from 
inguinal  hernia  ;    but  it  is  not  completely  reducible,  and  it      dull  on  percussion. 


SWELLING,     INGUINO-SCROTAL  741 

It  is  not  granular  like  an  omental  hernia,  and  it  can  even  be  shown,  with  some 
difficulty,  to  be  translucent.     Like  a  hernia,  it  gives  an  impulse  on  coughing. 

6.  Tumours  of  the  Cord  or  Round  Ligament — The  only  common  tumours 
of  these  structures  are  (a)  Lipoma  and  [b)  Fibro-myoma  of  the  round  ligament. 
The  former  is  so  soft  and  displaceable  that  it  gives  an  impulse  on  coughing, 
and  is  often  mistaken  for  an  omental  hernia,  especially  in  stout  patients.  The 
latter  is  hard  and  smooth,  somewhat  simulating  the  ovary  or  a  thick-walled 
hydrocele  of  the  canal  of  Nuck,  for  either  of  which  it  may  be  mistaken,  a  certain 
diagnosis  only  being  possible  by  exploration. 

7.  Aneurysm  and  other  Vascular  Swellings. — Aneurysm  of  the  external 
iliac  artery  may  be  mistaken  for  a  vascular  sarcoma  arising  from  the  pelvis. 
It  can  generally  be  recognized  by  the  classical  signs  of  aneurysm,  such  as 
expansile  pulsation,  bruit,  weakening  and  delay  of  the  corresponding  femoral 
pulse,  and  marked  reduction  of  the  size  of  the  swelling  as  a  result  of  pressure 
on  the  common  iliac  artery.     Saphenous  varix  has  been  referred  to  above. 

8.  New  Growths. — Sarcoma  of  the  pelvic  bones  or  of  the  soft  parts  in  this 
neighbourhood  is  hardly  altered  in  size  by  pressure  upon  the  common  iliac 
artery,  nor  does  it  give  such  a  loud  bruit  or  the  expansile  pulsation,  which  are 
characteristic  of  aneurysm.  The  ;tr-rays  may  give  evidence  which  is  valuable 
in  distinguishing  aneurysm  from  sarcoma. 

9.  Distended  Psoas  Bursa  may  give  rise  to  pulsation  communicated  from  the 
external  iliac  artery.  On  careful  examination  it  can  be  distinguished  by  the 
absence  of  the  classical  signs  of  aneurysm  already  mentioned,  by  its  trans- 
lucency  and  irreducibility.  There  may  also  be  signs  of  osteo-arthritis  of  the 
hip  joint.  R.  p.  Rowlands 

SWELLING,  INGUINO-SCROTAL.— The  most  important  swellings  which 
occupy  both  the  inguinal  and  scrotal  regions  are  : — (i)  Hernia  ;  (2)  Varicocele  ; 
(3)  New  growth  ;   (4)  Hydrocele  ;  (5)  Lymphangioma. 

Hernia  is  by  far  the  most  common,  and  when  it  is  reducible  there  is  very  little 
difficulty  in  the  diagnosis.  It  gives  the  characteristic  impulse  on  coughing, 
is  resonant  on  percussion,  and  when  it  contains  bowel  it  gurgles  on  reduction. 
When  it  contains  omentum  only,  the  diagnosis  is  more  difficult.  To  distinguish 
it  from  a  varicocele  it  is  only  necessary  to  reduce  the  swelling  and  then  to 
place  the  finger  firmly  upon  the  inguinal  canal  ;  a  varicocele  returns  in  a  few 
seconds,  but  a  hernia  does  not.  Moreover,  an  omental  hernia  has  a  granular 
feel  which  distinguishes  it  from  varicocele.  An  irreducible  omental  hernia  is 
distinguished  from  varicocele  by  its  irreducibility  ;  but  it  may  be  confused 
with  a  very  rare  condition,  lymphangioma  of  the  cord.  An  irreducible  hernia 
may  be  confused  with  encysted  hydrocele  of  the  cord.  When  a  hernia  contains 
bowel  its  resonance  distinguishes  it ;  but  when  it  contains  omentum  there 
is  more  difficulty.  An  encysted  hydrocele  or  a  hydrocele  of  a  hernial  sac  is 
more  even  and  elastic  than  an  omental  hernia,  which  is  usually  nodular.  More- 
over, it  may  be  possible  to  show  that  a  hydrocele  is  translucent.  This  help 
is  not  available  when  the  cyst  is  deep  or  contains  blood,  which  it  occasionally 
does  as  the  result  of  injury  or  strangulation  of  the  omentum  at  the  neck  of 
the  hernial  sac.  A  strangulated  hernia  is  distinguished  from  an  inflamed 
hydrocele  by  the  greater  severity  of  the  vomiting  and  other  constitutional 
symptoms,  and  the  completeness  of  constipation.  Moreover,  as  stated  above,  a 
strangulated  hernia  containing  bowel  is  resonant  on  percussion.  Strangulated 
omentum  may  be  very  difficult  to  distinguish  from  an  inflamed  hydrocele  or 
a  hydrocele  of  a  hernial  sac,  especially  as  either  of  these  may  complicate  it.  In 
such  cases  an  exploration  is  the  final  appeal.  It  should  not  be  forgotten  that 
two  or  more  varieties  of  inguino-scrotal  swellings  may  co-exist.     For  instance. 


742  SWELLING,     INGUINO-SCROTAL 

it  is  common  to  overlook  a  hernia  which  inay  comphcate  a  varicocele,  and  this 
is  especially  true  when  the  hernia  contains  only  omentum.  Again,  it  is  quite 
common  for  a  hydrocele  of  the  tunica  vaginalis  or  of  the  lower  part  of  the  cord, 
to  complicate  an  ordinary  omental  hernia.  In  such  a  case,  a  part  of  the  swelling 
may  be  reducible,  and,  unless  the  patient  is  examined  in  the  upright  position, 
the  upper  part  or  the  hernia  may  fail  to  appear  during  the  examination.  Again, 
the  bowel  may  be  reducible,  while  the  omentum,  being  adherent,  is  not  reducible, 
and  may  be  mistaken  for  an  encysted  hj'drocele  of  the  cord.  It  is  very  important 
in  all  these  cases  to  examine  for  translucency. 

Growths  of  the  testicle  invading  the  inguinal  region  are,  as  a  rule,  easily 
diagnosed,  because  of  the  history  and  the  observed  course  of  the  disease,  and  the 
general  condition  of  the  patient  at  the  later  stages.  Growth  of  the  retained  testis 
may  give  rise  to  more  difficulty  ;  it  may  be  confounded  at  first  with  hydrocele  of 
the  tunica  vaginalis,  hydrocele  of  the  hernial  sac,  or  omental  hernia,  unless  care 
be  taken  to  ascertain  if  both  the  testicles  are  present  in  the  scrotum.  Torsion 
of  a  retained  testicle  with  strangulation  of  its  vessels,  has  sometimes  given  rise 
to  inguinal  or  inguino-scrotal  swelling  which  has  closely  simulated  strangulated 
hernia  ;  but  although  there  may  be  much  abdominal  pain  and  local  tenderness, 
vomiting  is  rarely  so  severe  as  in  strangulated  hernia,  and  the  bowels  are  not 
really  obstructed.  Retained  testicle  is  dull  on  percussion,  and  thus  is  distin- 
guished from  strangulated  hernia  containing  bowel,  and  can  only  be  confused 
with  strangulation  of  the  omentum. 

The  oblique  hernia  is  the  only  common  one  to  reach  the  scrotum.  It  may 
be  acquired  or  congenital.  In  about  one-tenth  of  the  congenital  hernije  the 
bowel  and  the  testicle  are  in  the  same  peritoneal  sac  ;  in  the  great  majority  of 
congenital  herniae  the  two  sacs  are  distinct,  the  testicle  lying  below  the  hernia. 
The  same  is  true  of  acquired  inguinal  hernia.  It  is  important  to  remember  that 
nearly  all  inguinal  herniae  descend  into  congenital  or  pre-formed  sacs,  and  this 
is  especially  true  of  herniae  appearing  apparently  for  the  first  tirae  in  young 
adults.  In  such  cases,  on  careful  enquiry,  it  may  be  found  that  a  hernia  existed 
and  was  apparently  cured  by  a  truss,  in  infancj^  Again,  it  vaay  be  learned  that 
the  hernia  reached  the  scrotum  on  its  first  descent,  whereas  acquired  inguinal 
hernia  very  gradually  develops  as  the  result  of  straining  in  men  past  middle  age. 
The  swelling  at  first  appears  only  in  the  inguinal  region,  and  there  the  swelling 
increases  in  size,  and  extends  into  the  scrotum  only  after  some  months  or  years. 
Very  rarely,  a  direct  hernia  may  reach  the  scrotum  ;  it  is  distinguished  from 
oblique  hernia  by  the  fact  that  the  cord  is  antero-external  to  it,  instead  of 
postero-internal,  as  in  an  oblique  hernia.  It  may  be  possible  in  some  cases  to 
identify  the  contents  of  a  hernia.  Attention  has  been  drawn  above  to  the 
method  of  distinguishing  the  bowel  from  the  omentum.  Sometimes  the  appendix 
can  be  felt  distinctly,  especialh^  in  right-sided  hernia.  Occasionally  the  bladder 
may  be  identified,  as  in  Astlej^  Cooper's  classical  case.  When  the  patient  has 
apparently  emptied  the  bladder,  the  surgeon  reduces  the  hernia,  and  the  patient 
is  immediately  able  to  pass  more  water.  R.  p.  Rowlands. 

SWELLING,  MAMMARY. — Method  of  Examination. — The  clothes  should  be 
removed  to  the  waist,  so  that  a  clear  view  of  both  breasts,  the  thorax,  axillae, 
and  supraclavicular  fossae  may  be  obtained.  Both  breasts  should  then  be 
looked  at  to  see  whether  there  is  any  obvious  enlargement  or  abnormality  such 
as  redness  of  the  skin,  dilatation  of  veins,  tumour,  or  ulcer.  Next,  palpation  is 
to  be  employed,  using  the  flat  of  the  hand  and  not  the  tips  of  the  fingers  ;  the 
surgeon  should  place  himself  in  a  convenient  position,  using  the  right  hand  to 
examine  the  left  breast  and  the  left  hand  to  the  right  breast.  In  the  same 
manner  the  axillary  fosscc  are  to   be   explored,  it   being   remembered  that  the 


SWELLING,     MAMMARY  743 

lymphatic  glands  affected  in  diseases  of  the  breast  lie  on  the  surface  of  the 
thorax  and  not  round  the  axillary  vessels.  (See  Swelling,  Axillary.)  It 
often  facilitates  palpation  of  the  breast  with  the  flat  hand  if  the  observer 
stands  behind  the  patient  when  she  is  seated  in  a  chair.  In  cases  of  suspected 
cancer  the  examination  must  not  be  concluded  without  investigation  of  the 
supraclavicular  fossa;  for  fullness  or  enlargement  of  glands,  and  of  the  thorax 
and  liver  for  signs  of  secondary  growths. 

Swelling  in  Pregnancy  and  Lactation  is  normal  and  physiological.  Both 
breasts  are  equally  enlarged,  and  feel  tense  and  nodular.  The  superficial  veins 
are  usuallj^  prominent,  and  on  gentle  squeezing  a  few  drops  of  milk  are  discharged 
from  the  nipple. 

True  Hypertrophy  of  one  breast  is  rare.  It  may  be  found  in  nursemaids 
who  have  put  children  to  the  breast.  The  enlargement  in  the  majority  of 
so-called  cases  of  hypertrophy  is  really  due  to  the  presence  of  one  or  more  fibro- 
adenomata. 

Acute  Mastitis  occurs  usually  during  lactation,  occasionally  during  pregnancy, 
and  is  most  often  due  to  infection  with  pyogenic  organisms  which  have  gained 
entrance  through  cracks  in  the  nipple.  At  the  beginning  of  the  illness,  there  is 
shivering,  followed  by  fever  and  a  feeling  of  weight  and  pain  in  the  breast  ; 
the  pain  soon  becomes  very  acute.  In  the  early  stages  the  swelling  is  limited  to 
one  part  of  the  breast,  which  feels  more  resistant  than  normal  ;  the  skin  is  not 
reddened  at  first,  nor  are  the  lymphatic  glands  enlarged.  Pressure  over  the 
swelling  may  cause  extrusion  of  a  drop  of  pus  from  the  nipple,  and  this  is  dis- 
tinguished from  milk  by  its  viscidity  and  yellow  colour.  Later,  fluctuation 
may  become  evident,  and,  as  the  inflammation  approaches  the  skin,  this  becomes 
red  and  oedematous,  and  ultimately  the  abscess  may  point  and  burst  through  it ; 
at  the  same  time  other  foci  of  suppuration  form,  until  the  breast  may  be  nothing 
but  a  bag  of  pus.  The  presence  of  fever  and  the  intense  tenderness  of  one 
portion  of  the  breast  are  sufficient  to  distinguish  acute  mastitis  from  the  physio- 
logical engorgement. 

It  is  not  uncommon  to  find  a  small  alveolar  abscess,  the  size  of  a  hazel-nut,  in 
virgins. 

Soon  after  birth  and  at  puberty,  a  diffuse  enlargement  may  occur  in  both 
sexes,  and  a  small  quantity  of  milk  may  be  secreted.  If  the  breasts  are  handled 
or  squeezed,  this  congestive  condition  may  pass  into  true  inflammation  and 
suppuration. 

Clironic  Mastitis  may  attack  numerous  lobes  of  the  breast,  so  that  the  whole 
organ  has  a  granular  feel  (chronic  lobular  mastitis),  or  the  inflammation  may 
be  confined  to  one  segment  and  form  an  inflammatory  swelling  of  considerable 
size.  The  attention  of  the  patient  is  usually  first  called  to  the  breast  by  the 
presence  of  vague  pains  and  tenderness.  If  the  lump  is  picked  up  with  the 
fingers  it  is  easily  palpable,  but  if  pressed  back  against  the  chest  wall  the 
induration  is  much  less  distinct  than  with  carcinoma  or  fibro-adenoma.  The 
swelling  is  elastic,  and  its  outline  quite  diffuse,  more  so  than  in  the  case  of 
carcinoma.  The  axillary  glands  may  or  may  not  be  enlarged  ;  if  they  are, 
they  are  generally  numerous,  not  so  hard  as  in  cancer,  and  are  met  with  at  an 
earlier  period  in  the  disease.  The  opposite  breast  is  very  liable  to  be  diseased 
in  a  similar  manner.  The  diagnosis  is  often  very  difficult,  ordinary  carcinoma 
of  the  breast  being  confounded  with  it.  The  two  tumours  resemble  each  other, 
in  that  in  both  their  outlines  are  badly  defined  and  the  axillary  glands  are 
enlarged.  In  cancer,  however,  the  tumour  is  densely  hard,  and  at  an  early 
period  adhesions  form,  so  that  the  skin  puckers  on  attempting  to  move  it  over 
the  swelling.  A  further  difficulty  arises  from  the  fact  that  a  cyst  may  form  in 
connection  with  chronic  mastitis.      If  this  is  lax,  fluctuation  may  be  detected. 


744  SWELLING,     MAMMARY 

but  it  is  usually  so  tense  that  it  feels  hard  and  solid.  This  again  may  be 
mistaken  for  a  carcinoma  or  a  fibro-adenoma.  Where  there  is  the  least  doubt 
as  to  the  nature  of  the  swelling  and  any  possibility  of  the  presence  of  a  carcinoma, 
the  right  course  is  to  have  a  microscopic  section  cut  at  once. 

Multiple  Cystic  Disease  of  the  Breast, — This  condition  may  follow  on  chronic 
lobular  mastitis.  One,  or  sometimes  both  breasts,  become  filled  with  cysts, 
large  and  small,  some  microscopic  and  others  as  large  as  walnuts,  so  that  the 
organ  has  a  bossy  appearance.  The  whole  organ  is  often  very  painful,  the  pain 
radiating  from  the  breast  and  shooting  down  the  arm.  There  are  epithelial 
changes  in  the  lining  membrane  of  the  cysts,  and  some  authorities  think  that 
these  are  precursory  stages  in  the  formation  of  a  cancer. 

Cysts,  unless  in  connection  with  chronic  mastitis  or  fibro-adenomata,  are  very 
rare.     A  simple  serous  cyst  is  described,  and  is  due  to  lymphatic  obstruction. 

Galactocele  is  a  cyst  containing  milk,  and  is  formed  by  dilatation  of  one  of 
the  larger  lacteals  owing  to  obstruction.  These  galactoceles  occur  only  during 
lactation  ;  they  form  movable,  fluctuating  swellings,  and  on  pressure  milk  can 
be  squeezed  out  of  the  nipple.      They  are  rare. 

Tuberculosis  of  the  Breast  is  not  so  uncommon  as  was  previously  supposed, 
and  a  certain  number  of  cases  of  chronic  mastitis  and  chronic  abscess  are  really 
tuberculous.  The  disease  is  insidious,  starting  as  a  painless  irregular  swelling, 
the  periphery  of  which  is  hard  and  the  centre  soft.  Later,  the  skin  becomes 
reddened,  and  an  abscess  forms  which  may  burst  and  leave  a  sinus.  It  differs 
from  an  acute  abscess  in  that  the  duration  is  much  longer,  there  is  little 
or  no  pain  or  fever,  and  the  pus,  if  examined,  reveals  no  cocci.  The  facts 
that  its  history  is  a  long  one,  that  the  swelling  or  the  edges  of  it  are  hard, 
and  that  the  axillary  glands  are  enlarged,  render  this  condition  liable  to  be 
confounded  with  carcinoma,  of  the  ordinary  form,  or  one  in  which  suppuration 
has  occurred.  The  various  clinical  pathological  tests  for  tuberculous  disease 
may  be  applied,  but  the  best  method  is  to  cut  into  the  swelling  and  remove  a 
portion  of  the  wall  for  histological  examination. 

Chronic  submammary  abscess  causes  a  projection  forward  of  the  whole  breast  ; 
it  is  due  to  tuberculosis  of  the  underlying  ribs,  or  in  rare  instances  to  post- 
typhoidal  periostitis,  which  may  have  remained  latent.  The  diagnosis  is  made 
bacteriologically. 

Innocent  Tumours. — Pure  -fibromata,  lipomata,  and  enchondromata  are  of  rare 
occurrence,  and  merely  call  for  mention  here.  Fibro-adenoma  is  the  only 
common  innocent  tumour,  and  though  there  are  many  pathological  varieties, 
and  some  contain  cysts  and  some  intra-cystic  growths,  for  the  purposes  of  this 
article  all  will  be  classed  under  this  heading. 

Fibro-adenoma  is  an  encapsulated  tumour,  generally  single,  sometimes  multiple, 
varying  from  the  size  of  a  nut  to  that  of  an  orange.  Because  it  is  encapsulated, 
the  surrounding  tissues  are  not  infiltrated  ;  therefore,  if  superficial,  the  outline 
is  very  clearly  defined  and  the  mass  is  freely  movable,  both  under  the  skin, 
over  the  pectoral  muscle,  and,  most  important  of  all,  in  the  breast  substance. 
The  axillary  glands  are  not  enlarged.  The  tumours  cause  no  pain,  and  are 
usually  discovered  accidentally.  Generally  they  occur  in  women  between  the 
ages  of  twenty  and  thirty.  After  attaining  a  certain  size  they  remain  naore 
or  less  stationary,  unless  they  are  cystic,  when  they  may  go  on  growing  as  the 
result  of  dilatation  of  the  cyst  by  fluid.  The  diagnosis  is  generally  quite  easy, 
but  if  the  breast  is  fat  and  the  tumour  deep-seated,  it  may  not  always  be  quite 
easy  to  distinguish  from  an  early  carcinoma.  The  consistency  of  this,  however, 
is  hard,  while  the  adenoma  is  elastic. 

From  chronic  mastitis  it  is  distinguished  by  being  less  intimately  associated 
with  the  breast  than  is  the  case  with   the   inflammatory  nodules,  and  by  its 


SWELLING,     MAMMARY  745 

sharper  definition.  On  account  of  the  well-known  possibility  of  error,  however, 
no  definite  diagnosis  or  prognosis  should  be  given  until  the  tumour  has  been 
removed  and  a  pathological  report  on  its  character  received. 

Malignant  Tumours  are  carcinoma  and  sarcoma.  Carcinoma  is  the  most 
important  tumour  of  the  breast.  It  is  essentially  a  disease  of  the  female,  only 
about  one  per  cent  of  the  cases  occurring  in  males.  The  great  majority  are 
married,  and  between  the  ages  of  thirty-five  and  sixty. 

In  advanced  cases  the  disease  is  obvious  ;  the  tumour  is  large  and  hard, 
fixed  to  and  often  fungating  through  the  skin  ;  the  axillary  glands  are  enlarged 
and  hard,  and  the  patient  is  often  cachectic. 

What  is  wanted  is  a  diagnosis  in  the  early  stages,  while  the  patient  still  looks 
and  feels  in  perfect  health,  before  secondary  deposits  are  found  in  the  axillary 
glands,  and  while  successful  treatment  is  still  possible.  Too  much  insistence 
cannot  be  given  to  this  point ;  it  is  attainable,  and  should  always  be  attempted. 

The  Early  Diagnosis  of  Carcinoma  of  the  Breast.- — Usually  the  patient  feels 
no  pain,  but  discovers  a  lump  in  the  breast  accidentally  during  ablutions  ;  there- 
fore its  duration  must  generally  be  a  matter  of  doubt.  Clinically,  it  is  felt  as  a 
small  tumour  which,  unless  the  patient  is  very  fat,  can  be  palpated  easily  with 
the  flat  of  the  hand.  Its  chief  characteristic  is  that  its  outline  is  not  sharply 
defined,  and  that  it  is  hard — stony  hard.  In  the  very  early  stage,  the  tumour 
is  freely  movable  over  the  pectoral  muscles  and  under  the  skin,  but  it  is  not 
so  movable  in  the  breast  substance  as  is  a  fibro-adenoma.  Very  soon,  bands  of 
fibrous  tissue  that  connect  the  breast  with  the  skin  become  involved,  and  by 
their  contraction  prevent  free  movement  of  the  skin  over  the  swelling,  and  cause 
dimphng  and  puckering.  If  the  tumour  is  situated  anyivhere  near  the  centre 
of  the  breast,  milk-ducts  become  involved  in  the  growth,  and  as  they  contract 
cause  retraction  of  the  nipple.  If  a  nipple  which  was  previously  well  formed 
becomes  retracted,  this  is  a  very  important  piece  of  evidence  ;  it  is  to  be 
remembered,  however,  that  nipples  are  often  permanently  retracted.  Many 
cancerous  tumours,  even  when  extensive  infiltration  has  occurred,  cause  a 
shrinkage,  so  that  the  affected  breast  may  appear  smaller  than  the  healthy  one, 
and  in  the  atrophic  form  the  gland  may  almost  disappear.  In  the  ordinary 
form  (scirrhus)  it  will  be  rare  to  find  any  discharge  from  the  nipple  :  a  blood- 
stained discharge  may  be  an  indication  of  a  duct-carcinoma.  (See  Discharge 
FROM  THE  Nipple.) 

After  the  disease  has  lasted  six  months  the  axillary  glands  are  usuallj^  enlarged 
and  hard,  the  first  affected  being  those  running  along  the  lower  border  of 
the  pectoralis  minor.  Too  much  attention  must  not  be  given  to  the  absence 
of  palpable  glands,  because,  first,  it  is  hoped  that  the  diagnosis  may  be  made 
before  they  are  enlarged  ;  and  secondly,  if  the  patient  is  at  all  fat,  it  is  exceedingly 
easy  to  overlook  them.  Attention  is  to  be  centred  on  the  lump  itself.  As 
stated  before,  this  is  stony  hard,  and  that  fact  alone  may  be  sufficient  ground  on 
which  to  base  a  diagnosis.  The  two  main  conditions  which  have  to  be  distin- 
guished from  an  early  carcinoma  are  fibro-adenoma  and  chronic  mastitis.  In 
the  former,  the  swelling  is  well  defined,  elastic,  and  freely  movable  ;  in  the 
latter,  a  tumour  cannot  be  felt  distinctly  with  the  fiat  of  the  hand  ;  it  is  soft, 
and  the  whole  breast  is  often  nodular. 

The  difficulties  in  diagnosis  are  great  and  the  sources  of  error  numerous  ;  none 
of  the  swellings  may  be  typical :  they  may  be  obscured  by  the  obesity  of  the 
patient,  and  a  fluid  swelling  may  be  so  tense  as  to  simulate  a  soUd  one.  This 
being  so,  the  course  to  adopt,  whenever  the  slightest  doubt  arises,  is  to  incise 
the  swelling  and  submit  a  portion  to  microscopical  examination.  Seeing  the 
vital  importance  of  avoiding  mistakes  in  this  connection,  and  recognizing  the 
extent  of  human  fallacy,  there  is  a  growing  feeling  among  surgeons  that  all 


746  SWELLING     OF     THE     FACE 

tumours  oi  the  breast,  whatever  the  behef  as  to  their  character,  should  be 
removed,  or  at  least  cut  into,  so  that  their  true  histological  constitution  may 
be  ascertained  early  and  with  accuracy. 

Sarcoma  of  the  breast  is  rare.  It  generally  occurs  in  women  under  the  age 
of  thirty.  In  the  early  stage  it  is  not  easily  distinguishable  from  a  iibro-adenoma, 
particularly  one  which  is  enlarging  rapidly  on  account  of  a  cyst  or  intracystic 
growth.  It  is  soft,  grows  rapidly,  infiltrates  the  tissues,  and  forms  a  large 
fungating  tumour.  It  disseminates  rapidly,  both  via  the  lymphatics  and  by 
the  blood-stream.  George  E.  Cask. 

SWELLING  OF  THE  FACE. — In  this  article  are  included  only  swellings  of 
the  skin  and  subcutaneous  tissues.  Malignant  and  other  diseases  of  the  facial 
bones,  etc.,  are  considered  under  Swelling  of  the  Jaw,  and  Swelling  on 
A  Bone. 

Contusions  and  injuries  to  the  face  are  so  obvious  that  they  need  no  mention. 
The  remaining  swellings  will  be  classified  as  (i)  Non-inflammatory  ;  and  (2)  In- 
flammatory. 

1.  Non-inflammatory  Swellings. 

Renal  and  Cardiac  CEdema. — If  the  whole  face  is  puffy  and  the  eyelids  are 
oedematous,  the  urinary  and  cardiac  systems  are  to  be  exarained  for  disease. 
For  swelling  due  to  obstruction  of  the  superior  vena  cava  by  mediastinal  fibrosis, 
aneurysm,  or  new  growth,  see  QEdema  :  and  Veins^  Varicose  Thoracic. 

Angio-neurotic  CEdema  is  a  disease  characterized  by  the  occurrence,  some- 
times periodical,  of  local  oedematous  swellings,  more  or  less  limited  in  extent  and 
of  transient  duration.  It  is  not  confined  to  the  face,  but  the  eyelid  is  a  common 
situation  {Fig.  128,.  p.  458),  and  also  the  lips  and  cheek.  It  may  be  simulated 
closely  by  iirticaria  following  the  taking  of  fish  or  pork. 

Tumours  are  not  common.  They  may  be  fibroma,  lipoma,  epithelioma,  or 
sebaceous  cyst. 

2.  Inflammatory  Swellings. — Often  the  cause  is  obvious  :  for  instance,  a  boil, 
carbuncle,  or  suppurating  wound ;  or  the  "  blubber-lips "  that  result  from 
chronic  lymphangitis. 

Erysipelas  is  prone  to  occur  on  the  face.  It  is  marked  by  a  vivid  red  oedema- 
tous swelling,  associated  with  signs  of  fever.  The  redness  tends  to  spread,  the 
edges  being  raised  and  well  defined  from  the  healthy  skin.  The  oedema  may  be 
continuous,  or  it  may  disappear  in  one  place  and  re-appear  in  another.  In  the 
very  severe  cases  the  fever  is  high,  rigors  occur  {Fig.  166,  p.  614),  the  cuticle 
may  be  raised  in  blebs,  and  sloughing  may  ensue. 

Alveolar  Abscess  and  Dental  Caries  are  fertile  sources  of  facial  swelling.  (See 
Swelling  of  the  Jaw,  p.  747.) 

Parotitis  —  either  the  suppurative  or  epidemic  form  (mumps)  —  is  easily 
recognized  by  the  swelling  being  acute  and  limited  to  the  region  of  the  parotid 
gland. 

Anthrax  chiefly  affects  operatives  in  wool  and  horse-hair  factories,  and  workers 
of  raw  hides.  The  disease  is  characterized  by  the  formation  of  a  vesicle,  which 
bursts,  forms  a  scab,  and  then  becomes  surrounded  by  a  ring  of  vesicles,  and 
around  this  is  an  area  of  oedema.  The  diagnosis  is  made  by  the  microscope. 
A  drop  of  fluid  from  one  of  the  vesicles  contains  large,  square-ended.  Gram- 
staining  bacilli,  which  have  a  characteristic  growth  on  culture  media. 

Vaccinia. — An  accidental  infection  about  the  face  may  be  mistaken  for  an 
anthrax  pustule.  If  inquiry  into  the  attendant  circumstances  is  not  sufficient 
to  exclude  the  graver  disorder,  a  bacteriological  examination  should  be  made. 

Primary  Syphilitic  Sore,  if  found  on  the  face  {Fig.  10,  p.  86),  is  generally 
situated  on  the  upper  lip.     It  is  not  so  indurated  as  when  on  the  glans  penis. 


SWELLING     OF     THE     LOWER     JAW  747 

but  the  surrounding  oedema  is  more  marked,  and  the  neighbouring  lymphatic 
glands  are  considerabty  enlarged.  The  condition  is  often  missed  because  it  is 
not  expected.  An  absolute  diagnosis  can  be  made  by  finding  the  spirochsetas 
in  the  serum  discharged  from  the  ulcer  [Plate  XII,  Fig.  J),  and  by  Wasser- 
mann's  test. 

Insect  Bites — from  mosquitos,  gnats,  bees,  etc. — often  cause  large,  lump}^, 
irritating  swellings.  The  only  difficulty  in  diagnosis  is  when  they  become 
infected  with  pj-ogenic  organisms. 

The  various  skin  diseases  which  may  be  associated  with  swelling  of  the  face 
are  considered  under  Pustules  ;   Vesicles  ;   Wheals  ;   Etc.  George  E.  Gask. 

SWELLING  OF  THE  JAW,  LOWER,  —  Swelling  of  the  lower  jaw  may 
sometimes  be  mistaken  for,  or  masked  by,  swelling  of  the  cellular  tissues  in 
front  of  it.  The  real  site  of  the  swelling  is  first  to  be  ascertained  by  opening 
the  mouth  and  running  the  finger  along  the  outer  and  inner  borders  of  the 
mandible  and  comparing  the  two  sides. 

There  are  man}'  causes  for  enlargement,  and  they  inay  be  subdivided  under 
the  following  headings  : — 

1.  Injury. 

2.  Inflammatory  affections. 

(    Innocent — -Fibroma,  osteoma,  and  odontoma. 
(    Malignant — Sarcoma  and  epithelioma. 

4.  Acromegaly. 

5.  Leontiasis  ossea. 

1.  Injury, — A  A^wzfltowfl  or  traumatic  ^mosii^is  may  follow  on  a  blow.  If  the 
injury  has  been  sufficient  to  cause  a  fracture,  the  signs  are  obvious.  The  abnormal 
mobility  of  the  fragments,  the  irregularity  of  the  line  of  the  teeth  and  arch  of 
the  jaw,  and  the  laceration  of  the  gums,  are  sufficient  to  indicate  the  injury. 
The  nearer  the  line  of  fracture  is  to  the  symphysis,the  more  marked  is  the  mobility, 
and  diagnosis  is  only  difficult  when  the  fracture  is  of  the  ascending  ramus  and 
underneath  the  masseter  muscle.  A  skiagram  may  then  be  needed.  It  must 
be  remembered  that  a  fracture  of  the  mandible  is  commonly  compound,  and 
therefore  is  often  complicated  by  septic  infection.  Later,  callus  will  form  a 
tumour  which  might  be  mistaken  for  one  of  some  other  kind  until  the  course 
of  the  case  has  been  watched. 

2.  Inflammatory  Affections. 

Alveolar  Abscess. — This  is  a  verj^  common  swelling,  and  is  known  to  all  as 
associated  with  toothache.  An  ordinary  gum-boil  forms  at  the  edge  of  the 
gum,  and  is  quite  superficial.  A  more  troublesome  form  of  abscess  is  that  which 
develops  at  the  root  of  a  tooth,  which,  generally  carious,  may  yet  appear  healthy 
on  the  surface.  Pus  usually  points  between  the  gum  and  the  cheek,  but  it  may 
travel  a  long  way  between  the  bone  and  the  mucous  membrane,  and  point  on 
the  cheek,  in  the  submaxillar}'  region,  or  on  the  chin.  As  in  the  case  of  injury, 
periostitis  extending  up  under  the  muscle  may  be  difficult  to  diagnose,  and  it  is 
sometimes  mistaken  for  parotitis. 

In  the  early  stages  the  only  sign  is  toothache,  but  as  suppuration  becomes 
established,  there  are  also  pain,  swelling  of  the  gums,  a  furred  tongue,  trismus, 
enlargement  of  the  lymphatic  glands,  a  raised  temperature,  and  other  febrile 
symptoms.     The  presence  of  a  septic  tooth  indicates  the  diagnosis. 

Necrosis  of  the  Jaw,  often  preceded  by  an  acute  periosteal  abscess,  may  follow 
injury,  alveolar  abscess,  syphilis,  or  mercurial  or  phosphorus  poisoning,  and  in 
rare  cases  acute  exanthemata  or  typhoid  fever.  In  many  cases  it  may  be 
impossible  to  say  whether  the  bone  is  necrosed  or  not,  for  the  signs  are  much 
the  same  as  in  suppuration  in  connection  with  alveolar  abscess.     It  can  only 


748  SWELLIXG     OF     THE     LOWER     JAW 

be  diagnosed  for  certain  if  a  piece  of  loose  bone  can  be  felt  with  a  probe  or  seen 
by  the  aid  of  a  skiagram.  Its  presence  may  be  inferred  by  the  long  continuance 
and  profuseness  of  the  discharge. 

Syphilitic  disease  of  the  lower  jaw  is  rare,  and  if  present  will  not  usually  be 
confined  to  the  jaw.     If  there  is  doubt,  a  Wassermann's  reaction  will  be  of  ser\-ice. 

Actinomycosis. — -A  long-standing  and  obstinate  suppuration  about  the  lower 
jaw,  with  celluUtis  of  the  neck  and  formation  of  sinuses  in  the  skin,  should  lead 
to  the  suspicion  of  the  nature  of  the  trouble.  In  the  beginning  it  gives  rise  to 
inflammatory-  changes  which  simulate  alveolar  abscess,  and  the  similarity  is 
increased  bv  the  presence  of  carious  teeth,  through  which  the  fungus  is  beheved 
to  gain  acc^s  to  the  jaw.  In  the  pus,  the  smaU  yellow  grantdes  are  to  be  sought 
for,  and  the  Gram-staining  mvceUum  on  microscopical  examination  [Plate  XII 
Fig.  S\. 

3.  Tumours. — In  many  cases  there  will  be  no  difficult^-  in  deciding  whether 
a  swelling  is  inflammatory-  or  a  new  growth.  In  the  early  stages,  however — and 
it  is  never  to  be  forgotten  that  an  early  dia,gnosis  in  the  case  of  mahgnant  disease 
is  of  extreme  importance — there  may  be  grave  doubt.  Therefore,  all  possibiht\- 
of  inflammatory  mischief  should  be  excluded  by  a  careful,  thorough  examination 
of  the  mouth  and  teeth  for  any  source  of  infection,  and  for  this  purpose  it  is 
frequently  ad^-isable  to  innate  the  co-operation  of  a  dentist. 

Innocent  tumom^s  are  osteoma  and  fibroma  (more  commonly  called  a  fibrous 
epulis). 

Osteoma. — -This  is  a  rare  tumour.  It  is  ver\-  slow  growing,  is  ven.-  well  defined, 
bonv  hard,  and  does  not  usually  attain  a  \'eTX  large  size.  A  not  uncommon 
place  to  find  it  is  at  the  angle  of  the  jaw,  projecting  into  the  mouth.  It  may  be 
bilateral. 

Fibrous  Epulis. — This  is  a  common  tumour,  soft,  composed  of  fibrous  tissue, 
and  covered  by  the  mucous  membrane  of  the  gum.  It  arises  in  connection  vdtln. 
the  root  of  a  decayed  tooth,  and  if  not  treated  may  attain  a  suflacient  size  to  cause 
displacement  of  the  teeth  or  even  distortion  of  the  arch  of  the  jaw.  Sarcomata 
may  start  in  this  manner  ;  therefore  all  such  tumoiurs  should  be  submitted  to 
microscopical  examination  before  a  definite  diagnosis  or  prognosis  is  given. 

]SIahgnant  tumours  are  primary,  sarcomata,  and  secondary,  epithehomata, 
■which  start  in  the  gum  or  on  the  floor  of  the  mouth  and  invade  the  jaw  by  direct 
extension. 

Sarcomata. — The  diagnosis  of  these  may  be  quite  easy,  or  attended  by  the 
greatest  difficulty.  They  occur  at  any  age,  even  in  young  infants.  They  may 
be  of  rapid  growth,  associated  with  constitutional  changes  which  simulate 
inflammatory.-  conditions  before  a  large  size  has  been  attained,  or  they  may  be 
of  such  slow  development  as  to  be  confounded  "«ith  innocent  growths.  The 
necessitA-  of  early  diagnosis  cannot  be  urged  too  strongly,  for  it  is  on  this  that 
successful  treatment  depends. 

Seeing  that  a  growth  may  be  mistaken  for  a  swelling  due  to  suppuration, 
examination  should  first  be  directed  towards  seeing  if  any  of  the  ordinan,-  signs 
of  inflammation  are  present,  and  whether  there  is  an  ob\-ious  source  of  infection. 
The  histon,-  of  the  duration  of  the  illness  may  be  of  great  service,  and  also  the 
nature  of  the  swelling  itself.  Is  it  hard  or  soft,  is  the  bone  expanded,  are  tissues 
round  the  bone  infiltrated,  are  the  glands  enlarged  ?  Exercising  the  greatest 
care,  diagnosis  may  still  be  difficult,  and  much  ser\-ice  is  rendered  by  a  skiagram, 
with  the  aid  of  which  it  may  be  discovered  whether  the  swelling  is  reaUy  bony, 
or  in  the  case  of  periosteal  sarcoma  if  the  bone  has  been  eaten  into. 

If  the  diagnosis  can  be  settled  by  no  other  means,  the  growth  should  be  cut 
into  and  a  piece  removed  for  microscopical  examination,  even  if  the  tumour 
is  bony  and  a  chisel  and  mallet  be  required. 


SWELLING     OF     THE     UPPER     JAW  749 

Epithelioma — better  termed  squamous-celled  carcinoma — is  a  very  insidious 
and  dangerous  form  of  growth,  and  in  its  early  stages  very  apt  to  be  overlooked. 
It  may  start  as  a  small  ulceration  of  the  gum  about  a  decayed  tooth,  and  so  be 
mistaken  for  a  simple  ulcer,  and  it  may  not  be  until  a  large  tumour  has  formed 
that  the  condition  is  recognized,  when  most  valuable  time  will  have  been  lost 
from  the  point  of  view  of  treatment.  The  diagnosis  will  be  made  by  careful 
examination,  and  noting  that  the  ulcerated  gum  is  hard  and  indurated  and  does 
not  heal  when  the  decaj^ed  tooth  is  removed.  The  name  "  boring  epithelioma  " 
has  been  well  applied  to  this  condition.  To  make  the  diagnosis  sure,  a  piece 
from  the  edge  of  the  ulcer  should  be  removed  for  histological  examination  at 
the  earliest  moment  that  suspicion  is  aroused  as  to  its  malignancy. 

An  epithelioma  may  also  spread  from  the  tongue  or  floor  of  the  mouth  and 
cause  a  swelling  involving  the  jaw.     The  diagnosis  here  is  obvious. 

Tumours  of  the  Teeth,  Odontomata. — These  are  tumours  arising  from  any 
portion  of  the  dental  tissue,  either  from  the  tooth  germ  or  from  the  fully-formed 
tooth.  It  is  more  common  to  find  them  in  young  people,  and  clinically  they  are 
innocent  tumours. 

The  method  of  diagnosis  is  to  examine  the  teeth  and  find  out  if  any  of  them 
are  missing  or  abnormallj^  arranged.  It  is  easy  to  distinguish  them  from  a 
periosteal  sarcoma,  but  confusion  may  arise  between  them  and  a  very  slow- 
growing  endosteal  or  myeloid  sarcoma.  A  skiagram  will  generally  reveal  the 
true  state  of  affairs,  for  any  abnormality  or  misplacement  of  the  teeth  is  clearly 
shown.  It  is  well  to  remember  the  existence  of  these  tumours,  for  unnecessarily 
severe  operations  have  often  been  performed  in  ignorance. 

Two  diseases  in  which  the  mandible  becomes  enlarged,  but  in  which  the 
swelling  is  not  confined  to  the  one  bone,  and  is  only  one  of  the  manifestations  of 
the  complaint,  remain  to  be  mentioned  : — 

4.  Acromegaly. — The  lower  jaw  is  often  conspicuously  enlarged  in  this  disease, 
becoming  prominent  and  massive  {Fig.  88,  p.  263).  There  is  hypertrophy  of 
the  whole  bone  rather  than  a  swelling  in  it.  The  other  bones  of  the  face  are 
enlarged,  the  superciliary  ridges  are  exaggerated,  and  the  general  effect  of  the 
disease  is  to  give  the  patient  the  appearance  of  a  dull,  coarse-featured  person. 
In  addition,  the  hands  and  feet  become  much  enlarged ;  also,  in  the  late  stages 
of  this  very  chronic  illness,  headache  and  muscular  debility  become  prominent 
symptoms,  and  owing  to  swelling  of  the  pituitary  body,  bilateral  temporal 
hemianopia  is  to  be  expected  (see  Fig.  102,  p.  334). 

5.  Leontiasis  Ossea  is  the  name  given  to  a  rare  disease  in  which  hyperostoses  of 
the  facial  and  cranial  bones  are  the  distinguishing  features.  It  is  not  likely 
to  be  confounded  with  any  of  the  above-mentioned  swellings,  except  perhaps 
acromegaly,  from  which  it  is  distinguished  by  the  absence  of  changes  in  the 
hands  and  feet.  George  E.  Cask. 

SWELLING  OF  THE  JAW,  UPPER.— (See  article  on  Swelling  of  the  Jaw, 
Lower.)     The  remarks  there  made  apply  equally  to  swellings  in  the  upper  jaw. 

Special  attention,  however,  is  required  concerning  tumours  arising  in  the 
antrum  of  Highmore,  for  many  cause  no  pain  or  discomfort  until  the  late  stages. 
Though  innocent  tumours  may  start  in  the  antrum,  the  commonest  is  sarcoma. 
Rapid  growth,  bulging  into  and  invasion  of  surrounding  foss^,  pain,  and  discharge 
of  blood  and  pus  are  momentous  indications  of  malignant  disease.  In  the 
case,  though,  of  slow-growing  tumours  and  in  the  early  stages,  differentiation 
between  innocent  growths  or  suppuration  is  extremely  difficult.  Trans- 
illumination (see  Pain  in  the  Jaw,  Upper)  is  to  be  employed  {Fig.  62,  p.  204), 
also  puncture  of  the  antrum,  and  if  necessary  exploration.  George  E.  Gask. 

SWELLING   OF  THE   LEGS.— (See  CEdema.) 


750  SWELLING     ON     A     BONE 

SWELLING  ON  A  BONE,  —  It  is  presumed  that  the  swelhng  has  been 
ascertained  to  be  of  the  bone,  immovable  apart  from  it,  and  that  it  is  not 
merely  some  tumour  lying  close  to  it. 

The  following  method  of  examination  should  be  adopted  : — ■ 

1.  Inquiry  into  the  clinical  history,  mode  of  onset,  duration. 

2.  Search  for  the  signs  of  inflammation. 

3.  Evidence  as  to  whether  the  swelling  is  a  localized  projection  or  involves 
the  whole  circumference  of  the  bone. 

4.  Investigation  for  involvement  of  other  bones  or  further  signs  of  disease, 
e.g.,  tuberculosis,  syphilis,  rickets,  etc. 

5.  A  skiagram  should  always  be  taken  if  possible. 

6.  If  a  discharge  is  present,  a  bacteriological  examination  is  to  be  made. 

The  various  swellings  may  be  classified  under  the  following  headings  : — 
(I.)  Injury  ;   (II.)   Infective  Diseases  ;    (III.)   General  Diseases,  not  limited  to 
one  bone  ;    (IV.)  Tumours  ;    (V.)   Cysts. 

I. — Injury.  • 

A  blow  or  kick  may  give  rise  to  a  swelling  due  to  extravasation  of  blood 
or  serous  fluid  under  the  periosteum.  This  disappears  rapidly,  but  may  leave 
a  small  permanent  thickening  or  node.  Such  a  node  is  found  not  infre- 
quently on  the  shins  of  football  players.  A  fracture  of  bone  is  followed  by  the 
formation  of  callus,  which  forms  a  large  swelling  if  the  broken  ends  do  not  lie 
in  accurate  apposition,  or  if  there  is  too  much  movement  between  them.  After 
four  to  six  weeks  the  callus  begins  to  be  absorbed,  and  it  may  disappear  entirely  ; 
in  most  cases  a  small  permanent  swelling  indicates  the  site  of  fracture.  A 
green- stick  fracture  may  not  show  any  swelling  at  first,  and  may  be  overlooked 
on  this  account,  only  being  discovered  when  the  formation  of  callus  draws 
attention  to  it. 

II.— Infective  Diseases. 

These  give  rise  to  inflammatory  changes  in  bone,  the  signs  of  which  are 
more  or  less  obvious,  according  to  the  nature  and  virulence  of  the  infection. 
These  changes  have  usually  been  named  according  to  the  chief  starting-point 
(periostitis,  osteomyelitis,  etc.),  though  they  seldom  remain  confined  to  one 
particular  part  of  the  bone.  In  this  article  the  classification  will  be  made 
according  to  the  nature  of  the  infecting  organism,  viz.,  pyogenic  (staphylococci 
and  streptococci),  tubercle,  syphilis,  etc. 

A.  With  Pyogenic  Organisms. 

I.  Acute  infection  may  occur  through  wounds  or  injuries,  or  via  the  blood- 
stream. The  resulting  swelling  is  due  to  the  formation  of  pus  between  the 
periosteum  and  the  bone  ;  this  may  be  of  the  nature  of  a  localized  abscess,  or 
the  whole  of  the  periosteum  may  be  stripped  off  and  the  bone  lie  bare  in  a  bag 
of  pus.  The  disease  usually  occurs  in  young  people,  and  the  intimate  attachment 
of  the  periosteum  at  the  epiphyseal  lines  hmits  the  spread  of  suppuration  ;  in 
long-standing  cases  the  pus  may  burrow  further  and  even  burst  into  the  joint. 
Suppuration  is  rarely  limited  to  the  surface  of  the  bone,  but  spreads  into  the 
marrow,  causing  osteomyelitis  ;  lymphatic  absorption  and  septic  embolism  are 
liable  to  give  rise  to  a  general  blood-infection  and  pysemia. 

The  signs  of  inflammation  are  abundant :  the  swelling  is  acutely  painful 
and  tender,  the  skin  over  it  red  and  oedematous,  and  the  constitutional 
signs  of  fever  are  marked.  If  the  blood  is  examined,  a  high  leucocytosis 
will  be  found. 


SWELLING     ON     A     BONE 


751 


It  is  important  not  to  mistake  erythema  nodosum  for  this  affection  ;  in 
erythema  nodosum  the  red  swellings  are  generally  multiple,  bilateral,  and 
confined  to  the  shins  ;  it  is  rare  for  acute  osteomyelitis  to  be  bilateral  and 
symmetrical,  and  confined  to  the  parts  between  the  knees  and  the  ankles. 

2.  Chronic  infection. — Such  a  condition  as  detailed  above  may  often  become 
chronic  and  cause  a  swelling  which  may  last  for  months,  years,  or  through  life. 
If  the  pus  formed  under  the  periosteum  escapes,  either  by  bursting  or  through 
an  incision,  sinuses  form,  and  the  periosteum,  in  the  process  of  repair,  becomes 
thickened.  If  during  the  height  of  the  inflammation,  a  portion  of  the  bone 
has  died — necrosis — this  acts  as  a  foreign  body,  keeps  up  inflammation  and 
suppuration,  and  great  thickening  of 
all  the  constituent  parts  of  the  bone 
results  [Fig.  192).  Usually  the  dia- 
gnosis can  be  arrived  at  without 
difficulty.  Occasionally,  if  the  in- 
flammatory changes  have  not  been 
great,  and  the  amount  of  necrosis 
is  small  and  deeply-seated  (central 
necrosis),  a  condition  resembling  a 
slow-growing  sarcoma  may  result. 
If  a  skiagram  is  taken  it  will  be 
observed  that  the  chronic  inflamma- 
tor}^  periosteal  thickening  is  added 
on  to  or  "applied"  to  the  original 
compact  layer  of  bone,  whereas  in 
the  case  of  sarcoma,  though  there 
may  be  thickening  and  formation 
of  bony  or  calcareous  spicules  in  the 
growth,  the  compact  layer  is  eaten 
away  [Figs.  196^  198^  199,  pp.  754, 
756).  However,  this  may  be  some- 
what slender  evidence  onl  which  to 
base  the  diagnosis  between  so  im- 
portant a  condition  as  sarcoma  and 
inflammation,  and  if  doubt  arises  an 
incision  should  be  made  into  the 
tumour,  so  that  a  portion  may  be 
removed  for  pathological  investi- 
gation. 

B.  Tuberculous  Disease  usuallv 
starts  in  the  cancellous  tissue  of  the 
small  bones  of  the  carpus,  tarsus,  and 
phalanges,  and  at  the  ends  of  long 
bones.  The  inflammatory  changes, 
which  are  slight,  give  rise  to  caries 
of  the  aftected  bone  ;  the  external 
signs     of     inflammation     are     little 

marked,  and  it  is  comparatively  rare  for  any  swelling  of  the  bone  to  result, 
though  the  soft  parts  around  the  bone  may  be  swollen  considerably. 

Tuberculous  dactylitis  [Fig.  193)  furnishes  an  instance  in  which  the  disease 
forms  a  periosteal  swelling.  It  is  found  most  often  in  quite  young  children, 
and  the  bones  commonly  affected  are  the  metacarpal  bones  and  phalanges  of 
the  hand.  The  affected  digit  exhibits  a  fusiform  enlargement,  slightly  tender, 
which  on  rest  tends  to  diminish.      Tuberculous  periostitis  mav  develop  in  any 


-/■V^.    192. — Skiagram  from  a  case  of  chronic 
periostitis  of  the  uhia,  due  to  pyogenic  infection. 
Skiagram  by  Dr.  H^cgk   W'alskaiti. 


752 


SWELLING     ON     A     BONE 


long  bone,  on  the  ribs  and  the  humerus  most  commonly,  and  it  then  has  to  be 
differentiated  from  syphilis. 

Chronic  abscess  of  hone  occurs  most  frequently  in  the  young  adult,  and  nearly 
always  in  the  articular  extremity  of  a  long  bone,  by  preference  in  the  upper  end 
of  the  tibia.  Enlargement  of  the  bone  is  only  found  when  the  abscess  approaches 
the  surface  and  involves  the  periosteum.  The  skin  then  becomes  a  little  red 
and  oedematous,  and  there  is  generally  a  small  spot  that  is  exquisitely  tender  on 
firm  pressure.  It  is  to  be  noted  that  when  secondary  infection  with  pj^ogenic 
organisms  occurs — a  not  infrequent  event — all  the  swellings  described  under 
"  acute  infection  "  may  result.  A  skiagram  will  generally  reveal  the  true  condi- 
tion ;  if  not,  a  diagnostic  injection  of  Koch's  old  tuberculin  may  be  made,  or 
von  Pirquet's  skin  reaction  tested. 

C.  Syphilis  in  the  acquired  form  may  lead  to  periosteal  thickenings  in  the 
secondary   stage   and  to   gummata  in  the  tertiary.       The  former  give  rise   to 

excessively  tender  swellings  on  the 
surface  of  the  tibiae,  clavicles, 
sternum,  ribs,  or  skull.  They  are 
generally  multiple,  two  or  three 
often  being  found  on  the  same  bone. 
The  patient  complains  of  pain,  par- 
ticularly when  in  bed,  because  the 
extra  warmth  causes  further  dilata- 
tion of  already  inflamed  vessels. 
Relief  is  given  almost  at  once  by 
taking  potassium  iodide.  Sometimes 
one  of  these  swellings  is  followed  by 
the  formation  of  compact  periosteal 
bone,  giving  rise  to  a  node  which 
fades  gradually  into  the  surrounding 
parts,  like  a  hill  rising  gently  from 
a  plain. 

Gummata  may  form  localized 
swellings,  or  may  invade  the  whole 
substance  of  the  bone,  causing  osteo- 
myelitis and  general  thickening. 
The  condition  has  to  be  distinguished 
from  tuberculosis,  chronic  pj^ogenic 
infection,  and  sarcoma  ;  such  recog- 
nition is  arrived  at  by  means  of 
the  Wassermann  test,  and  the  fact 
that  antisyphilitic  remedies  cause  a 
marked  and  rapid  improvement. 
Diagnosis  by  incision  has  rarely  to  be 
resorted  to. 
In  congenital  syphilis  two  forms  of  bony  swelling  are  common  : — 
{a).  Periosteal  thickenings  of  the  bones  of  the  vault  of  the  skull,  called  Parrot's 

nodes — the  hot-cross  bun  or  natiform  skull. 

{b).   In  new-born  infants,   epiphysitis  and   separation  of  the  epiphyses.     So 

painful  is  a  limb  thus  affected  that  it  is  kept  motionless,  and  may  be  thought  to 

be  paralyzed. 

D.  Typhoid  Fever. — In  the  course  of  this  disease  a  periosteal  node  or  abscess 
may  form.  From  the  fluid  a  pure  culture  of  typhoid  bacilli  may  be  obtained, 
perhaps  for  a  long  time  after  the  fever.  The  nodes  by  no  means  always  break 
down  into  pus. 


F/g-.ig-},. — Skiagram  from  a  case  of  tuberculous 
dactylitis  of  the  first  phalanx  of  the  index  fins:er 
of  a  child. 

Skia°:rain   hy  Dr.  Htigh   Walshani. 


SWELLING     ON    A     BONE 


753 


III. — General  Diseases  not  Limited   to   One  Bone. 

1.  Rickets. — The  ordinary  form  is  well  known,  and  can  hardly  be  confused 
with  any  other  disease.  The  typical  bony  swellings  it  gives  rise  to  are  thickenings, 
due  to  irregular  growth  about  the  epiphyses  of  the  long  bones,  particularly  the 
lower  ends  of  the  radius  and  femur,  and  at  the  costo-chondral  junctions,  forming 
the  so-called  "  rickety  rosary."  There  may  also  be  bossing  of  the  bones 
forming  the  vault  of  the  skull. 

2.  Scurvy-rickets  is  quite  distinct  from  rickets.  It  arises  generally  in  infants 
under  twelve  months  old,  who  have  been  fed  too  exclusively  on  artificial  foods 
or  preserved  milk.  The  disease  therefore  is  more  common  among  the  children 
of  the  rich  than  the  poor.  The  child  is  often  brought  to  the  doctor  on  account  of 
the  sudden  appearance  of  an  exceedingly  painful  swelling  of  a  long  bone,  such 
as  the  femur.  The  swelling  may  fluctuate,  and  yield  on  aspiration  blood-stained 
fluid.       Spontaneous    fracture 

is  liable  to  occur.  The  dia- 
gnosis is  indicated  by  the  fact 
that  the  child  is  anaemic,  and 
has  spongy  gums  and  haemor- 
rhages from  the  mucous  mem- 
branes. The  condition  is  most 
likely  to  be  confused  with 
acute  suppurative  periostitis 
and  traumatic  fracture. 

3.  Osteitis  Deformans  (see 
Figs.  47,  48,  p.  182)  is  a  senile 
disease,  very  chronic,  and 
characterized  by  thickening, 
lengthening,  and  bending  of 
the  bones.  The  whole  osseous 
system  may  be  affected,  but 
attention  is  first  drawn  to  the 
disease  by  bending  of  the 
limbs  and  enlargement  of  the 
head.  In  the  rare  event  of 
one  bone  only  being  affected, 
it  may  be  confused  with  syphil- 
itic osteitis,  and  only  be 
recognized  on  the  failure  of 
antisyphilitic  remedies  and  by 
the  subsequent  involvement 
of  other  bones.  The  patient 
suffers  from  neuralgic  pains, 
and  in  the  later  stages  from 
dyspnoea.  In  such  cases 
death  sometimes  occurs  from 

the   development   of   multiple   sarcomata   of  the   bones. 

4.  Acromegaly  {Fig.  88,  p.  263)  is  characterized  by  enlargements  of  the  hands 
and  feet,  and  thickening  of  the  membrane  and  bones  of  the  skull  and  face  ; 
the  superciliary  ridges  and  the  lower  jaw  particularly  arc  enlarged.  There  is 
also  periosteal  thickening,  with  enlargement  of  the  ridges  of  insertion  of  muscles 
and  ligaments. 

5.  Leontiasis  Ossea. — In  this  disease  there  are  irregular  bony  outgrowths  from 
the  cranial  and  facial  bones. 

D  48 


I^ig.  104. — SkLiijram  or  a  common  variety  of  cancellous 
exostosis  of  the  femur. 

Skiagram  hy  Dr.  Hugh   M'alshani. 


754 


SWELLING     ON    A     BONE 


6.  Swellings  of  bones  associated  with  diseases  of  joints  may  be  found  in 
gout,  osteo-arthritis,  and  pulmonary  hypertrophic  osteo-arthropathy.  (See  Joints, 
Affections  of.) 

IV. — Tumours. 

These    are    innocent    and    malignant.       Innocent    tumours   as   a   whole    are 

characterized  by  their  long  history,  slow 
growth,  localized  projection,  and  the 
absence  of  all  signs  of  inflammation. 
Varieties  of  Innocent  Tumours. 
I.  Osteoma  or  exostosis  is  the  com- 
monest form  {Fig.  194).  The  usual  site 
is  in  the  neighbourhood  of  the  epiph}^- 
seal  line  of  a  long  bone.  In  this  position 
the  tumour  becomes  pedunculated,  is 
capped  with  cartilage,  and  often  is  sur- 
mounted by  an  adventitious  bursa 
containing  fluid. 


Fig'.  195. — Skiagram  of  an  enchondroma  of 
the  fifth  metacarpal  bone.  Compare  with 
Pigs.  197,  198,  199.  Enchondroma  and  sar- 
coma do  not  appear  unUke  in  skiagrams. 

Skiagram  by  Dr.   Hugh  IValshain. 

The  ungual  phalanx  of  the  great 
toe  is  another  common  site  for  a 
similar  tumour.  Multiple  exostoses 
are  not  uncommon,  and  they  may 
be  hereditary.  Diagnosis  can  be 
made  at  once  by  means  of  a  skia- 
gram, and  with  this  aid  it  can  be 
seen  that  the  swelling  is  composed 
of  cancellous  tissue  continuous  with 
that  of  the  bone.  A  spurious  oste- 
oma may  arise  by  ossification  of  a 
tendon  or  by  an  extension  of  the 
ridge  into  which  the  tendon  is 
inserted. 

Ivory  exostoses  may  be  found  on 
the  flat   membrane   bones  of  the  skull,  in  the  auditory  meatus  growing  from 
the  petrous  bone,  and  causing    displacement   of  the  eye  if  springing  from  the 
orbital  plate  of  the  frontal  bone  or  the  walls  of  the  frontal  sinus. 


196. 


-Skiagram   of   a  periosteal  sarcoma  of 
the  tibia. 
Skiagram  by  Dr.  Hugh   Walshaiu. 


SWELLING     ON    A     BONE 


755 


2.  Chondromata  may  grow  from  any  bone.  They  are  most  commonly  mul- 
tiple, affecting  the  phalanges  and  metacarpal  bones  of  the  hand  [Fig.  195). 
The  result  is  increasing  deformity,  with  pain  and  ulceration  of  the  skin. 

3.  Fibromata  grow  from  the  iibrous  tissue  of  the  periosteum,  but  are  rare 
except  in  the  form  of  an  epulis  of  the  jaw.  (See  also  Swelling  of  the 
Jaw,    Lower). 

4.  Lipomata  are  extremely  rare.  They  grow  from  the  outer  layer  of  the 
periosteum. 

Malignant   Tumours. 

These  mav  occur  either  primarily  (sarcoma),  or  secondarily  by  metastasis 
or  bv  invasion  (sarcoma  and  carcinoma). 


Fig.  197. — Skiagram  of  an  early  myeloid  sarcoma  of  the  lower  end  of  the  radius. 
This  and  the  two  succeeding  figures  should  be  compared  with  Fig;.  195,  which 
shows  that  enchondroma  and  sarcoma  are  not  distinguishable  by  -i--rays  alone. 

Skiagram  by  Dr.  HiigJi   Jl'alshaiii. 


I.  Periosteal  sarcomata  are  of  so  many  types,  and  of  such  varying  degrees 
of  malignancy,  that  it  is  a  difficult  task  to  lay  down  any  rule  as  to  their 
characteristics.  As  a  rule,  the  softer  their  consistency  and  the  nearer  they 
approach  to  the  embryonic  type  of  the  tissue,  the  more  malignant  they  are  ; 
the  nearer  they  reach  the  fully-formed  tissues  and  contain  cartilage,  bone,  or 
fibrous  tissue,  the  slower  growing  and  less  malignant  they  are.  A  tj-pical  case 
may  be  represented  as  a  rapidly  growing  tumour,  generally  about  the  end  of  a 
long  bone  [Fig.  196).     It  is  not  usually  painful,  and  the  signs  of  local  inflamma- 


756 


SWELLIXG     ON    A     BONE 


tion  and  general  fever  are  little  marked  or  absent.  The  patient  is  commonlj^ 
a  young  adult,  who  often  gives  a  history  of  injury  to  the  part,  and  may  lose 
weight  and  strength  before  actual  cachexia  sets  in.  The  veins  over  the  swelling 
become  prominent,  the  lymphatic  glands  enlarged,  and  metastases  b}-  the  blood- 
stream occur  early.  It  has  to  be  distinguished  from  chronic  and  syphihtic 
periostitis.  If  a  skiagram  is  insufficient,  a  piece  of  the  tumour  maj'  have  to  be 
excised,  decalcified,  and  a  microscopic  section  from  it  prepared.  This  form  of 
sarcoma  is  the  worst  possible,  and  seeing  that  amputation  does  not  cure  and 
often  does  not  prolong  life,  this  extreme  resource  may  be  delaj-ed  where  either 
gumma  or  chronic  periostitis  is  still  a  possible  diagnosis. 


J'ig.  igS. — Skiagram  giving  the  antero-posterior  view  ot 
a  myeloid  sarcoma  of  the  lower  end  of  the  radius.  The 
growth  is  at  a  later  stage  than  that  depicted  in  Fig^.  197. 


Fig:    199   shows   the   same   growth  as  Fig 
58,  but  seen  from  the  lateral  aspect. 

Skiagrams  by  Dr.  Hugh  Wahhaiii. 


2.  Endosteal  or  myeloid  sarcomata  are  01  much  slower  growth  ;  so  slow  are 
they  that  some  pathologists  are  inclined  to  denote  then  as  benign  tumours. 
They  are  prone  to  affect  the  ends  of  the  long  bones,  particularly  the  lower  end 
of  the  femur,  the  upper  end  of  the  tibia,  the  upper  end  of  the  humerus,  the  lower 
end  of  the  radius  {Figs.  197,  198,  199),  the  sternal  end  of  the  clavicle,  and  the 
upper  jaw  (malignant  epulis).  Attention  is  first  called  to  the  part  by  pain  ;  then 
a  more  or  less  uniform  swelhng  appears.  This  is  at  first  bonj'  hard,  and  only 
as  the  shell  of  bone  yields  does  softening  occur,  or  crackling  on  pressure.  The 
lymphatic  glands  are  not  enlarged,  and  metastases  do  not  occur.  In  the  early 
stages,  diagnosis  has   to  be   made  from  rheumatism  and  chronic  abscess,   and 


SWELLING,     PELVIC  757 


later  from  chronic  osteomyelitis  and  periosteal  sarcoma  ;  it  is  easily  made  by 
the  aid  of  ,r-rays  as  a  rule,  but  it  is  most  important  not  to  mistake  the 
callus  that  is  produced  after  fracture  for  a  sarcoma ;  this  mistake  is  not 
always  obviated  even  by  the  use  of  the  ;i;-rays,  unless  the  latter  reveal  the 
line  of  fracture  as  well  as  the  callus  around  it. 

3.  Carcinoma  is  always  secondary.  Squamous-celled  carcinoma  may  spread 
from  an  epitheliomatous  ulcer  of  the  leg,  or  to  the  jaw  from  the  lip  or  floor  of 
the  mouth.  It  is  mostly  spheroidal-celled  carcinoma  which  infects  bone  by 
metastatic  growths,  particularly  from  the  breast.  A  swelling  of  bone  may  be 
found,  but  this  is  rarely  discovered  until  attention  is  called  to  it  by  a  spontaneous 
fracture. 

V. — Cysts. 

1.  Blood  cysts  are  found  in  degenerating  sarcomata. 

2.  Hydatid  cysts  are  uncommon  in  this  country.  They  affect  the  diaphyses 
of  the  long  bones,  converting  the  shaft  into  a  thin- walled  tube,  which  undergoes 
spontaneous  fracture. 

3.  Cj'sts  of  the  jaw,  or  dentigevoiis  cysts,  are  considered  in  the  article  on 
Sw^ELLiNG  OF  THE  LowER  Jaw.  George  E.  Gask. 

SWELLING,  PELVIC. — There  are  so  many  swellings  which  may  rise  up  out 
of  the  peh"is  into  the  abdomen,  and  also  which  may  appear  to  be  pelvic  when 
they  are  really  primarily  abdominal,  that  a  list  in  tabulated  form  may  be  of 
value  : — 

Bladder. — Simple  distention  of  ;    New  growth. 
Vagina. — Haematocolpos. 

Uterus. — Pregnancy  :    normal  or  abnormal,  or  associated  with  tumours  of  the 
uterus  or  ovary 
New  growths  :     Fibromyoma.     Sarcoma.     Carcinoma. 
HEematometra.     Chorion-epithelioma. 
Ovary. — Cysts.     Solid  new  growths. 


Fallopian  Tubes. — -Hjdrosalpinx 
Pyosalpinx 
Salpingo-oophoritis 


New  growths 
Carcinoma 
Tubal  gestation 

Progressive  extra-uterine  gestation. 
Pelvic  Peritoneum. — Encj-sted  peritoneaL  fluid 

Hematocele  due  to  extra-uterine  gestation 
Haematocele  due  to  haemorrhage  from  a  corpus  luteum 
Pelvic  abscess 
Ascites 

Hydatid  cysts 
Retroperitoneal  lipoma. 
Pelvic  Cellular  Tissue. — Cellulitis.     Pelvic  hsematoma. 
Appendix  Vermiformis. — Abscess  around 

Appendicitis  with  pregnancy. 
Pelvic  Bones. — New  growths  of. 
Omentum. — New  growths  of.     Cysts  of. 
Phantom  Tumours. 
Pancreatic  Cysts. 

Kidney. — Tumours  of.     Hydronephrosis.     Pyonephrosis. 
Gall-bladder.^Distention  of. 
Spleen. — Enlargement  of. 
Urachus. — Cyst  of. 


758  SWELLING,     PELVIC 


It  is  obvious  that  many  of  these  lesions  are  not  pelvic  at  all  ;  but  they  are 
not  omitted  from  the  list,  because  they  are  liable  to  be  mistaken  for  pelvic 
tumours.  Thus  pancreatic,  renal,  splenic,  and  gall-bladder  tumours  may  reach 
the  pelvic  brim,  but  the  history  ought  to  show  that  they  have  grown  down  from 
above,  not  up  from  below.  Further,  renal  tumours  may  be  associated  with 
urinary  changes,  or  absence  of  urinary  secretion  on  the  affected  side,  as 
detected  by  the  cystoscope.  Splenic  enlargements  may  be  associated  with 
blood-changes,  and  gall-bladder  distention  with  icterus.  Pancreatic  cysts  are 
the  least  hkely  to  be  mistaken  for  pelvic  swellings,  but  they  have  been  difficult 
to  distinguish  from  ovarian  tumours  with  long  pedicles. 

Naturally,  the  commonest  difficulty  which  arises  in  the  diagnosis  of  pelvic 
swellings  is  to  =  differentiate  between  the  distended  bladder,  pregnant  uterus, 
ovarian  cyst,  and  uterine  fibromyoma,  and  the  commonest  mistakes  are  made 
between  these  swellings.  The  distended  bladder  is  clearly  the  easiest  to  dispose 
of,  because  the  passage  of  a  catheter  will  settle  the  question  ;  and  yet  the  neglect 
of  this  simple  procedure  has  led  to  more  than  one  abdomen  being  opened. 

The  history  is  of  value  in  differentiating  the  other  swelhngs,  for  amenorrhoea 
is  the  rule  in  pregnancy,  menorrhagia  in  fibromyoma,  and  no  change  in  menstrua- 
tion in  ovarian  tumours.  These  assumptions  are  absolutelj^  correct  in  almost  99 
out  of  every  100  cases,  but  exceptions  do  exist.  The  cardinal  point  in  diagnosis 
is  not  to  think  of  the  possible  fallacies  until  the  common  rule  has  been  thoroughly 
considered.  Normal  menstruation  during  pregnancy  is  almost  unknown,  but 
it  is  believed  that  menstruation  is  possible  up  to  the  third  month  of  pregnancy. 
This  is  physiologically  unsound,  for  menstruation  represents  the  failure  of  the 
uterus  to  receive  a  fertilized  ovum,  and  should  not  be  even  possible  if  conception 
does  occur.  That  haemorrhages  occur  during  the  early  months  of  pregnancy  is 
true ;  but  in  most  cases  these  haemorrhages  represent  threatened  abortion,  and 
not  menstruation.  Further,  fibroids  are  associated  with  haemorrhages.  This  is 
absolutely  true  in  the  case  of  interstitial  or  submucous  growths  ;  but  there  may 
be  no  disturbance  of  menstruation  in  subperitoneal  fibroids.  Ovarian  tumours 
only  disturb  menstruation  when  they  are  double,  and  destroy  all  ovarian  tissue. 
As  long  as  a  small  piece  of  ovarian  tissue  remains  undestroyed,  there  is  no  reason 
why  menstruation  should  not  occur  normally. 

Palpation  of  these  tumours  may  be  fallacious,  although  there  is  no  difficulty  in 
distinguishing  foetal  parts  when  the  foetus  is  big  enough.  In  the  early  months 
the  pregnant  uterus  may  fluctuate  like  a  cyst ;  a  softened  fibroid  may  do  the 
same,  whilst  on  the  other  hand  a  tense  ovarian  cyst  may  feel  so  hard  as  to  be 
mistaken  for  a  fibroid.  Whilst  the  presence  of  the  foetal  heart  is  characteristic  of 
pregnancy,  its  absence  cannot  be  taken  as  evidence  of  a  fibroid  or  of  an  ovarian 
tumour.  It  is  not  always  possible  to  hear  the  foetal  heart  even  in  advanced 
pregnancy.  If  the  pedicle  of  a  tumour  can  be  felt  definitely  attached  to  one 
uterine  cornu,  it  is  strong  presumptive  evidence  of  an  ovarian  tumour.  It 
is  useful  to  pull  down  the  uterus  with  a  tenaculum,  at  the  same  time  pushing 
up  the  tumour  so  as  to  make  tense  the  pedicle,  which  might  then  be  palpated  by 
the  vaginal  touch.  When  small  tumours  are  in  question,  the  first  point  which 
arises  is.  Can  the  tumour  be  separated  from  the  uterus  bimanually  ?  If  so, 
it  can  be  neither  a  fibromyoma  of  the  uterus  nor  a  normal  uterine  pregnancy. 
This  point  can  only  be  made  out  by  careful  bimanual  examination,  and  undoubt- 
edly may  require  considerable  skill  in  some  cases. 

Early  pregnancy  in  a  retroverted  uterus  should  not  give  rise  to  diagnostic  difficul- 
ties if  it  be  remembered  that  the  soft,  boggy  fundus  is  felt  through  the  posterior 
fornix,  that  the  cervix  looks  down  the  vagina  or  forwards  to  the  symphysis,  and 
that  the  posterior  mass  is  continuous  with  the  cervix.  If  the  retroverted 
uterus  is  associated  with  vesical  distention,  the  picture  is  usually  clear  enough. 


SWELLING,     PELVIC  759 


The  history  of  constant  dribbUng  of  urine  (distention  with  overflow),  amenor- 
rhoea,  other  signs  of  pregnancy,  and  the  presence  of  tsvo  tumours — one  in  front, 
tense  and  elastic,  the  other  behind,  soft  and  boggy — and  finally,  the  passage  of  a 
catheter,  will  settle  the  question.  The  diagnosis  of  sohd  ovarian  tumours  is 
not  alwavs  possible,  for  the  pedicle  is  often  short,  and  the  tumour  is  then  so 
close  to  the  uterus  that  the  two  cannot  be  separated.  They  are  therefore  likely 
to  be  mistaken  for  fibroids  of  the  uterus.  They  do  not  often  cause  menorrhagia, 
however,  and  this  may  be  remembered  as  a  cardinal  point. 

Large  tumoiivs  arising  in  the  pelvis  are  not  often  difficult  to  differentiate  from 
one  another,  bearing  in  mind  that  ovarian  tumours,  uterine  fibroids,  pregnancy, 
and  ascites  are  the  common  conditions  which  are  met  with.  In  this  connection, 
it  cannot  be  repeated  too  often,  that  amenorrhcea  stands  for  pregnancy,  and  occa- 
sionallv,  for  ovarian  tumours  when  double.  Menorrhagia  goes  with  uterine 
fibroids  except  in  the  case  of  subperitoneal  tumours.  Exceptions  to  these  general 
statements  are  uncommon,  and  mistakes  in  diagnosis  will  occur  but  seldom 
if  the}'  are  borne  in  mind.  Ascites  has  to  be  differentiated  from  ovarian  cysts, 
and  occasionally  from  hydramnios.  In  general,  ascites  gives  dullness  in  the 
flanks  on  percussion,  with  resonance  over  an  area  somewhere  about  the  umbilicus, 
whilst  ovarian  cysts  give  dullness  all  over  the  front  of  the  abdomen,  with  resonant 
areas  in  the  flanks  and  epigastric  angle.  When  ascites  exists  along  with  ovarian 
tumours,  the  free  fluid  may  be  so  large  in  amount  that  the  tumour  cannot  be 
felt ;  as  a  rule,  however,  it  can  be  touched  on  dipping  through  the  fluid.  Ascites 
with  an  ovarian  tumour  does  not  necessarily  mean  malignancy,  but  it  may  do  so. 
Fibroma  of  the  ovary,  and  simple  ovarian  cyst  with  a  tAvisted  pedicle,  will  always 
be  accompanied  by  some  fluid. 

When  pregnancy  is  associated  with  tumours,  the  diagnosis  may  be  of  great 
difficulty.  The  difficulty,  however,  does  not  lie  in  the  recognition  of  the 
pregnancy  ;  amenorrhcea,  breast  changes,  foetal  movements,  and  the  foetal  heart 
will  usually  make  that  clear  enough  ;  it  lies  in  deciding  the  nature,  or  even  the 
presence,  of  a  tumour  along  with  the  pregnant  uterus.  In  the  early  months, 
when  the  presence  of  two  tumours  can  be  demonstrated,  the  diagnosis  is  easier, 
but  in  the  later  months,  the  great  size  of  the  abdomen,  and  the  way  in  which  the 
swelhngs  merge  into  one  another,  may  obscure  the  picture.  The  relation  to  the 
uterus,  whether  a  part  of  it,  or  attached  to  it  by  a  pedicle  ;  the  feel  of  the 
tumour,  whether  sohd  or  cystic,  soft  or  hard  ;  and  the  previous  history ;  will 
always  be  of  assistance  in  making  out  the  nature  of  the  growth.  It  must  not  be 
forgotten  that  fibroids  are  extremely  hkely  to  soften  and  degenerate  during 
pregnancy,  so  that  they  are  liable  to  be  mistaken  for  ovarian  cysts. 

In  the  case  of  ovarian  tumours,  it  is  often  impossible  to  be  sure  of  the  exact 
nature  of  the  growth,  and  this  has  to  be  decided  microscopically  after  removal. 
It  is,  however,  important  to  distinguish  malignancy  in  growths  of  the  ovary, 
and  certain  points  w-ill  stand  out  in  favour  of  this.  Thus,  fixation  of  the 
growth  in  the  pelvis,  obvious  ascites,  emaciation  of  the  patient,  and  rapid 
growth  in  size  of  the  abdomen,  are  points  in  favour  of  malignancy. 

In  the  case  of  definitely  uterine  tumours,  the  diagnosis  of  malignant  growths  is 
not  often  difficult,  but  may  have  to  be  settled  by  the  microscopic  examination  of 
curetted  fragments.  Fibroids  are  only  hkely  to  be  mistaken  for  mahgnant 
growths  when  they  produce  constant  bleeding  as  a  result  of  extrusion,  infection, 
and  sloughing.  Rapid  growth  of  a  fibroid  is  naore  hkely  to  be  the  result  of 
degenerative  changes,  such  as  formation  of  cysts  or  necrobiosis,  than  to  the 
development  of  a  sarcoma  or  other  malignant  growth  along  with  it. 

With  small  tumours  confined  to  the  pelvis,  or  rising  only  a  little  above  the 
brim,  diagnosis  is  often  a  matter  of  extreme  difficult}^  In  practice,  how'ever, 
extra-uterine  gestation  and  its  resulting  blood-tumours  stand  out  pre-eminently 


76o  SWELLING.     PELVIC 


as  swellings  which  must  be  recognized  at  once,  if  successful  treatment  is  to  be 
adopted.  Before  rupture  or  abortion  has  occurred,  a  tubal  gestation  is  essen- 
tially a  small  tumour  in  one  postero-lateral  corner  of  the  pelvis,  attached  to  the 
uterus,  indefinite  in  consistence,  and  perhaps — though  not  always — associated 
with  amenorrhoea  of  short  duration,  and  attacks  of  pain  in  the  pelvis  of  an  acute 
nature.  Definite  signs  of  pregnancy  may  be  entirely  wanting.  It  may  be 
mistaken  for  a  chronic  salpingo-oophoritis,  a  small  cystic  ovary,  a  small  pedun- 
culated fibroid,  or  a  small  ovarian  dermoid.  The  differential  diagnosis  may 
be  absolutely  impossible  ;  but  attacks  of  pain  unassociated  with  menstruation 
are  not  hkely  to  occur  in  any  of  the  latter  conditions.  The  attacks  of  pain  are 
usually  the  result  of  over-distention  and  stretching  of  the  tube  from  haemor- 
rhage into  its  wall  or  lumen  around  the  fertilized  ovum.  When  tubal  abortion 
has  occurred,  or  tubal  rupture,  the  .signs  of  internal  bleeding,  accompanied  by 
sudden  pain  and  collapse,  with  hsemorrhage  from  the  i;terus,  usually  make  up 
a  complete  and  unmistakable  picture.  Hccmorrhage  is  more  commonly  severe 
and  copious  in  tubal  rupture  than  in  tubal  abortion.  If  the  patient  recovers 
from  the  initial  bleeding,  the  clinical  picture  may  be  that  of  a  retro-uterine 
hcsmatocele,  or  of  a  peritubal  hematocele.  In  this  form,  the  uterus  is  pushed 
forwards  and  upwards  against  the  symphysis  pubis,  and  the  mass  of  blood-clot 
can  be  felt  posteriorly  bulging  the  posterior  fornix,  and  also  the  anterior  wall 
of  the  rectum.  The  tumour  is  usually  partly  resonant  in  front,  because  intestine 
adheres  to  it.  Tubal  abortion  is  most  likely  to  be  mistaken  for  an  ordinary 
uterine  abortion  ;  but  the  presence  of  a  mass  on  one  side  of  the  uterus,  with  a 
closed  cervix,  and  the  absence  of  uterine  contractions  or  extrusion  of  any 
products  of  conception,  should  make  the  case  clear. 

Progressive  extra-uterine  gestation  is  a  rare  occurrence,  and  is  the  result  of 
continued  growth  of  an  embryo  after  a  partial  separation  from  the  tube,  as  a 
result  of  rupture,  or  extrusion  from  the  fimbriated  end  (abortion).  The  continued 
enlargement  of  a  mass  beside  the  uterus,  with  amenorrhoea  and  progressive  signs 
of  pregnancy,  are  the  most  characteristic  points.  The  diagnosis,  however,  is 
difficult,  because  there  is  always  some  effused  blood  which  is  likely  to  obscure  the 
outlines  of  the  uterus,  and  make  it  appear  to  be  a  part  of  the  pelvic  mass. 

The  swellings  due  to  salpingo-oophoritis  are  usually  quite  easy  to  distinguish. 
They  form  fixed  masses  in  the  pelvis,  seldom  of  an}^  definite  shape,  but  occasion- 
ally presenting  the  characteristic  retort  shape,  with  its  narrow  end  near  the  uterus, 
which  the  tube  assumes  when  distended  with  fluid.  The  history  is  usually  that 
of  an  acute  illness  at  some  period,  with  pain  in  the  pelvis,  rise  of  temperature,  and 
peritoneal  irritation.  It  is  preceded,  as  a  rule,  by  uterine  discharges  and  menor- 
rhagia.  This  inflammatory  disturbance  in  married  women  is  associated  with 
long  periods  of  sterihty,  owing  to  the  sealing  up  of  the  tubes.  The  diagnosis  of 
suppuration  with  salpingo-oophoritis  is  often  impossible,  but  is  always  important, 
because  the  treatment  may  depend  on  it.  Constant  rises  of  temperature  of 
the  hectic  type,  wasting,  and  daily  sweating,  are  the  usual  accompaniments 
of  suppuration  here  as  elsewhere. 

A  large  pelvic  abscess  may  accompany  salpingo-oophoritis,  or  may  occur  alone 
without  infection  of  the  tubes,  as  we  see  occasionally  in  puerperal  septic  infections. 
When  it  does  occur,  it  is  of  course  peritoneal  ;  it  fixes  the  uterus  in  a  central 
position,  bulges  into  the  posterior  fornix  and  rectum,  tends  to  rupture  into  the 
rectum,  is  acute  in  onset,  and  accompanied  by  signs  of  local  peritonitis.  It 
is  likely  to  be  confounded  with  pelvic  cellulitis,  in  which  the  uterus  is  fixed  in  a 
laterally  displaced  position.  It  bulges  one  lateral  fornix,  tends  to  burrow  along 
the  round  ligament  to  the  groin,  is  slow  and  chronic  in  onset,  and  is  not  accom- 
panied by  signs  of  local  peritonitis.  It  always  follows  labour,  whereas  pelvic 
abscess  of  peritoneal  origin  may  occur  with  salpingo-oophoritis  quite  apart  from 
pregnancy.     Pelvic  cellulitis  never  bears  any  relation  to  salpingo-oophoritis. 


SWELLING,     POPLITEAL  761 

Encyated  peritoneal  ftuid,  hydatid  cysts,  and  retroperitoneal  lipoma  are  generally 
diagnosed  as  ovarian  cysts,  and  their  true  nature  is  only  discovered  at  opera- 
tion. There  are  no  definite  signs  by  which  these  conditions  may  be  diagnosed, 
and  as  they  all  require  operative  treatment,  post-operative  diagnosis  meets 
their  requirements. 

Distention  of  the  vagina  by  menstrual  fluid  is  not  likely  to  be  mistaken  for 
anything  else,  if  only  on  account  of  the  absolute  closure  of  the  hymen  which  gives 
rise  to  it.  Haematocolpos  is  practically  the  only  central  tumour  met  with 
between  the  rectum  and  the  bladder,  reaching  from  the  hymen  to  the  pelvic  brim. 
The  uterus  can  usually  be  felt  like  a  cork  movable  upon  its  upper  extremity. 

Urachal  cysts  occur  in  front  of  the  uterus  and  in  close  relation  to  the  bladder  ; 
but  in  spite  of  this  they  are  usually  mistaken  for  ovarian  cysts.  It  is  to  be 
remembered,  however,  that  ovarian  cysts  only  get  in  front  of  and  above  the 
uterus  when  they  are  large.     Urachal  cysts  rarely  attain  a  large  size. 

Appendicitis  with  pregnancy  occasionally  occurs,  and  may  be  mistaken  for 
such  a  condition  as  torsion  of  an  ovarian  pedicle.  The  swelhng  due  to  appendix 
inflammations  is,  however,  in  close  relation  to  the  anterior  superior  spine  of  the 
ilium,  and  apparently  adherent  to  the  ihac  fossa.  The  lump  is  ill  defined,  and 
rarel}'  fluctuates  unless  there  is  a  large  abscess.  The  acute  onset  may  be  similar 
to  that  of  torsion  of  an  ovarian  pedicle.  There  is  usually  a  definite  fluctuating 
tumour  when  an  ovarian  cyst  is  present,  and  some  interval  betAveen  it  and  the 
ihac  crest  can  usually  be  felt. 

Phantom  tumours  are  due  to  diaphragmatic  contraction,  causing  the  abdominal 
wall  to  bulge.  They  are  usually  mistaken  by  patients  for  pregnancy,  but  are 
not  accompanied  by  anv  of  the  signs  of  pregnancy.  Amenorrhoea  must  be 
excepted  from  this,  however,  because  these  cases  usually  occur  about  the  meno- 
pause. Their  true  nature  can  usually  be  discovered  by  making  the  patient 
breathe  normally,  relaxing  the  diaphragm  ;  but  if  any  doubt  exists,  the  pro- 
trusion will  disappear  under  an  anaesthetic. 

Growths  of  the  pelvic  bones  are  very  rare  tumours,  usually  cartilaginous  or  sar- 
comatous. They  are  only  likely  to  be  mistaken  for  adherent  inflammatory 
masses,  due  to  salpingo-oophoritis.  They  will  be  found  to  be  continuous  with 
the  bones  forming  the  pelvis,  and  when  growing  from  the  sacrum  may  have  the 
rectum  in  front  of  them  ;  all  other  tumours  have  the  rectum  behind  them. 
They  may,  however,  bear  no  relation  to  the  rectum  at  all  if  they  occur  on  the 
right  side  of  the  pelvis.  In  most  cases  of  this  nature,  the  i;terus  and  adnexa  can 
be  palpated  bimanually,  and  shown  to  be  free  from  disease  and  unconnected  with 
the  mass.  When  complicated  by  the  presence  of  a  pregnant  uterus,  their  true 
nature  may  be  very  difficult  to  determine.  Bearing  in  mind  that  they  are 
absolutely  fixed  and  continuous  with  the  bones  of  the  pelvis,  the  diagnosis 
ought  not  to  be  uncertain.  Thos.  G.  Stevens. 

SWELLING,  PERINEPHRIC— (See  Kidney,  Enlargement  of.) 

SWELLING,   POPLITEAL, — Popliteal  swellings  may  be  divided  into  : — 

1.  Fluid  Swellings : 

Bursa  I       Abscess 

Baker's  cyst  |       Aneurysm. 

2.  Solid  Swellings  not  connected  with  Bone : 

Enlarged  glands  |       Innocent  tumours. 

]Malignant  tumours  | 

3.  Solid  Tumours  connected  with  Bone  : 

Exostosis  I        Periostitis 

Sarcoma  |       Separation  of  the  epiphysis. 


762  SWELLING,     POPLITEAL 

I.  Fluid    Swellings. 

Bursa, — The  bursa  underneath  the  insertion  of  the  semimembranosus  muscle 
into  the  posterior  aspect  of  the  inner  tuberosity  of  the  tibia  is  often  enlarged. 
When  the  leg  is  extended  it  stands  out  as  a  tense  fluctuating  swelling  on  the 
inner  side  of  the  popliteal  space  ;  on  flexion  it  disappears  completely.  It  may 
be  found  enlarged  in  young  athletes  and  cause  no  symptoms  whatever.  On 
account  of  its  frequent  communication  with  the  knee  joint,  it  is  often  distended 
when  that  joint  is  the  seat  of  osteo-arthritis,  and  the  changes  found  in  the 
synovial  membrane  of  the  knee  are  found  also  in  the  synovial  membrane  lining 
the  bursa,  for  the  two  are  continuous.  When  much  fluid  is  present,  fluctuation 
can  be  detected  between  the  joint  and  the  bursa. 

The  bursa  under  either  of  the  two  heads  of  the  gastrocnemius  muscle  may 
be  enlarged,  but  this  is  rare. 

Baker's  Cyst  occurs  in  connection  with  chronic  tuberculosis  of  the  knee  joint, 
and  is  formed  by  the  extension  of  a  clironic  abscess  which  spreads  along  a  plane 
of  fascia.  Such  an  abscess  may  present  itself  in  the  popliteal  space.  The 
condition  of  the  knee  joint  will  indicate  the  disease. 

Acute  Abscess  is  recognized  by  the  signs  of  acute  inflammation  ;  the  skin 
is  red  and  oedematous,  the  pulse  and  temperature  are  raised,  and  the  swelling 
is  very  painful.  The  knee  is  kept  flexed  in  order  to  avoid  pressure.  The 
abscess  maj^  be  caused  b):^  suppurating  lymphatic  glands  or  by  suppurative 
periostitis  or  necrosis  of  the  lower  end  of  the  femur.  In  the  former  case  the 
abscess  will  be  superficial,  and  in  the  latter,  deep  to  the  popliteal  vessels. 

Aneurysm  of  the  Popliteal  Artery  [Plate  XIII)  gives  rise  to  an  expansile 
pulsating  tumour,  the  pulsation  being  synchronous  with  the  heart's  beat. 
Pressure  on  the  femoral  artery  above  will  cause  a  diminution  in  size  of  the  swell- 
ing and  cessation  of  pulsation.  The  pulse  at  the  ankle  on  the  affected  side  may  be 
smaller  than  that  on  the  opposite,  and  delayed.  If  a  stethoscope  be  placed  over 
the  swelling  a  distinct  bruit  can  be  heard.  The  complaint  of  the  patient  will 
probably  be  of  pain,  which  may  be  referred  down  the  leg  if  either  pophteal  nerve 
is  pressed  on,  or  in  the  site  of  the  swelling  if  the  bone  is  eroded.  Varicose  veins 
are  almost  always  present  on  account  of  pressure  on  the  popliteal  vein.  Owing 
to  its  pulsatile  character,  an  aneurysm  is  not  often  mistaken  for  anything  else, 
but  it  must  be  remembered  that  every  swelling  that  pulsates  is  not  an  aneurj'sm. 
A  soft  vascular  sarcoma  growing  from  the  end  of  the  femur  ma}^  be  pulsatile, 
and  over  it  a  bruit  may  be  heard,  but  the  tumour  is  not  as  compressible  as  an 
aneurysm,  and  the  effects  on  the  distal  pulse  are  not  so  marked.  A  skiagram 
will  usually  settle  the  question  at  once.  Distinction  must  also  be  drawn  between 
a  tumour  that  pulsates  and  a  tumour  to  which  pulsation  is  communicated. 
For  instance,  an  abscess  or  a  solid  swelling  lying  over  the  popliteal  artery 
may  appear  to  pulsate,  but  the  movement  is  heaving  in  character  and  not 
expansile.  In  the  rare  event  of  an  aneurysm  having  become  filled  with  clot,  it 
might  be  taken  for  a  solid  tumour  growing  either  from  the  soft  parts  or  from  the 
bone.      Under  this  delusion  a  leg  has  been  amputated  for  sarcoma. 

2.  Solid  Swellings  not  connected  with  Bone. 

Enlarged  Glands. — It  is  not  common  to  find  the  popliteal  glands  enlarged 
from  any  cause.  It  is  possible  that  they  may  become  infected  with  pj'Ogenic 
organisms  from  a  sore  on  the  back  of  the  leg. 

Tumours  are  rare.  They  may  be  innocent,  e.g.,  lipoma;  or  sarcomatous, 
starting  in  the  connective  tissue  of  the  popliteal  space,  or  attached  to  one  of  the 
muscles.  The  innocent  tumours  are  of  long  history  and  well  defined  ;  the 
malignant,  rapidly  growing  and  infiltrating. 


PLA  TE     XIII. 

POPLITEAL        ANEURYSM 


y 


Reproduced  by  Jiermissioii  froju  a  zvato-colour  paititing  in  the  Gordon  Museian, 
Guys   Hospital. 


INDEX     OF     DIAGNOSIS 


SWELLING,     PULSATILE  763 

3.   Solid  Swellings  connected  with  Bone. 

In  all  cases  of  bony  tumour  a  skiagram  is  of  immense  service,  and  should 
always  be  obtained  if  possible. 

Innocent  Tumours. — Cancellous  exostoses  may  be  found,  generally  in  children 
and  3'oung  adults,  growing  from  the  region  of  the  epiphysial  cartilage  of  the 
femur  {Fig.  194,  p.  753).  There  may  be  others  in  other  parts  of  the  skeleton, 
and  sometimes  several  members  of  the  family  are  affected  similarly.  The 
swelling  is  of  slow  growth,  well  defined,  and  rarely  gives  any  trouble.  It  is 
most  often  found  at  the  inner  side  of  the  popliteal  space.  There  is  one  thing 
that  may  be  confounded  with  it,  namely,  ossification  of  the  insertion  of  a  tendon 
or  muscle.     The  adductor  longus  muscle  is  the  one  most  commonly  affected. 

Malignant  Tumours  are  endosteal  and  periosteal  sarcoma.  Central  sarcoma 
in  its  early  stages  so  closely  resembles  chronic  osteitis  and  periostitis  that  it 
may  be  impossible  to  come  to  a  correct  conclusion  without  the  aid  of  a  skiagram. 
With  this  help  the  difficulty  vanishes,  for  a  myeloid  tumour  is  seen  clearl}'  as 
a  well-defined  tumour  causing  enlargement  of  the  bone  (compare  Figs.  197,  198, 

199,  pp.  75 5>  756). 

Periosteal  sarcoma  causes  a  general  enlargement  of  the  whole  of  the  lower  end 
of  the  femur  or  upper  end  of  the  tibia  {Fig.  196,  p.  754),  not  swelling  in  the 
popliteal  space  only.  It  is  mentioned  here  because  of  its  occasional  confusion 
with  periostitis  with  popliteal  necrosis. 

Periostitis. — Popliteal  necrosis  with  abscess  formation  may  give  rise  to  a 
big  swelling.  The  signs  of  inflammation  will  usually  be  well  marked  and  accom- 
panied by  constitutional  symptoms  and  leucocytosis.  Chronic  periostitis,  or 
chronic  abscess  of  the  bone,  or  central  necrosis,  may  be  extremely  difficult  to 
distinguish  from  a  periosteal  sarcoma.  A  skiagram  should  be  taken,  and  if 
necessary  an  incision  is  to  be  made  down  to  the  tumour,  and  a  piece  removed 
for  histological  examination.      (See  Swelling  on  a  Bone.) 

Separation  of  the  Epiphysis. — In  the  somewhat  rare  accident  of  separation 
of  the  lower  epiphysis  of  the  femur,  the  lower  fragment  becomes  displaced 
backwards,  forms  a  prominence  in  the  popliteal  space,  and  presses  on  the 
vessels,  sometimes  to  a  dangerous  extent.  George  E.  Gask. 

SWELLING,  PULSATILE. — When  a  tumour  can  be  felt  pulsating,  the  first 
point  to  decide,  if  possible,  is  whether  the  pulsation  is  expansile  or  whether  it  is 
merely  transmitted  by  a  non-expansile  tumour  which  is  in  direct  contact  with 
large  pulsating  vessels.  The  distinction  is  sometimes  obvious,  especially  when 
the  tumour  has  developed  in  a  place  where  there  are  no  particularly  large  blood- 
vessels to  transmit  pulsation,  for  instance  in  the  foot,  or  in  direct  connection  with 
a  long  bone  at  some  spot  not  immediatelyadjacent  to  the  main  artery  of  the  limb. 
The  chief  difficulty  arises  when  the  mass  is  either  in  the  root  of  the  neck  or  in  the 
abdomen  and,  to  a  less  extent,  when  it  is  in  the  axilla,  the  inner  aspect  of  the 
upper  arm,  in  front  of  the  elbow,  in  the  groin,  or  in  the  pophteal  space.  Care- 
ful palpation  is  probably  the  best  means  of  determining  whether  there  is 
actual  expansile  pulsation  or  not ;  in  the  case  of  the  abdomen  it  is  important 
to  make  the  examination  with  the  patient,  not  only  upon  his  back,  but  also  in 
the  knee-elbow  posture,  for  sometimes  a  tumour  which  is  in  contact  with  the 
aorta  in  the  dorsal  position  falls  away  from  it  and  ceases  to  transmit  pulsation 
in  the  ventral  posture. 

If  it  can  be  decided  definitely  that  the  tumour  is  itself  pulsating,  most 
probably  it  is  either  an  aneurysm  of  an  artery  or  else  a  very  vascular  growth, 
especially  osteosarcoma.  The  existence  of  egg-shell  crackling  with  pulsation 
in  a  tumour  would  be  highly  suggestive  of  osteosarcoma,  though  it  is 
conceivable  that  it  might  also  be  felt  over  an  aneurysm  that  had  extensively 


764  SWELLING,     PULSATILE 

eroded  the  adjacent  bones.  Aneurysm  will  be  the  probable  diagnosis  when  the 
markedly  pulsatile  swelling  occurs  directly  along  the  course  of  a  known  artery. 
Absence  of  pulsation  does  not,  however,  exclude  aneurysm,  for  the  latter  may  be 
either  too  deeply  situated  for  the  pulsation  to  be  felt,  or  else  the  sac  may  be 
partly  or  wholly  filled  by  organized  or  organizing  clot. 

Sometimes  there  may  be  doubt  as  to  whether  there  is  really  pulsation  or  not, 
when  digital  examination  alone  is  relied  upon  ;  in  such  cases,  direct  apphcation  of 
the  ear  to  the  part  in  such  a  way  that  the  pinna  is  in  uniform  contact  with  the 
patient's  skin,  will  sometimes  bring  pulsation  to  the  notice  very  clearly  when 
its  amount,  appreciable  to  the  membrana  tympani,  is  too  shght  for  the  hand 
to  detect ;   this  applies  particularly  to  deep-seated  intrathoracic  aneurysms. 

It  must  be  remembered,  on  the  other  hand,  that  marked  pulsation  may  suggest 
aneurysm  without  any  being  present,  particularly  at  the  root  of  the  neck  and  in 
the  abdomen  ;  a  normal  subclavian  artery  may  sometimes  seem  to  be  abnormal, 
particularly  if  it  is  pushed  forward  or  displaced  by  a  mass  below  or  behind  it,  for 
instance  an  accessory  cervical  rib.  Undue  pulsation  of  the  abdominal  aorta, 
especially  in  women,  is  also  to  be  remembered  as  a  possible  source  of  erroneous 
diagnosis  (see  Pulsation,  Undue  Abdominal  Aortic). 

It  should  also  be  remembered  that  normal  arteries  cause  very  violent 
pulsation  in  cases  of  marked  aortic  regurgitation,  and  in  severe  cases  of 
exophthalmic  goitre,  in  which  the  whole  neck,  including  the  enlarged  thyroid 
gland,  may  be  seen  to  be  pulsating  vigorously. 

We  need  not  here  discuss  in  detail  the  differential  diagnosis  between  one 
kind  of  aneurysm  and  another,  though  one  might  mention  in  particular  the 
so-called  cirsoid  aneurysm  of  the  scalp  [Plate  XIV),  which  is  rather  a  conglomera- 
tion of  many  abnormally  dilated  arteries  in  the  form  of  an  arterial  nsevus  than  a 
true  aneurysm.     Its  position  on  the  scalp  will  at  once  suggest  the  diagnosis. 

A  pulsatile  orbital  tumour  will  generally  be  due  either  to  an  osteosarcoma, 
or  to  an  arterio-venous  aneurysmal  communication  between  the  internal  carotid 
artery  or  its  ophthalmic  branch,  and  the  cavernous  sinus.  The  presence  of  a 
loud  bruit  would  be  in  favour  of  the  latter. 

It  is  important  not  to  mistake  for  the  ordinary  pulsatile  tumours  those  which 
may  move  sjmchronously  with  respiration,  such  for  instance  as  hernia  pul- 
monalis,  hernia  cerebri,  and  certain  congenital  abnormalities  of  the  brain  and 
spinal  cord,  such  as  meningomyelocele  {Fig.  75,  p.  254). 

It  is  unhkely  that  a  pulsatile  liver  will  be  mistaken  for  any  other  kind  of 
pulsatile  tumour.  The  cases  in  which  it  occurs  are  those  of  chronic  failure  of 
cardiac  compensation,  generally  mitral  stenosis  with  oedema  of  the  legs,  lividity, 
orthopnoea,  and  perhaps  ascites,  which  have  generally  been  present  for  some 
time  before  the  nutmeg  liver  becomes  obviously  pulsating. 

Rarely,  the  cardiac  pulsations  may  be  transmitted  direct  to  fluid  contained 
in  a  pleural  cavity,  so  that  the  bulging  intercostal  spaces  may  pulsate 
synchronously  with  the  radial  artery  and  simulate  some  more  serious  pulsatile 
tumour.  The  history  and  the  physical  signs,  including  displacement  of  the 
heart  towards  the  opposite  side,  will  generally  indicate  the  correct  diagnosis, 
though  there  may  be  some  trepidation  on  the  part  of  the  operator  who  decides 
to  insert  the  exploring  needle  into  the  pulsating  swelling.  Herbert  French. 

SWELLING,  SCROTAL — It  is  first  essential  to  prove  that  the  swelling  is 
really  limited  to  the  scrotal  region,  and  this  is  best  done  by  grasping  the  root 
of  the  scrotum  between  the  fingers  and  thumb,  and  thus  ascertaining  if  the 
swelling  does  or  does  not  extend  into  the  inguinal  region  along  the  cord.  Failure 
to  take  this  obvious  precaution  has  led  to  the  tapping  of  a  hernia  with  disastrous 
results.     True  scrotal  swellings   may  arise  in   any  of  the  following   tissues  : — 


PLATE     XIV. 


CIRSOID       ANEURYSM 


X 


Rep7-odticed  by  perjiiission  from  a  zvaier-coloii7-  painting  in  the  Gordon  Museum, 
Guy's    Hospital. 


INDEX     OF     DIAGNOSIS 


SWELLING,     SCROTAL  765 

(i)  Skin;  (2)  The  various  connective-tissue  coverings  of  the  testicle;  (3)  Tunica 
vaginahs  ;  {4)  Testicle;  (5)  Epididymis;  (6)  The  lower  end  of  the  spermatic 
cord  ;   (7)  The  urethra  ;  (8)  The  bones  of  the  pubic  arch. 

1.  The  nature  of  swellings  affecting  the  Skin  is  usually  obvious.  The  only 
common  ones  are  :  Boils,  soft  sores  and  chancre,  sebaceous  cysts,  warts  and 
epithelioma.  The  latter  soon  ulcerates,  commonly  occurs  in  sweeps,  and  the 
groin  glands  soon  become  enlarged. 

2.  Swellings  of  the  various  Connective-tissue  Coverings  are  very  rare,  but 
occasionallv  a  fibrosarcoma  may  occur.  These  swellings  are  movable  upon  the 
testicle.  The  symmetrical  enlargement  called  elephantiasis  scroti,  due  to  the 
Filavia  sanguinis  hominis,  is  limited  to  the  tropics. 

3.  The  Tunica  Vaginalis  may  become  distended  with  fluid,  thus  forming  the 
ordinary  vaginal  hydrocele.  Except  in  late  cases,  this  is  translucent,  and  is  thus 
distinguished  from  a  hsematocele  of  the  same  cavity.  It  should  not  be  forgotten 
that  a  hydrocele  with  thick  walls  may  fail  to  give  translucency.  When  proved 
to  be  translucent,  it  has  to  be  distinguished  from  encysted  hydrocele  of  the 
epididymis  and  encysted  hydrocele  of  the  cord.  Vaginal  hydrocele  occupies 
the  lower  part  of  the  scrotum  and  envelops  the  testicle,  which  cannot  be  felt  as 
a  separate  object.  Encysted  hydrocele  of  the  epididymis  is  placed  behind  and 
above  the  testicle,  from  which  it  is  distinct,  although  attached  at  the  upper  and 
posterior  part.  Moreover,  this  variety  of  hydrocele  never  attains  a  large  size, 
rarely  getting  larger  than  a  tangerine  orange.  It  is  not  tightly  distended,  but 
is  usually  flabby,  and  it  contains  a  characteristic  milky  fluid  in  which  chole- 
sterin  crystals  {Fig.  94,  p.  281)  are  present.  Encysted  hydrocele  of  the  cord  is 
placed  above  the  testicle,  which  can  be  felt  as  a  separate  object.  It  rarely  attains 
a  large  size,  and  is  often  elliptical  in  shape,  extending  upwards  along  the  cord. 
All  the  hydroceles  fluctuate.  To  test  for  this  it  is  necessary  to  fix  the  swelling 
against  some  hard  object.  Bleeding  may  occur  into  any  of  them  as  a  result  of 
injury  or  constitutional  disease.  It  is  almost  impossible  to  distinguish  between 
an  opaque  hydrocele  and  a  haematocele  without  tapping  the  swelling.  In 
syphilitic  disease,  with  irregular  adhesion  between  the  parietal  and  the  visceral 
walls,  a  loculated  hydrocele  may  occur. 

4.  Swellings  of  the  Body  of  the  Testicle  may  be  inflammatory  or  neoplastic. 
Acute  inflammatory  swellings  rarely  attain  a  large  size,  and  they  are  usually 
associated  with  enlargement  of  the  epididymis,  and  occur  as  a  part  of  acute 
epididymo-orchitis  due  to  urethritis  of  some  kind,  or  to  mumps  or  as  a  post- 
typhoidal  phenomenon.  Chronic  inflammatory  swelHngs  give  rise  to  more 
difficulty.  They  are  usually  either  tuberculous  or  syphilitic,  or  else  due  to  chronic 
torsion.  In  the  former  disease,  swelling  of  the  epididjrmis  is  practically  always 
primary  and  more  advanced  ;  but  in  infants  the  body  of  the  testis  becomes 
involved  at  a  very  early  stage.  The  enlarged  epididymis  can  be  felt  enveloping 
the  posterior  border,  and  the  upper  and  lower  poles  of  the  testicle.  There  is 
often  a  little  hydrocele  which  may  obscure  the  shape  of  the  testicle.  If  there 
is  adhesion,  with  perhaps  an  abscess  or  a  sinus  at  the  posterior  and  lower  part 
of  the  scrotum,  it  is  characteristic  of  suppurative  disease  of  the  epididymis, 
usually  of  a  tuberculous  nature.  Moreover,  in  tuberculous  disease,  the  vas  is 
thickened,  usually  in  a  nodular  manner.  It  is  important  to  examine  aU  the 
palpable  part  of  the  vas,  for  sometimes  the  nodules  are  hmited  to  the  inguinal 
region.  Von  Pirquet's  tuberculin  reaction  is  a  valuable  aid  if  its  limitations  are 
remembered.  In  striking  contrast  Avith  this,  syphilitic  enlargement  of  the 
testicle  leaves  the  epididymis  unaffected,  and  is  limited  to  the  testicle,  which 
enlarges  unevenly,  often  affecting  the  tunica  albuginea  and  the  tunica  vaginalis 
in  a  nodular  manner.  The  syphilitic  testicle  rarely  attains  three  times  the 
natural  size.      It  is  curiouslj'  devoid  of  pain.     The  testicular  sensation  is  often 


766  SWELLING,     SCROTAL 

lost,  and  there  is  little  or  no  thickening  of  the  cord.  Its  anterior  surface  is 
■uneven  and  Tn.a.y  become  adherent  to  the  coverings,  which  may  later  ulcerate, 
and  ultimately  give  rise  to  a  hernia  testis  on  the  front  of  the  swelling.  This 
contrasts  with  the  postero-infero-lateral  position  of  tuberculous  sinus  or  hernia 
testis.  Chronic  torsion  of  the  testis  is  generally  the  result  of  a  blow,  or  of  an 
injury  in  the  saddle  ;  the  symptoms  may  be  obscure  until  the  testicle  begins 
to  swell.  Operation  is  generally  resorted  to  with  the  idea  that  the  condition  is 
tuberculous  or  malignant,  and  even  then  the  diagnosis  may  be  in  doubt  until 
microscopical  examination   of  the   organ  has  been   made. 

It  is  often  very  difficult  to  distinguish  syphilitic  enlargement  of  the  testicle 
from  that  due  to  growth  ;  but  a  course  of  large  doses  of  antisj^philitic  remedies 
and  the  Wassermann  reaction  may  settle  the  matter.  Malignant  new  growth 
nearly  always  grows  steadily,  and  being  entirely  within  the  tunica  albuginea  it 
maintains  the  shape  and  smooth  surface  of  the  testicle  until  it  reaches  a  size 
much  larger  than  that  of  a  syphilitic  testicle.  Moreover,  it  causes  much  more 
pain,  and  usually  some  thickening  of  the  cord^  with  later  enlargement  of  the 
glands  in  the  loin.  In  some  cases  the  diagnosis  betw-een  sj^philitic  testicle, 
growth^  and  haematocele  may  be  so  difficult  and  so  irrgently  necessary  as  to 
demand  an  exploration. 

Malignant  grow^ths  of  the  testicle  can  be  divided  into  four  varieties.  :  [a] 
Carcinoma  ;   (b)   Sarcoma  ;    (c)   Embrj^oma  ;   (d)   Endothelioma. 

Carcinoma  is  far  more  common  than  sarcoma,  although  the  contrary  has 
been  beheved  for  many  years,  owing  to  the  fact  that  many  carcinomatous 
growths  with  small  alveoli  have  been  ^v^ongly  labelled  sarcoma.  The  average 
age  of  patients  with  carcinoma  testis  is  43,  and  of  those  with  sarcoma  testis,  34. 
The  average  duration  of  carcinoma  before  operation  is  1+  years  ;  of  sarcoma, 
II  months.  Sarcoma  advances  much  more  rapidly  and  kills  earlier  than 
carcinoma.  The  former  disseminates  through  the  veins,  whereas  the  latter 
travels  along  the  lymphatics  and  infects  the  lumbar  glands.  Embryoma  is, 
according  to  Nicholson,  "  the  commonest  new  growth  of  the  testicle,  but  it  is 
often  overlooked."  It  can  be  shown  to  contain  structures  derived  from  all 
the  three  blastodermic  layers  of  the  embryo.  The  average  age  at  the  time  of 
operation  is  29,  the  average  known  duration  before  operation  is  5^-  years. 
"  Although  not  necessarily  malignant,  it  ma^^  produce  metastases  composed  of 
all  the  tissues  of  the  primary  growth,  or  one  tissue  may  become  actively  malignant, 
in  which  case  the  deposits  will  be  formed  of  that  tissue  alone."  It  may  spread 
along  the  lymphatics  or  disseminate  through  the  veins. 

5.  The  Epididymis  may  become  enlarged  as  the  result  of  {a)  Inflammation  ; 
{h)  New  growth  ;    (c)  Cystic  degeneration. 

a.  Inflammatory  swellings  are  characterized  by  being  elongated  in  a  vertical 
direction  ;  by  their  relation  to  the  testicle,  which  they  overlap  at  its  posterior 
border,  and  its  upper  and  lower  poles  ;  and  lastlj^,  by  being  flattened  from  side 
to  side,  so  that  the  antero-posterior  diameter  is  greatly  increased.  Inflam- 
matory swellings  may  be  : — (i)  Gonorrhoeal  ;  (ii)  Septic,  secondary  to  some 
other  form  of  urethritis  ;    (iii)  Tuberculous. 

i.  The  gonorrhoeal  varietv  is  distinguished  by  its  acuteness,  great  tenderness,  the 
surrounding  oedema,  and  the  bacteriological  examination  of  the  urethral  discharge. 
Its  onset  is  usually  between  the  second  and  tenth  week.  Occasionally  a  subacute 
form  develops  later,  at  any  time  during  the  course  of  gleet.  This  is  very  difficult 
to  distinguish  from  the  tuberculous  variety.  Most  cases  of  tuberculous  epididy- 
mitis end  in  suppuration,  but  the  gonorrhoeal  variety  very  rarely  breaks  down. 

ii.  The  inflammation  of  the  epididymis  following  other  varieties  of  urethritis 
(such  as  ulceration  near  a  stricture  or  due  to  impacted  calculus,  instrumenta- 
tion, or  prostatectomy),  is  often   sufficiently  indicated  by  the  history  if  care  be 


SWELLING,     SCROTAL  767 

taken  to  go  into  this  thoroughly.  The  sweUing  following  prostatectomy  is  apt 
to  suppurate.  Some  of  these  can  be  mistaken  very  easily  for  tuberculous 
disease. 

iii.  Tuberculous  epididymitis,  as  a  rule,  is  far  more  insidious  and  painless 
in  its  onset  than  other  forms  of  epididymitis  ;  but  it  should  not  be  forgotten 
that  early  subacute  or  even  acute  attacks  of  inflammation  may  accompany  this 
disease,  and  that  these  are  often  the  means  of  drawing  the  patient's  attention 
for  the  first  time  to  a  disease  which  has  been  going  on  insidiously  for  some 
months.  It  has  frequently  been  said  that  tuberculous  nodules  are  limited  to 
the  globus  major,  and  that  those  left  after  gonorrhoeal  urethritis  are  confined 
to  the  globus  minor.  It  is  more  true  to  say  that  the  latter  are  limited  to 
the  globus  minor,  whereas  tuberculous  disease  may  attack  any  part  of  the 
epididymis.  Wherever  the  tuberculous  disease  starts,  the  inflammatory  pro- 
ducts soon  spread  through  the  thin  fibrous  capsule  of  the  epididymis,  and  then 
gravitate  towards  the  postero-infero-lateral  corner  of  the  scrotum,  where 
adhesion  occurs,  followed  later  by  an  abscess  and  a  sinus.  In  the  diagnosis 
of  tuberculous  from  other  forms  of  epididymitis,  the  general  state  of  health, 
and  especially  the  presence  or  absence  of  other  tuberculous  lesions^  are  of  great 
importance.  Nodular  thickening  of  the  vas  deferens  and  of  the  vesiculae 
seminales  and  prostate  are  also  valuable  signs  when  the  disease  is  well 
advanced.  It  should  be  remembered  that  the  disease  travels  upwards  along  the 
vas,  so  that  in  its  early  and  hopeful  stages  the  upper  part  of  the  vas  and 
vesiculae  seminales  are  not  enlarged. 

b.  Primary  new  growth  of  the  epididymis  is  excessively  rare,  so  that  it  need 
not  give  rise  to  much  concern  in  diagnosis  ;  it  will  generally  be  regarded  as 
tubercle  until  after  operation  and  microscopical  examination  of  part  of  the 
tissue  excised.  ^^^^-^ 

c.  Cystic  disease  of  the  epididymis  may  occur  in  the  form  of  :  (i)  Solitary 
cysts  (vide  supra)  ;  (ii)  Multiple  cysts.  The  latter  condition  rarely  occurs  except 
in  men  past  middle  age,  and  is  analogous  to  cystic  degeneration  of  the  breast. 
The  condition  is  almost  painless  and  harmless.     These  swellings  are  translucent. 

6.  Swellings  of  the  Lower  End  of  the  Cord. — The  most  important  swelling 
of  the  lower  part  of  the  spermatic  cord  is  varicocele.  It  is  apt  to  be  mistaken 
for  omental  hernia,  but  the  mistake  should  never  be  made,  because  of  the 
characteristic  feel  of  the  varicocele,  and  the  reappearance  of  the  swelling  after 
it  has  been  completely  reduced  and  the  finger  is  firmly  pressed  on  the  external 
abdominal  ring. 

7.  Urethral  Conditions. — Occasionally  a  peri-urethral  abscess  may  form  a 
swelling  in  the  scrotum.  Tenderness,  oedema,  and  fluctuation,  together  with 
the  history  and  evidence  of  urethral  disease,  serve  to  make  the  diagnosis  clear. 
Primary  epithelioma  of  the,  urethra  is  distinguished  by  the  great  pain  and  urethral 
obstruction  that  it  engenders. 

8.  Diseases  of  the  Pubic  Bones. — Inflammatory  products  may  travel  into  the 
scrotum  from  disease  of  the  bones  of  the  pubic  arch,  especially  from  the 
neighbourhood  of  the  symphysis  pubis.  Acute  necrosis  of  these  bones  is 
sufficiently  indicated  by  the  grave  constitutional  symptoms  which  always 
accompany  it.  Caries  gives  rise  to  more  difficulty.  The  writer  has  known 
a  case  of  tuberculous  caries  of  the  lower  part  of  the  symphysis  pubis  in  which 
the  inflammatory  products  gravitated  backwards  and  to  the  left,  so  as  to  form 
a  large  firm  swelling  in  the  left  half  of  the  scrotum,  where  it  gave  rise  to  much 
difficulty  in  diagnosis,  and  was  thought  to  be  either  a  sarcoma  arising  from 
the  fibrous  covering  of  the  crus  penis,  or  possibly  a  gummatous  mass  in  the 
same  situation.  Sufficient  attention  was  not  paid  to  the  fact  that  the  man 
had  chronic  phthisis.  R.  p.  Rowlands 


768 


SWELLING,      VULVAL 


SWELLING,  VULVAL. — The  differential  diagnosis  of  vulval  tumours  must 
necessarily  include  not  only  true  swellings  of  the  vulva,  but  also  swellings  which 
appear  at  the  vulva  as  a  result  of  the  displacement  of  other  structures,  such  as 
occur  in  prolapse  and  cystocele,  and  in  addition  lesions  hke  kraurosis  vulvee, 
which  are  not  strictly  swellings  at  all.  The  lesions  of  the  vulva  may  be  tabulated 
under  various  headings,  as  set  forth  in  the  following  scheme  : — 

Inflammatory    Lesions. — 


Simple  vulvitis 

Gonorrhoeal  vulvitis 

Soft  chancre 

Papillomata 

Syphilis  : 

Hunterian  chancre 
Condyloma 
Tertiarj?  lesions 
Cystic  Swellings. — 

Hydrocele  of  the  canal  of 
Nuck 

Sebaceous  cysts 
Blood  Cysts. — 

Varicocele 

Rupture  of  a  varicose  vein 
New  Growths. — 

Caruncle 

Fibroma 

Lipoma 

Angeioma 

Neuroma 

Fibromyoma  of  round  liga- 
ment 
Hernise. — 

Inguinal 

Posterior  labial 
Displacement. — 

Prolapse  of  urethral  mucous 
membrane 

Prolapse  of  uterus 
Unclassified. — Simple  anasarca. 


Tuberculosis 
Furunculosis 
Leukoplakic  vulvitis 
Kraurosis  vulvse 
Pseudo-elephantiasis 
Esthiomene. 


Mucous  cysts 
Implantation  cysts 
Dermoid  cysts. 

Traumatic  haematoma. 


Endothelioma 
Squamous-celled  carcinoma 

(epithelioma) 
Columnar-celled  carcinoma 
Sarcomata  of  various  kinds. 


Perineal. 


Cystocele 

Inversion  of  the  uterus 

Fibromyoma  of  the  vaginal  wall. 


Certain  of  these  lesions  stand  out  pre-eminently  as  presenting  difficulties 
in  diagnosis.  The  general  principles  by  which  solid  tumours  are  distinguished 
from  cystic,  inflammatory  swellings  from  new  growths,  or  new  growths 
from  herniae,  need  not  be  insisted  upon  here.  Perhaps  the  commonest 
difficulty  which  arises  in  practice  is  the  diagnosis  of  gonorrhoeal  vulvitis  from 
simple  vulvitis,  and  also  between  the  gonorrhceal  soft  chancre  and  the  syphilitic 
condyloma,  the  latter  differentiation  being  of  much  more  practical  importance 
than  the  former  as  far  as  the  patient  is  concerned.  In  the  acute  stage  of  a 
gonorrhoeal  vulvitis  there  is  a  chance  of  recognizing  the  gonococcus  in  the  dis- 
charge, if  films  made  from  it  are  suitably  stained.  Practically,  all  acute  forms 
of  vulvitis  appear  alike  cUnically,  so  that  the  recognition  of  the  gonococcus 
becomes  a  matter  of  importance.  The  way  to  recognize  the  gonococcus  is  to 
make  films  of  the  discharge  on  a  shde,  dry,  fix  by  passing  them  through  a 
flame ;   then  stain  by  Gram's  method,  and  counterstain  by  neutral  red.     The 


SWELLING,      VULVAL  769 


gonococcus  is  not  stained  by  Gram's  method,  but  is  coloured  red  by  the 
counter-stain.  The  gonococci  are  seen  in  pairs  inside  leucocytes  of  the  poly- 
morphonuclear t^'pe  {Plate  XII,  Fig.  R).  In  chronic  gonorrhoeal  infections 
with  vulval  swelhng,  as  a  rule  the  organism  cannot  be  found  in  the  general 
vulval  discharge,  but  might  be  found  in  the  urethra  or  in  the  cervix. 
A  gonorrhoeal  infection  may  be  suspected  if  the  patient  gives  a  history  of  an 
acute  onset,  accompanied  by  scalding  on  micturition,  and  when  there  is  redness 
of  the  orifices  of  Bartholin's  glands,  and  much  redness  and  swelling  of  the 
carunculae  m\Ttiformes.  Papillomata  or  warts  of  the  vulva  may  occur  also 
in  chronic  gonorrhoeal  infections,  and  there  is  no  evidence  of  a  reliable  nature 
to  show  that  they  occur  in  any  other  kind  of  infection. 

The  soft  chancre  of  gonorrhoea  may  be  mistaken  for  the  condyloma  of  secondary 
syphilis,  but  as  a  rule  this  difficulty  should  not  occur.  The  soft  chancre  is  a 
typical  punched-out  ulcer  with  a  somewhat  red  base  and  clean  edges,  discharg- 
ing pus.  The  condyloma,  on  the  other  hand,  is  a  raised,  fiat-topped  excrescence, 
with  sodden,  epithelium-covered  surface.  Soft  chancres  are  not  very  numerous, 
as  a  rule,  and  are  generally  limited  to  the  vulva.  Condylomata  are  numerous, 
and  may  occur  all  over  the  labia,  around  the  anus,  and  even  on  the  skin  of  the 
thighs  and  gluteal  region.  Condylomata  are  from  the  start,  or  will  be  very  soon 
after  their  origin,  accompanied  by  a  sore  throat  and  a  t^'pical  papular  skin  rash. 
In  other  words,  condylomata  are  always  accompanied  by  typical  secondary' 
syphilitic  lesions.  Soft  chancres  clear  up  with  antiseptics  ;  condylomata  persist 
for  long  periods,  but  clear  up  in  two  or  three  weeks  as  a  rule  under  mercurial 
treatment.  It  must  not  be  forgotten  that  soft  sores  and  condylomata  may 
occur  together  in  the  same  patient,  in  wfiich  case  the  diagnosis  may  be  still 
more  difficult. 

Another  practical  differentiation  which  gives  rise  to  anxiety  is  that  between 
the  Hunterian  chancre  or  primary  syphilitic  sore,  and  squamous  epithelioma  of 
the  vulva.  This  is  a  question  which  is  of  vital  importance  to  the  patient,  if 
valuable  time  is  not  to  be  lost  in  the  treatment  of  a  malignant  epithelioma. 
The  two  lesions  look  much  alike  at  first ;  they  form  raised  hard  indurated  masses 
in  the  skin,  which  may  ulcerate  quickly  as  a  result  of  necrosis  of  the  superficial 
portions.  Both  give  rise  to  a  thin  watery  discharge,  and  to  enlarged  glands  in 
the  inguinal  region  which  do  not  suppurate  at  first,  but  may  do  so  later  in  the 
case  of  an  epithelioma.  It  must  not  be  forgotten  that  a  primary  chancre  is  very 
seldom  seen  in  women,  whilst  squamous  epithelioma  is  relatively  common. 
Of  course  the  chancre  will  be  followed  in  due  course  by  secondary  lesions,  but 
it  is  not  safe  to  wait  for  these  to  appear  in  a  doubtful  case.  The  only  reasonable 
way  to  deal  with  such  a  case  is  to  excise  the  doubtful  swelling  at  once  and  submit 
it  to  microscope  examination  by  an  expert.  A  squamous  epithelioma  is  easily 
detected  in  this  manner  in  quite  early  stages,  and  does  not  in  the  least  resemble 
a  syphilitic  lesion  microscopically.  The  Spirochcsta  pallida  may  be  recognized 
in  scrapings  of  a  hard  chancre  fixed  and  stained  by  Giemsa's  or  Levaditi's 
methods  [Plate  XII,  Fig.  J).  In  sections,  too,  the  spirochaete  may  be  demon- 
strated, but  it  must  be  remembered  that  for  this  purpose  the  excised  growth 
must  be  fixed  in  5  per  cent  formahn  solution.  Wassermann's  serum  test  may 
assist  the  diagnosis. 

Tertiary  syphilitic  lesions  are  by  no  means  common  on  the  vulva.  When 
they  do  occur,  they  give  rise  to  spreading  ulceration,  with  great  destruction  of 
tissue,  and  scarring  in  the  older  healed  portions.  Here,  the  only  hkely  lesions  to 
be  mistaken  are  some  forms  of  epithehoma,  and  tubercle.  Obviously,  in  such 
conditions  the  only  rehable  method  of  diagnosis  is  to  be  found  in  excision  of 
parts  of  the  lesion  and  microscopic  examination  of  sections  made  from  them. 
The  disease  known  as  esthiomene  is  probably  a  tertiary  svphilitic  affection. 
D  49 


770  SWELLING,      VULVAL 


Pseudo-elephantiasis  of  the  vulva  is  usually  a  syphilitic  affection  of  the  labia 
minora,  giving  rise  to  great  enlargement,  with  a  rough  and  thickened  appearance 
of  the  skin.  It  could  only  be  mistaken  for  real  elephantiasis  due  to  lymphatic 
obstruction  by  the  Filaria  sanguinis  hominis  [Plate  XII,  Fig..  F),  a  disease 
which  is  practically  never  seen  in  this  country. 

Unilateral  oedema  of  a  labium  minus  is  a  fairly  common  condition,  and  is 
usually  associated  with  an  infected  wound  or  with  a  primary  syphilitic  chancre. 
Bilateral  oedema  is  almost  always  associated  with  general  anasarca,  the  result  of 
renal  disease,  cardiac  disease,  or  pressure  upon  pelvic  veins.  It  is  not  likely  to 
be  mistaken  for  any  other  disease. 

Leukoplakic  vulvitis  and  kraurosis  vulvce  have  certainly  been  confounded  with 
one  another  clinically,  and  also  in  the  published  descriptions  of  the  lesions.  In 
the  former,  the  labia  majora  and  minora  and  the  prepuce  of  the  clitoris  are 
affected,  whilst  the  vestibule  always  escapes.  In  the  latter,  the  lesion  affects  the 
vestibule,  the  orifice  of  the  vagina,  and  the  labia  minora.  There  is  much  greater 
contraction  of  the  vaginal  orifice  in  kraurosis.  Leukoplakia  often  precedes  a 
squamous  epithelioma  ;  kraurosis  is  said  not  to  do  so.  Leukoplakia  occurs  at 
all  ages,  whilst  kraurosis  is  a  disease  of  post-menstrual  life.  Leukoplakic  vulvitis 
appears  as  a  white  sodden  hardening  of  the  skin,  with  flattening  and  shrinkage 
of  the  labia.  Kraurosis  at  first  looks  red  and  swollen,  but  later  takes  a  yellowish 
tinge.  Leukoplakia  causes  intense  itching  ;  kraurosis  gives  rise  to  great  pain 
and  tenderness,  with  a  very  severe  form  of  dyspareunia. 

Apart  from  a  cyst  developing  in  Bartholin's  gland  or  duct,  cystic  swellings  of 
the  vulva  are  not  common.  A  Bartholinian  cyst  is  recognized  by  its  position  on 
one  side  of  the  vaginal  entrance,  distending  the  posterior  part  of  the  conjoined 
labia,  and  also  within  the  hymeneal  ring.  As  a  rule,  the  orifice  of  the  gland  can 
be  seen  on  the  inner  side  of  the  cyst.  The  contents  of  this  form  of  cyst  may 
be  glairy  mucoid  fluid,  or  may  be  purulent  if  the  infecting  agent  is  virulent.  In 
practice,  a  Bartholin  cyst  is  not  likely  to  be  mistaken  for  anything  else  ;  but  it 
is  wise  to  remember  that  the  posterior  labial  hernia  occurs  in  the  same  situation, 
and  that  new  growths  of  the  vulva  may  occur  there  as  elsewhere.  Bartholin 
cysts  are  always  the  result  of  infection,  and  as  a  rule  a  history  of  vulval  inflamma- 
tion can  be  obtained. 

Varicocele  of  the  vulva  occurs  practically  only  in  connection  with  pregnancy, 
and  is  unmistakable.  It  has  the  same  "  bag  of  worms  "  feel  as  a  varicocele  in  a 
man,  and  as  the  veins  are  close  to  the  skin,  a  bluish  colour  is  always  to  be  noted. 
It  is  attended  by  much  aching  pain,  especially  on  standing.  The  veins  are 
degenerate,  and  liable  to  rupture  as  a  result  of  labour  or  traumatism. 

Hcsmatoma  of  the  vulva  is  recognized  as  a  blue  or  violet-coloured  swelling 
covered  by  tense  shiny  skin,  and  often  spreading  up  into  the  pelvis  by  the  side 
of  the  vagina.  The  history  alone  will  often  decide  the  nature  of  the  swelling, 
but  the  appearance  is  quite  typical  as  a  rule.  Hsematoma  of  the  vulva  may 
occur  apart  from  pregnancy,  and  then  is  always  traumatic. 

Urethral  caruncle  and  prolapse  of  the  urethral  mucous  membrane  may  be  mistaken 
for  one  another.  The  former,  however,  is  always  a  pedunculated  or  sessile 
new  formation,  invariably  springing  from  the  posterior  wall  of  the  urethral 
orifice.  It  bleeds  readily,  is  often,  but  not  always,  exquisitely  painful,  and  is 
usually  the  result  of  infection.  Prolapse,  on  the  other  hand,  appears  as  a  raised 
projection  with  rounded  margins,  and  with  the  urethral  canal  in  the  centre  as 
a  dimple.  The  prolapsed  portion  may  not  necessarily  include  the  whole  ring  of 
the  mucous  membrane.  It  may  give  rise  to  pain,  and  being  always  more  or 
less  strangulated,  it  is  prone  to  bleed,  much  in  the  same  way  as  a  caruncle.  It 
occurs  as  a  result  of  some  straining  effort,  or  may  accompany  pelvic  floor  pro- 
lapse ;    it  is  not  the  result  of  infection. 


TACHYCARDIA  771 


The  differential  diagnosis  of  the  new  growths  of  the  vulva  presents  no  points 
of  difference  from  their  diagnosis  in  other  parts  of  the  body.  The  only  common 
benign  tumour  is  the  pedunculated  fibroma,  or  molluscum  fibrosum,  whilst  squamous 
carcinoma  {epithelioma)  is  the  only  malignant  growth  which  occurs  at  all 
frequenth'. 

If  the  general  characters  of  a  hernia  are  borne  in  mind,  there  should  be  no  risk 
of  overlooking  or  mistaking  any  of  the  varieties  which  occur  in  the  vulva.  The 
resonance  on  percussion  if  the  hernia  contains  bow^el^  the  reducibility  of  the 
contents,  and  the  protrusion  through  a  pre-existing  opening,  will  usually  suffice 
to  distinguish  herniae  from  other  swelhngs.  An  obstructed  or  strangulated 
hernia  is  not  so  easy  to  recognize,  but  the  accompanying  acute  symptoms 
and  the  previous  history,  usually  suffice  to  make  the  case  clear. 

Hydrocele  of  the  canal  of  Nuck,  an  uncommon  condition,  maj^  be  mistaken  for 
an  inguinal  hernia  ;  but  as  a  rule  it  is  irreducible,  definitely  fluctuating  and 
circumscribed,  and  has  no  obvious  neck  running  into  the  inguinal  canal.  When 
the  canal  of  Xuck  has  a  patent  peritoneal  communication,  the  swelling  disappears 
as  the  patient  hes  down,  but  it  is  not  reducible  in  the  characteristic  manner  of 
a  hernia.     Such  a  condition  is  very  rare. 

The  displacements  included  in  the  list  above  are  all  dealt  with  under  the 
heading  of  Prolapse  of  the  Uterus.  Thos.  G.  Stevens. 

SYNCOPE.— (See  Coma.) 

TACHE  CEREBRALE.  — rac/?e  cerebrate  is  the  term  used  to  denote  that 
condition  in  which,  after  the  finger  has  been  drawn  with  moderate  firmness  across 
the  patient's  skin,  the  fine  along  which  it  has  passed  becomes  of  a  bright  red 
colour  from  dilatation  of  the  superficial  arterioles  and  capillaries,  as  a  result  of 
the  mechanical  stimulation  ;  the  phenomenon  develops  within  thirty  seconds  or 
a  minute  of  the  finger  stroke,  and  the  red  mark  remains  evident  for  two  or  three 
minutes,  or  more.  If  letters  or  figures  are  marked  out  onthe  skin  in  this  way, 
they  appear  as  though  they  had  been  written  in  red,  so  that  the  condition 
has  also  been  termed  dermatographia.  It  was  at  one  time  thought  to  be  a 
characteristic  symptom  of  tuberculous  meningitis,  but  not  only  is  it  sometimes 
absent  in  cases  of  the  latter,  but  it  is  also  present  in  a  very  large  number  of 
other  different  conditions,  and  sometimes  in  perfectly  healthy  people.  All  forms 
of  meningitis  may  give  rise  to  it,  so  that  it  is  not  even  a  means  of  distinguishing 
one  t^-pe  from  another.  It  is  seen  in  an  extreme  degree  in  cases  of  urticaria, 
particularly  the  factitious  variety  in  which  numerous  wheals  may  develop  as  the 
result  of  hardly  more  than  ordinary  touching  of  the  skin.  A  similar  condition 
has  sometimes  been  observed  in  the  later  stages  of  severe  febrile  illnesses  in 
general.  Herbert  Frendi. 

TACHYCARDIA,  or  abnormal  rapidity  of  the  heart's  action  might,  strictly 
speaking,  be  held  to  include  every  condition  under  which  the  pulse-rate  is  faster 
than  the  normal ;  but  by  common  consent  it  is  restricted  for  clinical  purposes 
to  cases  in  which  there  is  no  pyrexia.  Nearly  all  fevers  produce  undue  rapidity 
of  the  heart's  action,  though  some,  such  as  typhoid  fever,  tuberculous  meningitis, 
cerebral  abscess,  yellow  fever,  and  influenza  do  so  to  a  much  less  extent  than 
others.  The  rapid  heart-action  of  fevers,  however,  does  not  generally  come 
into  one's  mind  when  one  uses  the  term  tachycardia  ;  indeed  the  latter  is  chiefly 
employed  for  conditions  in  which  it  is  rapid  without  there  being  anj-thing  which 
at  first  sight  would  seem  to  be  a  sufficient  cause.  Probably  the  best  example 
of  this  condition  is  to  be  found  in  cases  of  pronounced  Graves'  disease  or 
exophthalmic  goitre. 


TACHYCARDIA 


The  following  is  a  list  including  this  and  some  other  causes  of  tachycardia  : — 
Graves'  disease  or  exophthalmic  goitre 
Parox^'smal  tachycardia 
Nervousness  and  excitement 

Exertion,  especially  when  the  patient  is  out  of  training  or  ansemic 
Tobacco  heart 
JNIitral  stenosis 
Pneumogastric  irritation  bj^  : — 

Caseous  glands  Thoracic  aneurysm 

Mediastinal  fibrosis  Thoracic  new  growth 

Pneumogastric  "  neuritis  "  after  : — 

Diphtheria,  influenza^  and  other  microbial  infections 
Drugs  : 

Digitahs  !         Belladonna. 

Alcohol 

The  four  classical  s^miptoms  of  Graves'  disease  are  :  A  staring  appearance  of 
the  eyes,  generally  spoken  of  as  exophthalmos,  though  there  need  be  no  actual 
protrusion  of  the  eye-balls  ;  moderate  and  almost  sj^mmetrical  enlargement 
of  the  thyroid  gland  ;  a  pulse-rate  between  120  and  180  per  minute — usuallj'' 
about  140  when  the  attack  is  moderately  severe  ;  and  extreme  nervousness, 
vdth.  fine  tremor  of  the  outstretched  fingers.  When  all  these  symptoms  are 
present  at  the  same  time,  there  can  be  no  doubt  as  to  the  diagnosis,  but  very 
often  some  of  them  are  absent,  and  it  is  possible  for  tachj^cardia  to  be  the  only 
s^^nptorQ  of  the  disease  ;  indeed,  in  a  patient,  particularlj-  a  woman  between 
tAvent\-  and  ioxty  3'ears  of  age,  a  persistent  pulse-rate  of  over  120  would  arouse 
serious  suspicion  that  the  case  was  really  one  of  Graves'  disease,  even  if  the 
other  three  classical  signs  were  absent. 

Paroxysmal  tachycardia  should  be  distinguished  at  once  from  Graves'  disease 
in  which  tachycardia  alone  has  developed,  by  the  fact  that  the  tachycardia 
is  not  persistent,  but  occurs  in  paroxysms  ;  the  patient  is  more  often  a  woraan 
than  a  man,  and  may  have  long  periods  of  perfect  health  ;  almost  suddenlj^, 
the  result  sometimes  of  a  fright  or  shock,  sometimes  without  apparent  cause 
at  all,  there  AviU  be  a  sense  of  something  the  matter  in  the  precordial  region, 
amounting  as  a  rule  to  little  more  than  a  flutteriag  or  palpitation,  together 
with  a  feeling  of  faintness  and  lack  of  strength,  and  perhaps  of  numbness  or 
of  pins-and-needles  in  the  extremities,  and  when  examined  the  patient  may 
present  no  other  abnormalit\"  than  a  pulse-rate  of  perhaps  160  or  even  200  to 
the  minute.  The  attack  may  last  a  few  minutes,  or  an  hour  or  Irwo,  rarely  for 
days  or  weeks  ;  it  will  cease  as  suddenlj^  as  it  began,  and  a  similar  attack  is 
almost  certain  to  recur  after  a  longer  or  shorter  interval — the  main  symptom 
of  the  complaint  being  summarized  by  the  title  "  paroxj^smal  tachj^cardia." 

The  very  rapid  heart  action  that  maj^  be  produced  hy  nervousness,  or 
excitement,  or  by  some  ordinary  exertion  such  as  coming  rather  rapidly  upstairs 
when  one  is  out  of  training,  or  when  the  patient  is  suffering  from  some  degree 
of  ancemia,  or  during  convalescence  after  an  illness,  or  after  the  over-use  of 
tobacco,  is  a  familiar  phenomenon  ;  the  tachycardia  rapidly  disappears  when 
the  patient  rests,  and  the  diagnosis  is  not  as  a  rule  difficult.  If  ordinary 
resting  for  a  while  does  not  cause  the  rate  of  the  heart-beat  to  return  nearly  or 
quite  to  normal,  there  ma}'  be  doubt  as  to  the  diagnosis,  unless  the  patient  can 
be  re-examined  on  another  occasion  ;  if  there  is  persistent  tachj'cardia  a 
suspicion  of  incipient  Graves'   disease  will  be  aroused. 

Mitral  stenosis  is  of  all  the  valvular  lesions  of  the  heart  the  most  liable  to 
lead  to  rapidity  of  the  heart's  action ;  but  it  seldom  happens  that  the  pulse-beat 


TACHYCARDIA  773 


is  fast  until  there  has  been  other  evidence  of  failure  of  the  cardiac  compensation. 
The  diagnosis  will  generally  be  obvious  from  the  history  of  acute  rheumatism 
or  chorea,  the  typical  facies  and  malar  flush,  and  the  cardiac  bruits. 

It  is  exceedingly  difficult  to  be  certain  of  a  diagnosis  of  irritation  of  a  pneumo- 
gastric  nerve  within  the  thorax  unless  the  existence  of  mediastinal  new  growth, 
aneurysm  or  fibrosis  is  already  known  on  account  of  the  abnormal  physical  signs, 
the  visible  tumour,  or  the  varicose  distention  of  the  superficial  thoracic  veins  ; 
it  an  intrathoracic  abnormality  is  known  to  exist,  and  tachycardia  becomes  a 
prominent  feature  of  the  case,  it  will  probably  be  due  either  to  mechanical 
interference  with  the  heart's  action  or  to  similar  interference  with  one  or  other 
vagus  nerve.  Caseous  glands,  irritating  the  pneumogastric  nerve,  are  still  more 
difficult  to  be  sure  of ;  but  occasionally  one  ventures  upon  this  diagnosis  when 
a  child,  who  has  been  fed  on  untested  or  unsterilized  cow's  milk,  develops 
obscure  ill-health  associated  with  persistent  tachycardia.  Such  diagnosis 
would  be  still  further  suggested  if  there  were  at  the  same  time  enlarged 
glands  in  both  sides  of  the  neck,  if  there  were  pyrexia  without  any  obvious 
explanation  of  it,  or  if  there  were  any  evidence  of  obstruction  to  the  right 
bronchus,  for  the  right  bronchial  gland  is  enlarged  far  more  often  than 
is  the  left. 

Diphtheria,  influenza,  and  possibly  other  microbial  infections,  are  occasionally 
followed  by  very  marked  and  persistent  tachycardia  during  convalescence, 
or  even  for  weeks,  months,  or  years  afterwards.  After  diphtheria,  the  condition 
is  generally  fatal.  Influenza  is  always  a  dangerous  diagnosis  because  it  is  so 
difficult  to  establish,  but  in  certain  cases  in  which  the  original  diagnosis  has 
been  influenza.,  tachycardia  to  the  extent  of  200  heart-beats  per  minute  may  be 
present  for  months  without  the  patient  suffering  from  any  severe  cardiac 
symptoms,  and  the  condition  ultimately  terminates  in  recovery  with  a  return 
of  the  heart-beat  to  the  normal  rate.  Precisely  what  is  the  nature  of  these 
cases  it  is  impossible  to  say,  but  it  has  been  thought  by  some  that  the  symptom 
is  due  to  inflammatory  changes  in  the  pneumogastric  nerve,  produced  by  what- 
ever one  means  by  the  toxins  of  the  disease.  Whether  this  be  so  or  not,  the 
fact  that  persistent  tachycardia  may  arise  out  of  febrile  illnesses  should  be  borne 
in  mind. 

There  are  certain  drugs  which  cause  the  heart's  beat  to  be  very  rapid,  the 
best  known  perhaps  being  digitalis,  belladonna,  thyroid  extract,  and  alcohol. 
Certain  patients  suffering  from  cardiac  symptoms  seem  unable  to  bear  digitalis, 
the  heart  being  driven  into  the  condition  spoken  of  as  delirium  cordis  ;  the 
diagnosis  is  not  difficult  when  the  drug  that  is  being  given  is  known.  When 
alcohol  is  the  cause  of  the  tachycardia,  the  fact  is  generally  obvious.  Belladonna 
in  small  doses  slows  the  heart,  but  there  are  great  variations  in  the  degree  to 
which  different  patients  tolerate  this  remedy,  even  pharmacoeopial  doses 
sometimes  producing  toxic  symptoms  of  which  tachycardia  is  one.  Widely 
dilated  pupils  and  dryness  of  the  tongue  will  help  to  point  to  the  diagnosis  in 
cases  in  which  the  belladonna  is  taken  otherwise  than  medicinally.  Tachycardia 
is  the  chief  symptom  by  which  one  recognizes  that  a  patient  for  whom  thyroid 
extract  has  been  prescribed  is  receiving  too  large  a  dose.  Herbert  French. 

TALIPES.— (See   Club-Foot.) 

TASTE,  ABNORMALITIES  OF — Abnormalities  of  taste  may  be  grouped 
under  three  main  headings,  namely  :  (i)  Impairment  or  loss  of  ordinary 
taste  sensations  ;  (2)  Perverted  taste  sensations  ;  (3)  Sensations  of  a  foul  taste 
in  the  mouth.  The  following  are  the  conditions  that  may  produce  each 
of  these  : — 


774 


TASTE,     ABNORMALITIES     OF 


Impairment  or  Loss  of  Taste  {Ageustia)  : 
(a).  Due  to  nerve  lesions  : 

Paresis  or  paralysis  of  the  lingual  branch  of  the  fifth  nerve 

Paralysis  of  the  facial  nerve,  including  the  chorda  tympani 

Glosso-pharyngeal   nerve    paralysis 

Bulbar  paralysis 

Cerebral  tumour,  especially  of     the  uncinate  gyrus 

Hysteria. 

[b) .  Due  to  affections  either  of  the  mouth  or  nose  : 

A  common  cold  i  Other  varieties  of  nasal  obstruc- 


Hay  fever  (coryza  e  feno) 
Atrophic  rhinitis 
Hypertrophic  rhinitis 
Nasal  polypus 
Adenoids 


tion 
Bromism 
lodism 
Mercurial  and  other  varieties  of 

stomatitis  (p.   88). 

{c).   Febrile  conditions,  especially  when  associated  with  coating  of  the  tongue. 
[d).  After  destruction  of  the  nerve  endings  in  the  tongue  by  corrosives  taken 
accidentally  or  with  suicidal  intent. 

Perverted  Taste  Sensations   [Parageustia)  : 


Pregnancy 

Hysteria  I 

Foul  Taste  in  the  Mouth  [Cacogeustia) 
(a).  Local  conditions  of  mouth  or  nose  : 

Caries  of  the  teeth 

Retention    of    food   particles 
between  healthy  teeth 

Furred  tongue  from  any  cause 

Excessive  smoking 

Mouth  breathing  at  night 

Gumboil 

Septic    stumps    under  tooth- 
plate 

[b) .   Severe  fevers  associated  with  dryness  of  the  mouth  and  coating  of  the 
tongue  especially  in  : — 
Pneumonia 
Typhoid  fever  | 

(c).  Septic  lung  conditions,  especially- 


Epileptic  aura 
Insanity. 


Epithelioma    of    the    tongue  or 

mouth 
Stomatitis      from      any      cause 

(p.  88) 
Septic  infection  of  the  antrum 

of  Highmore,   or  one  of  the 

other  sinuses  communicating 

with  the  nose. 


Peritonitis 
Septicaemia,  etc. 


Phthisis,  with  secondary  in- 
fection of  cavities 

Bronchiectasis 

Bronchiolectasis 

Foetid  bronchitis 

Empyema  ruptured  into  the 
lung 

{d).   Certain  drugs  or  poisons,  especiall}'- 
Mercury 
Copper 
Arsenic 
Lead 
Iodides 
Paraldehyde 


Gangrene  of  the  lung 

Liver  abscess  ruptured  into  the 
lung 

Subdiaphragmatic  abscess  rup- 
tured into  the  lung. 


Asafoetida 
Creosote 
Guaiacol 
Valerian 
Cod-liver  oil 
Castor  oil. 


TENDERNESS     IN     THE     CHEST  775 

From  a  diagnostic  point  of  view,  impairment  of  taste  sensations  is  of  little 
consequence  except  when  it  occurs  in  people  who  are  otherwise  apparently 
well.  When  it  is  the  chief  symptom  in  the  case,  however,  it  may  be  of  con- 
siderable importance.  When  there  is  simple  impairment  of  taste,  and  it  can  be 
determined  that  this  is  unilateral,  the  symptom  is  almost  certainly  due  to  a 
lesion  involving  either  some  portion  of  the  third  branch  of  the  fifth  nerve,  the 
chorda  tympani,  or  the  glosso-pharjmgeal  nerve.  It  is  not  often  difficult  to 
distinguish  between  these  three,  for  if  the  chorda  tympani  is  involved  it  is 
almost  certain  that  the  facial  nerve  will  also  be  affected  upon  the  same  side,  and 
this  will  be  evidenced  by  paresis  or  paralysis  of  the  face  of  the  infranuclear  type 
(p.  536)  ;  there  may  be  excessive  watery  secretions  from  the  submaxillary  gland 
upon  the  same  side  ;  the  commonest  condition  to  cause  these  symptoms  is 
disease  of  the  middle  ear  extending  to  the  Fallopian  canal.  If  it  is  found  that 
sensations  of  taste  are  impaired  only  in  the  posterior  third  of  the  tongue  upon  one 
side,  the  lesion  probably  affects  the  glosso-pharyngeal  nerve,  and  it  is  very  possible 
that  there  may  be  paresis  of  the  same  side  of  the  palate  or  partial  paralysis  of  the 
pharjmx  at  the  same  time.  WTien  the  Hngual  branch  of  the  fifth  is  involved,  the 
impairment  of  sensation  is  in  the  anterior  two-thirds  of  the  tongue  on  the  same 
side.  The  lesion  may  be  a  tumour  or  an  injury  affecting  the  lingual  nerve  in  the 
mouth  ;  or  it  may  be  part  of  a  more  general  affection  of  the  fifth  nerve  of  that  side, 
with  corresponding  interference  with  cutaneous  sensibiUty  of  more  or  less  of  the 
skin  of  the  face,  according  to  the  extent  to  which  the  different  branches  of  the 
fifth  nerve  are  involved  ;  if  the  motor  root  is  affected,  the  fact  can  be  ascertained 
by  feeUng  the  masseter  and  temporal  muscles,  which,  when  the  patient  clenches 
his  teeth,  do  not  harden  so  much  on  the  affected  as  on  the  sound  side. 

WTien  sensation  on  both  sides  of  the  tongue  is  affected,  it  is  possible 
that  the  lesions  described  above  may  be  bilateral ;  but  it  is  much  more 
likely  that  the  defect  is  then  not  primarily  nervous,  unless  it  is  due  to 
bulbar  paralysis,  the  progressive  labio-giosso-pharyngo-laryngeal  weakness  of 
which  is  pathognomonic. 

When  the  cause  of  impaired  sensation  is  in  the  nose,  as  in  the  case  of  coryza, 
rhinitis,  polypi,  or  adenoids,  it  will  be  found  that  sonie  substances  can  be 
tasted  easily  and  others  not  at  all ;  this  depends  upon  the  fact  that  taste  consists 
of  two  parts,  flavour  and  savour  ;  savour  depends  upon  sensation  transmitted 
by  the  olfactory  nerves — the  so-called  taste  of  roast  beef  for  instance  ;  savours 
will  be  defective  when  the  nose  is  the  cause  of  abnormal  taste-sensations ;  while 
flavours  such  as  the  taste  of  sugar,  gentian,  or  salt,  which  are  transmitted  by 
the  gustatory  nerves  of  the  tongue,  will  still  be  fuUy  preserved. 

The  differential  diagnosis  of  the  other  conditions  enumerated  in  the  above 
list  need  not  be  detailed,  for  the  conclusion  come  to  will  depend  upon  the  result 
of  careful  inquiry  into  the  history,  investigation  of  the  abnormal  physical  signs, 
and  the  other  symptoms  in  the  case.  One  would  only  emphazise  the  possibility 
of  caries,  or  decomposing  food  existing  between  teeth  that  superficially  look 
quite  sound,  and  the  fact  that  septic  infection  of  the  accessory  sinuses  of  the 
nose  may  be  long  overlooked,  though  in  each  case  abnormal  taste  sensations 
ma\-  be  prominent.  Herbert  French. 

TENDERNESS  IN  THE  CHEST  implies  that  pain  is  felt  when  some  part 
of  the  chest  wall  is  touched  or  pressed.  Such  tenderness  is  quite  a  common 
symptom,  and  mav  occur  in  a  great  variety  of  diseases.  In  some  instances  the 
pain  felt  is  a  direct  pain,  due  to  stimulation  of  sensory  nerves  actually  in  the 
diseased  area.  In  others — perhaps  the  majority — the  pain  is  a  referred  pain  (the 
"  somatic  pain  "  of  Ross),  felt  in  the  skin  and  subcutaneous  tissues  that  are 
tender,  but  due  to  a  visceral  lesion  remote  from  the  tender  area. 


776 


TENDERNESS     IN     THE     CHEST 


Causes    of    Tenderness    in    the    Chest. 

These  may  best  be  considered  and  classified  in  accordance  with  the  situation 
of  the  lesion  to  which  it  is  due. 

I.   Lesions  of  the  Chest  Wall  :    the  pain  is  for  the  most  part  direct  : — 


Inflammations  of  the  skin 
and  underlying  tissue 

Intercostal  myositis 

Myalgia 

Pleurodynia 

Affections  of  the  ribs  and 
sternum 

Blood  diseases 


Intercostal  neuritis 

Injury  of  the  intercostal  nerves 

Intercostal  neuralgia 

Hysteria 

Herpes  zoster 

Pleurisy 

Mediastinal  disease 

Pericarditis. 


Abdominal  Viscera  :    the  pain  is  usually  a  referred 


Stomach  and  cesophagus 
Liver. 


2.  Lesions  of  Thoracic  and 

pain ;  felt  in  lesions  of  the — 
Lungs 

Heart  and  aorta 
Diapliragm 

I.  Lesions  of  the  Chest  Wall. — Tenderness  in  the  chest  is  probably  the  chief 
complaint  in  superficial  inflammatory  lesions  of  the  chest  wall,  such  as  bruises, 
burns,  cuts,  and  superficial  infections  of  all  sorts,  the  diagnosis  of  which  will 
probably  leap  to  the  eye,  and  need  not  be  discussed  further. 

Pain  will  be  the  chief  coraplaint  in  intercostal  myositis,  often  vaguely  called 
rheumatic,  that  occurs  after  chill  or  strain  of  the  intercostal  muscles  ;  but 
the  affected  muscles  will  also  be  tender  on  pressure,  the  tenderness  being  in 
the  deeper  structures,  not  in  the  superficial  tissues.  The  condition  is  also 
known  as  intercostal  myalgia  or  pleurodynia  ;  it  has  to  be  distinguished  from 
pleurisy  by  the  absence  of  friction-sounds  on  auscultation  ;  and  from  disease 
of,  or  pressure  on,  the  intercostal  nerves.  No  doubt  the  tenderness  is  due  to 
irritation  of  the  sensory  fibres  in  the  intercostal  muscles.  Similar,  but  more 
transient,  pain  and  tenderness  may  be  met  with  in  the  stitch  to  which  the 
untrained  athlete  is  prone  ;  here  the  tenderness  is  very  possibly  due  to  trauma 
of  fibres  of  an  intercostal  muscle. 

Tenderness  in  the  chest  may  result  from  disease  or  injury  of  the  ribs  or  sternum, 
when  it  will  be  localized  to  the  injured  spot  ;  fracture,  inflammation,  or  new 
growth  may  be  the  immediate  cause.  If  fracture  is  present,  a  history  of  a  fall 
or  injury  should  be  obtainable  ;  and  crepitus  between  the  fragments  on  move- 
ment, or  deformity,  should  be  made  out.  Sternal  or  costal  ostitis,  or  periostitis, 
may  follow  injury  ;  or  occur  in  the  course  of  such  diseases  as  enteric  fever, 
tuberculosis,  pyaemia  or  septicopj^semia  ;  the  local  signs  of  inflammation  (pain, 
redness,  heat,  swelling)  and  the  general  condition  of  the  patient,  should  make 
the  diagnosis  fairly  simple.  Tenderness  in  the  chest  due  to  new  growth  in  the 
ribs  or  sternum — such  as  hydatid,  sarcoma,  secondary  deposits  from  carcinoma 
of  the  thyroid  gland,  prostate,  or  ovary — is  a  rarity  that  need  only  be  men- 
tioned. Tenderness  of  the  ribs  and  sternum,  as  well  as  of  the  long  bones  of 
the  limbs,  is  not  uncommon  in  certain  blood  diseases,  in  which  hyperplasia  of 
the  red  marrow,  or  excessive  accumulation  of  white  cells  in  it,  may  occur  :  such 
as  pernicious  anaemia  or  leukaemia.  The  diagnosis  here  must  be  made  on  the 
results  of  examination  of  the  blood.  In  all  these  instances  the  tenderness  is 
deep,  and  due  to  irritation  of  the  sensory  nerves  of  the  periosteum  or  bone  ;  the 
pain  felt  on  pressure  is  a  direct  pain. 

Tenderness  at  certain  points  of,  or  all  along,  the  course  of  an  intercostal  nerze 
is  common  in  various  affections  of  these  structures.     The  particularly  tender 


TENDERNESS     IN     THE     CHEST  777 

spots  are  three  in  number,  and  correspond  to  the  points  at  which  the  posterior 
primary,  the  lateral  cutaneous,  and  the  anterior  cutaneous  branches  are  given  off, 
near  the  spinal  column,  the  mid-axillary  line,  and  the  sternal  margin,  respect- 
ively. Such  tenderness  may  be  marked  in  intercostal  neuritis,  which  is  rare  ; 
in  intercostal  neuralgia,  which  is  often  diagnosed  when  some  more  serious  intra- 
thoracic disorder  is  really  present,  such  as  pneumonia  or  pleurisy  ;  and  in  cases 
of  pressure  on  an  intercostal  nerve,  such  as  may  be  set  up  by  abscess  about  the 
spinal  column,  aneurysm  of  the  descending  aorta,  or  new  growth  invading  the 
spinal  canal.  Whenever  a  patient  complains  of  severe  or  obstinate  pain  and 
tenderness  in  the  side,  careful  and  repeated  physical  examinations  should  be 
made  while  the  possibility  that  some  such  deep-seated  disease  may  be  present 
is  kept  in  view,  before  the  diagnosis  of  intercostal  neuralgia,  or  of  functional 
nervous  disease  (hysteria),  is  made.  In  exceptional  cases  of  hysteria,  zones  of 
tenderness  in  the  chest,  possibly,  too,  Charcot's  spasmogenic  zones,  may  be 
found. 

Pain  and  tenderness  along  an  intercostal  nerve  are  common  in  herpes  zoster, 
and  may  be  present  before,  during,  and  after  the  appearance  of  the  characteristic 
rash.  The  tenderness  often  has  the  three  spots  of  maximum  development  men- 
tioned above  ;  it  is  particularly  in  the  second  half  of  life  that  herpes  may  be 
followed  by  a  long  period  of  pain  and  tenderness  along  the  course  of  the  affected 
nerve.  Until  the  rash  has  appeared,  or  in  the  comparatively  infrequent  cases 
when  the  rash  leaves  no  scarring  behind  it,  the  diagnosis  of  herpes  may  be 
difficult  ;    the  rash,  once  seen,  can  hardly  be  mistaken. 

Tenderness  of  the  chest  is  a  common  complaint  in  pleurisy,  and  is  no  doubt 
due  to  inflammation  of  the  sensitive  nerve-endings  in  the  adjacent  periosteum 
and  the  tissues  of  the  intercostal  spaces  ;  the  pleura  itself  would  appear  to  be 
devoid  of  nerves  of  sensation.  The  physical  signs  of  pleurisy  should  suffice  to 
make  the  diagnosis  a  simple  matter  if  a  careful  physical  examination  be  made. 
The  tenderness  is  deep  as  a  rule,  and  not  exhibited  by  the  skin  and  loose  sub- 
cutaneous tissues. 

The  sternum  may  be  tender  in  the  rare  cases  of  mediastinal  inflammation  or 
tumour  that  are  met  with  from  time  to  time  ;  tenderness  and  direct  pain  may 
similarly  be  caused  by  the  pressure  of  aneurysms  on  the  internal  surface  of  the 
chest-wall.  The  diagnosis  in  these  cases  must  be  made  on  the  results  of  the 
physical  examination  of  the  patients,  and  will  not  be  detailed  here. 

Tenderness  with  pain  over  the  precordia  is  fairly  common  in  pericarditis, 
but  it  will  hardly  be  the  patient's  chief  complaint,  and  should  not  give  rise  to 
trouble  in  diagnosis.  It  may  be  so  extreme  as  to  preclude  percussion  or  a  satis- 
factory physical  examination.  Similar  pain  and  tenderness  have  also  been 
found  at  the  epigastrium  and  the  upper  costal  angles  in  these  cases  ;  due,  perhaps, 
to  involvement  of  the  diaphragm  in  the  inflammatory  process. 

2.  Lesions  of  the  Underlying  Viscera.  —  Tenderness  in  the  chest  is  very 
frequently  a  symptom  of  disease  in  the  underlying  viscera,  thoracic  or  abdominal, 
when  the  pains  to  which  it  gives  rise  are  in  most  cases  referred  pains.  The 
tenderness  is  therefore,  as  a  rule  superficial,  confined  to  the  skin  and  subjacent 
areolar  and  fatty  tissues  ;  if  these  can  be  drawn  aside,  pressure  can  be  made 
on  the  deeper  tissues  that  normally  underlie  the  tender  area  without  provoking 
pain.  Properly  speaking,  "  tenderness  in  the  chest  "  can  only  refer  to  tactile 
hypersesthesia,  or  the  eliciting  of  pain  on  pressure,  whether  light  or  heavy. 
Such  tactile  hypersesthesia,  or  the  production  of  unpleasant  sensations  or  pain 
by  the  very  lightest  touch,  is  common  in  neuralgia  and  in  neuroses,  or  in  cases 
of  referred  pain.  But  a  similar  hyperaesthesia  for  cold,  or  less  often  for  heat, 
sometimes  occurs  in  the  chest — in  tabetic  patients,  for  example  ;  this  may 
perhaps  be  regarded  as  a  special  form  of  "  tenderness."     In  the  same  way  hyper- 


778  TENDERNESS     IN     THE     CHEST 

aesthesia  for  pain,  or  hyperalgesia,  in  which  a  normally  painless  stimulus  or 
impression  becomes  transformed  into  an  acutely  painful  sensation,  is  to  be 
regarded  as  a  form  of  "  tenderness  "  in  the  chest.  Further,  perversions  of 
sensation  sometimes  occur  in  organic  nervous  diseases,  such  as  sjrringomyelia 
or  tabes.  Thus,  tenderness  may  be  elicited  by  the  continuous  application  of  a 
pressure  that  is  painless  if  applied  only  for  a  short  time  (summation  of  painful 
stimuli)  ;  or  the  pain  may  be  first  felt  some  little  time  after  the  application  of 
the  stimulus  to  the  tender  area  (retarded  sensation). 

Chest  tenderness  is  not  rare  in  cases  of  acute  or  chronic  disease  of  the  lungs, 
particularly  tuberculosis  ;  in  these,  it  is  hard  to  be  sure  that  one  is  not  deahng 
with  referred  pains  due  to  old  or  recent  pleurisy  or  pleural  adhesions.  The 
tenderness  may  be  either  superficial  or  deep  ;  sometimes  it  is  so  marked  as  to  be 
elicited  even  by  the  pressure  of  the  clothes.  It  is  generally  felt  most  about  the 
region  of  the  apices  of  the  lungs,  the  curve  of  the  shoulder,  or  the  scapula.  It  is 
often  a  very  chronic  trouble,  vanishing  during  periods  of  general  improvement, 
returning  again  when  the  patient's  health  is  low  or  the  pulmonary  lesion  is' 
progressing.  Similar  tenderness  is  often  met  with  in  acute  bronchitis, 
or  with  chronic  bronchitis  and  emphysema  ;  the  diagnosis  must  be  made  on 
general  lines.  It  must  be  remembered  that  identical  areas  of  referred  chest- 
tenderness  may  be  observed  in  disorders  of  such  various  organs  as  the  heart, 
lungs,  liver,  and  stomach ;  and  that  a  patient  may  be  long  treated  for 
"  rheumatism  "  of  the  shoulder,  for  example,  when  he  is  realh^  suffering  from 
one  or  more  of  such  widely  different  disorders  as  tuberculosis,  gall-stones, 
gastritis,  or  coronary  sclerosis. 

Direct  tenderness  about  the  precordia  is  sometimes  seen  in  heaj't  disease  ; 
as  a  rule,  however,  the  tenderness  is  due  to  hyperaesthesia  of  referred  origin.  It 
is  most  marked  in  angina  pectoris,  and  often  persists  after  the  anginal  pains 
have  passed  off.  Both  the  pain  and  the  tenderness  are  felt  within  the  area  of 
distribution  of  the  first  to  the  eighth  dorsal  nerve  roots  ;  the  roots  usually 
receiving  the  first  and  most  intense  impressions  are  the  second  dorsal.  The 
left  ventricle,  the  commonest  primarjr  seat  of  pain,  is  in  relation  with  the  second 
to  the  fifth  dorsal  nerve-roots  ;  the  auricle  with  the  fifth  to  the  eighth  ;  the 
ascending  aorta  with  the  third  and  foiurth  cervical  and  the  first  to  the  third 
dorsal.  It  is  commonly  stated  that  the  pain  and  tenderness  in  morbus  cordis 
are  of  two  sorts,  direct  and  referred  ;  but  Mackenzie  argues  with  some  force  that 
they  are  in  reality  always  referred — a  viscero-sensor}^  reflex.  The  nerve- 
connections  stated  above  explain  the  extensive  radiation  and  wide  distribu- 
tion that  may  be  exhibited  by  the  tenderness  and  pain  in  the  superficial 
tissues  that  may  form  such  prominent  symptoms  of  heart  disease  ;  for  the 
chest,  neck,  and  arm  may  all  be  affected.  The  tenderness  of  angina  pectoris 
commonly  occupies  the  same  areas  as  the  pain,  takes  the  form  of  a  soreness, 
smarting,  or  of  hyperalgesia  to  touch,  and  may  last  for  days  after  the  pain 
is  over.  In  some  cases,  touching  or  stimulating  the  hyper-algesic  area  on 
the  chest,  arm,  or  neck,  may  refiexly  induce  an  anginal  attack  —  even  the 
pressure  of  a  stethoscope  applied  for  auscultation  may  suffice — which  is  a 
strong  argument  for  regarding  the  tenderness  as  a  viscero-sensory  reflex  or  a 
referred  tenderness.  Such  anginal  attacks  and  tenderness  are  commonest  in 
coronary  sclerosis,  aortic  aneurysm,  aortic  reflux,  and  acute  aortitis  ;  they  may 
also  be  seen  in  any  form  of  heart-disease  in  which  hypertrophy  and  dilatation 
have  taken  place,  and  the  heart  has  to  do  more  work  than  it  can  manage.  In 
well-marked  cases,  the  cardiac  origin  of  areas  of  tenderness  in  the  chest  should 
not  be  difficult  to  diagnose,  owing  to  their  association  with  severe  anginal  pains 
on  the  one  hand,  and  with  the  fact  that  the  pain  is  brought  on  by  exertions  or 
emotions  that  increase  the  work  of  the  heart.    Identical  areas  of  tenderness  may 


TENDERNESS     IN     THE     EPIGASTRIUM  779 

be  found  in  pleurisy  or  chronic  pulmonax}'  tuberculosis  ;  but  here  the  pain  will 
be  connected  with  respiration  or  coughing  in  an  unmistakable  manner,  and 
there  will  be  the  history  and  signs  of  pulmonary  rather  than  of  cardiac  disease. 
Identical  areas  of  chest  tenderness  may  be  found  in  diseases  of  the  stomach, 
in  the  areas  of  distribution  of  at  any  rate  the  fourth  and  fifth  dorsal  nerves  ;  the 
diagnosis  here  will  turn  on  the  history  of  gastro-intestinal  disorder,  and  on  the 
radiation  of  the  pain  and  the  discovery  of  tenderness  in  the  epigastrium. 

Tenderness  in  the  chest  may  be  seen  in  injuries  or  inflammations  of  the 
diaphragm,  the  lower  costo-chondral  margin  being  affected.  The  diaphragm  is 
innervated  bv  the  phrenic  nerves  mainly,  and  so  is  connected  with  the  third, 
fourth,  and  fifth  cervical  nerve-roots  ;  accordingly,  referred  diaphragmatic  pain 
and  tenderness  ma}-  also  be  felt  in  the  top  of  the  shoulder,  an  area  innervated 
by  the  fourth  cervical  nerve.  In  most  cases,  these  areas  of  tenderness  w^ill  be 
due  to  diaphragmatic  pleurisy. 

Diseases  of  the  stomach,  particularly  gastric  ulcer  and  flatulent  dyspepsia, 
mav  give  rise  to  pain  and  tenderness  in  the  chest  that  may  be  verj^  hard  to 
distinguish  from  those  due  to  cardiac  disease.  As  a  rule,  the  history  of  gastric 
disturbances  should  be  of  great  assistance  in  coming  to  a  correct  diagnosis  ; 
although  it  must  be  remembered  that  flatulence  and  temporary  gastric  upsets 
are  not  infrequenth^  seen  in  true  angina  pectoris.  Further,  the  pain  and 
tenderness  due  to  diseases  of  the  stomach  are  mainly  abdominal,  are  in  the 
epigastric  and  left  hypochondriac  regions,  and  in  the  lower  half  of  the  back  of 
the  chest ;  whereas  in  cardiac  disorders  they  are  characteristically  situated 
higher  up  in  the  chest  and  back. 

It  is  possible  that  disease  or  painful  stimulation  (as  bj^  hot  drinks)  of  the 
oesophagus  may  produce  an  area  of  referred  tenderness  in  the  chest,  over  the 
lower  third  of  the  sternum  and  in  the  middle  line,  in  correspondence  with  the 
pain  that  is  felt  here  in  these  conditions. 

Tenderness  in  the  right  side  of  the  chest  near  the  costal  margin  is  not  rare  in 
diseases  of  the  liver  and  gall-bladder,  corresponding  to  the  cutaneous  distribution 
of  the  seventh,  eighth,  and  ninth  dorsal  nerves  ;  for  the  most  part,  however, 
the  pain  and  tenderness  are  in  the  epigastrium  and  the  right  h}-pochondrium. 
In  addition,  the  right  phrenic  nerve  (third  to  fifth  cervical)  sends  twigs  to  the 
liver  and  gall-bladder,  so  that  tenderness  and  pain  may  also  be  felt  in  the  right 
shoulder,  just  as  they  may  be  in  disorders  of  the  diaphragm.  It  is  particularly 
in  cases  of  gall-stone  or  biliary  colic  that  these  areas  of  tenderness  are  likely  to 
be  found.  In  patients  with  hepatic  abscess,  the  spread  of  inflammation  to  the 
chest  wall  may  give  rise  to  direct  pain  and  tenderness  in  the  chest,  with  the 
development  of  characteristic  local  and  general  s\Tnptoms  and  signs  ;  the  dia- 
gnosis here  will  have  to  be  made  from  such  things  as  axillary  abscess,  empyema 
making  its  wav  through  the  chest-wall,  or  abscess  arising  in  the  chest-waU. 

A.  J.  J  ex-Blake. 

TENDERNESS  IN  THE  EPIGASTRIUM.— In  thin  and  nervous  subjects, 
particularly  women,  tenderness  may  be  elicited  on  deep  pressure  in  the  epigas- 
trium over  the  coeliac  plexus.  In  the  absence  of  other  sjTnptoms  this  is  of  no 
significance.  The  upper  bellies  of  the  recti  may  be  tender  after  strain,  e.g.  from 
hard  exercise,  vomiting,  coughing,  or  retching.  The  fact  that  the  tenderness 
is  in  the  abdominal  wall  maj-  be  proved  by  pinching  it  up  laterally  when  the 
muscles  are  relaxed.  Epigastric  tenderness  may  also  be  due  to  dHatation  of 
the  right  ventricle,  to  pleurisj-,  or  to  any  of  the  painful  conditions  of  the  liver, 
stomach,  or  pancreas,  the  differential  diagnosis  of  which  is  considered  under 
the  heading  of  Paix  ix  the  Epigastrium.  Robert  Hutchison. 

TENDERNESS  IN  THE  HYPOCHONDRIUM  (LEFT),— (See  Paix  ix  the 
Hypochoxdrium,  Left.) 


78o  TEXDERXESS     IX     THE    ILIAC     FOSSA 

TENDERNESS  IN  THE  HYPOCHONDRIUM  (RIGHT).— (See  Pain  in  the 
HvpocHOXDRirM,  Right.) 

TENDERNESS  IN  THE  ILIAC  FOSSA  (LEFT).— There  is  no  particular 
condition  to  be  recorded  in  which  tenderness  in  the  left  iliac  fossa  is  unaccom- 
panied by  either  pain  or  swelling.  (See  Pain  in  the  Iliac  Fossa,  Left  ;  and 
S%^'ELLiNG  IN  the  Iliac  Fossa,  Left.)  Georgc  E.  Gask. 

TENDERNESS  IN  THE  ILIAC  FOSSA  (RIGHT).  (See  also  Swelling  in 
the  Ill^c  Fossa,  Right.) 

If  a  patient  complains  only  of  tenderness  in  the  right  iUac  fossa,  if  there  are 
no  other  guiding  s^-mptoms  and  no  sweUing,  and  if  the  case  is  not  acute,  it  maj- 
be  supposed  that  there  is  some  slight  inflammation  of  the  ccecwm  or  vermiform 
appendix,  or  irritation  of  the  mucous  membrane  of  the  csecum  by  the  accumu- 
lation of  faeces.  It  is  not  uncommon,  in  ver^^  acute  abdominal  conditions 
ob^■iously  requiring  immediate  laparotomy,  to  find  that  tenderness  in  the  right 
ihac  fossa,  without  swelhng,  is  associated  with  signs  of  acute  general  peritonitis. 
There  are  three  chief  causes  for  this  : — 

1.  Acute  perforative  or  gangrenous  appendicitis. 

2.  Perforated  gastric  or  duodenal  ulcer. 

3.  A  ruptured  tubal  gestation. 

The  commonest  of  the  three  is  appendicitis. 

Acute  Appendicitis. — The  fact  that  the  pain  and  tenderness  started  and  are 
most  marked  in  the  right  ihac  fossa  points  to  the  diagnosis.  There  may  have 
been  a  previous  attack  in  which  the  s^miptoms  were  more  definitely  locahsed. 

Perforated  Gastric  or  Duodenal  Ulcer. — Usuall}^  the  tenderness  will  be  in  the 
hj^ogastrium,  but  there  are  cases  in  which  confusion  arises  because  the  tender- 
ness is  most  marked  in  the  right  ihac  fossa,  and  because  there  is  no  previous 
historj'  of  indigestion,  haematemesis,  melaena,  or  vomiting.  In  anj^  case  where 
grave  s^-mptoms  are  prominent,  an  exploratory  laparotomj^  is  not  to  be  delayed, 
and  it  is  onh'  a  question  of  whether  the  abdomen  is  to  be  opened  over  the  appendix 
region  or  over  the  stomach. 

Ruptured  Tubal  Gestation. — It  is  highlj-  desirable  that  a  diagnosis  of  this  com- 
plaint should  be  made  early.  There  will  generally  be  the  signs  of  internal 
haemorrhage — pallor,  fall  of  temperature,  rise  of  pulse-rate,  and  the  presence  of 
free  fluid  in  the  abdomen  ;  the  patient  is  usually  a  week  or  more  overdue  as 
to  a  menstrual  period,  and  the  acute  symptoms  come  on  sjmchronoush^  with  a 
loss  of  blood  per  vaginam  that  may  be  mistaken  for  the  onset  of  the  ordinary 
menses.  George  E.  Gask. 

TENDERNESS  IN  JOINTS.— (See  Joints,  Affections  of.) 

TENDERNESS  IN  THE  LIMBS.— (See  Pain  in  the  Limbs,  General  ;  and 
Sensation,  Some  Abnormalities  of.) 

TENDERNESS    IN   THE   SCALP  occurs  in  two  main  varieties  :— 
I.  Direct    Tenderness,  due  to  injurv  or  disease,  such  as — 
Bruising  or  infected  wounds 
Inflammation   or  suppuration  complicating    pediculosis,    ringworm, 

favus,  eczema,  pruritus,  acne,  etc. 
Herpes  and  dermatitis  herpetiformis,  er\-sipelas 
Lupus  er\-thematosus,  von  Recklinghausen's  disease 
Sclerodermia,  Brocq's  "  pseudopelade  " 
Diseases  of  the  skull — ^rickets,  syphilis,  tumour. 


TENDERNESS     IN     THE     SCALP 


7S1 


2.   Referred  Tenderness,  either  due  to  disease  elsewhere,  or  functional  : — 
Meningitis,    increased    intracranial    pressure,    intracranial    tumour, 

concussion  of  the  brain,  otitis  media. 
Neuralgia,  major  and  minor,  whether  primary  or  due  to  disease  of 

the  eves,  ears,  teeth,  or  viscera. 
Neurasthenia  and  hysteria. 
Fig.  200  exhibits  the  cutaneous  nerve-supply  of  the  scalp  and  face,  indicating 
the   areas  in  which  tenderness  and  pain  are  to  be  expected  when   disease  or 
disorder  of  the   various   nerves   is  present. 

I.  If  tenderness  in  the  scalp  is  due 
to  bruising  or  wounds,  it  should  not 
be  difficult  of  diagnosis  when  the  history 
has  been  obtained.  A  similar  tender- 
ness is  naturally  to  be  expected  when- 
ever inflammation  or  suppuration  occurs 
as  a  complication  or  later  stage  of  any 
of  the  numerous  skin  diseases  to  which 
the  scalp  is  liable,  such  as  pediculosis, 
ringworm — a  suppurating  ringworm  is 
known  as  kerion — seborrhceic  dermatitis, 
favus ;  the  itching  of  eczema  or  pruritus 
may  be  so  severe  as  to  lead  to  scratch- 
ing which  breaks  the  skin,  with  the 
result  that  impetigo  or  pus-infection 
ensues.  In  young  men  and  women  acne 
may  spread  back  to  the  scalp  from  the 
forehead,  face,  or  neck  ;  acne  decalvans 
is  a  mild  staphylococcal  infection  of  the 
hair-follicles    that    slowly  creeps   across 

the  scalp,  and  leaves  it  bald  by  destroying  the  hair -follicles.  Furunculosis  of 
the  scalp,  and  inflammation  of  a  sebaceous  cyst,  need  only  be  mentioned  in  this 
connection. 

In  herpes  ophthalmicus,  or  herpes  zoster  of  the  area  supplied  by  the  ophthalmic 
or  first  branch  of  the  trigeminal  or  fifth  cranial  nerve,  extreme  tenderness  over 
the  affected  area  may  be  noted  while  the  eruption  lasts  ;  and  after  it  has  dis- 
appeared, tenderness  and  itching  may  be  left  behind  for  many  months  or  years. 
Dermatitis  herpetiformis  is  a  somewhat  similar  grouped  vesicular  or  bullous 
eruption,  with  ringed  and  other  er^-thematous  lesions,  but  characterized  by  a 
much  more  extensive  distribution  than  herpes  zoster  ;  when  it  involves  the 
scalp  much  tenderness  may  ensue,  although  the  chief  complaint  will  be  of 
itching,  and  the  course  of  the  disorder  is  long  and  uncertain.  Erysipelas  is 
common  in  the  scalp,  and  should  be  diagnosed  readily.  Lupus  erythematosus 
of  the  scalp  may  cause  tenderness  while  progressing  actively,  when  it  may 
resemble  even  a  severe  persistent  er\-sipelas ;  as  a  rule  it  is  a  very  chronic,  slowly 
progressive  disorder,  commoner  in  females  than  in  males,  starting  between  the 
ages  of  twent^'-five  and  forty-five.  It  produces  smooth  and  depressed  areas 
of  complete  and  permanent  baldness,  reddened  by  abundant  injected  venules. 
In  von  Recklinghausen' s  disease,  subcutaneous  neurofibromas  are  found  all  over 
the  body,  in  association  with  freckling  and  pigmentation  ;  occurring  on 
the  scalp,  these  tumours  will  make  it  tender,  whereas  the  tumours  of  fibroma 
molluscum  {Fig.  201),  a  disorder  at  first  sight  resembling  von  Recklinghausen's 
disease,  are  not  sensitive  to  pressure.  Sclerodermia  of  the  scalp  may  occasion 
much  tenderness,  particularly  in  its  early  stages  ;  it  is  a  chronic  diffuse  infil- 
tration of  the  skin  that  ends  in  atrophy,  and  by  many  is  supposed  to  include 


fig'.  200. — The  cutaneous  nerve-supply  of  the 
scalp.  G  A,  Great  auricular  nerve  ;  G  O-  SO, 
and  Th.  O,  Great,  small,  and  third  occipital 
nerves  ;  V  i,  V  2.  V  3,  Ophthalmic,  superior 
maxillary,  and  inferior  maxillary  divisions  of 
the  trigeminal  (or  fifth  cranial)  nerve. 


782 


TEXDERXESS     IX     THE     SCALP 


the  "  pseudo pelade  "  of  Brocq,  an  atrophic  indurative  affection  of  the  scalp 
giving  rise  to  depressed  areas  of  absolute  and  permanent  baldness  that  adhere 
to  the  underlying  skull,  and  connected  by  Brocq  with  alopecia  areata. 

Tenderness  of  the  scalp  is  common  in  rickets,  and  is  the  main  cause  of 
the  head-rolling  and  restlessness  of  the  recumbent  ricketv'  chUd.  It  is  due 
to  hvperaemia  and  disordered  growth  of  the  cranial  bones  ;  and  can  often  be 
diagnosed  at  sight  by  the  thinness  of  the  hair  or  positive  baldness  of  the  occipital 
region  to  which  the  head-rolling  leads.  A  similar  tenderness  of  the  cranial 
bones  is  seen  in  congenital  syphilis,  and  is  caused  by  the  rarefying  (craniotabes) 
or  hyperplastic  (hot-cross-bun  skull)  osteitis  present.  In  adults  with  neglected 
syphilis  the  skull  may  be  tender  from  secondaiy  syphilitic  periostitis  or  tertiary 
gumma  ;  besides  the  tenderness,  pain  is  present,  and  is  characteristically  worse 
at  night.  Tumour  of  the  cranial  bones  may  give  rise  to  tenderness  of  the  over- 
lying scalp  or  periosteum  ;  in  adults  such  tumours  are  usually  secondary  to 
malignant  disease  of  the  breast,  thyroid  gland,  testis,  or  prostate.  In  children 
they  are  often  secondary  to  sarcoma  of  the  suprarenal  gland,  and  may  be  the 
first  clinical  evidence  that  anvthing  is  amiss. 


201. — MoUuscum  fibrosiim  in  a  comparatively  early  stage. 

F7-m>i  photog7-aph  lent  hy  Dr.  A.  Rcitdlc  Short. 


2.  Tenderness  in  the  scalp  may  be  due  to  organic  disease  that  is  not  in 
direct  connection  with  it.  In  meningitis,  whether  syphilitic,  tuberculous,  or  due 
to  pus-producing  microbes,  local  or  general  tenderness  of  the  scalp  maj-  be  a 
marked  feature  ;  and  the  same  is  true  in  cases  with  increased  intracranial  pressure 
due  to  any  cause  whatever.  The  chief  complaint,  however,  will  be  of  headache 
{q-v.).  In  intracranial  tumour  the  scalp  and  periosteum  are  sometimes  tender 
to  pressure  in  the  neighbourhood  of  the  growth  ;  the  associated  signs,  such  as 
vomiting  on  change  of  position,  slow  pulse,  optic  neuritis,  and  local  paresis  or 
paralysis,  should  aid  the  diagnosis.  Tenderness  of  the  scalp  in  the  occipital 
region  and  below  it  has  often  been  noted  after  concussion  of  the  brain,  whether 
mild  in  degree  or  severe,  and  apart  from  neurasthenia  ;  the  pain  and  tenderness 
may  each  be  both  superficial  and  deep. 

Tenderness  of  the  scalp  is  often  marked  in  neuralgia,  a  vague  term  applied  to 
any  severe  pain  that  follows,  or  seems  to  follow,  the  distribution  of  a  nerve.  In 
trigeminal  neuralgia,  neuralgia  major,  or  tic  douloureux,  the  pain  and  tenderness 
often  spread  back  to  the  vertex  and  parietal  eminence,  in  correspondence  with 


TENDERNESS     IN     THE     SCALP 


783 


the  cutaneous  distribution  of  the  first  or  oplithahiaic  branch  of  the  fifth  nerve. 
Pressure  over  the  tender  area  will  often  bring  on  a  paroxysm  of  pain  ;  yet  while 
the  pain  is  raging,  the  patient  often  gains  some  relief  by  firm  pressure  over  the 
painful  part.  When  the  paroxysm  is  recently  past,  pressure  does  not  have  any 
obvious  effect  in  some  cases.  Identical  neuralgic  pain  and  tenderness  may  be 
met  with  in  the  rare  cases  where  a  tumour  presses  on  the  trigeminal  nerve  or  its 
roots,  as  may  happen  in  patients  with  meningeal  new  grow-ths  ;  the  diagnosis 
here  is  important,  because  operative  removal  of  the  Gasserian  ganglion  would  be 
useless  in  such  a  case.  Definite  loss  of  sensation  occurs  if  the  nerve  is  involved 
in  a  tumour,  whereas  in  tic  douloureux  there  is  no  anaesthesia  ;  in  addition,  the 
other  signs  of  intracranial  tumour  should  be  looked  for. 

In  another  group  come  the  cases  of  neuralgia  minor,  in  which  pain  and  tender- 
ness in  the  scalp  form  a  visceral  reflex,  and  are  due  to  disease  in  the  eyes,  teeth, 
ear,  and  thoracic  or  abdominal  viscera.  A  referred  visceral  pain  usually  brings 
with  it  superficial  tenderness,  and  both  the  pain  and  the  tenderness,  according 
to  Head,  are  found  over  "  segmental  "  areas,  or  areas  that  do  not  correspond 
with  the  distribution  of  the  peripheral  nerves,  but  follow  a  central  distribution 

The  Segmental  Are.\s  of  the  Scalp  {after  Head). 


MD.'^; 


-j      V-Fr.n 


Fig.  2C2. — The  segmental  areas.  Fig.  203. — The  maxima  of  the  segmental 

areas  shown  in  Fig.  202. 
Fi\  n,   Fronto-nasal  ;    Mo,  Mid-orbital;    Oc.  Occipital;    P,  Parietal;   T,  Temporal;   V,  Vertical. 


{Figs.  202,  203).  In  other  patients,  however,  the  same  lesions  produce  areas  of 
pain,  and  less  often  of  tenderness  also,  that  do  follow  distributions  correspond- 
ing with  those  of  the  peripheral  nerves  ;  and  these  are  described  as  cases 
of  neuralgia  minor  proper.  To  give  examples  of  reflex  neuralgia,  disease  of 
the  upper  bicuspids  may  cause  pain  and  tenderness  in  the  temporal  region  ; 
disorders  of  the  eye,  particularly  astigmatism  and  hypermetropia,  iritis,  and 
glaucoma,  may  cause  headache  and  tenderness  spreading  from  the  forehead  to 
the  vertex  and  to  the  temporal  area  ;  suppuration  in  the  middle  ear  may  make 
the  whole  side  of  the  head  tender.  Certain  areas  on  the  head  are  segmentally 
united  with  other  areas  on  the  body  ;  the  temporal  area  of  the  scalp  is  connected 
thus  with  the  seventh  dorsal  segment,  and  so  diseases  of  the  heart,  lungs,  or 
stomach  may  all  bring  about  temporal  pain  and  tenderness,  associated  with  the 
segmental  area  of  cutaneous  tenderness  about  the  level  of  the  epigastrium  that 
directly  represents  the  seventh  pair  of  dorsal  nerves.  It  is  probable  that  a 
number  of  patients  with  undetected  disease  of  the  teeth,  eyes,  ears,  or  viscera, 
are  treated  for  "  neuralgia  "  for  long  periods,  when  a  more  careful  examination 
of  their  historv'  and  investigation  of  their  physical  condition  would  lead  at  once 


784  TENDERNESS     IN     THE     SCALP 

to  the  proper  diagnosis.  In  a  certain  number  of  cases  pain  and  tenderness  in 
the  scalp  are  due  to  general  diseases  such  as  diabetes  meUitus,  malaria,  and 
rheumatism  ;  a  fact  that  leaves  room  for  much  looseness  in  diagnosis. 

In  both  neurasthenia  and  hysteria  complaints  of  pains  and  tenderness  are 
common,  and  the  scalp  may  be  affected  just  as  any  other  part  of  the  body  may. 
The  neurasthenic  often  has  occipital  tenderness,  with  pain  referred  to  the  hair  ; 
brief  mental  effort  niay  bring  on  pain  and  tenderness  in  the  sinciput  or  vertex. 
The  hysterical  patient  may  be  prostrated  by  headache,  with  extreme  tenderness 
of  the  scalp.  It  is  not  necessary  to  say  that  the  greatest  care  to  exclude  organic 
disease  of  every  sort  should  be  taken  before  the  diagnosis  of  neurasthenia  or 
hysteria  is  made  in  a  patient  complaining  of  tenderness  in  the  scalp.  It  is 
noticeable  that  any  conditions  tending  to  build  up  the  strength  and  improve 
the  nutrition  of  neuralgic,  neurasthenic,  or  hysterical  patients,  are  likely  to  lessen 
the  pains  and  areas  of  tenderness  of  which  they  so  often  complain.  Conversely, 
these  persons  are  always  much  worse  when  their  health  is  low,  and  particularly 
when  they  are  ansemic.  a.  J.  J  ex-Blake. 

TENDERNESS  IN  THE  SPINE  occurs  in  conditions  of  two  different  sorts. 
In  the  first  it  is  due  to  local  disease  of  the  skin  or  subcutaneous  tissues,  fasciae, 
muscles,  bones,  or  nerve-tissue  in  the  immediate  neighbourhood  of  the  spine  ; 
and  the  pain  felt  when  the  tender  spot  is  touched  is  a  direct  pain.  In  the  second 
there  is  no  local  disease,  and  the  pain  felt  on  stimulation  of  the  tender  area 
is  a  referred  pain,  due  in  most  cases  to  organic  disease  of  one  or  other  of  the 
viscera,  in  a  few  to  some  obscure  nervous  disorder.  The  tenderness  varies  widely 
in  degree.  In  the  severest  cases,  whether  direct  or  referred,  the  pain  may  be  such 
that  the  patient  cannot  endure  even  the  light  pressure  of  the  clothes  ordinarily 
worn,  and  is  in  agony  the  moment  a  finger  is  laid  upon  the  tender  place. 

I.  When  due  to  Local  Disease,  the  tenderness  is  usually  associated  with  rigidity 
of  the  spine  in  the  tender  section,  a  protective  reflex  designed  to  give  rest  to  the 
diseased  part.  This  is  particularly  well  marked  when  it  is  bone — the  vertebral 
column — that  is  diseased.  A  similar  but  less  complete  and  more  extensive 
rigidity  will  be  noted  when  the  local  disorder  is  in  the  muscles  or  fasciee  of  the 
back.  Should  the  local  disease  or  injury  be  so  extensive  as  to  involve  or 
compress  the  spinal  cord,  special  symptoms  (girdle-pain,  paresis,  anaesthesia, 
etc.)  will  be  added.  The  chief  morbid  states  in  which  such  tenderness  of  the 
spine  occurs  are  summarized  in  the  following  table  : — 

Diseases  of  the  skin  and  subcu-    (Trauma,      infected     wounds,     abscess- 
taneous  tissue  j      formation,  etc. 


Diseases  of  the  muscles,  fascia, 
or  nerves 


Gout,  rheumatism,  trauma,  herpes,  etc. 

,  Tuberculosis  and  other  infections 
Caries    sicca,     spondylitis     deformans, 
"  typhoid  spine  " 
Diseases  affecting  the  vertebrcs       -!  Erosion  by  aortic  aneurysm 

I  Invasion  by  malignant  disease 
Trauma,    with    or    without    injury    to 
the  cord. 
Traumatic    neurasthenia,     with   \ 
local  lesions  that  are  not   de-   '-  "  Railway  spine." 
monstrable  i 

To  consider  these  lesions  in  detail  :  Obviously  the  skin  and  subcutaneous 
tissues  may  be  tender  over  the  spine  after  falls  or  blows  on  the  back,  infected 
wounds,  in  acne  and  furunculosis,  in  abscess-formation,  whether  the  infection 


TENDERNESS     IN     THE     SPINE  785 

is  derived  from  without,  or  from  within  as  in  pyaemia  ;  a  psoas  abscess  has  been 
known  to  point  and  discharge  on  the  back  over  the  vertebral  column.  Tenderness 
in  the  spine  due  to  affections  of  the  fascicB  and  muscles  may  be  experienced  by 
any  ill-trained  person  who  over-uses  or  strains  his  spinal  muscles  ;  it  is  also 
common  in  gouty  patients  ;  and  frequently  it  is  associated  in  the  rheumatic 
with  attacks  of  lumbago.  Deep-seated  inflammations  in  this  region  are  not  rare, 
and  are  seen  usually  in  connection  with  spinal  caries  ;  less  often  the  inflammation 
may  be  due  to  pyaemia,  empyema  perforating  spontaneously,  trichiniasis  and 
other  very  rare  forms  of  myositis,  when  they  chance  to  attack  the  spinal  region. 
In  a  few  instances,  no  doubt,  disease  of  the  spinal  nerves,  particularly  when 
their  posterior  primary  divisions  are  affected,  gives  rise  to  tenderness  in  the 
spine  as  well  as  along  the  course  of  the  nerves  themselves  ;  this  may  occur 
when  pressure  on  the  nerves  or  their  roots  exists,  and  in  cases  of  herpes 
zoster  or  neuritis.  Most  of  the  causes  of  spinal  tenderness  enumerated  above 
are  comparativeh'  rare  ;  and  their  diagnosis  should  not  be  difficult  if  a  careful 
examination  of  the  patient  be  made,  and  his  other  signs  and  symptoms  of 
disease  be  noted. 

The  cases  in  which  the  tenderness  is  due  to  disease  of  the  vertebrae  are 
far  more  important  than  the  above,  and  probably  commoner  also,  as  well  as 
far  more  serious  from  the  point  of  view  both  of  prognosis  and  treatment. 
Excluding  spinal  trauma,  which  usually  declares  itself  obviously  and  is  considered 
below,  the  three  disorders  to  which  the  vertebrae  are  liable  in  this  connection 
are  tuberculosis,  invasion  by  malignant  disease,  and  erosion  by  an  aneurysm. 
In  other  rarer  instances  they  may  be  affected  with  similar  symptoms  and  results 
by  actinomycosis,  pyaemic  abscess,  the  spread  of  infection  from  adjoining 
parts  (retropharyngeal,  mediastinal,  subdiaphragmatic,  perinephric,  or  pelvic 
abscesses),  hydatid  disease,  spondylitis  deformans,  and  vertebral  arthritis  due 
to  the  gonococcus  and  other  microbes.  When  caused  by  vertebral  tuberculosis, 
the  spinal  tenderness  is  local,  and  is  generally  accompanied  by  more  or  less 
angular  deformity  of  the  spinal  column,  collapse  of  the  diseased  and  softened 
anterior  part  of  the  vertebral  body,  causing  abnormal  projection  of  its  dorsal 
spine  at  the  same  time.  If  it  is  the  posterior  part  of  the  affected  vertebra  that 
collapses,  the  spinous  process  will  sink  inwards  ;  it  must  be  remembered,  how- 
ever, that  congenital  defect  or  deficiency  of  a  spinous  process  is  not  very  rare, 
and  may  be  mistaken  for  the  result  of  injury  or  disease.  Whether  deformity 
accompanies  spinal  caries  or  no,  rigidity  of  the  diseased  part  of  the  spinal  column 
is  sure  to  be  present.  It  is  maintained  by  involuntary  contraction  of  the 
appropriate  muscles,  and  becomes  conspicuous  when  the  patient  is  encouraged 
to  bend  his  back  in  any  direction,  or  to  rotate  the  body  on  the  pelvis.  In 
addition,  pain  will  be  felt  in  the  back  when  the  patient's  vertex,  shoulders, 
sacrum,  or  legs  are  jarred  ;  his  gait,  too,  and  method  of  holding  himself  and 
turning,  designed  to  relieve  the  diseased  part  of  the  spinal  column  from  shock 
or  strain,  will  be  characteristic.  In  children  who  are  not  well  looked  after, 
this  spinal  tenderness  and  deformity  may  be  unnoticed  and  the  diagnosis  of 
spinal  caries  not  established  until  a  psoas  abscess  has  formed  and  has  declared 
itself  by  pain  in  the  leg,  or  lameness.  The  importance  here  of  early  diagnosis 
cannot  be  overstated  ;  spinal  tuberculosis  is  commonest  in  children,  but  may 
occur  at  any  age.  It  often  happens  that  rickety  children  are  suspected  of 
"  spinal  disease  "  by  their  parents  ;  they  present  marked  spinal  curvature, 
due  to  flabbiness  of  the  muscles,  and,  like  all  their  bones,  their  spines  may  be 
tender  on  pressure.  But  there  is  no  localized  spinal  tenderness  in  rickets, 
there  is  no  angular  deformity,  the  spinal  curvature  vanishes  when  the  child  is 
suspended  by  the  head  or  arms,  no  pain  is  caused  by  jarring  or  rotating  the 
spinal  column,  and  there  is  no  rigidity  of  the  back.  And  the  other  ordinary 
D  50 


786  TENDERNESS     IN     THE     SPINE 

evidences  of  rickets  will  be  present,  so  that  the  diagnosis  should  not  be  difficult. 
In  adults,  however,  and  particularly  during  the  second  half  of  life,  it  may  often 
be  difficult  to  determine  whether  a  persistent  tenderness  over  some  part  of 
the  spine,  associated  with  persistent  pain  and  rigidity,  is  due  to  tuberculosis, 
aneurysm,  or  malignant  disease  affecting  the  vertebral  column.  The  occurrence 
of  angular  curvature,  due  to  softening  and  collapse  of  the  vertebral  body,  would, 
argue  in  favour  of  tuberculosis,  being  comparatively  rare  in  aneurysm  or 
malignant  disease  ;  evidence  of  tuberculous  mischief  in  the  patient's  joints, 
lungs,  or  larynx,  a  history  of  cough  or  blood-spitting,  or  a  marked  family  history 
of  tuberculosis,  would  all  point  in  the  same  direction.  Aortic  aneurysm,  eroding 
the  vertebral  column  and  causing  pain  and  tenderness  by  pressing  on  the  nerves 
in  its  vicinity,  would  be  suggested  if  the  patient  were  a  middle-aged  man  giving 
a  history  of  syphilitic  infection,  and  exhibiting  more  or  less  arterial  degenera- 
tion. Examination  under  the  ,r-rays  and  testing  for  the  presence  or  absence  of 
Wassermann's  reaction  might  be  of  great  assistance  here  ;  deep  abdominal 
palpation,  under  an  anaesthetic  if  necessary,  might  reveal  the  expansUe  pulsation 
of  an  aortic  aneurysm.  Secondary  deposits  of  malignant  disease,  invading 
or  enconipassing  a  vertebra,  may  occasion  marked  spinal  tenderness  and  pain 
in  the  back  of  the  severest  description  ;  in  rare  cases,  the  malignant  growth 
may  be  primary.  The  vertebrae  are  the  bones  most  often  invaded  by  secondary 
malignant  growths  ;  the  primary  growths  most  frequently  responsible  for 
secondary  deposits  in  the  bones  are  carcinoma  of  the  thyroid,  testis,  prostate, 
and  mamma,  primary  sarcoma  of  bone,  and  melanotic  sarcoma.  Here  again 
the  diagnosis  may  be  very  difficult,  in  the  earlier  stages  of  the  disorder 
particularly,  because  the  primary  growth  may  be  small  and  deep-seated,  and 
may  have  given  rise  to  no  signs  or  symptoms  leading  to  its  discovery,  so  that 
the  presence  of  secondary  deposits  is  not  suspected.  In  the  later  stages,  the 
growth  often  burgeons  into  the  spinal  canal,  and  causes  symptoms  of  paraplegia 
by  compressing  the  spinal  cord.  When  this  occurs  the  diagnosis  is  easier,  for 
the  site  of  the  compression  may  be  indicated  by  a  girdle-pain  and  a  zone  ot 
hyperaesthesia  ;  while  anaesthesia,  with  paresis  or  paraplegia,  is  found  below  it, 
the  sphincters  are  affected,  the  knee-jerks  are  increased,  and  ankle-clonus  and 
Babinski's  extensor  plantar  reflex  can  be  elicited.  But,  as  has  been  pointed 
out  already,  it  may  be  impossible  to  find  any  definite  physical  signs  in  a  patient 
complaining  of  very  severe  and  intractable  pain  and  tenderness  in  some  part 
of  his  spinal  column  ;  and  raost  physicians  of  experience  must  have  met  with 
sad  cases  where  such  patients  have  been  treated  as  malingerers,  the  honesty  of 
their  complaints  failing  to  win  recognition  until  a  pathological  basis  for  them 
has  been  established  at  an  autopsy. 

Little  more  need  be  said  about  most  of  the  other  local  diseases  that  may  make 
the  affected  region  of  the  spine  both  tender  and  painful.  Caries  sicca  is  the 
name  given  to  an  obscure  rarefying  osteitis  of  chronic  course,  non-suppurative, 
that  raay  attack  the  vertebra".  The  signs  and  symptoms  of  vertebral  actino- 
mycosis resemble  those  of  tuberculosis.  In  chronic  pycemia  a  vertebral  abscess 
may  arise,  and  in  patients  with  abscesses  in  the  spinal  region — such  as  pelvic, 
perinephric,  subdiaphragmatic ,  mediastinal^  or  retropharyngeal — a  spread  of 
infection  to  the  vertebrae  may  conceivably  occur,  giving  rise  to  tenderness  in 
the  affected  part  of  the  spine  ;  hydatid  disease  of  the  spinal  canal  or  vertebral 
column  may  do  the  same  in  persons  exposed  to  echinococcus  infection.  But  in 
all  these  instances  the  tenderness  in  the  spine  wUl  be  but  a  minor  symptom  of 
a  serious  and  more  or  less  acute  disorder,  with  other  features  that  are  more 
characteristic.  Tenderness  in  the  spine  is  often  marked  in  spondylitis  deformans, 
the  name  given  to  practically  any  chronic  non-suppurative  form  of  vertebral 
arthritis.     It  is  no  doubt  an  infectious  process,  and  occurs   after  gonorrhoea. 


TENDERNESS     IN     THE     SPINE  787 

influenza,  enteric  fever  (the  "  typhoid  spine  "),  tonsillitis,  and  other  bacterial  dis- 
orders. It  is  characterized  by  stiif^ness  in  some  portion  of  the  vertebral  column, 
with  irregular  deposits  of  new  bone  in  the  adjoining  ligaments,  particularly  the 
anterior  common  ligament,  well  seen  by  the  use  of  A^-rays.  The  chief  sign  is 
stiffness  in  the  back,  and  in  a  few  of  the  cases  osteo-arthritis  of  some  joints  of  the 
limbs  occurs  as  well  ;  in  instances  where  the  hip  or  shoulder  are  thus  involved  the 
disease  has  been  named  "  spondylose  vhizomelique  "  by  Marie.  Men  are  affected 
four  or  jive  times  as  often  as  women,  and  the  disease  usually  begins  between 
the  ages  of  twenty  and  fifty.  Its  diagnosis  may  be  difficult,  because  the  chief 
complaint  may  be  of  pain  in  the  hips,  legs,  abdomen,  or  thorax,  or  of  "  sciatica  " 
or  "  lumbago,"  so  that  disease  of  the  vertebral  column  may  be  neither  suspected 
nor  looked  for.  In  most  patients,  the  affected  region  of  the  spine  is  tender  ; 
much  spasm  of  the  dorsal  muscles  is  found  in  the  more  acute  cases,  while  in 
those  of  long-standing,  atrophy  from  disuse  will  be  found.  The  typhoid  spine 
is  a  rare  sequela  of  enteric  fever,  usually  occurring  early  in  convalescence.  The 
patient  complains  of  tenderness  and  the  most  acute  pain  in  the  lower  part  of 
the  vertebral  column,  after  an  initial  stage  of  backache.  Fever  is  present  at 
first  in  half  the  cases,  and  no  doubt  the  condition  is  commonly  due  to  vertebral 
periostitis  set  up  by  the  Bacillus  typhosus.  The  symptoms  last  for  manj^  months 
as  a  rule,  and  deformity  of  the  spine  is  left  in  half  the  patients  ;  but  suppuration 
of  the  affected  vertebrse  seems  to  be  unknown.  Men  are  more  often  affected 
than  women,  and  the  diagnosis  should  not  be  a  matter  of  great  difficulty.  In 
milder  cases  no  physical  signs  of  vertebral  disease  appear,  and  so  the  affection 
has  been  described  as  hysterical,  the  spine  as  an  irritable  spine  ;  in  yet  other 
instances,  the  spinal  cord  appears  to  be  involved,  as  if  the  periostitis  affected 
the  spinal  canal,  loss  of  control  over  the  sphincters  being  observed,  with  paresis 
of  the  legs,  and  changes — usually  increase — in  the  reflexes. 

Tenderness  in  the  spine  due  to  trauma  may  be  the  expression  of  either  organic 
or  functional  disease  resulting  therefrom,  and  the  precise  diagnosis  may  be 
extremely  difficult.  The  trauma  is  usually  a  raUway  or  other  accident  of 
locomotion  ("  railway  spine  "),  a  fall,  a  sudden  shock  or  concussion  ;  in  another 
group  of  cases  it  is  either  a  single  sudden  muscular  over-strain,  due  to  over- 
exertion or  the  effort  to  avoid  an  accident,  or  the  more  chronic  over- strain  to  which 
rowing  men,  football  players,  and  the  like  are  exposed.  A  gross  injury  may 
produce  fracture  of  a  vertebra,  with  or  without  displacement  of  the  fragments 
such  as  can  be  demonstrated  by  use  of  the  x-xdt,YS  ;  subperiosteal  or  subdural 
hemorrhage,  haemorrhage  into  the  spinal  canal,  haemorrhage  into  or  bruising 
of  the  cord,  all  of  which  will  give  rise  to  localizing  cord-symptoms  (girdle-pain 
at  the  level  of  the  lesion,  varying  degrees  of  paresis  and  anaesthesia  below  it) 
when  the  lesion  is  marked.  At  the  other  end  of  the  scale  are  found  the  sufferers 
from  traumatic  neurasthenia,  who  have  been  exposed  to  identical  injury  or 
over-strain,  but  present  no  definite  signs  of  disease  in  the  spine  or  cord,  although 
quite  incapacitated  for  months  or  years,  by  weakness  and  severe  pains  in  the 
injured  region.  These  patients  often  have  increased  knee-jerks  and  even  ankle- 
clonus  ;  but  definite  evidences  of  organic  disease  are  wanting,  the  sphincters 
are  unaffected,  Babinski's  extensor  plantar  reflex  is  not  obtained,  muscular 
wasting  is  not  found,  unless  from  disuse,  and  the  various  pains  and  tendernesses 
of  which  complaint  is  made  have  a  neurasthenic  or  even  a  hysterical  distribution 
and  character.  Traumatic  neurasthenia  may  follow  after  surgical  operations 
or  comparatively  slight  injuries  to  the  head,  back,  or  testicle,  in  addition  to  the 
severer  traumas  and  strains  already  mentioned  ;  and  it  must  be  noted  that  a 
delay  of  one  or  more  weeks,  an  incubation-period,  may  intervene  between  the 
receipt  of  the  injury  and  the  development  of  the  neurasthenic  pains.  It  would 
be  unfair  to  take  such  a  delay  as  evidence  of  a  hysterical  factor  in  the  case,  or  of 
malingering. 


788 


TEXDERNESS     IK     THE     SPINE 


ist  Dorsal 
Spina 


It  is  clear  from  the  foregoing  paragraph,  that  traumatic  neurasthenia  includes 
cases  in  which  it  is  not  possible  to  say  for  certain  whether  a  local  organic  lesion 
of  the  spine  exists  or  not.  Such  instances  form  a  natural  transition  to  those 
in  which  there  is  : — 

2.  Tenderness  in  the  Spine  due  to  Functional  Disorders,  or  to  Disease  in  Other 
Parts  of  the  Body. — In  very  few  of  these  is  there  an}-  deformit}^  of  the  spinal 
column  ;  it  is  flexile  and  not  rigid  ;  and  pain  is  rarely  produced  when  it  is 
carefully  bent,  twisted,  or  jarred,  so  long  as  direct  stimulation  of  the  tender 
part  is  avoided.  As  a  rule,  the  tenderness  is  superficial  rather  than  deep,  and 
it  is  often  associated  with  other  areas  of  tenderness  in  the  side  or  front  of  the 
body. 

In  h5'steria,  complaint  of  pain  and  tenderness  in  the  spine  and  back  is  not 
rare — ^the  "  hA'sterical  spine."  The  tenderness  over  the  vertebrae  is  often 
accompanied  by  tenderness  on 
either  side  of  it ;  in  extent  it 
may  change  from  time  to  time, 
invohT.ng  a  single  vertebra  or 
even  most  of  the  vertebral 
column. 

In  neurasthenia  the  spine 
may  be  tender  from  top  to 
bottom,  and  more  or  less 
rigidity  is  often  found  also. 
When  the  tenderness  is  local- 
ized to  a  small  part  of  the 
back,  it  may  easily  be  taken 
as  evidence  of  local  organic 
disease ;  but  the  presence  of 
other  neurasthenic  s\Tnptoms 
— ^headache,  irritability,  fatig- 
ability after  brief  exertion — 
and  the  absence  of  signs  of 
definite  local  disease  or  in- 
volvement of  the  cord,  should 
help  in  the  diagnosis.  To  dis- 
tinguish clearly  between  neur- 
asthenia and  hysteria  is  often 
difi&cult,  and  particularly  so  in 
the  milder  cases  of  traunaatic 
neurasthenia,      because      the}- 

ma}^  develop  hysterical  features  such  as  areas  of  anaesthesia,  a  craving  for 
sjnnpathy,  a  tendency  to  exaggerate  the  symptoms,  and  so  forth.  The  harmful 
efiects  of  mental  worry  on  neurasthenia,  of  the  uncertainty  attaching  to 
an  impending  law-suit  in  which,  perhaps,  damages  for  injury  are  being  claimed, 
are  well  known. 

Tenderness  in  the  spine  is  ver}^  commonly  a  reflex  from  disease  in  one  or  other 
of  the  thoracic,  abdominal,  or  pelvic  viscera.  The  tenderness  is  characteristically 
superficial  in  these  cases,  and  acute  pain  may  result  from  light  pressure  on  the 
area  involved  ;  and  if  the  tender  tissues  can  be  pulled  aside  sufficiently,  it  will 
be  found  that  pressure  on  the  spine  itself  causes  no  pain  Avhatever.  The 
different  viscera  produce  this  tenderness  with  some  regularity  in  different  and 
definite  spinal  areas,  and  the  fact,  worked  out  by  Head,  Mackenzie,  and  others, 
is  of  ser\dce  in  diagnosing  the  site  of  the  actual  lesion  from  which  the  patient 
is  suffering.     A  scheme  of  the  areas  is  given  in  the  diagram  {Fig.  204). 


■pyg.  204. — Areas  of  referred  spinal  pain  and  tenderness 
{after  I\Iackenzie).  A,  In  diseases  of  the  heart ;  B,  In 
dise.-ises  of  the  stomach  ;  C,  In  diseases  of  the  liver ; 
D,   In  diseases  of  the  rectum  and  uterus. 


THIRST,     EXTREME  789 


The  organs  and  diseases  most  often  giving  rise  to  this  referred  tenderness  and 
pain  in  the  spine  are  as  follows  :  The  aorta,  in  aortitis,  arteriosclerosis,  and 
aneurysm  ;  the  heart,  in  coronary  sclerosis  particularly,  myocarditis,  myocardial 
fibrosis,  acute  dilatation  and  failing  compensation  ;  the  stomach,  in  gastric 
ulcer,  malignant  disease,  gastritis  ;  the  liver,  in  cholelithiasis,  cholangitis,  new 
growth,  and  the  venous  congestion  of  tricuspid  reflux  ;  the  intestine  and  rectum, 
in  acute  inflammatory  disorders  and  in  constipation  ;  the  uterus,  in  labour, 
menstruation,  and  inflammatory  affections.  It  would  appear  that  the  lungs, 
whether  inflamed  or  wounded,  do  not  give  rise  to  a  referred  tenderness  ;  on  the 
other  hand,  the  whole  or  any  part  of  the  thoracic  spine  may  become  tender 
in  disorders  of  the  pleura,  such  as  pleurisy,  pleural  adhesions,  or  new  growth. 
To  illustrate  the  frequency  with  which  pain  and  tenderness  of  the  spine  occur, 
may  be  quoted  the  axiom  of  many  hospital  out-patient  departments,  that 
there  is  no  woman  in  London  who  has  not  got  a  pain  at  the  bottom  of  her  back 
— a  libel  on  the  sex,  one  may  hope. 

The  importance  of  distinguishing  between  the  cases  in  which  the  physical 
signs  of  organic  disease  in  the  vertebral  column  or  cord  are  absent,  and  those 
detailed  in  Class  i  above,  need  not  be  emphasized  further.  The  referred  pains 
and  tendernesses  disappear  or  are  relieved  with  the  cure  or  relief  of  the  cardiac, 
gastric,  or  other  disorder  to  which  they  are  due.  The  diagnosis  of  the  cause 
of  tenderness  over  the  fourth  dorsal  vertebra,  for  example,  which  may  be  due 
to  disease  of  the  heart,  pleura,  or  stomach,  must  be  made  on  general  lines,  and 
by  consideration  of  the  o!;her  signs  and  symptoms  exhibited  by  the  patient. 

A.  J .  J  ex-Blake. 
TETANIC   CONTRACTIONS.— (See  Contractions.) 

THERMO-AN^STHESIA.— (See  Sensation,  Some  Abnormalities  of.) 

THIRST,  EXTREME. — Cases  of  extreme  thirst  may  be  subdivided  into 
two  main  groups ;  namely,  those  with  and  those  without  polyuria.  To  the 
former  belong  such  conditions  as  diabetes  mellitus,  diabetes  insipidus,  hysteria, 
and  so  on,  which  are  discussed  under  Polyuria.  To  the  other  group  belong 
such  conditions  as  are  for  the  most  part  so  obvious  as  to  require  no  more  than 
simple  enumeration  under  main  headings,  as  follows  : — 

1.  Prolonged  abstention  from  drinking,  purposeful,  or  the  result  of  necessity. 

2.  Fevers  and  febrile  states. 

3.  Excessive  loss  of  fluid  :  (a)  From  the  skin  by  profuse  perspirations,  natural 
or  pathological  ;  [b]  From  the  stomach,  from  repeated  vomiting  ;  (c)  From  the 
bowel, from  excessive  diarrhoea;  {d)  Into  serous  membranes,  as  in  acute  peritonitis. 

4.  After  severe  haemorrhage  :  [a)  External,  e.g.,  post-partum  ;  [b)  Internal, 
e.g.,  from  duodenal  ulcer. 

5.  Gastrectasis  due  to  pyloric  stenosis,  owing  to  the  fact  that  the  stomach 
absorbs  little  fluid  as  compared  with  the  intestines. 

6.  Poisoning  by  such  drugs  as  dry  up  the  secretions  of  the  mouth,  notably 
belladonna  and  its  allies,  or  astringents  such  as  alum,  gallic  acid,  tannic  acid,  or 
perchloride  of  iron. 

7.  The  exhibition  of  excess  of  various  salts,  particularly  sodium  chloride, 
either  as  such,  or  incorporated  in  various  food-stuffs. 

It  is  clear  that  in  some  cases  more  than  one  factor  at  a  time  may  be  causing 
extreme  thirst.  Herbert  French. 

THRILLS,  PRECORDIAL — In  order  to  arrive  at  a  diagnosis  of  the  cause  of 
any  thrill  which  is  felt  over  the  prsecordia,  two  facts  must  first  be  ascertained, 
namely  (i)  The  situation  of  the  thrill;  and  (2)  Its  rhythm.  Having  discovered 
a  thrill  over  the  mitral  area,  that  is,  in  the  region  of  the  apex  beat,  and  found 


790  THRILLS,     PRECORDIAL 

that  it  is  presystolic  in  rhythm,  it  is  obvious  that  it  is  due  to  mitral  stenosis. 
The  valvular  lesion  will  be  confirmed  by  the  presence  of  a  presystolic  bruit, 
as  it  is  rare  to  find  the  thrill  without  a  bruit  being  associated  with  it.  On 
the  other  hand,  if  the  thrill  be  systolic  in  time,  and  mitral  regurgitation  be 
present,  the  thrill  is  due  to  this  valvular  lesion.  A  systolic  thrill  at  the  cardiac 
apex  may  also  be  caused  by  pericardial  friction  fremitus,  or  pleuritic  fremitus. 
A  pericardial  friction  fremitus  can  be  distinguished  from  an  endocardial  thrill 
b}-  being  more  rubbing  in  character,  usually  occurring  both  during  systole  and 
diastole,  while  an  endocardial  thrill  is  a  more  purring  vibration,  and  it  only 
occurs  during  systole  in  this  situation.  The  pericardial  friction  is  confirmed  by 
auscultation.  Pleuritic  fremitus  in  this  region  may  be  distinguished  from  an 
endocardial  thrill  and  pericardial  friction  fremitus  by  asking  the  patient 
to  hold  his  breath,  when  the  fremitus  will  disappear.  These  distinguishing 
features  between  endocardial  thrill,  pericardial  friction  fremitus,  and  pleuritic 
fremitus,  apply  to  any  area  in  which  thrills  are  detected.  A  pericardial  friction 
fremitus  may  be  present  over  the  whole  or  any  part  of  the  prsecordia,  but  the 
most  common  situation  is  near  the  base  of  the  heart. 

A  systolic  thrill  in  the  second  right  intercostal  space  close  to  the  sternum  may 
be  due  to  aortic  stenosis,  thickening  of  the  aortic  valve,  atheroma,  and  dilatation  or 
aneurysm  of  the  ascending  portion  of  the  thoracic  aorta,  and  the  diagnosis  of 
the  cause  of  the  thrill  can  only  be  made  by  the  other  physical  signs  which  indicate 
the  morbid  condition  present.  Thus,  if  there  be  dullness  in  the  second  right 
intercostal  space,  over  which  the  thrill  is  felt,  there  is  dilatation  or  aneurysm 
of  the  arch  of  the  aorta.  There  is  no  dullness  in  this  situation  when  the 
thrill  is  due  to  aortic  obstruction  or  to  atheroma  of  the  aorta.  Kot  only  may 
dullness  on  percussion  accompany  the  thrill,  but  there  may  be  pulsation,  and 
even  a  pulsating  tumour,  in  this  region,  showing  that  there  is  an  aneurysm  of 
the  aorta.  Other  signs  of  an  aneurysm  may  be  present,  and  an  x-rs-y  examina- 
tion is  helpful  in  confirming  the  diagnosis. 

A  diastolic  thrill  may  also  be  felt  in  the  second  right  intercostal  space  close 
to  the  sternum,  but  it  is  rare  ;  when  present,  it  is  due  to  aortic  regurgitation,  and 
is  accompanied  by  the  characteristic  diastolic  bruit.  Sometimes  the  thrill,  like 
the  bruit,  is  most  marked  in  the  third  left  space  close  to  the  sternum. 

It  must  also  be  remembered  that  pericardial  friction  fremitus  may  be  felt 
in  the  aortic  area,  and  can  be  distinguished  by  the  diagnostic  signs  which  have 
aheady  been  considered. 

In  the  pulmonary  area,  viz.,  in  the  second  left  intercostal  space  close  to  the 
sternum,  systolic  thrills  also  occur,  and  are  due  to  congenital  affections  of  the 
heart,  especially  pulmonary  stenosis,  and  patency  of  the  ductus  arteriosus.  An 
extensive  thrill  felt  over  the  base  of  the  heart  in  young  children  is  nearly  always 
due  to  a  congenital  malformation  of  the  heart,  and  can  be  distinguished  by  the 
other  signs  of  congenital  heart  disease  which  are  usuall}'  present,  especially 
cj-anosis  and  clubbing  of  the  fingers.  When  thrills  in  this  area  are  due  to  con- 
genital malformation,  the  apex  beat  is  generally  near  its  normal  position.  The 
cardiac  dullness  usually  extends  to  the  right  of  the  sternum  as  the  result  of 
the  enlargement  of  the  right  ventricle,  and  there  is  commonly  a  loud  universal 
systolic  bruit,  having  its  point  of  maximum  intensity  over  the  base  of  the  heart. 
The  following  signs  of  congenital  malformation  of  the  heart,  other  than  patent 
ductus  arteriosus,  are  also  to  be  expected  :  cyanosis,  either  continuously  present 
or  occurring  at  intervals,  dyspnoea,  especially  upon  exertion,  clubbing  of  the 
fingers  and  toes,  and  polycythsemia.  With  patent  ductus  arteriosus  there  may 
be  no  symptoms  accompanying  the  abnormal  physical  signs.  Thrills  due  to 
congenital  malformations  of  the  heart  may  occur  almost  anywhere  over  the 
praecordia  ;   the}-  are  systolic  and  sometimes  diastolic  in  time,  often  felt  over  a 


THYROID     GLAND,     ENLARGEMENT     OF     THE  791 

large  area,  and  of  very  marked  intensity.  Wlien  present,  they  are  always 
accompanied  by  ample  evidence  of  congenital  disease. 

It  must  be  remembered  that  a  thrill  may  occur  in  the  second  left  intercostal 
space  close  to  the  sternum,  and  be  associated  with  a  functional  pulmonary  bruit. 
In  such  a  case,  the  functional  origin  of  the  thrill  may  be  distinguished  by  the 
general  condition  of  the  patient,  who  will  be  suffering  from  anaemia  or  some 
debilitating  condition.  The  signs  of  congenital  heart  disease,  just  mentioned, 
will  be  absent,  so  that  the  diagnosis  of  the  cause  of  the  thrill  is  usually  quite 
easy. 

Presystolic  and  systolic  thrills  sometimes,  but  very  rarely,  occur  to  the  right 
of  the  sternum  in  the  tricuspid  area,  due  to  stenosis  and  incompetence  of  this 
valve.  /.  E.  H.  Sawyer. 

THYROID  GLAND,  ENLARGEMENT  OF  THE.— An  enlarged  thyroid  gland 
gives  rise  to  a  swelling  in  the  mid-line  of  the  neck,  internal  to  the  sterno- 
mastoid  muscles  and  the  carotid  vessels,  which,  if  the  swelling  is  large  enough, 
are  pushed  outwards.  The  gland  is  intimately  connected  with  the  larynx  ; 
hence  the  most  important  sign  of  a  thyroid  tumour  is  that  it  rises  and  falls  with 
the  larynx  and  trachea  during  deglutition.  In  the  great  majority  of  cases  the 
presence  of  this  sign  alone  is  sufficient  to  make  a  correct  diagnosis.  There  are 
two  sources  of  fallacy  :  (i)  A  swelling  not  thyroid  in  origin  but  lying  in  front 
of  it,  such  as  a  sub-hyoid  bursa  or  sebaceous  cyst,  and  also  a  suppurative  or 
syphilitic  perichondritis  of  the  thyroid  cartilage,  may  present  the  above  sign  ; 
(2)  A  thyroid  swelling,  if  fixed,  as  it  may  be  by  inflammation  or  malignant 
growth,  may  not  present  it.  In  the  vast  majority  of  cases,  however,  a  swelling 
in  the  position  of  the  thyroid  gland  which  moves  on  deglutition  indicates  an  ■ 
enlargement  of  that  gland. 

Varieties  of  Enlargement  and  their  Differential  Diagnosis. — During  menstruation 
and  pregnancy  the  thyroid  is  said  to  become  enlarged,  but  this  is  rarely  sufficient 
to  cause  symptoms  ;  if  the  gland  happens  to  be  the  seat  of  pre-existing  disease 
the  increase  of  swelling  may  be  sufficient  to  induce  respiratory  difficulty. 

Parenchymatous  Goitre,  or  a  general  hypertrophy  of  the  whole  gland,  is 
the  commonest  form  of  enlargement.  All  parts  of  the  gland  are  affected  more 
or  less  equally  ;  the  tumour  being  bilateral,  the  normal  shape  is  preserved. 
The  swelling  is  freely  movable,  painless,  and  soft  in  consistency.  It  is  rarely 
congenital,  and  more  often  appears  about  puberty.  Its  rate  of  growth  is  usually 
very  slow,  and  it  may  attain  an  enormous  size  without  causing  any  other 
symptoms. 

Cystic  Goitre  is  a  loose  term  used  to  cover  any  form  of  enlargement  of 
the  thyroid  which  is  chiefly  caused  by  the  presence  of  one  or  more  cysts.  If 
the  cyst  is  large  and  lax,  fluctuation  may  be  made  out.  The  cysts,  however, 
are  often  small  and  tense,  and  cannot  be  distinguished  from  solid  adenomata'. 
Cysts  are  rarely  present  without  some  enlargement  of  the  rest  of  the  gland. 

Adenomatous  Goitre. — The  common  cause  of  unilateral  enlargement  is  the 
presence  of  an  adenoma,  a  definite  encapsuled  tumour  which  may  contain  cysts 
and  grow  to  a  large  size.  A  haemorrhage  into  one  of  these  cysts  may  cause  a 
very  rapid  enlargement,  and  so  give  rise  to  a  suspicion  of  malignancy.  Adeno- 
mata may  be  single  or  multiple  ;  when  present  in  both  lobes,  the  enlargement 
may  be  difficult  to  distinguish  from  the  parenchymatous  form. 

Malignant  Disease  is  seldom  met  with.  It  occurs  with  equal  frequency  in 
both  sexes,  and  is  rarely  seen  before  the  age  of  forty.  In  the  early  stages,  while 
still  confined  within  the  capsule  of  the  gland,  it  may  be  difficult  to  differentiate 
from  the  other  forms  of  goitre.  It  should  be  recognized  by  its  rapid  growth,  its 
hardness,  and  irregular  and  bossy  outline.     When  the  neoplasm  has  penetrated 


792  THYROID     GLAXD.     ENLARGEMENT     OF     THE 

the  capsule  and  invaded  surrounding  structures,  the  diagnosis  is  made  with 
more  ease.  The  tumour  may  become  iixed,  no  longer  moving  on  deglutition  ; 
often  one  or  other  vocal  cord  is  paralyzed,  a  condition  rarely  seen  with  innocent 
goitre  ;  and  involvement  and  ulceration  of  the  trachea  is  common.  The  lym- 
phatic glands  maj"  be  enlarged,  but  as  those  first  implicated  are  placed  deeply, 
def\-ing  detection,  not  much  help  is  gained  from  this  source. 

Exophthalmic  Goitre  (Graves'  disease,  von  Basedow's  disease)  is  far  more 
common  in  women  than  in  men  {Fig.  85,  p.  261),  and  rarely  occurs  before 
puberty  or  after  middle  life.  The  most  prominent  features  of  the  disease  are  : 
(I)  Exophthalmos;  (2)  Tach^xardia  with  palpitation  ;  (3)  Enlargement  of  the 
thjTToid  gland,  often  pulsatile  ;  (4)  Tremulousness  of  the  hands  and  general 
nervous  excitability^  ;  (5)  Breathlessness  on  exertion.  The  vision  is  normal, 
but  when  the  eyebaU  is  moved  downwards  the  upper  hd  does  not  follow  as  in 
health  (von  Graefe's  sign).  The  palpebral  aperture  is  wider  than  in  health, 
owing  to  retraction  of  the  upper  and  lower  lids  (Stellwag's  or  Dalrymple's  sign). 
Pigmentation  of  the  skin  maj^  be  intense  and  simulate  Addison's  disease,  but  the 
mucous  membrane  of  the  mouth  is  not  affected  as  in  the  latter  maladv. 

A  well-marked  case  is  quite  characteristic,  but  there  are  others  extremely 
hard  to  separate  from  simple  parench\Tiiatous  enlargement,  for  with  this, 
especially  in  young  girls,  ancemia  is  often  associated,  and  with  it  the  symptoms 
of  tachycardia,  palpitation,  and  breathlessness.  It  often  becomes  a  matter  of 
opinion  whether  a  given  case  should  be  styled  simple  parenchymatous  goitre 
or  incipient  Graves'  disease. 

The  above  are  the  commonest  forms  of  enlargement.  Others  much  rarer  are  : 
Enlargement  due  to  pyogenic  infection,  either  acute  or  chronic.  In  pyaemia  it  is 
not  uncommon  to  find  the  thyroid  the  seat  of  multiple  abscesses.  Tuberculous 
and  gummatous  disease  m.a.\  also  cause  enlargement,  and  a  slight  degree  of  goitre 
has  been  noted  in  typhoid  jever,  acute  rheumatism,  malaria,  variola,  cholera,  and 
secondary  syphilis.  Hydatid  cysts  of  the  th^Toid  gland  have  been  noted  on  a 
few  occasions.  It  ha^dng  been  ascertained  that  the  swelling  in  the  neck  is 
definitely  th^-roid  in  origin  and  its  nature  defined,  it  remains  to  see  whether 
there  are  any  pressure  signs  on  the  surrounding  structures. 

Pressure  on  the  Trachea. — Dyspnoea  is  hy  far  the  most  important  of  all  the 
sj'mptoms  that  maj-  be  produced  by  enlargement  of  the  thjToid  gland.  It 
may  be  the  onh-  thing  complained  of  b}-  a  patient  not  even  aware  of  the  presence 
of  a  goitre.  The  size  apparently  is  not  so  important  as  the  shape  and  situation, 
for  one  reaching  to  the  waist  may  cause  no  obstruction,  and  one  the  size  of  a 
cherrj-,  if  situated  between  the  sternum  and  trachea,  may  givx  rise  to  the  most 
intense  dyspnoea.  If  the  goitre  is  unilateral,  the  trachea  is  pushed  over  towards 
the  opposite  side  and  flattened  ;  if  bilateral,  as  in  the  parenchymatous  form,  it 
is  compressed  laterally.  The  dyspnoea  maj^  be  constant  and  distressing,  or 
only  noticeable  on  exercise  or  on  h'ing  down.  Most  such  patients  like  to  lie 
high  in  bed,  propped  up  on  piUows.  An  idea  as  to  the  amount  of  pressure  on 
the  trachea  may  sometimes  be  gained  by  a  question  on  this  point. 

Pressure  on  Nerves. — Unless  malignant,  a  goitre  rareh^  causes  much  pressure 
on  nerves.  Those  that  ma}'  be  involved  are  :  (a)  The  recurrent  laryngeal, 
resulting  in  paralysis  of  a  vocal  cord  ;  (b)  The  sympathetic,  shown  by  contraction 
of  the  pupil  on  the  affected  side  and  ptosis  ;  (c)  The  vagus  ;  [d)  Rarely  the 
nerves  of  the  brachial  and  cervical  plexuses.  If  any  of  these  nerves  are  involved, 
suspicion  must  arise  as  to  the  malignancy  of  the  tumour. 

Pressure  on  the  (Esophagus.- — Being  placed  behind  the  trachea,  the  oesophagus 
generally  escapes  pressure  b}-  a  goitre,  though  this  is  to  be  remembered  as  a 
rare  cause  of  dysphagia. 


TINNITUS  793 


Pressure  on  Veins  is  common,  particularly  on  the  internal,  external,  and 
anterior  jugulars.  The  pressure  is  rarely  more  than  sufficient  to  make  them 
stand  out  prominently.  George  E.  Gask. 

TINEA,  VARIETIES  OF. — (See  Fungous  Affections  of  the  Skin.) 

TINNITUS  is  a  symptom  which  occurs  in  a  large  proportion  oi  cases  of  disease 
of  the  ear,  and  occasionally  when  there  is  no  obvious  lesion  of  the  auditory 
mechanism.  The  sounds  complained  of  are  usually  subjective,  but  they 
may  occasionally  have  an  objective  origin.  Tinnitus  may  be  continuous  or 
intermittent.  Its  intensity  and  character  vary  greatly  in  different  patients  ; 
to  some  it  is  an  intolerable  annoyance,  and  occasionally  has  even  been  the 
cause  of  suicide.  The  character  of  the  sound  should  always  be  ascertained,  as 
this  may  give  some  clue  to  the  cause.  Thus  a  pulsatile  or  rhythmical  sound 
may  be  produced  by  the  flow  of  blood  through  the  internal  carotid  artery, 
which  in  its  course  through  the  carotid  canal  is  separated  from  the  tympanum 
only  by  a  thin  plate  of  bone,  which  may  be  deficient.  A  creaking  noise  may 
be  produced  by  cerumen,  or  a  foreign  body,  in  the  external  auditory  meatus. 
A  bubbling  noise  may  be  due  to  the  presence  of  exudation  in  the  middle  ear, 
the  result  of  catarrhal  inflammation.  A  cracking  or  clicking  sound  may  be 
caused  by  spasmodic  contraction  of  the  dilatator  tubas  and  salpingopharyngeus 
muscles  which  are  attached  to  the  Eustachian  tube.  When  the  character  of  the 
sound  is  described  as  humming,  hissing,  roaring,  whistling,  or  musical,  its  origin 
is  subjective,  and  is  due  to  some  irritation  of  the  auditory  nerve,  rarely  cerebral 
or  in  its  course,  but  usually  at  its  terminations  in  the  lab\Tinth. 

A  distinction  must  be  made  between  tinnitus  and  hallucinations  of  hearing, 
the  latter  usually  taking  the  form  of  hearing  voices,  and  indicating  mental 
trouble,  usually  of  a  serious  nature.  Tinnitus,  however  caused,  is  usually 
influenced  markedly  by  the  general  health  and  environment  of  the  patient. 
Thus,  sometimes  the  noises  are  less  marked  when  the  patient  is  in  the  open  air, 
when  his  attention  is  occupied  by  other  matters,  or  when  the  sense  of  hearing 
is  occupied  by  listening  to  objective  noises.  Similarly,  the  trouble  may  only 
be  present  at  night,  but  may  appear  in  the  day-time  if  the  patient  closes 
the  external  auditory  meatus  with  his  finger.  Generally  speaking,  tinnitus 
becomes  less  marked  and  more  bearable  when  the  general  health  of  the  patient 
is  good,  and  increases  when  the  sufferer  is  out  of  health  or  overworked,  either 
mentally  or  physically.  Working  in  close,  stuffy  rooms,  or  in  proximity  to 
noisy  machinery,  over-indulgence  in  alcohol,  and  excessive  smoking,  have  a 
bad  effect  ;  in  women  the  trouble  may  be  increased  during  pregnancy,  men- 
struation, or  the  menopause. 

Though  tinnitus  is  very  common  in  diseases  of  the  ear,  yet  serious  lesions 
of  the  middle  ear,  internal  ear,  or  auditory  nerve,  may  be  present  without 
this  symptom.  There  is  no  constant  relation  between  tinnitus  and  deafness. 
The  former  may  be  present  with  perfect  hearing,  but  when  long  continued  the 
hearing  nearly  always  becomes  impaired.  The  sounds,  too,  may  persist  when 
the  patient  has  become  totally  deaf. 

Tinnitus  may  occur  in  the  following  diseases  of  the  ear  : — 

1.  The  presence  of  cerumen,  aural  polypi,  or  a  foreign  body  in  the  external 
auditory  meatus.  Removal  of  the  offending  body  will  in  this  case  probably 
lead  to  the  cessation  of  the  tinnitus. 

2.  In  any  inflammatory  disease,  acute  or  chronic,  suppurative  or  nonsuppu- 
rative, of  the  middle  ear.  In  catarrhal  inflammation  of  the  middle  ear,  the  noise 
frequently  has  the  character  of  bursting  bubbles,  and  is  due  to  movements 
of  the  viscid  exudation  in  the  ear  itself.       In    otosclerosis,  tinnitus  is  a  very 


794  TINNITUS 


prominent  and  usually  early  symptom.  It  may  occur  before  any  alteration 
in  hearing  is  present. 

3.  In  diseases  of  the  internal  ear,  tinnitus  is  especially  liable  to  occur  in 
a  severe  and  intractable  form.  Thus,  it  is  especially  likely  to  be  present  in 
Meniere's  disease,  syphilitic  disease  of  the  internal  ear,  and  in  those  lesions  of 
the  internal  ear  which  may  arise  in  the  course  of  typhoid  and  other  specific 
fevers.  Extension  of  suppuration  to  the  labyrinth  from  the  middle  ear  is  also 
an  important  cause  ;  and  it  may  be  present,  usually  associated  with  deafness, 
after  a  fracture  of  the  base  of  the  skull. 

Tinnitus  has  been  recorded  as  occurring  in  a  cerebral  tumouv  involving  the 
roots  of  the  auditory  nerve,  but  this  is  a  very  unusual  condition. 

"  Noises  in  the  ears  "  may  be  present  in  a  considerable  number  of  general 
diseases,  either  with  or  without  a  lesion  of  the  ear.  Thus,  it  is  frequently  present 
in  ancsmia,  and  in  diseases  such  as  leukcBmia  or  pernicious  ancemia,  in  which 
anaemia  is  a  prominent  symptom. 

Some  cardiac  lesion,  especially  aortic  regurgitation,  may  be  found  in  the 
pulsatile  variety  of  tinnitus,  treatment  of  which  may  lead  to  the  disappearance 
of  this  symptom.  Gout,  chronic  nephritis,  and  arteriosclerosis  with  high  blood- 
pressure,  may  also  be  responsible  for  tinnitus,  and  it  may  occur  during  attacks 
of  migraine.  Sometimes  it  has  apparently  a  reflex  origin,  being  associated  with 
neiu"algia  or  digestive  disturbances.  Malaria  may  also  be  a  cause,  though 
here  the  trouble  is  likely  to  be  the  result  of  large  doses  of  quinine.  Other  drugs 
likely  to  cause  the  trouble  are  salicylates  and  antipyrine. 

It  must  be  remembered  that  tinnitus  may  be  an  exceedingly  severe  symptom, 
and  that  patients  not  infrequently  present  themselves  for  treatment  on  this 
account  rather  than  for  any  coexistent  deafness.  Philip  Turner. 

TREMOR  occurs  when  the  normally  continuous  contractions  of  a  muscle  at 
work,  or  the  normally  uniform  tone  of  a  muscle  at  rest,  are  replaced  by  a  succession 
of  separately  perceptible  muscular  twitches.  In  these  circumstances,  a  movement 
which  is  normally  uniform  becomes  tremulous  ;  a  position  that  can  be  steadilj' 
maintained  under  normal  conditions  is  now  kept  unsteadily  or  shakil}-. 

The  normal  muscular  contraction  is  due  to  the  discharge  of  a  rhythmic  series 
of  nervous  impulses  from  the  motor  neurons  that  govern  the  muscle.  It  is 
estimated  that,  in  health,  from  five  to  fifty  such  nervous  impulses  leave  the 
motor  nerve-cells  and  reach  the  contracting  muscle-fibres  every  second,  the 
actual  number  per  second  varying  in  different  motor  neurons,  and  also  in  the 
same  neuron  according  to  its  temporary  condition  of  nutrition  or  fatigue.  It 
is  when  the  number  of  nervous  impulses  received  per  second  by  the  contracting 
muscle-fibres  becomes  low,  that  steady  and  apparently  uniform  muscular  con- 
tractions are  likely  to  be  replaced  by  tremors. 

Tremors  are  of  very  various  periods,  amplitudes,  and  general  characters  in 
different  cases.  Their  physiology  and  pathology  are  not  at  present  fully  under- 
stood, so  that  it  is  not  yet  possible  to  classify  them  etiologicalh'.  From  a  clinical 
point  of  view  they  may  be  classified  roughly  in  accordance  with  their  more 
obvious  physical  characteristics — their  fineness,  periodicity^,  regularit}^,  and 
the  circumstances  that  favour  or  inhibit  their  production.  But  it  must  be 
understood  that  an  unbroken  series  of  graduated  tremors  can  be  traced  in  various 
diseases,  passing  by  imperceptible  degrees  from  the  rapid  and  minute  oscillations 
observed  in  paral3'sis  agitans  to  the  extremely  coarse  and  irregular  movements 
composing  the  intention-tremor  of  disseminated  sclerosis.  A  similar  variety  of 
regular  tremors  may  be  observed  sometimes  in  a  normal  person,  as  the  tempera- 
ture of  his  body  falls  from  exposure  to  cold,  or  during  the  occurrence  of  a  rigor. 
Hence  a  rigid  clinical  classification  of  tremors  is  impossible. 


TREMOR 


795 


Mercury- 
Lead 


Classification. 
Fine  Tremor. 

Exposure  to  cold,  nervousness,!         Chronic  intoxications,  e.g.,  by — 
emotion 

Muscular  fatigue  or  weakness 

Convalescence 

Congenital  and  familial  tremor 

Senile  tremor 

Paralysis  agitans 

General  paralysis  of  the  insane 

Graves'  disease 

Occupation  neurosis 
Unilateral  Fine  Tremor. 

Cerebral  tumour  Chronic  hemiplegia  Hysteria  Chorea. 

Coarse  Tremor. 

Exaggerated  degrees  j    Familial  and  hereditarj'    ,     Chronic  hemiplegia, 
of  fine  tremors         '  ataxias  i 


Chronic  intoxications,  e.g 

Alcohol  Cocaine 

Tobacco 

Absinthe 

Morphia 
High  pyrexia 
Hysteria 
Neurasthenia 
Railway  spine 
Ursemia. 


Congenital  cerebral  diplegia 
Some  cerebral  or  cerebellar  lesions. 


Intention  Tremor. 

Disseminated  sclerosis 
Hysteria 

Fine  Tremor. — This  consists  of  regular  oscillations  of  small,  amplitude  due 
to  alternating  contractions  in  antagonistic  muscles  or  groups  of  muscles,  repeated 
from  three  to  nine  times  per  second.  It  is  usually  most  marked  in  the  extremities, 
but  ma}'  also — as  in  old  age  and  in  paralysis  agitans — affect  the  head  and  neck. 
It  may  occur  only  when  some  movement  is  attempted  ;  or  it  may  continue  also 
when  the  patient  is  at  rest.  Fine  tremors  cease  almost  invariably  during  sleep  ; 
emotion  habitually  increases  them.  They  are  not  purposive  movements  ;  and 
should  be  distinguished  from  the  fibrillar  contractions  (see  Contractions)  of 
individual  muscle-fibres  or  muscle-bundles,  seen  in  some  degenerations  of 
muscular  tissue. 

Fine  tremors  occurring  in  consequence  of  cold,  nervousness,  excessive  emotion, 
convalescence,  and  muscular  fatigue  or  weakness,  are  matters  of  the  commonest 
daily  observation.  They  are  most  noticeable  in  the  upper  extremities,  although 
in  Homer's  time  the  lower  limbs  would  seem  to  have  been  most  seriously  affected. 
They  tend  to  pass  off  as  the  patient's  condition  of  mind  or  body  improves,  and 
should  occasion  little  trouble  in  diagnosis,  if  the  fact  of  their  existence  and 
frequent  occurrence  be  kept  in  mind. 

Congenital  and  familial  fine  tremors  occur  mostly  in  children  or  young  adults, 
mainly  in  the  hands  and  arms,  face,  or  tongue.  The  oscillations  are  often  absent 
while  the  patient  is  at  rest,  but  make  their  appearance  whenever  movement  is 
attempted,  and  are  increased  by  nervousness  or  emotion.  They  can  often  be 
suppressed  for  a  time  by  a  strong  effort  of  the  will,  and  in  many  instances  they 
disappear  as  the  child  grows  up,  or  the  adult  grows  older.  They  cause  practically 
no  inconvenience,  and  are  not  accompanied  by  any  other  abnormalities  in  the 
neuro-muscular  apparatus.  Their  diagnosis  should  be  made  plain  by  the  patient's 
past  personal  and  family  histories. 

Senile  tremor  and  paralysis  agitans  may  well  be  considered  together.  Senile 
tremor  comes  on  with  old  age  in  the  form  of  fine  regular  or  irregular  oscillations 
affecting  the  arms  and  the  head.  Both  sides  of  the  body  are  involved,  the  head 
is  involved  early,  and  the  tremor  ceases  during  repose  and  in  sleep.  The  muscles 
of  the  affected  parts  are  neither  rigid  nor  weak.  These  senile  tremors  must  be 
carefully  distinguished  from  the  tremors  of  paralysis  agitans,  or  Parkinson's 
disease,  a  progressive  and  far  more  serious  disorder.     In  paralysis  agitans,  the 


796  TREMOR 

tremors  are  of  several  varieties.  A  fine  oscillatory  to-and-fro  tremor,  with  from 
three  to  six  excursions  per  second,  affects  the  extremities  and  head  in  some  cases. 
In  others,  the  tremor  is  coarser,  rh\"thmical,  slower,  and  to  some  extent  purposive  ; 
in  tj-pical  instances  it  produces  the  alternating  movements  in  the  thumb  and 
index  finger  described  as  "  bread-crumbhng  "  or  "  cigarette-rolling."  These 
may  be  combined  with  more  irregular  movements  of  flexion  and  extension  at  the 
wrist,  pronation  and  supination  of  the  forearm.  The  progressive  development 
of  these  tremors  and  movements  is  often  characteristic  ;  beginning  in  one  hand, 
the  fine  tremor  may  spread  to  the  other  after  some  months  or  ^-ears,  and 
ultimatelv  the  lower  limbs,  the  head  and  neck,  the  lips  and  tongue,  and  even  the 
muscles  of  the  trunk,  may  become  involved.  As  a  rule,  the  movements  continue 
when  the  patient  is  sitting,  or  Ijing  at  rest ;  in  severe  cases  they  may  persist,  even 
during  sleep.  In  most  instances  they  can  be  lessened  by  an  effort  of  the  will,  and 
diminish  also  on  passive  or  voluntary-  movement.  If,  on  the  other  hand,  they 
increase  on  voluntary  movement,  a  tolerable  imitation  of  an  intention  tremor 
may  result.  They  are  augmented  by  emotion  or  excitement.  In  cases  of  some 
duration  a  weU-marked  coarse  shaking  of  the  arms  may  be  a  noticeable  feature  ; 
w^hUe  contractions  alternating  in  the  flexor  and  extensor  muscles  of  the  legs 
may  cause  the  feet  to  chatter  when  they  are  placed  on  the  floor  ;  the  thighs 
are  commonly  held  in  adduction. 

Paralvsis  agitans  is  characterized  by  other  signs  that  facihtate  its  diagnosis, 
and  the  chief  of  these  are  : — (a)  Muscular  rigidity,  causing  a  fixed,  expressionless 
facial  aspect  (see  Facies),  a  monotonous  voice,  a  bent  and  rigid  carriage,  and 
a  shuffiing,  hesitating  gait,  with  festination,  propulsion,  and  retropulsion. 
Festination  impUes  that  the  patient  in  walking  from  one  point  to  another, 
starts  with  slowness  and  difiicultv',  but  he  accelerates  as  he  goes  along,  much 
as  if  he  were  running  after  his  own  centre  of  gravity,  and  at  the  end  he 
may  even  faU  down  fonvards  unless  there  is  some  object  at  hand  for  him  to 
catch  hold  of.  Propulsion,  retropulsion,  and  the  rarely  observed  lateropulsion, 
are  terms  meaning  that  when  the  patient  is  standing  at  rest  and  is  sent 
off  with  a  vigorous  push  to  walk  forwards,  backwards,  or  sideways,  the 
same  acceleration  and  procHvit}-  to  faU  down  at  the  end — forwards,  back- 
wards, or  sideways — are  observed.  (b)  Muscular  weakness  of  the  tremulous  or 
rigid  parts.  (c)  ParcesthesicB,  such  as  aching  pains  about  the  Umbs  or  bod}-, 
flushes  of  heat  or  cold.  The  sphincters  and  mental  faculties  are  not  affected 
in  paralysis  agitans,  while  the  deep  reflexes  are  usually  normal,  but  may  be 
increased.  It  must  not  be  forgotten  that  cases  of  Parkinson's  disease  occur,  in 
which  tremor  is  absent ;  the  presence  of  the  other  signs  mentioned  above, 
however,  should  suffice  for  its  recognition.  Bilateral  cortical  degeneration,  with 
its  slowlv  increasing  rigidity,-  and  muscular  Aveakness,  and  its  set  facial  expression, 
may  resemble  paralysis  agitans  ;  but  it  is  accompanied  by  progressive  mental 
failure,  increase  of  the  deep  reflexes,  sphincter  troubles,  and  the  other  evidences 
of  cortical  degeneration. 

The  tremor  of  certain  tvpes  of  general  paralysis  of  the  insane  is  a  fine,  irregular 
oscillation,  often  with  a  twitching  character.  It  first  appears  in  the  hands  and 
arms,  and  mav  spread  till  it  is  conspicuous  in  the  tongue,  lips,  and  face,  when  it 
is  associated  with  the  characteristic  changes — slowness  and  blurring — in  the 
speech.  For  the  most  part  this  tremor  occurs  on  exertion  ;  it  varies  in  extent, 
and  may  almost  disappear  during  periods  of  general  improvement.  In  the 
later  stages  of  the  disease  a  coarse  universal  tremor  sets  in,  combined,  perhaps, 
with  grinding  of  the  teeth.  In  these  patients  the  moral  and  intellectual  changes, 
tottering  gait,  alterations  in  the  tendon-  and  pupil-reflexes,  and  other  phenomena 
of  general  paralysis,  will  probably  not  escape  attention. 

In  Graves'  disease  a  fine,  regular,  and  rapid  tremor,  about  eight  to  the  second, 


TREMOR  797 


on  exertion,  is  one  of  the  cardinal  signs.  It  affects  the  arms  and  hands  most, 
less  often  the  legs  ;  and  it  is  increased  by  movement  or  by  excitement.  In 
addition,  attacks  of  trembling  that  affect  the  whole  body  may  occur.  It  is  only 
in  aggravated  cases,  however,  that  these  tremors  are  so  severe  as  to  interfere 
with  the  customary  employments  of  the  hands.  The  tremors  of  Graves'  disease 
are  likely  to  be  of  comparatively  sudden  onset,  and  the  patient  will  generally 
exhibit  many  of  the  other  prominent  signs  or  symptoms  of  hyperthyroidism, 
such  as  thyroid  enlargement,  exophthalmos  and  the  other  ocular  phenomena, 
tachycardia,  attacks  of  palpitation,  wasting,  sweating,  or  mental  changes,  so 
that  the  diagnosis  ought  not  to  be  difficult. 

Fine  tremors  are  frequently  observed  in  many  of  the  chronic  intoxications, 
particularly  those  due  to  alcohol,  absinthe,  lead,  mercury,  nicotine,  carbon 
disulphide,  morphine,  cocaine,  and  many  other  organic  compounds  that  may 
be  taken  in  excess  in  rare  cases,  whether  intentionally  or  by  accident.  Alcoholic 
tremor  is  fine,  regular,  and  rapid  ;  it  is  well  shown  in  the  outspread  fingers  of  the 
extended  hand  and  in  the  feet.  In  many  cases  it  can  be  felt  by  the  observer's 
hand  more  readily  than  it  can  be  perceived  by  his  eye  ;  or  it  may  be  rendered 
more  conspicuous  by  laying  a  sheet  of  paper  on  the  backs  of  the  outspread 
pronated  fingers  and  hand.  It  is  absent  during  rest,  and  is  increased  by  move- 
ment, excitement,  or  fatigue.  It  may  also  affect  the  tongue,  lips,  and  facial 
muscles,  taking  the  form  of  a  rapid  and  rather  irregular  twitching,  increased  on 
exertion.  This  tremor  is  an  early  sign  of  alcoholism,  and  is  often  more 
marked  in  the  morning  hours,  when  it  is  due,  perhaps,  to  fatigue  and  want  of 
alcoholic  stimulation  ;  it  can  be  controlled  to  some  extent  by  the  will.  Asso- 
ciated with  it  is  a  certain  general  nervousness  and  jumpiness  ;  in  addition,  the 
patient  will  no  doubt  exhibit  some  of  the  other  signs  of  chronic  alcoholism — 
venous  stigmata  or  acne  rosacea  on  the  nose  and  face,  restlessness,  insomnia, 
gastric  disturbances — particularly  the  morning  vomiting  of  mucus  on  an  empty 
stomach — paraesthesia  and  weakness  of  the  extremities,  mental  and  moral 
deterioration,  and  so  forth.  If  the  main  facts  of  the  case  can  be  made  out, 
tremors  due  to  alcoholism  should  not  be  hard  to  diagnose.  A  history  of 
chronic  alcoholism  should  always  be  enquired  after  most  carefully,  both  from 
the  patient,  who  may  deny  it  in  toto,  and  from  the  patient's  friends,  who  may 
hasten  to  admit  more  than  the  facts  warrant.  This  is  of  importance,  because 
mere  nervousness  at  the  prospect  or  realization  of  an  interview  with  a  medical 
man,  will  often  bring  on  a  fine  but  temporary  tremor,  indistinguishable,  for 
the  time  being,  from  the  lasting  fine  tremor  of  the  heavy  drinker.  If  such  a 
tremulous,  but  teetotal,  patient  has  indigestion  and  acne  rosacea,  and  repudiates 
any  veiled  suggestion  of  alcoholism  with  apparently  unnecessary  warmth,  there 
is  some  danger  lest  these  evidences  should  be  taken  as  confirming  the  apparently 
natural,  but  erroneous,  diagnosis  of  alcoholism. 

The  tremor  of  mercurial  poisoning,  a  very  rare  complaint  nowadays,  is  at  first 
fine,  but  later  becomes  coarse  and  even  choreiform.  It  begins  in  the  face,  hands, 
and  arms,  and  may  spread  to  all  parts  of  the  body.  At  first,  it  is  brought  out 
only  by  excitement,  or  on  attempted  movement.  Later,  it  may  persist  even 
during  sleep,  and  speech  may  be  interfered  with  from  involvement  of  the  muscles 
of  the  tongue,  pharynx,  and  larynx.  Other  prominent  symptoms  of  mercurialism 
that  should  not  be  absent  are  profuse  salivation,  stomatitis,  anaemia,  and  cerebral 
symptoms  of  various  kinds.  Mercurial  tremors  may  have  to  be  diagnosed  from 
those  of  paralysis  agitans  or  disseminated  sclerosis. 

In  lead  poisoning  a  fine  tremor  of  the  affected  limb  is  sometimes  met 
with  in  cases  marked  by  paralysis.  The  oscillations  may  also  be  seen  in 
the  tongue  and  lips,  particularly  in  the  rarer  instances  of  chronic  plumbism 
that  exhibit  cerebral   symptoms  and  simulate   general  paralysis  of  the  insane. 


798  TREMOR 


The  diagnosis  of  these  unusual  cases  would  be  difficult  unless  a  suspicion  of 
lead-poisoning  were  aroused,  either  by  a  history  of  exposure  to  the  intoxication, 
or  by  the  occurrence  of  other  and  well-known  signs  and  symptoms  of  piumbism  ; 
especially  anaemia,  blue-black  line  on  the  gums,  colic,  constipation,  and  dropped 
wrist. 

In  hysteria  the  clinical  picture  of  any  or  every  disorder  of  movement  or 
sensation  may  be  more  or  less  closely  reproduced  ;  and  tremors  of  every  variety 
m.ay  be  met  with  in  hysterical  patients.  The  diagnosis  may  be  extremely 
difficult  until  hysteria  is  suspected,  when  it  may  be  confirmed  by  the  discovery 
of  signs  and  symptoms  that,  singly  or  together,  are  pathognomonic.  Such  would 
be  the  occurrence  of  hysterical  fits  ;  of  hemiansesthesia,  or  of  anaesthetic  or 
paraesthetic  areas,  varying  from  day  to  day,  and  not  corresponding  with  the 
known  distribution  of  the  peripheral  nerves  ;  of  flaccid  or  spastic  paralyses,  that 
change  from  time  to  time  with  great  suddenness,  and  perhaps  vanish  when  the 
patient  believes  herself  to  be  no  longer  under  observation  ;  of  emotional  out- 
bursts and  psychical  changes.  Certain  symptoms  are  so  characteristic  that  they 
have  been  labelled  as  hysterical  :  such  as  the  hysterical  aphonia  due  to  bilateral 
adductor  paralysis  ;  the  globus  hystericus,  or  sensation  of  choking  due  to  the 
rising  of  a  ball  into  the  throat  ;  the  clavus  hystericus,  a  peculiar  vertical  headache 
that  feels  as  if  it  were  due  to  a  nail  driven  into  the  top  of  the  head.  The  diagnosis 
of  hysteria  should  never  be  made  lightly  ;  but  only  after  a  careful  consideration 
of  the  history,  signs,  and  symptoms,  and  when  all  evidences  of  organic  disease 
have  been  looked  for  and  found  wanting.  Unless  a  careful  examination  be  made, 
the  tremor  of  intracranial  tumour,  for  example,  or  of  disseminated  sclerosis,  may 
be  wrongly  diagnosed  as  hysterical. 

Unilateral  Fine  Tremor  is  but  rarely  seen.  It  may  be  a  hysterical  manifestation, 
functional,  and  significant  of  no  underlying  lesion  of  the  central  nervous  system  ; 
the  diagnosis  of  hysterical  tremor  has  been  considered  immediately  above. 
Unilateral  tremor  may  occur  in  tumour  of  the  frontal  region  of  the  brain  ;  if  present, 
it  occurs  in  both  arm  and  leg,  and  only  on  the  same  side  of  the  body  as  the 
tumour.  The  patients  will  often  exhibit  mental  changes,  such  as  inattention, 
incoherence,  loss  of  memory,  alterations  in  character  ;  sometimes,  too,  irritative 
phenomena  occur. 

Unilateral  fine  tremor  may  develop  on  either  the  same  or  the  opposite  side  of 
the  body  in  tumour  of  the  mid-brain  and  sub-thalamic  region.  The  general  sym- 
ptoms of  cerebral  tumour  will  be  present,  and  in  addition  certain  localizing  signs 
may  make  their  appearance.  The  chief  of  these  would  be  paralysis  of  the  third 
nerve,  loss  of  sensibility  over  the  area  supplied  by  the  fifth  nerve,  eccentric 
position  of  the  pupil,  defective  reaction  of  the  pupil  to  light,  and  weakness  of 
the  upward  movements  of  the  eyeballs. 

It  may  be  added  that  fine  tremors  occasionally  occur  in  the  paretic  limbs 
after  hemiplegia.  The  history  of  the  case  and  the  presence  of  other  signs 
characteristic  of  hemiplegia  should  make  the  diagnosis  here  a  comparatively 
straightforward  matter.  Fine  tremor  may  be  seen  in  chorea,  and  may,  of 
course,  be  unilateral  in  such  cases. 

Coarse  Tremor. — Coarse  tremors  may  be  developed  as  temporary  exaggera- 
tions or  later  developments  of  the  fine  tremors  occurring  in  several  of  the 
morbid  states  already  considered.  Thus,  when  the  body  is  thoroughly  chilled 
or  fatigued,  or  when  a  patient  is  in  a  rigor,  the  initial  fine  tremor  will  often  pass 
on  into  a  very  coarse  tremor,  as  the  amplitude  of  the  involuntary  muscular 
contractions  increases,  their  rhythm  remaining  much  the  same.  The  fine  tremor 
of  paralysis  agitans  or  general  paralysis  may  similarly  grow  into  a  coarse  tremor  ; 
coarse  tremors  are  not  infrequently  seen  in  hysteria.  The  diagnosis  in  all  these 
cases  must  be  made  on  the  lines  already  indicated. 


TREMOR 


799 


Coarse  tremor  is  met  with  sometimes  in  the  various  forms  of  familial  and 
hereditary  ataxia.  Thus  in  Friedreich's  disease,  in  addition  to  the  intention 
tremor  considered  below,  irregular  involuntary  motions,  described  as  coarse 
tremors  in  some  cases,  as  choreiform  in  others,  take  place  in  the  arms  while  the 
patient  is  at  rest.  Irregular  nodding  or  tremulous  movements  of  the  head  and 
trunk,  also  occur  in  advanced  cases  ;  the  muscles  of  articulation  and  of  the  face 
may  exhibit  irregular  purposeless  contractions  or  quiverings  when  conversation 
is  attempted.  In  spmo-cerebellar  ataxia,  irregular  choreiform  movements,  or 
constant  tremors,  large  and  small,  may  be  seen  in  the  head,  trunk,  and  limbs, 
whenever  the  attempt  is  made  to  hold  them  steady,  but  unsupported.  Similar 
disturbances  have  been  recorded  in  cerebellar  ataxia  and  in  the  olivo-ponio- 
cerebellar  atrophy  of  Dejerine  and  Thomas.  In  all  these  conditions  the  ataxia 
is  the  prominent  symptom,  the  coarse  tremor  being  no  more  than  an  occasional 
epiphenomenon  ;  the  diagnosis  between  them  must  be  sought  in  special  manuals, 
and  also  under  the  heading  Ataxy  {q.v.). 

The  coarse  tremor  of  the  affected  limbs  seen  in  patients  with  chronic  or  spastic 
hemiplegia  or  diplegia,  and  in  some  other  cerebral  disorders,  is  a  variant  of  the 
athetoid  or  choreiform  movements  that  are  characteristic  of  those  conditions. 
They  are  considered  under  the  heading  Convulsions  {Paramyoclonus  multiplex) . 
As  has  been  mentioned  already,  it  is  practically  impossible — were  it,  indeed, 
desirable — to  draw  any  hard-and-fast  line  between  the  grosser  fine  tremors  and 
the  finer  coarse  tremors.  In  the  same  way,  coarse  tremors  merge  insensibly 
into  the  lesser  degrees  of  athetotic  and  choreiform  convulsions. 

Intention  Tremor — known  also  as  action  or  volitional  tremor — has  been  defined 
as  tremor  produced,  or,   if  not  produced   at   least  exaggerated,  by  voluntary 

movements.     These  tremors  affect  the  upper  extremities,  and  sometimes  the 

head  and  trunk  also  ;    the  limb 

is  quiet  when  not  in  actual  use, 

but  as  soon  as  voluntary  move- 
ment is  attempted  irregular  and 

involuntary    to-and-fro    motions 

begin  in  it,  and  are  superadded 

to      the      intended     movement. 

These  to-and-fro  motions  become 

more    marked,     and    sometimes 

more     rapid     the     more    nearly 

achievement      of      the      desired 

movement      is     reached.       The 

greater  the  amount  of  precision 

demanded     by      the     voluntary 

action,  the  greater  becomes  the 

amplitude  of    these   involuntary 

excursions.     Wishing    to    drink, 

the    patient    may    lift    the    cup 

from  the  table  steadily  enough  ; 

but   as  the   cup  approaches  his 

lip,  the  involuntary  movements 

appear  and  rapidly  increase  till  its  contents  are  jerked  wildly  in  all  directions 

as  it  reaches  his  mouth.     The  tremor  may  spread   from  the  muscles  that  are 

being  put  into  action,  and  cause  extensive  jerky  movements  of  the  head  and 

trunk.     The   pathogeny  of    intention  tremor  is    obscure.     Very  possibly  it  is 

due  to  destruction  of  the  short  intersegmental  nerve-fibres  in  the  substance  of 

the  spinal  cord.     The  destruction  of  these  fibres  would  render  impossible  the 

accurate  mutual  adjustment  of  the  contractions  of  antagonistic  muscle-groups 


F70.  205. —  Movements  in  intention  tremor. 


-Movements  in  ataxy. 

The  dotted  lines  show  the  direction  of  the  movement 
attempted. 


8oo  TREMOR 

that  is  essential  lor  the  smooth  performance  of  even  the  simplest  willed 
movements. 

Intention  tremor  is  one  of  the  most  characteristic  features  of  disseminated 
sclerosis.  The  arms  are  most  often  and  most  markedly  affected  ;  but  careful 
observation  wiU  often  show  that  none  of  the  voluntary  muscles  escape  in\'oh-e- 
ment.  The  head  may  oscillate  whenever  the  patient  is  holding  it  up  ;  the  trunk 
may  exhibit  jerky  movements  whenever  he  sits  or  stands  ;  and  the  legs  whenever 
he  stands  or  walks,  after  the  disease  has  made  some  progress.  Disseminated 
sclerosis  has  been  carefully  studied  of  late  years,  and  has  sho^^■n  itself  to  be  a 
protean  disorder.  Typical  examples,  however,  may  be  recognized  by  the 
occurrence  of  intention  tremor  [Fig.  205),  muscular  rigidits^  n^-stagmus,  pallor 
of  the  optic  discs,  and  staccato  or  scanning  speech.  The  deep  reflexes  are 
increased  ;  the  gait  is  spastic  or  ataxic ;  Babinski's  sign  is  present ;  subjective 
sensorv  signs  are  far  commoner  than  objective  :  and  control  over  the  sphincters 
mav  sometimes  be  impaired  fairly  early  in  the  disease.  In  manj^  instances, 
however,  some,  or  even  many,  of  these  characteristics  are  absent ;  the  diagnosis 
of  disseminated  sclerosis  may  then  be  far  from  easy,  especiall}'  in  its  early  stages. 
In  hysteria,  for  example,  intention  tremor  ma}'  occur  in  just  the  same  wa}'  as 
a  fine  or  a  coarse  tremor  may  ;  and  other  points  of  correspondence  between 
hysteria  and  disseminated  sclerosis  may  often  be  found  in  the  age  and  sex  of 
the  patient,  in  the  remittent  course  pursued  by  either  of  the  disorders,  in  the 
frequent  occurrence  and  partial  recovery  of  various  parah'ses  and  of  amblyopia 
with  contraction  of  the  visual  fields,  and  in  exaggeration  of  the  deep  reflexes. 
But  distinct  differences  between  the  two  are,  fortunateh',  not  wanting.  In 
hysteria,  the  objective  senson,-  signs  are  weU  marked,  the  optic  discs  are  not 
affected,  nystagmus  is  absent,  Babinski's  sign  probabh*  never  occurs,  and  control 
over  the  sphincters  is  not  lost.  Attention  to  these  points  should  suffice  to 
clear  up  the  diagnosis  between  hysteria  and  disseminated  sclerosis  ;  but  in  the 
earhest  stages  of  the  latter  it  ma\'  be  necessary  to  keep  the  patient  under 
observation  for  some  little  time  before  a  definite  opinion  can  be  pronounced. 
Intention  tremor  has  also  been  described  as  an  exceptional  feature  in  patients 
suffering  from  neurasthenia. 

An  intention  tremor  is  not  very  rare  in  the  familial  and  hereditary  ataxias, 
among  which  may  be  mentioned  Friedreich's  disease  and  cerebellar  ataxy  ; 
but  the  disturbance  of  movement  in  these  disorders  is  characteristically  an 
Ataxy  [q.v.). 

It  is  necessary  to  refer  briefl}-  to  certain  intracranial  conditions  in  which 
intention  tremor  occasionally  or  exceptionalh-  occurs.  The  congenital  or  acquired- 
cerebral  diplegia  of  backward  or  mentally  defective  children,  occasionally  appear- 
ing as  a  familial  disease,  and  characterized  by  bilateral  spastic  paralysis  affecting 
the  limbs,  or  limbs  and  body,  is  sometimes  associated  with  intention  tremor. 
It  is  athetosis  [vide  supra)  that  is  characteristic  of  these  cases  ;  but  disordered 
movements  of  all  sorts  occur  in  them.  In  addition,  the  sphincters  are  commonlv 
affected,  the  deep  reflexes  are  increased,  optic  atrophy  or  inequaUty  of  the 
pupils  are  frequently  found  ;  and  if  the  patient  is  able  to  get  about,  a  spastic 
or  "  scissor  "  cross-legged  gait  is  to  be  seen.  A  congenital  cerebral  diplegia 
in  which  the  spastic  weakness  is  most  marked  in  the  legs,  is  described  as  a 
case  of  Little's  disease.  The  intention  tremor  occurring  in  birth  palsy  or  in 
infantile  hemiplegia  has,  unfortunately  enough,  been  described  under  the  name 
chorea  spastica. 

Intention  tremor  has  also  been  recorded  in  a  few  instances  of  lesion  of  the 
superior  cerebellar  peduncle,  corpora  quadrigemina,  or  optic  thalamus,  particularly 
when  the  tegmentum,  red  nucleus,  and  rubro-spinal  tract  are  involved.  It  may 
be  noted  in  patients  with  so-called  extra-cerebellar  tumours  growing  in  connection 


TRISMUS  80 1 


with  the  eighth  nerve,  and  occupying  the  posterior  fossa  of  the  skull  between  the 
pons  and  cerebellum.  It  is  seen  in  a  certain  proportion  of  the  cases  of  cere- 
bellar atrophy,  whether  the  degeneration  is  primary  parenchymatous,  progressive 
and  due  to  interstitial  and  vascular  lesions,  or  acute  and  following  some  acute 
specific  fever.  Intention  tremor  is  also  present  in  some  patients  with  olivo- 
ponto-cevebellar  atrophy.  The  diagnosis  of  these  rare  instances  will  naturally 
depend  upon  the  development  of  other  general  and  localizing  signs  of  intra- 
cranial disease.  A.  J.  J  ex-Blake. 

TRISMUS. — Trismus,  or  lockjaw,  signifies  a  maintained  closure  of  the  jaws  by 
tonic  muscular  spasm,  so  that  the  mouth  cannot  be  opened.  It  is  best  seen  in 
cases  of  tetanus.  The  term  does  not  include  mechanical  inability  to  open  the 
jaws  owing  to  such  affections  as  mumps,  alveolar  abscess  with  surrounding 
inflammatory  oedema,  angina  ludovici,  quinsy  or  severe  tonsillitis,  an  odontoma, 
epithelioma  of  the  mouth,  myositis  ossificans,  and  so  forth  ;  but  there  are  at 
least  two  mechanical  conditions  that  may  not  at  first  sight  be  obvious,  but 
which  may  lock  the  jaws  together  and  simulate  true  trismus — impaction  of  a 
wisdom  tooth,  and  arthritic  changes  in  the  temporo-maxillary  joint.  These  will 
be  diagnosed  as  the  result  of  a  careful  local  examination  of  the  teeth  and  of 
the  joint  respectively,  and  in  the  latter  case  there  maybe  osteo-arthritic  changes 
in  other  joints  also. 

Circumstantial  evidence  will  generally  serve  to  distinguish  trismus  due  to 
hysteria  or  to  facial  neuralgia  ;  and  if  there  is  any  doubt  as  to  the  nature  of  the 
case  at  first,  this  will  disappear  if  the  patient  can  be  watched  for  a  while.  If 
there  are  convulsive  seizures  in  a  hysterical  patient  with  trismus,  they  can 
generally  be  distinguished  from  those  due  to  tetanus  or  to  strychnine  poisoning 
by  their  polymorphous  character,  and  by  the  fact  that  touching  the  patient, 
and  other  similar  stimulation,  does  not  bring  them  on  so  certainly  as  would  be 
the  case  with  strychnine  or  tetanus. 

The  rigidity  of  the  face  muscles  that  may  be  found  in  certain  cases  of  tuberculous 
or  posterior  basal  or  cerebrospinal  meningitis  never  occurs  by  itself,  and  it  is  a 
minor  symptom  amongst  others  that  generally  point  to  the  correct  diagnosis. 
The  same  applies  to  epilepsy  and  to  uramia. 

Malingering  may  sometimes  take  the  form  of  lockjaw-,  and  it  ma}^  be  a  little 
while  before  the  fraud  can  be  detected  ;  sleep  is  sure  to  come  in  time,  and  as 
the  result  of  fatigue  the  malingerer's  muscles  relax  completely. 

Catalepsy  may  include  trismus  amongst  its  varieties  of  maintained  muscular 
contractions  ;  the  general  mental  symptoms  will  assist  the  diagnosis,  and  as  a 
rule  there  are  no  convulsive  seizures. 

Trichinosis  is  very  rare  nowadays,  but  if  infected  pork  is  eaten  raw,  or 
insufficiently  cooked,  the  larv^  of  the  parasites  find  their  way  to  many  different 
muscles,  and  they  show  some  predilection  for  those  of  the  tongue,  mouth,  and 
jaws.  The  resultant  irritation,  pain,  and  stiffness  cause  trismus,  whose  nature 
may  be  difficult  to  determine  unless  the  history  points  to  pork  as  the  origin. 
The  patient  is  very  ill  in  the  earlier  stages,  with  high  fever,  and  the  condition 
is  often  fatal.  There  may  be  an  epidemic  of  the  malady.  The  blood  exhibits 
marked  eosinophilia.  The  final  criterion  of  the  diagnosis  is  the  discovery  of 
the  typical  parasites  coiled  up  in  their  little  oval  cysts  amongst  the  affected 
muscle  fibres. 

Hydrophobia  and  tetany  seldom  exhibit  trismus  as  a  prominent  symptom. 
The  former,  though  it  is, almost  unknown  in  Great  Britain  now,  would  suggest 
itself  if  anj^  convulsive  illness  developed  after  a  definite  bite  by  a  dog,  wolf, 
or  other  similar  animal,  particularly  if  the  spasmodic  muscular  difficulty  was 
markedly  increased  by  efforts  at  swallowing.  The  symptoms  may  not  develop 
D  51 


8o2  TRISMUS 

for  weeks  or  months  after  the  bite,  so  that  the  patient  may  fall  ill  when  he  has 
come  home,  after  being  bitten  abroad.  Tetany,  also  rare,  is  at  once  dis- 
tinguished by  its  typical  carpo-pedal  contractions  {Fig.  i,  p.  3),  and  by  the 
fact  that,  though  it  may  be  severe  for  a  time,  it  does  not  kill.  It  is  apt  to 
follow  pregnane}',  or  operations  on  the  thyroid  gland,  or  to  be  associated 
with  gastrectasis.     A  mild  form  occurs  in  rickety  children. 

Strychnine  poisoning  gives  rise  to  generalized  twitchings  and  convulsions  long 
before  trismus,  the  lateness  of  the  development  of  the  latter  serving  to  distinguish 
it  from  tetanus.  There  may  be  evidence  of  strj^chnine  having  been  taken  or 
administered,  either  by  the  mouth  or  hj'podermically  ;  the  symptoms  develop 
very  acutely,  and  are  apt  to  be  rapidly  fatal. 

Tetanus  is  the  cause  par  excellence  of  trismus  ;  and  the  diagnosis  is  often 
obvious  enough  if  there  is  a  clear  historj^  of  an  illness  developing  steadily  in  an 
otherwise  healthy  person  or  new-born  infant,  starting  with  stiffness  of  the  neck 
muscles,  spreading  to  those  of  the  face  and  jaw,  and  thence  to  the  rest  of  the 
trunk  and  limbs,  with  a  tendency  to  extremely  painful  exacerbations  on  the 
slightest  stimulation,  even  by  a  stroke  with  a  feather  or  the  banging  of  a  door  ; 
risus  sardonicus  ;  opisthotonos  ;  no  complete  relaxation  of  the  stiffening  muscles 
unless  chloroform  is  given  ;  a  duration  of  da^'S  rather  than  hours,  and  a  termina- 
tion in  death  more  often  than  in  recovery,  especially  if  all  these  things  follow  a 
few  days,  or  a  week  or  more,  after  a  small  penetrating  wound  with  a  rusty  nail, 
or  a  piece  of  stick  or  other  similar  body  that  may  have  been  contaminated  with 
tetanus  bacilli  from  the  soil  (see  Plate  XII,  Fig.  T).  It  may  even  be  possible 
to  demonstrate  the  drum-stick  bacilli  in  films  prepared  from  the  deeper  parts  of 
the  wound.  The  chief  difficulty  arises  when  there  is  no  clear  history,  or  when 
the  wound  has  been  so  small  that  it  has  healed  or  cannot  be  found.  Even 
then,  most  cases  are  so  typical  that  they  can  be  diagnosed  as  tetanus  without 
much  difficult}'. 

Unnecessary  anxiety  arises  chiefly  in  cases  of  impacted  wisdom  teeth,  and  of 
hysteria,  where  tetanus  maj^  at  first  be  suspected,  though  the  subsequent  course 
of  the  malady  soon  serves  to  exclude  this.  Herbert  French. 

TUMOURS.— (See   Swellings.) 

TUMOURS  OF  THE  SKIN.— The  malignant  tumours  which  affect  the  skin 
include  carcinoma,  epitheUoma,  Paget's  disease,  sarcoma,  mycosis  fungoides, 
and  xeroderma  pigmentosum. 

As  a  rule,  cancer  en  cuirasse  and  nodular  (lenticular)  cancer  are  secondary  to 
cancer  of  the  breast  or  other  parts,  and  their  diagnosis  is  self-evident.  In 
7nslanotic  carcinoma  the  tumours  differ  greatly  in  size,  and  also  in  colour, 
varying  from  a  slate  tint  to  bluish-black  ;  they  appear  more  frequently  on 
the  genitalia  and  the  extremities  than  elsewhere.  The  only  condition  from 
which  melanotic  cancer  requires  to  be  distinguished  is  pigmented  sarcoma,  and 
for  this  histological  examination  is  necessary. 

Paget's  disease,  occurring  chiefly  in  women  after  the  age  of  forty,  begins  as 
a  reddening  of  a  patch  of  skin,  usually  on  or  around  the  nipple,  followed  by 
branny  desquamation.  Infiltration  soon  produces  a  bright-red,  granular, 
indurated  surface,  with  a  sticky,  yellowish  discharge,  which  by  forming  crusts 
ma}^  obscure  the  nature  of  the  lesions,  save  at  the  border,  which  continues  to 
be  characteristic — sharply  defined,  indurated,  and  sometimes  distinctly  raised. 
After  a  period,  which  is  usually  about  two  years,  but  may  be  much  longer, 
deep-seated  parts  may  become  affected,  this  extension  of  the  disease  showing 
itself  on  the  breast  by  retraction  and  induration  of  the  nipple  and  the  formation 
of  a  tumour  in  the  substance  of  the  eland.      In  the  earlv  stage  Paget's  disease 


TUMOURS     OF     THE     SKIN  803 

has  to  be  distinguished  from  chronic  eczema,  which  it  closely  resembles.  Its 
difl'erentiating  features  are  the  bright-red,  granular  surface  exposed  after  removal 
of  the  crusts,  the  induration  at  the  well-defined  edge,  the  intractability,  the  age 
of  the  patient,  and  (later)  the  retraction  of  the  nipple.  The  diagnosis  may  be 
made  certain  by  microscopic  examination  of  scrapings  in  iodized  serum  or 
liquor  potassae,  when  the  bright,  oval,  nucleated  bodies  styled  psorosperms 
will  be  seen,  some  still  contained  within  the  host-cells,  others  surroimded  by 
distinct  capsules. 

Epithelioma  begins  usually  as  a  single  growth,  superficial,  deep-seated,  or 
papillary,  but  all  the  forms  alike  are  marked  by  peripheral  extension,  infiltration 
and  destruction  of  neighbouring  parts,  central  ulceration,  and  (except  in  rodent 
ulcer,  for  which  see  Ulceration  of  Face)  a  tendency  to  the  formation  of 
secondary  growths  in  lymphatic  glands,  in  viscera  and  elsewhere.  Epithelio- 
mata  have  a  predilection  for  the  natural  orifices,  for  such  moist  parts  as  the 
glans  penis,  for  exposed  regions,  and  parts  exposed  to  friction  and  trivial 
injuries.  A  wart,  a  mole,  an  ulcer,  lupus  vulgaris  lesions,  or  an  A^-ray  cicatrix, 
may  be  the  starting-point.  If  the  tumour  begins  in  the  skin,  it  appears  first 
as  a  papule  ;  if  in  a  gland,  as  a  nodule.  In  the  former,  the  more  frequent 
case,  the  papule  becomes  firmer  and  extends  laterally  ;  infiltration  is  evidenced 
by  the  hard,  raised,  pearly  border.  Ulceration  occurs  in  the  centre  of  the 
growth  while  extension  is  proceeding  in  the  depths  and  at  the  sides.  If  the 
necrotic  process  involves  the  vascular  tissue,  there  is  more  or  less  haemorrhage. 
If  the  lateral  extension  predominates,  the  discoid  type  of  epithelioma,  as  in 
sweep's  cancer  of  the  scrotum,  is  the  result  ;  the  surface  is  raised,  with  a  steep 
border,  and  is  bright-red,  with  a  firm,  granular  surface.  If  the  granulations 
are  of  large  size,  the  growth  is  of  the  papillary  type.  The  chief  diagnostic 
features  of  epithelioma  are :  the  origin  as,  usually,  a  single  growth,  the  site,  the 
starting-point,  the  slight  discharge,  the  characteristic  border,  the  secondary 
growths  in  glands  and  elsewhere.  From  a  wart  or  a  mole,  epithelioma  can 
be  distinguished  conclusively  only  by  microscopical  examination  or  by  long- 
continued  observation,  and  should  signs  of  ulceration  or  crustation  appear  in 
such  growths,  epithelioma  should  be  suspected.  The  so-called  tubercular 
ulcerating  sj^philides  are,  as  a  rule,  multiple,  and  not  rounded,  but  rather 
segmental.  (For  the  diagnosis  of  epithelioma  from  lupus  vulgaris,  see  under 
Nodules.) 

Sarcoma  of  the  skin  is  most  frequently  secondary  to  growths  commencing 
in  the  lymphatic  glands  or  the  deeper  structures.  Sarcomata  vary  considerably 
in  colour,  from  reddish  to  brown  or  bluish-black,  and  also  in  consistence  ;  those 
of  the  spindle-celled  type  are  fairly  firm,  the  small-celled  ones  soft,  with  all 
intervening  grades  of  density.  They  may  appear  in  any  part  of  the  body, 
but  are  often  found  on  moles,  warts  and  ulcers.  The  diagnosis  usually  depends 
upon  histological  examination,  and  it  must  suffice  to  say  that  a  tumour  which 
arises  in  previously  healthy  skin,  or  in  a  mole  or  wart,  or  at  the  site  of  an  injury, 
which  is  soft  and  reddish  from  the  vascularity  that  is  a  marked  feature  of  this 
kind  of  tumour,  or  bluish  from  pigment,  and  which,  after  a  period  of  slow  growth 
rapidly  enlarges,  projects  above  the  surface,  and  readily  ulcerates  and  bleeds, 
is  probably  a  sarcoma. 

In  the  early  stage  of  mycosis  fungoides  the  lesions  are  dull  red  or  livid  patches, 
sometimes  slightly  tinged  with  yellow,  varying  in  size  from  the  area  of  a 
finger-nail  to  that  of  the  palm  of  the  hand,  with  border  sometimes  well  marked, 
sometimes  fading  off,  most  frequently  raised  or  thickened,  but  occasionally  flat. 
At  first  the  patches  are  smooth  and  dry,  afterwards  they  become  scaly,  and  later 
still  they  may  be  moist  or  covered  with  crusts.  Presently  the  surface  becomes 
infiltrated,  and  tumours  as  small  as  a  pea  or  as  large  as  an  apple,  firm  and 


8o4.  TUMOURS     OF     THE     SKIN 

lobulatedj  broader  at  the  free  than  at  the  attached  end,  and  somewhat  resem- 
bUng  tomatoes,  project  above  the  level  of  the  skin  ("  fungoides ").  As  a 
rule,  progressive  thickening  occurs,  leading  on  to  fungation.  The  l3Tnphatic 
glands  may  be  enlarged  throughout  the  bod3^  In  the  premycotic  or  eczematous 
stage — which  is  sometimes  absent — the  diagnosis  may  hesitate  between  mycosis 
fungoides  and  an  eczematous  or  urticario-eczematous  condition,  and  in  some 
cases  it  may  be  impossible  at  this  stage  to  distinguish  definitely  bet\veen  the 
two.  But  in  mj^cosis  fungoides  the  lesions  will  make  httle  response  to 
therapeutic  measures,  the  red  of  the  patches  may  be  slightly  tinged  with 
yellow,  and  they  are  naore  persistent  than  those  of  eczema.  The  only 
malignant  condition  which  mycosis  fungoides  in  the  mycotic  stage  at  all 
resembles  is  sarcoma,  but  there  is  seldom  an^'  difficulty  in  distinguishing 
between  the  two. 

The  initial  lesions  of  xerodermia  pigmentosum  (Kaposi's  disease)  are  small 
spots  resembling  freckles,  but  rather  darker,  which  appear  chiefly  on  the  face, 
neck,  arms  and  legs,  and  generally  begin  within  the  first  t%vo  years  of  Hfe. 
Usually  they  disappear  in  winter  and  return  in  summer ;  but  after  a  time  they 
become  permanent,  and  often  quite  black.  At  first  the  condition  suggests 
nothing  but  excessive  freckling,  but  presently  amid  the  "  freckles  "  appear 
white,  glazed,  atrophic  spots,  telangiectases,  and  superficial  ulcers  discharging 
pus  which  dries  into  j'^ellow  crusts.  After  some  years,  small,  wartj-looking 
growths  develop  on  the  "  freckles."  Tumours  now  form  and  ulcerate,  producing 
fungous  masses,  and  the  process  extends  both  widely  and  deeply,  and  destroys 
every  tissue  it  encounters,  not  excepting  bone.  It  is  only  in  the  earliest  stage 
that  there  can  be  anj^  difficult}^  in  recognizing  this  very  distinctive  disease.  In 
that  stage  it  may  be  mistaken,  as  is  suggested  above,  for  simple  lentigo,  from 
which  there  may  be  nothing  but  the  more  extensive  distribution  to  distinguish 
it.  With  the  appearance  of  the  later  lesions  lentigo  will  be  dismissed  from  con- 
sideration, and  it  should  be  not  less  easy  to  rule  out  sclerodermia. 

The  benign  tumours  of  which  the  diagnosis  may  be,  in  very  different  degrees, 
open  to  doubt,  are  sebaceous  and  dermoid  cysts,  fibroma  moUuscum,  von 
Recklinghausen's  disease,  neurofibromata,  myoma  cutis,  m^-xoma,  the 
xanthomas,  rhinoscleroma,  moUuscum  contagiosum,  colloid  milium,  benign 
adenoides  cysticum,  and  keratosis  follicularis. 

Sebaceous  cysts,  most  frequently  seen  on  the  scalp,  the  face,  and  the  back, 
rounded,  often  somewhat  flattened  on  the  top,  and  sometimes  as  large  as  an 
orange,  are  distinguished  from  fatty  tumours  by  the  absence  of  lobulation  and  the 
fact  that  the  sebaceous  contents  can  be  squeezed  out  w^hen  there  is  an  opening. 
Dermoid  cysts  may  resemble  fibromata,  but  if  they  are  incised  a  sebaceous- 
looking  material  escapes.  Fibroma  moUuscum,  a  pear-shaped  or  rounded  fibrous 
tumour,  usually  covered  by  smooth  skin  and  pedunculated,  varying  in  size 
from  a  pin's  head  to  an  orange,  and  nearly  always  multiple  {Fig.  201  p.  782), 
differs  from  a  sebaceous  cyst  by  its  solid  structure,  and  from  a  fatty  tumour 
by  its  usual  pedunculation  and  the  absence  of  lobulation.  Von  Reckling- 
hausen's disease,  of  which  the  lesions  consist  of  nodular  tumours,  on  and  around 
which  there  is  coffee-coloured  pigmentation,  is  differentiated  from  ordinary 
fibroma  in  that  the  tumours  are  composed  of  fibrous  and  nervous,  and  not 
simply  of  fibrous,  tissue.  There  is  also  a  perceptible  thickening  of  the  nerves 
of  the  arms.  N euro- fibromata,  which  have  their  origin  in  the  tendon-sheaths 
or  the  sheaths  of  the  nerve  fibres,  and  range  in  size  from  a  pin's  head  to  very 
large  dimensions,  are  sometimes  mistaken  for  rheumatic  nodules,  but  instead 
of  specially  affecting  the  region  of  the  elbows  and  the  scalp,  they  occur  on  the 
trunk  and  extremities  generallj^,  nor  is  there  (except  from  coincidence)  a  history 
of  rheumatism. 


TUMOURS     OF     THE     SKIN  805 

Superficial  myoma  cutis  occurs  in  the  form  of  nodular  tumours  on  the  arms, 
back,  chest,  and  cheek  ;  the  deeper  kind,  originating  in  the  subcutaneous 
muscular  structures,  occurs  as  a  solitary  tumour,  commonly  on  the  breasts  and 
genitals.  The  former  growths  are  soft  and  elastic,  and,  like  the  latter,  are 
often  painful.  The  distinctive  clinical  feature  of  mj^oma  cutis  generally  is  that 
it  contracts  under  the  influence  of  cold.  This,  with  the  pain,  the  absence  of 
any  tendency  to  ulceration,  and  the  aspect  and  slow  course  of  the  growth  or 
growths,  should  enable  the  affection  to  be  identified. 

Myxoma,  when  it  arises  in  the  skin — most  frequently  in  the  loose  skin  of  the 
scrotum  and  labia — usually  forms  rounded,  pedunculated,  translucent  tumours 
which  tend  to  enlarge  slowl3\  They  have  to  be  distinguished  from  molluscum 
contagiosiim.  This  begins  by  the  formation  of  small  growths  that  have  been 
likened  to  tiny  mother-of-pearl  shirt-buttons.  They  are  usually  flattened  at 
the  top,  where  as  a  rule  there  is  a  depression  in  which  can  be  seen  a  small 
aperture  leading  into  the  interior  of  the  tumour.  Through  this  orifice  a  whitish 
material,  or  sometimes  a  milky  fluid,  can  be  squeezed  out.  When  they  are 
very  small  the  tumours  resemble  the  vesicles  of  varicella,  but  a  microscopic 
examination  of  the  contents  will  obviate  the  confusion.  A  small  molluscum 
body  on  the  genitals  may  resemble  a  hard  chancre,  but  similar  growths  will 
be  found  elsewhere. 

Xanthoma  planum,  often  associated  with  jaundice  and  migraine,  and 
characterized  by  the  formation  of  yellow  or  yellowish- white  plaques  (rarely 
nodules),  usually  in  the  upper  eyelid  and  sometimes  affecting  also  the  lower 
lid,  is  easy  of  recognition,  the  appearance  of  the  yellow  patches  embedded  in 
the  corium,  and  almost  imperceptible  to  the  touch,  being  absolutely  distinctive. 
Xanthoma  multiplex,  however,  is  not  identified  quite  so  easily.  Here  the  lesions 
are  nearly  always  nodular,  and  often  observe  a  linear  grouping,  and  the  colour 
varies,  a  blackish  or  reddish  pigment  being  mixed  sometimes  wdth  the  yellow. 
Usually  the  nodules  occur  in  connection  with  hepatic  disease.  The  condition 
has  been  confounded  with  urticaria  pigmentosa,  but  there  is  no  itching,  there 
are  no  wheals,  and  it  is  impossible  to  produce  factitious  lesions.  The  tumours 
may  be  indistinguishable  from  multiple  dermoids  of  the  skin  until  microscopic 
examination  is  made.  Xanthoma  diabeticorum  differs  from  other  forms  of 
xanthoma,  inter  alia,  in  the  presence  of  a  raised  red  area  around  the  yellow 
spots.  This  feature  has  led,  in  the  early  stages  of  the  affection,  to  confusion 
with  acne,  but  if  the  lesions  are  punctured  they  will  prove  to  be  solid.  In  the 
same  stage  the  lesions  may  simulate  those  of  lichen  planus,  but  the  resemblance 
soon  disappears. 

Rhinoscleroma  begins,  usually  before  the  age  of  forty,  in  and  around  the 
nostrils  as  nodules  in  the  cutis,  and  in  the  deeper  layers  of  the  mucous  membrane. 
These  coalesce  to  form  a  hard,  smooth,  ghstening  growth  which  spreads  inwards 
from  the  lip  and  downwards  to  the  pharynx  from  the  posterior  nares.  The 
growth  does  not  break  down  spontaneously,  but  is  generally  slowly  progressive. 
It  is  not  likely  to  be  mistaken  for  anything  but  epithelioma,  which  is  prone  to 
ulcerate,  generally  has  infiltrated  edges,  seldom  attacks  the  upper  lip,  and  usually 
begins  later  in  life.  In  rhinophyma,  pustules  are  often  present,  the  growth  is 
soft,  and  there  is  vascular  dilatation. 

In  colloid  milium,  small,  yellow,  cyst-like  formations  containing  a  gelatinous 
substance  appear  in  the  skin,  chiefly  on  the  upper  part  of  the  face.  They  may 
become  depressed  in  the  centre  and  be  slowly  absorbed,  or  may  inflame  and 
dry  up.  The  only  condition  from  which  colloid  milium  needs  to  be  distinguished 
is  epithelioma  adenoides  cysticum,  in  which  the  tumours,  shining  and  translucent, 
contain  one  or  more  white,  brightly  refracting,  milium-like  bodies.  The  face 
is  the  part  most  frequently  attacked,  but  the  growths  may  appear  on  almost 


8o6  TUMOURS     OF     THE     SKIN 

any  part  of  the  bod)^     They  are  not  yellow,  like  the  growths  in  colloid  milium, 
nor  are  they  soft. 

Keratosis  follicularis  begins  as  small  brown  or  yellow  crusts,  hard  and  dry, 
which,  when  detached  from  the  underlying  tissue,  are  found  to  present  on  their 
under  surface  a  softish  prolongation  which  dips  into  a  follicle.  At  first  discrete, 
the  lesions  may  become  confluent,  and  there  is  thickening  of  the  affected  parts 
until  nodular  masses  are  formed,  from  which  oozes  an  offensive  discharge.  The 
affection  is  slowly  progressive.  At  the  outset  the  condition  may  be  mistaken 
for  keratosis  pilaris,  but  it  is  not  confined  to  the  situations  affected  by  that 
disease.  The  prolongation  into  a  follicle  gives  it  some  resemblance  to  molluscum 
contagiosum,  but  it  has  a  less  limited  distribution,  nor  have  the  growths  the 
pearl}^  appearance  of  the  molluscum  bodies,  while  the  aperture  in  the  individual 
lesions  is  larger.  Malcolm  Morris. 

TYMPANITES.— (See  Meteorism.) 

ULCERATION  OF  THE  CORNEA. — The  course  of  all  corneal  ulcers  conforms 
to  a  general  type,  though  the  chnical  varieties  may  vary.  The  process  begins 
with  an  infiltration  in  the  substance  of  the  cornea,  either  central  or  peripheral ; 
the  result  of  this  infiltration  is  a  local  loss  of  transparency,  though  in  early  stages 
the  surface  of  the  cornea  may  still  retain  its  polish.  The  infiltration  proceeds 
to  suppuration,  which  is  followed  by  a  loss  of  substance,  the  corneal  surface 
being  dull  and  irregular,  and,  in  the  centre  of  the  ulcer,  depressed  below  the  sur- 
rounding level.  The  base  of  the  ulcer  is  grey  or  yellowish,  and  the  surrounding 
portion  of  the  cornea  may  be  opaque  with  more  or  less  grey  infiltration. 

The  suppuration  is  followed,  in  cases  which  have  a  favourable  termination, 
by  vascularization,  superficial  vessels  from  the  surrounding  conjunctiva  encroach- 
ing on  the  cornea  and  invading  the  suppurating  area.  The  vascularization  is 
followed  by  cicatrization,  the  surface  of  the  cornea  again  becoming  pohshed  but 
flattened  and  opaque.  The  opacities  resulting  from  corneal  ulcers  are  localized, 
well  defined  and  opaque,  in  contrast  to  the  diffuse  indefinite  haze  which  follows 
such  non-suppurative  forms  of  inflammation  as  interstitial  keratitis.  Corneal 
ulcers  may  not  heal,  but  occasionally  lead  to  perforation  of  the  cornea,  prolapse 
and  adhesion  of  the  iris,  anterior  polar  cataract,  or  panophthalmitis.  Iritis, 
iridocyclitis,  and  pus  in  the  anterior  chamber  (hypopyon)  may  also  be  associated 
conditions.  The  usual  subjective  symptoms  are  pain,  photophobia,  and  lachry- 
mation.  The  presence  of  corneal  ulcers  is  demonstrated  most  satisfactorily  by 
the  instillation  of  a  drop  or  two  of  fiuorescin,  which  stains  necrotic  corneal 
epithehum  or  exposed  corneal  substance,  green.  The  brightly-stained  ulcer 
shows  up  in  marked  contrast  to  the  surrounding  clear  cornea. 

Corneal  ulcers  may  occur  in  the  following  clinical  varieties  : — 

Catarrhal,  or  simple  infective  ulcers.  These  usually  occur  as  minute  grey 
infiltrated  spots  in  the  centre  or  periphery  of  the  cornea.  They  heal  very  rapidly 
as  a  rule.  They  may  follow  injury  to  the  corneal  epithelium  by  foreign  bodies, 
or  may  be  associated  with  acute  conjunctivitis  or  rhinitis. 

Phlyctenular  ulcers  are  associated  with  phlyctenular  conjunctivitis,  the  ulcer 
forming  after  the  epithelium  on  the  top  of  a  phlyctenule  has  been  rubbed  off. 
They  are  usuall}^  marginal,  but  may  occasionally  make  their  way  on  to  the  cornea, 
a  leash  of  conjunctival  blood-vessels  trailing  after  them.  Similar  ulcers  may  be 
associated  with  acne  rosacea. 

Hypopyon  ulcer,  or  ulcus  serpens.  This  is  a  shallow  ulcer  affecting  chiefly 
the  superficial  layers  of  the  cornea,  in  or  about  its  centre.  The  middle  layers 
of  the  cornea  are  comparatively  unaffected,  but  at  the  posterior  surface  the 
infiltration  again  becomes  dense,  with  much  fibre  and  debris,  associated  with 


ULCERATION     OF     THE     CORNEA  807 

the  formation  of  more  or  less  pus  in  the  anterior  chamber.  The  ulcers  often 
perforate  ;  they  are  usually  due  to  infection  with  the  pneumococcus.  The 
pus  in  the  anterior  chamber  is  always  sterile,  unless  there  is  perforation  of 
Descemet's  membrane.  These  ulcers  do  not  react  to  ordinary  methods  of  treat- 
ment as  a  rule,  but  require  cauterization,  either  by  pure  carbolic  acid  or  the 
galvano-cautery.     The  hypopyon  then  disappears  rapidly. 

Mooren's  ulcer,  or  rodent  ulcer  of  the  cornea,  is  a  chronic  serpiginous  ulcer, 
usually  affecting  the  eyes  of  elderly  people.  It  begins  at  the  margin  of  the  cornea 
and  spreads  slowly  over  the  whole  surface,  the  advancing  edge  being  much 
undermined.  The  ulcer  is  always  shallow,  and  perforation  never  occurs  ;  the 
ulcer  may  heal  in  places,  but  this  is  seldom  permanent,  and  the  ulceration  usually 
spreads  over  the  whole  surface  of  the  cornea,  whatever  method  of  treatment 
nfiay  be  employed  to  arrest  its  progress,  though  recently  radium  has  been  used 
with  some  success.     No  specific  organism  has  yet  been  discovered. 

A  dendritic  ulcer  is  characterized  by  its  peculiar  shape — a  long  central  stem 
with  small  linear  ramiiications.  It  is  not  really  an  ulcer,  but  an  infiltration 
under  the  corneal  epithelium,  which  in  the  later  stages  may  become  necrotic  and 
break  down.  It  is  best  treated  by  rubbing  off  the  affected  corneal  epithelium 
with  a  pointed  stick  dipped  in  absolute  alcohol. 

Corneal  ulcers  may  occur  in  association  with  pannus  in  trachoma,  their  usual 
site  being  at  the  margin  of  the  vascular  area.  Occasionally  they  penetrate 
more  deeply  into  the  corneal  substance. 

Corneal  ulcers  frequently  follow  gonorrhceal  and  diphtheritic  conjunctivitis. 
They  spread  rapidly,  and  often  lead  to  perforation  of  the  cornea  and  panophthal- 
mitis. The  diagnosis  depends  on  bacteriological  methods  and  the  discovery 
of  the  causative  micro-organisms. 

Keratomalacia,  a  disease  of  childhood,  is  associated  with  night  blindness  and 
xerosis  or  dryness  of  the  conjunctiva.  Characteristic  foamy  white  patches  are 
seen  on  both  sides  of  the  cornea.  The  cornea  becomes  dull,  grey,  and  cloudy, 
and  ultimately  disintegrates  from  purulent  infiltration,  associated  with  very 
slight  signs  of  ocular  inflammation.  The  ocular  condition  is  associated  with 
marasmus  and  malnutrition.     The  prognosis,  both  as  to  eye  and  vision,  is  bad. 

Keratitis  e  lagophthalmo  is  associated  with  paralysis  of  the  seventh  nerve. 
Owing  to  the  failure  of  the  orbicularis  palpebrarum,  the  eye  cannot  be  closed, 
and  does  not  remain  closed  during  sleep.  The  lower  part  of  the  cornea  is  exposed, 
becomes  dry,  and  the  corneal  epithelium  dies,  with  consequent  ulceration  of 
the  cornea.  The  condition  can  be  cured  by  diminishing  the  palpebral  aperture 
by  sewing  the  eyelids  partially  or  completely  together. 

Similar  exposure  of  the  cornea  and  consequent  ulceration  is  seen  occasionally 
in  cases  of  Exophthalmos  (q-v.),  for  instance  in  severe  Graves'  disease. 

Keratitis  neuroparalytica.  In  paralysis  of  the  fifth  nerve,  or  as  a  result  of 
excision  of  the  Gasserian  ganglion,  the  cornea  becomes  dull  and  cloud}^  and 
necroses  in  the  centre,  only  the  periphery  remaining  clear.  A  hypopyon  forms, 
and  in  some  cases  the  whole  eye  is  destroyed,  though  occasionally  the  keratitis 
may  lead  only  to  a  permanent  opacity.  The  condition  is  due  to  arrest  of 
lachrymal  secretion  and  absence  of  corneal  sensation,  which  is  followed  by 
abolition  of  the  winking  reflex.  Foreign  bodies  lodge  on  the  cornea  and  are 
not  removed.     The  prognosis  is  bad,  and  is  little  affected  by  treatment. 

Corneal  ulcers  may  be  associated  with  herpes  jrontalis,  vesicles  forming  on 
the  cornea  simultaneously  with  the  vesicles  on  the  skin,  especially  along  the 
course  of  the  supraorbital  nerve.  The  ulceration  is  often  severe  and  may  lead 
to  perforation  and  destruction  of  the  eye,  and  is  in  any  case  followed  by  con- 
siderable corneal  opacity.  The  cornea  is  usually  insensitive,  and  the  intraocular 
tension  may  be  raised. 


8o8  ULCERATION     OF     THE     FACE 

Tuberculous  ulceration  is  not  common  fortunately,  but  it  should  be  borne  in 
mind  as  a  possibility  in  chronic  or  resistant  cases.  The  diagnosis  depends  on 
the  history,  the  presence  of  tuberculous  glands  or  other  similar  lesions,  positive 
reaction  to  the  various  tuberculin  tests,  and,  most  conclusively  of  all,  upon 
the  detection  of  tubercle  bacilli  in  the  discharge  from  the  ulcer  itself. 

Herbert  L.  Eason. 

ULCERATION  OF  THE  FACE,— The  ulcers  most  often  met  with  on  the 
face  are  lupous,  scrofulous,  syphilitic,  or  malignant.  In  lupus  vulgaris,  the 
ulceration  is  extremely  chronic.  The  lesion  begins  as  a  papule,  develops 
into  a  nodule,  and. after  a  while,  in  the  majority  of  cases,  the  lupous  tissue  breaks 
down  and  forms  a  granular  sore  covered  with  greenish-black  crusts  ;  but  around 
the  ragged  edge  will  still  be  seen  the  characteristic  "  apple- jelly  "  nodules  in 
different  stages  of  development.  The  ulceration  may  extend  through  the 
whole  thickness  of  the  skin  and  may  become  the  seat  of  warty  vegetations. 
In  the  nose,  where  the  integument  is  thin,  it  may  cause  necrosis  of  cartilage. 
The  course  the  pathological  process  runs,  from  the  papule  onwards,  as  here 
described,  and  the  frequent  presence  of  the  different  lesions  simultaneously, 
shed  sufficient  light  on  the  character  of  the  ulceration.  I  need  only  say  further 
that  the  ulcer  of  lupus,  however  deeply  it  may  extend,  never  erodes  bone.  This 
alone  is  sufficient  to  differentiate  lupus  from  the  ulcers  of  syphilis  and  cancer. 
It  nearly  always  begins  before  the  age  of  twenty. 

In  the  ulcers  of  scrofula,  though  they  have  no  absolutely  distinctive  characters, 
it  will  often  be  noticed  that  the  edge  is  undermined  and  the  surrounding  skin 
blue  and  of  low  vitality.  Their  occurrence  in  children  of  strumous  aspect,  or 
in  elderly  persons  who  bear  the  stigmata  of  scrofulous  lesions  dating  from 
childhood,  and  their  tendency  to  become  chronic  owing  to  the  feeble  resistance 
offered  by  the  tissues  to  morbid  processes,  leave  no  room  for  doubt  as  to  their 
true  nature. 

It  is  in  the  late  secondary  and  the  tertiary  stages  of  syphilis  that  cutaneous 
lesions  on  the  face,  as  elsewhere,  are  prone  to  ulceration,  instead  of  to  the 
resolution  to  which  typical  secondary  syphilides  tend.  The  whole  structure  of 
the  skin,  or  mucous  membrane,  is  frequently  involved,  the  ulceration  is  deep, 
and  frequently  the  ulcers,  while  healing  in  the  centre,  extend  at  the  margins, 
and  so  assume  the  characteristic  circinate  or  serpiginous  form.  The  appearance 
of  the  ulcers,  with  the  history,  and  the  marks  of  earlier  syphilitic  lesions,  will 
supply  all  the  guidance  the  diagnostician  needs  ;  Wassermann's  serum  test  and 
the  effects  of  mercury  and  iodide  of  potassium  may  serve  to  clinch  the  diagnosis. 

As  a  rule  rodent  ulcer  occurs  in  persons  of  more  than  middle  age,  and  its 
favourite  points  of  attack  are  the  outer  edge  of  the  orbit  and  the  side  of  the 
nose.  It  begins  as  a  small,  circumscribed  nodule,  dull  brownish- red  in  colour, 
flat,  depressed  in  the  centre,  and  firm  to  the  touch.  After,  it  may  be,  years, 
the  cuticle  covering  it  is  broken,  and  an  ulcer  with  depressed  granular  centre 
and  infiltrated  border  is  formed.  Very  slowly  this  extends,  both  in  circum- 
ference and  in  depth,  infiltrating  and  destroying  the  subjacent  tissues,  including 
bone.  Usually  the  destruction  of  the  underlying  parts  is  more  marked  in  the 
centre,  so  that  the  ulcer  becomes  crateriform.  Its  invariable  features — the 
inconsiderable  suffering  it  inflicts,  the  singular  slowness  of  its  progress,  its 
depressed  centre,  and  the  firm,  raised,  rolled  edge,  its  failure  to  affect  neighbouring 
glands,  and  its  incurability  except  by  extirpation  or  by  physiotherapy — are  so 
characteristic  as  to  leave  little  scope  for  diagnosis.  Epitheliomatous  in  structure, 
it  differs  from  epithelioma  in  that  the  latter  growth  has  a  very  hard  and  everted 
edge,  and  a  foul  base  roughened  with  granulation,  is  often  attended  by  severe 
pain,  is  much  more  rapid  in  its  course,  and  infects  the  glands  in  its  vicinity. 
(See  also  Tumours  of  the  Skin.)     It  differs  from  lupus  vulgaris  in  its  mode 


ULCERATION     OF     THE     FOOT 


809 


of  onset,  in  the  absence  of  the  "  apple-jelly  "  nodules,  and  in  not  being  a  disease 
that  stai'ts  in  childhood.  It  may  be  diagnosed  from  tertiary  syphilitic  ulcers  by 
the  characters  described  above,  and  also  by  its  usually  solitary  character  and  its 
resistance  to  treatment.  Malcolm  Morris. 

ULCERATION  OF  THE  FOOT.— The  ulcer  which  attacks  the  foot  specially, 
though  not  exclusively,  for  the  hand  may  be  affected  in  the  same  way,  is  that 
known  as  perforating  ulcer  {Fig.  207).  The  exciting  cause  is  pressure  upon  or 
injury  to  a  foot  in  which  there  is  interference  with  the  nerve  supply,  either  from 
peripheral  lesion,  as  in  peripheral  neuritis,  or  from  damage  to  the  nerve-trunk,  as 
in  leprosy,  syphilis,  or  diabetes  mellitus,  or  to  the  nerve-centre,  as  in  locomotor 
ataxy  and  general  paralysis.  The 
commonest  situation  of  the  ulcer 
is  at  the  point  of  greatest  pressure 
— the  ball  of  the  great  toe,  or  the 
under  aspect  of  the  metatarso- 
phalangeal joint  of  the  big  or  little 
toe.  The  ulcer,  which  is  more  of  a 
sinus  than  a  true  ulcer,  and  [  is 
usually  painless,  may  be  simple  or 
multiple,  and  both  feet  may  be 
affected.  It  often  begins  by  sup- 
puration under  a  corn.  When  the 
horny  covering  is  cast  off,  a  track 
is  seen  which  extends  downwards 
until  the  bone  is  exposed.  The 
process  is  usually  very  slow,  and  if 
the  pressure  from  walking  is  con- 
tinued the  thickened  epidermis 
forms  a  kind  of  corn-shield  around 
the  opening.  The  more  essential 
symptoms  of  the  neurotic  disorder 
of  which  perforating  ulcer  is  but 
an  incidental  manifestation,  will 
disclose  the  true  nature  of  the 
lesion.  The  only  malady  with 
which  it  can  be  confused  is  a 
suppurating  corn.  From  this  it  is 
distinguished  by  the  absence  or 
small  degree  of  pain,  and  by  its 
irresponsiveness  to  the  simple  sur- 
gical treatment  to  which  a  suppura- 
ting corn  readily  yields. 

Mycetoma  is  a  fungous  disease  that  is  known  alternatively  as  Madura  foot, 
because,  endemic  in  Madura  and  other  parts  of  India,  it  usually  affects  the  foot 
or  the  leg,  though  sometimes  the  hand,  and  in  rare  cases  the  shoulders  or  the 
scrotum.  The  affection  appears  in  several  forms,  according  as  they  are  due 
to  different  species  of  discomyces  and  aspergillus.  The  lesions  may  be  black 
("  melanoid  ")  or  pink  ("  ochroid  ").  The  disease  begins  with  slight  swelling 
and  redness  or  local  induration,  and  as  it  progresses  the  foot  swells  and  the 
swelling  surface  becomes  dotted  with  small  nodules,  each  containing  the  opening 
of  a  sinus  which  discharges  a  viscid,  syrupy,  slightljr  purulent,  sometimes  blood- 
streaked  fluid,  in  which  are  suspended  rounded  granules,  greyish  or  yellowish 
in  colour.      In  other  cases  the  granules  are  black,  at  first  resembling  gunpowder, 


Pig'.  207. — Perforating;   ulcer  of  foot  ;   from   a  case 
of  tabes  dorsalis. 


8io  ULCERATION     OF     THE     FOOT 

though  later  they  may  form  black  or  dark  brown  masses.  As  the  foot  enlarges, 
the  leg,  from  disuse,  atrophies.  The  only  condition  from  which  mycetoma 
needs  to  be  discriminated  is  actinomycosis.  This  affection  usually  begins  in  the 
bone  or  other  deep  structures  of  the  jaw,  face,  or  neck,  may  thence  spread  to 
the  surface,  and  may  involve  the  viscera.  In  the  discharge  the  ray  fungus 
may  be  found  in  the  form  of  tiny,  friable,  yellowish  or  greyish  bodies,  though 
microscopical  methods  and  the  discovery  of  the  characteristic  ray  fungi 
{Plate  XII,  Fig.  S)  will  generally  be  required  before  the  nature  of  the  case 
can  be  confirmed.  Malcolm  Morris. 

ULCERATION  OF  THE  LEG  may  be  classified  under  three  headings : — 
(i)  Non-infective  Ulcers. — These  include  those  that  are  not  due  to  any  specific 
infection,  but  which  are  caused  by  various  factors  which  interfere  with  the 
vitality  of  the  part  by  injury,  lack  of  circulation,  or  innervation  of  the  tissue. 
(2)  Infective  Ulcers  resulting  from  the  direct  action  of  a  definite  specific  infection, 
e.g.,  tuberculosis  or  syphilis.  (3)  Ulcerating  Tumours. — These  are  malignant 
tumours,  which  have  originated  in  or  invaded  the  skin. 

I.  Non-infective    Ulcers. —  Varieties  and  Causes. 

Varicose  Ulcer. — The  presence  of  varicosity  in  the  veins  of  the  leg  diminishes 
the  free  return  of  blood,  and  so  leads  to  congestion  and  interference  with 
nutrition,  and  thus  to  ulceration.  In  the  majority  of  cases  the  ulcer  is  situated 
on  the  inner  side  of  the  leg  about  three  inches  above  the  ankle.  It  may  be  small, 
or  may  encircle  the  limb.  For  some  distance  round  the  ulcer  the  skin  suffers 
from  the  effects  of  passive  congestion.  It  becomes  indurated  and  of  a  purplish- 
brown  colour,  and  numerous  small  varicose  veins  may  be  seen  in  it.  Any  slight 
injury  may  cause  an  abrasion  of  this  weakened  skin,  and  thus  another  ulcer 
be  formed.  On  a  patient  the  subject  of  a  varicose  ulcer,  the  scars  of  previous 
ulcers  are  frequently  found.  The  presence  of  varicose  veins  associated  with 
an  ulcer  will  usually  lead  to  the  conclusion  that  the  latter  is  dependent  on  the 
former,  and  that  view  will  probably  be  correct,  but  it  may  not  be  the  whole 
truth,  for  syphilitic  and  varicose  ulcerations  may  be  present  at  the  same  time. 
Before  the  introduction  of  Wassermann's  test  for  syphilis,  it  was  common  practice 
to  give  antisyphilitic  remedies  in  order  to  clear  up  the  diagnosis,  and  this  may 
still  be  done  when  the  serum  test  cannot  be  carried  out. 

Lymphatic  Obstruction  also  leads  to  loss  of  nutrition,  and  ulceration  may  result. 
The  best  instance  is  seen  in  elephantiasis  due  to  Filaria  sanguinis  hominis. 
In  this  country  elephantiasis  is  rare.  Other  instances  that  may  be  cited  are 
swellings  of  the  leg  following  a  badly  united  fracture  ;  the  cicatricial  contractions 
of  extensive  burns  ;  phlegmasia  alba  dolens,  or  white  leg,  during  pregnancy  or 
after  labour. 

A  theroma  of  the  A  rteries  leads  to  a  feeble  or  imperfect  circulation  of  the  blood, 
and  so  to  loss  of  nutrition.  Ulcerative  conditions  of  the  lower  part  of  the  leg 
are  therefore  common  in  such  cases,  and  even  gangrene  may  result. 

Old  Age. — Owing  to  a  weaker  condition  of  the  tissues,  ulcers  are  much  more 
frequent  in  old  people  than  in  the  young. 

Cold. — A  similar  condition  is  brought  about  by  exposure  to  cold,  especially 
in  persons  whose  nutrition  is  imperfect,  whether  from  bad  or  insufficient  food. 
The  first  effect  of  cold  is  to  produce  a  chilblain  ;  this  if  rubbed  or  irritated  may 
degenerate  into  an  ulcer. 

Trauma. — In  a  normal  individual,  any  lesion  of  the  skin  of  the  leg,  such  as 
that  caused  by  a  kick,  a  scratch,  or  a  cut,  will  heal  quickly,  and  no  ulcer  result. 
Circumstances  may  arise  which  interfere  with  the  healing  process.  Perhaps  the 
most  frequent  cause  which  leads  to  the  formation  of  an  ulcer  is  infection  with 
pyogenic   organisms,   and   the  prevention   of    the   discharge   from  the  wound. 


ULCERATION     OF     THE    LEG 


8ii 


Fig^.  208. — Gummatous  ulcer. 
Cleanly  punched  out.     Slongh  on  base. 


Fig.  log. — Tuberculous  ulcer. 
Undermined  edges  with  perforations  and  tags. 


Occasionally  there  is  also  accidental  contamination  of  the  wound  with  some 
specific  organism,  such  as  that  of  diphtheria  or  phagedaena. 

An  important  cause  of  want  of  healing  of  an  ulcer  is  interference  with  its 
contraction.  If  contraction  is  impossible,  as  when  a  sore  is  situated  over  and 
adherent  to  a  bone,  healing  may  come  to  a  standstill. 

Deficient  Innervation  leads  to  loss  of  nutrition.  Examples  are  seen  in  infantile 
palsy  ;  rubbing  of  the  boot  or  pressure  of  an  instrument  is  prone  to  be  followed 
by  an  obstinate  ulcer.  In  cases  of  hemiplegia,  even  when  the  patient  is  lying 
on  a  w^ater-bed,  ulceration  in  the  form  of  bed-sores  will  occur  much  more 
rapidly  on  the  paralyzed  side  than  on  the  other.  Perforating  ulcer  of  the  foot 
is  a  well-known  sequel  of  tabes  dorsalis. 

Diabetes  mellitus  is  an  instance  of  a 
constitutional  condition  leading  to  the 
formation  of  an  ulcer.  All  the  preced- 
ing were  local  causes.  Ulceration  and 
Gangrene  [q.v.)  are  prone  to  occur,  no 
doubt  because  the  resistance  of  a  dia- 
betic individual  to  micro-organisms  is 
lowered,  also  because  the  arteries  are 
often  atheromatous,  and  possibly  be- 
cause the  innervation  of  the  whole 
body  is  interfered  with. 

2.  Infective  Ulcers. — It  is  possible  for 
the  legs  to  be  attacked  by  any  form  of 
acute  infective  ulcer,  such  as  anthrax  or 
glanders,  but  such  an  event  is  rare. 
The  chief  ulcers  that  belong  to  this 
group  are  chronic,  and  due  to  syphilis 
or  tuberculosis. 

Syphilitic  Ulcers  are  the  result  of 
gummata  which  have  formed  in  the 
subcutaneous  tissues.  These  ulcerated 
gummata  are  almost  always  circular, 
and  present  a  punched-out  appearance 
{Fig.  208)  ;  they  are  generally  multiple 
and  tend  to  run  into  one  another,  so 
that  the  ulcer  has  a  serpiginous  outline. 
They  tend  to  heal  at  one  side,  while 
they  progress  at  another.  On  the  leg, 
especially  about  the  front  of  the  tibia, 
circular  scars  of  old  ulcers  can  usually 
be  found.  The  scars  are  thin  and 
supple,  and  if  in  the  lower  part  of  the 
leg,  usually  pigmented.      Gummata  are 

often  found  with  varicose  veins  or  ulcers,  and  it  seems  probable  that  the  low 
state  of  nutrition  of  the  tissues  caused  by  the  obstruction  of  venous  return 
is  favourable  to  their  formation.  Diagnosis  can  in  most  cases  be  made  on  the 
distribution  and  shape  of  the  ulcer,  especially  if  they  are  on  the  outer  aspect 
of  the  lower  third  of  the  leg,  and  on  the  presence  of  other  signs  of  syphilis. 
In  cases  of  doubt,  a  Wassermann's  reaction  is  of  service. 

Tuberculous  Ulcer  usually  follows  the  formation  and  bursting  of  a  tuberculous 
abscess,  starting  either  in  the  subcutaneous  tissue  or  in  a  bone,  and  the  history 
may  help  materially  in  diagnosis.  The  ulcer  is  very  chronic,  and  is  characterized 
by  undermining  of  the  skin  for  a  considerable  distance  from  the  edge  [Fig.  209). 


-'TJ: 


F/o 


— Diagram  of  epitheliomatous  ulcer. 
Growth  in  excess  of  destruction.      A,   Normal 
skin  ;      B,    Heaped-up   edges  ;      C,    Ulcerated 
portion. 


Fig.  211. — Diagram  of  rodent  ulcer. 

A,  Normal  skin;    £,  Smooth,  wire-like  edges; 

C,  Shallow  cavity. 

Frovi  Introduction  to  Surgery, 
by    Prof.    Rutherford  Morison. 


8i2  ULCERATION     OF     THE     LEG 

The  surface  is  pale,  and  the  granulations  very  small,  with  here  and  there  small 
areas  of  caseation. 

Pritnan,'  tuberculosis  of  the  skin,  or  lupus,  is  not  often  found  on  the  leg,  though 
it  may  occur  there  as  in  any  other  part  of  the  skin.  A  useful  guiding  rule  is 
that  lupus  never  starts  later  than  the  age  of  twenty  and  lasts  for  years,  whereas 
a  gumma  starts  at  a  later  period  and  tends  to  heal  spontaneoush'.  In  lupus 
the  chief  characteristic  is  the  presence  of  minute,  semi-transparent  nodules  at 
the  margin  of  the  ulcer  and  in  the  skin  around,  resembling  apple  jelly.  If 
further  methods  of  diagnosis  are  required,  a  diagnostic  injection  of  Koch's 
old  tuberculin  may  be  used,  or  von  Pirquet's  skin  test  applied. 

3.  Ulcerating  Tumours. 

Epithelioma  mav  develop  in  a  simple  varicose  ulcer  that  has  existed  for  many 
years.  The  change  may  be  ver\"  slow,  or  rapid.  The  ulcer  spreads,  the  edges 
become  heaped-up,  everted,  and  indurated  [Fig.  210).  The  glands  become 
enlarged  and,  if  the  disease  is  allowed  to  progress,  the  bone  is  attacked.  If 
any  doubt  arises  as  to  a  change  in  the  character  of  an  ulcer,  a  piece  from 
the  edge  should  be  removed  for  pathological  investigation. 

Rodent  Ulcer  (Fig.  211)  usually  attacks  the  face,  though  it  may  be  found  on 
any  part  of  the  body.     It  has  to  be  distinguished  from  lupus  and  gumma. 

Sarcoma,  starting  in  the  deeper  tissues,  may  fungate  through  the  skin,  which 
has  given  way  before  the  pressure  of  the  tumour.  George  E.  Gask. 

ULCERATION   OF   THE    THROAT.— (See  Sore  Throat.) 

ULCERATION  OF  THE  TONGUE. — To  enable  a  good  view  to  be  obtained  of 
the  affected  part,  the  patient  should  be  seated  in  a  strong  light  and  the 
protruded  tongue  gently  wiped  with  a  piece  of  soft  linen  to  remove  moisture. 
The  presence  of  an  ulcer  being  ascertained,  its  nature  may  be  considered  under 
the  following  heads  : — 


Carcinomatous 

Syphilitic 

Dental 


4.  Tuberculous 

5.  D^'speptic 

6.  Ulcer  in  connection  Avith  stomatitis. 


I.  Carcinomatous  Ulcer. — ^This  is  much  commoner  in  men  than  in  women, 
probably  owing  to  the  fact  that  chronic  glossitis  due  to  smoking  and  sj^philis 
is  more  common  in  the  male  sex.  It  is  practically  unknown  before  the  age  of 
thirty,  and  rarely  starts  before  forty-five.  The  ill  and  wearied  expression  of 
the  patient  may  awaken  suspicion  before  the  tongue  is  seen,  for  the  pain  and 
trouble  caused  by  an  epithelioma  ha^'e  a  very  rapid  and  marked  effect.  The 
tongue  in  a  ncrmal  indiA-idual  can  be  protruded  from  one  to  one  and  a  half  inches 
beyond  the  teeth  ;  if  the  protrusion  is  limited,  or  if  it  is  not  protruded  straight, 
it  can  generally  be  inferred  (except  in  cases  of  paralysis)  that  there  is  some 
tumour  binding  it  down,  and  a  very  careful  search  should  be  made  for  an 
ulcer,  which  may  be  patent  at  once,  or  if  on  the  under  surface  might  escape 
a  superficial  glance.  Xext,  the  position  of  the  ulcer  is  to  be  studied,  and  its 
relation  to  any  sharp  and  carious  tooth.  Usually  an  epithelioma  is  on  the  side 
of  the  tongue,  but  there  is  no  rule  ;  it  may  be  anywhere  on  the  anterior  two- 
thirds,  on  the  under  surface,  or  on  the  floor  of  the  mouth. 

As  regards  the  ulcer  itself,  the  tA'pical  appearance,  when  fairly  developed, 
may  be  described  as  irregular,  deep,  foul,  sloughy,  with  raised  nodular  everted 
edges,  and  a  surrounding  area  of  induration,  the  result  of  infiltration.  The 
lymphatic  glands  are  enlarged  and  hard,  and  they  may  be  fixed.  The  sub- 
maxillar}' set  is  generally  the  first  afi'ected,  but  it  is  of  interest  to  note  that  the 
disease  sometimes  misses  these  and  infects  the  carotid  and  even  the  supra- 
clavicular  glands.     Examination,   therefore,    should   not   be   concluded   before 


ULCERATION     OF     THE     TONGUE  813 

the  whole  of  the  neck  has  been  looked  at.  The  diagnosis  should  have  been  made, 
however,  before  the  disease  had  developed  thus  far  ;  in  its  earliest  stages  an 
epithelioma  may  be  represented  by  a  superficial  ulcer,  a  sixteenth  of  an  inch 
in  diameter,  by  a  crack  or  a  small  lump,  without  any  enlargement  of  the  glands. 
In  all  these  conditions,  however,  the  ulcer  is  hard,  and,  moreover,  is  very 
resistant. to  any  form  of  treatment.  Any  ulcer  of  the  tongue  occurring  in  a 
middle-aged  man,  and  lasting  for  more  than  tv/o  or  three  weeks,  should  awaken 
suspicion. 

Diagnosis  from  Syphilitic  Ulcer. — This  may  be  a  very  real  difficulty,  owing 
to  the  fact  that  the  two  conditions  may  exist  side  by  side,  and  that  the  syphilitic 
leucoplakia  or  leucomic  wart  may  be,  as  is  believed  by  many  clinicians,  the 
actual  precursor  of  a  cancer.  A  positive  Wassermann's  reaction,  therefore, 
would  not  be  proof  that  an  epithelioma  is  not  present.  If  a  well-formed 
gumma  is  present,  antisyphilitic  remedies  soon  make  a  great  change  in  its 
appearance,  and  a  diagnosis  may  be  made  in  this  way,  but  not  more  than  ten 
or  fourteen  days  should  be  allowed  to  pass  in  uncertainty. 

There  are  many  cases  in  which  the  cleverest  surgeon  is  in  doubt,  and  seeing 
the  rapid  course  this  disease  runs,  and  the  vital  importance  of  securing  an  early 
diagnosis,  it  is  urged  here  with  the  greatest  possible  insistence  that  the  only 
certain  method,  and  the  one  to  be  employed  early,  is  that  of  taking  out  a  piece 
of  the  ulcer,  or,  if  small,  the  whole  ulcer,  and  submitting  it  to  histological 
examination. 

Diagnosis  from  Dental  Ulcer. — The  ulcer  in  this  case  is  caused  by  a  bad  tooth, 
and  therefore  is  in  a  position  on  the  tongue  corresponding  to  the  latter.  Further, 
the  ulcer  is  soft  to  the  touch,  and  heals  rapidly  when  the  offending  tooth  is 
stopped  or  extracted.  There  is  seldom  difficulty  in  differentiation  except  when 
the  ulcer  is  of  very  long  standing. 

2.  Syphilitic  Ulcer. — This  may  be  primary,  secondary,  or  tertiary.  Primary 
Syphilis  or  Chancre  is  certainly  rare  on  the  tongue  and,  owing  partly  to  its  rarit}-- 
and  partly  to  the  fact  that  it  is  unexpected,  it  is  frequently  missed.  It  is  more 
common  in  men  than  in  women,  but  it  may  occur  even  in  children.  It  starts  as 
a  small  pimple,  which  ulcerates  and  becomes  indurated,  though  the  induration  is 
not  so  marked  as  when  it  is  situate  on  the  glans  penis.  General  enlargement  of 
the  lymphatic  glands  is  an  early  and  marked  feature,  and  this  is  an  important 
help  to  diagnosis.  Pathological  aids  to  diagnosis  are  Wassermann's  reaction, 
and  the  examination  for  spirochaetae  {Plate  XII,  Fig.  J)  in  serum  from  the  sore. 
Furthermore,  the  sore  heals  rapidly  under  the  influence  of  mercury,  and  the 
appearance  of  secondary  symptoms  will  certainly  settle  the  question. 

Secondary  Syphilis  manifests  itself  by  the  formation  of  mucous  patches  and 
superficial  ulcers.  The  latter  are  almost  always  multiple,  and  situated  along 
the  edges  and  tip  of  the  tongue,  and  with  them  are  also  found  similar  sores  on 
the  mucous  membrane  of  the  cheek,  lips,  palate,  and  tonsil,  and  at  the  edges 
of  the  mouth.  The  ulcers  are  small,  round,  painful,  with  sharply  cut  edges  and 
a  greyish  floor.  All  the  constitutional  signs  and  other  secondary  symptoms 
will  be  present,  so  that  there  should  be  no  difficulty  in  forming  a  correct 
diagnosis. 

Tertiary  Syphilis  or  Gummatous  Ulcerations. — These  are  divided  into  superficial 
and  deep.  Superficial  gummata  begin  as  small  round-celled  infiltrations  in 
the  mucous  and  submucous  tissue.  The  ulcers  are  usually  shallow,  often 
irregular  and  associated  with  chronic  glossitis,  fissures,  and  leucoplakia.  They 
are  extremely  important,  for,  as  stated  above,  such  a  condition  is  very  often 
followed  by  an  epithelioma.  They  are  also  very  resistant  to  antisyphilitic 
remedies,  which  only  adds  to  the  difficulty  of  diagnosis.  The  ulcers  themselves 
are  not  at  first  indurated,  but  if  surrounded  by  interstitial  fibrosis  may  appear 


8i4  ULCERATION     OF     THE     TONGUE 

hard.  Therefore  a  histological  examination  is  eminently  desirable  if  there  is 
the  least  doubt. 

A  deep  gumma  starts  as  a  hard  swelling  in  the  substance  of  the  tongue  ;  later 
it  softens,  breaks  down,  and  shows  itself,  generally  in  the  middle  line,  as  a  deep 
cavity  with  irregular,  soft,  undermined  walls,  and  a  wash-leather-like  slough  at 
its  base.  It  is  not  painful,  and  does  not  increase  in  size.  The  important 
thing  is  to  distinguish  it  from  epithelioma  and  tuberculous  disease.  Unlike 
epithelioma,  it  is  not  hard,  and  its  historj^  is  short.  Furthermore,  it  yields  very 
rapidlv,  under  the  influence  of  potassium  iodide  or  salvarsan. 

3.  Dental  Uleer  is  a  traumatic  ulcer  due  to  repeated  small  injuries  received  from 
the  sharp  edge  of  a  decayed  tooth.  It  is  therefore  situated  in  such  a  position, 
generally  on  the  side  of  the  tongue,  that  it  is  opposite  the  tooth.  The  ulcer  is 
single,  small,  superficial,  and  not  indurated  unless  it  is  of  long  standing.  It  is 
therefore  not  easily  mistaken  for  any  other  kind  of  ulcer,  or  if  doubt  arises  it 
is  allayed  by  stopping  or  extracting  the  tooth,  when  the  ulcer  quickly  heals. 

There  is  a  form  of  dental  ulcer  which  is  found  on  the  frsenum  of  the  tongue 
in  children  suffering  from  whooping-cough  ;  during  the  violent  expiratory  spasms 
peculiar  to  the  illness,  the  under  surface  of  the  tongue  may  suffer  from  rubbing 
over  the  lower  incisor  teeth. 


DESCRIPTION     OF     PLATE     XV. 

Fig.  A. — Old  leukoplakia  of  many  years'  duration.  Quite  recent  development 
of  epithelioma,  in  the  form  of  a  very  slightly  raised  smooth  red  plaque,  feeling 
about  as  thick  as  a  sixpence.  Between  it  and  the  middle  line  is  a  tiny  nodule 
resembling  a  pimple. 

Fig.  B. — Area  of  thin  leukoplakia  on  the  right  border  of  the  tongue,  with  a 
small  epithelioma,  which  had  developed  in  the  site  of  a  bite  received  several  months 
previously. 

Fig.  C. — Leukoplakia  of  many  years'  duration,  with  the  very  earliest  condition 
of  epithelioma  to  the  left  of  the  middle  line  in  the  form  of  a  very  small  area  of 
leukoplakia  (a),  slightly  more  raised  and  a  little  firmer  than  the  rest.  The  diagnosis 
depended  as  much  on  the  slight  hardening  as  on  the  appearance. 


4.  Tuberculous  Uleer  of  the  Tongue  is  rare  ;  but  it  occurs  at  that  period  of  life 
during  which  tuberculous  disease  of  the  lung  is  common,  that  is  to  say,  between 
the  ages  of  fifteen  and  thirty-five.  It  is  due  to  infection  with  tubercle  bacilli 
brought  up  into  the  mouth,  and  if  a  patient  is  found  to  be  suffering  from  tuber- 
culous disease  of  the  lungs  or  larynx  and  also  from  an  ulceration  of  the  tongue, 
there  is  a  strong  probability  that  the  latter  is  of  the  same  nature  as  the  former. 
The  ulcer  itself  may  be  situated  on  the  tip  or  side  of  the  tongue  ;  it  has  an 
irregular  outline,  and  the  base  is  nodular,  sloughy,  or  caseous.  It  has  often  been 
mistaken  for  epithelioma  or  gumma.  The  fact  that  it  is  not  hard,  and  that 
phthisis  is  present,  should  put  one  on  one's  guard.  As  against  gumma,  a 
Wassermann's  reaction  would  be  negative.  A  von  Pirquet's  test  or  a  dia- 
gnostic injection  of  Koch's  old  tuberculin  might  be  employed,  but  a  more 
reliable  method  is  the  removal  and  microscopical  examination  of  a  piece  of  the 
ulcer,  when  the  histological  appearances  of  tubercle  will  be  seen.  The  tubercle 
bacillus  (Plate  XII,  Fig.  K)  is  not  always  found. 

5.  Dyspeptic  Ulcer,  as  the  name  implies,  is  connected  with  disorders  of  digestion. 
The  ulceration  is  often  multiple,  each  ulcer  being  round,  small,  often  covered 
with  a  greyish  slough,  and  with  a  bright  ring  of  inflammation  round  it.     They 


PLATE     XV. 

CANCER       OF      THE      TONGUE:        VERY      EARLY      CONDITIONS 
(From  drawings  kindly  lent  by  H.  T.    liuiLi.N,   F.  R.C.S.) 


Fig.  A. 


Piz.  B. 


Reproduced  by  permission  fro)ii   '''J7ie  Medical  Annual." 


INDEX     OK      DIAGNOSIS 


URATE     DEPOSIT     IN     THE     URINE  815 

are  placed  on  the  dorsum  of  the  tongue  near  the  tip.  The  mouth,  too,  is  very 
foul,  and  the  cervical  glands  may  be  enlarged. 

5.  Ulcers  in  connection  with  Stomatitis  (Ulcerative  Stomatitis). — Septic  infec- 
tion of  the  mouth  due  to  a  variety  of  causes,  such  as  irritation  from  decayed 
teeth,  alkalies,  acids,  or  mercury,  may  be  accompanied  by  the  formation  of  small 
vesicles  which,  on  bursting,  give  rise  to  superficial  ulcers.  They  are  not  limited 
to  the  tongue,  but  appear  on  the  mucous  membrane  of  the  cheeks  and  gums  as 
well.  Aphthous  stomatitis  commonly  occurs  in  conjunction  with  the  febrile 
diseases  of  childhood.  It  is  characterized  by  the  formation  of  whitish  spots 
on  the  buccal  mucous  membrane,  and  by  the  shedding  of  epithelium  small 
superficial  ulcers  may  be  formed. 

The  ulcers  of  the  tongue  are  here,  so  to  speak,  accidental,  occurring  in  the 
course  of  a  general  inflammation  of  the  mouth,  and  will  hardly  be  confounded 
with  any  other  form  of  ulcer.  George  E.  Gask. 

UNCONSCIOUSNESS.— (See  Coma.) 

UNEQUAL  PULSES.— (See  Pulses,  Unequal.) 

UNEQUAL  PUPILS. — (See  Pupil,  Abnormalities  of  the.) 

URATE  DEPOSIT  IN  THE  URINE.— A  precipitate  of  urates  is  often 
recognizable  at  once  by  its  pink  colour,  which  is  due  to  their  carrying  down  with 
them  the  uroerythrin  pigment  of  the  urine.  Urates  themselves  are  white, 
however,  and  if,  as  is  sometimes  the  case,  there  is  no  uroerythrin  present  for  them 
to  carry  down,  they  form  a  white  precipitate  which  may  be  mistaken  for  mucus, 
phosphates,  or  pus.  They  may  be  distinguished  at  once,  however,  by  warming 
the  urine  back  to  body  temperature  ;  they  re-dissolve  long  before  boiling 
point  is  reached.  They  are  also  soluble  in  liquor  potassae,  unlike  phosphates. 
Microscopically  they  are  nearly  always  amorphous,  though  in  rare  cases  they 
assume  the  form  of  small  spheres  with  irregular  projecting  spicules — the  so-called 
"  thorn-apple  "  or  "  hedgehog  "  crystals. 

Their  only  significance  from  a  clinical  point  of  view  is  that  they  indicate  a 
concentrated  urine.  It  does  not  follow  that  a  urine  is  not  concentrated  if  no 
precipitate  of  urates  occurs,  but  the  fact  that  the  urates  re-dissolve  on  warming 
serves  to  show  that,  although  there  may  be  enough  water  to  keep  them  in 
solution  at  body  temperature,  the  urine  becomes  supersaturated  with  them  as 
it  cools,  and  precipitates  them  out. 

The  reason  for  the  urinary  concentration  has  to  be  learned  from  collateral 
evidence.  It  may  be  that  there  has  been  much  sweating,  and  in  hot  weather  a 
precipitation  of  pink  urates  is  a  very  common  physiological  condition  which  is 
apt  to  alarm  some  patients  when  they  first  notice  it.  On  the  other  hand,  the 
concentration  may  be  due  to  pathological  conditions,  of  which  the  commonest 
are  fevers,  chronic  valvular  disease  with  heart  failure,  and  maladies  which  lead 
to  loss  of  fluid  by  vomiting,  sweating,  or  diarrhoea.  The  urates  themselves 
afford  hardly  any  clue  to  the  cause  of  the  concentration,  and  their  appearance 
is  just  the  same  whether  their  deposition  is  due  to  physiological  or  pathological 
changes. 

The  most  marked  examples  of  uratic  deposits  are  to  be  seen  perhaps  in  cases 
of  acute  rheumatic  fever,  lobar  pneumonia,  and  chronic  heart  disease  with 
failing  compensation.  It  is  a  general  rule,  moreover,  that  when  the  kidneys  are 
themselves  affected  there  is  decidedly  less  tendency  for  uratic  deposits  to  form 
than  when  the  primary  disease  is  in  the  heart  or  lungs  ;  thus  when  one  may  be 
in  doubt  as  to  whether  a  given  case  of  chronic  heart  failure  is  due  to  primary 
renal  disease  or  heart  disease,  the  occurrence  of  an  abundant  urate  deposit 


8i6 


URIC     ACID     DEPOSIT     IN     THE     URINE 


affords  some  evidence  in  favour  of  the  latter  and  against  the  former.  It  is 
no  absolute  rule,  however,  and  almost  any  concentrated  urine  may  precipitate 
urates. 

Students  are  a  little  apt  to  confuse  the  significance  of  urates  with  that  of  uric 
acid,  though  the  two  are  entirely  independent  from  a  clinical  standpoint. 

Herbert  French. 

URETHRA,   DISCHARGE  FROM.— (See  Discharge,  Urethral.) 

URIC  ACID  DEPOSIT  IN  THE  URINE.— The  most  typical  form  taken  by  a 
precipitate  of  uric  acid  in  a  urine  is  that  known  as  the  cayenne-pepper  deposit. 
It  is  made  up  of  numbers  of  unmistakable,  though  seldom  voluminous, 
characteristic  light- brown  prismatic  crystals  [Fig.  212),  arranged,  either  as 
separate  "  whetstones,"  or  in  overlapping  bundles,  or  "  rosettes  "  ;  occasionally, 
crystallization  is  imperfect,  and  they  appear  as  "  dumb-bells."  Intrinsically, 
they  are  colourless  ;  but  they  differ  from  all  other  urinary  deposits  in  that  they 
carry  down  with  them  the  ordinary  yellowish-brown  urochrome  pigment  of  the 
urine.     For  clinical  purposes  the  best  test  for  them  is  the  microscope. 

Besides  the  cayenne-pepper  deposit,  uric  acid  crystals  may  be  present  in  con- 
siderable numbers  in  the  midst  of  other  precipitates,  such  as  mucus,  or  oxalate 


Fig.  212. — Uric  acid  crystals  of  various  types. 

of  lime  ;  in  which  case  they  may  not  be  discernible  without  the  use  of  the 
microscope  ;  or,  again,  they  may  become  aggregated  together  into  small  pellets 
or  calculi,  which  the  patient  may  be  conscious  of  as  "  gravel  "  on  micturition. 

A  deposit  of  uric  acid  is  generally  found  in  a  decidedly  acid  urine  of  high 
specific  gravity  ;  but  it  may  occur  in  urines  of  almost  any  reaction  or  specific 
gravity.  A  great  deal  more  importance  has  been  attached  to  this  uric  acid 
than  it  deserves,  on  account  of  its  relationship  with  gout.  A  cayenne-pepper 
deposit  by  no  means  indicates  gout  ;  indeed,  it  may  be  perfectly  physiological, 
occurring  abundantly  sometimes  in  healthy  young  persons,  particularly  boys. 
It  does  not  even  follow  from  its  occurrence  that  there  is  excess  of  uric  acid, 
either  in  the  urine  or  in  the  tissues  ;  for  the  precipitation  depends  nearly  as 
much  upon  the  relative  proportions  of  phosphates,  chlorides,  and  inorganic 
sulphates  to  uric  acid,  and  upon  the  absolute  and  relative  amounts  of  sodium, 
potassium,  and  other  bases  in  the  urine,  as  upon  the  absolute  amount  of  uric 
acid.  The  greater  the  tendency  of  the  bases  to  form  phosphates,  by  mass  action 
or  otherwise  (see  Phosphaturia),  the  less  the  tendency  for  the  soluble  quadri- 
urates,  and  the  greater  the  liability  for  less  soluble  biurates,  to  be  produced,  the 


URIC     ACID     DEPOSIT     IN     THE     URINE  817 

relatively  insoluble  uric  acid  being  liberated  from  the  latter  and  deposited  in 
crystalline  form. 

Considerable  care  has  to  be  exercised,  therefore,  before  any  useful  clinical 
deductions  can  be  drawn  from  the  fact  that  a  urine  contains  a  deposit  of  uric 
acid.  It  is  true  that  a  persistent  tendency  to  it  is  often  associated  with  gout  ; 
but  the  latter  should  be  diagnosed  from  the  collateral  evidence  rather  than 
upon  the  uric-acid  crystals  in  the  urine.  Many  gouty  subjects  precipitate  no 
uric  acid  in  their  urine  at  all.  Naturall}',  there  will  be  a  greater  tendency  to 
such  deposition  when  the  total  amount  of  uric  acid  present  is  greater  than 
normal.  Uric  acid  in  the  urine  is  derived  from  t^vo  sources — exogenous  and 
endogenous.  The  exogenous  sources  are  such  foodstuffs  as  are  rich  in  nucleo- 
proteid,  and  in  the  so-called  xanthin  bases,  or  purin,  or  alloxuric  bodies,  xanthin, 
guanin,  hypoxanthin,  adenin,  heteroxanthin,  paraxanthin,  episarkin,  epiguanin , 
methylxanthin,  and  carnin,  which  are  mainly  derived  from  nuclein.  Analyses 
of  the  various  foodstuffs  as  to  purin  bases  need  not  be  given  here,  for  it  is  easy 
to  remember  that,  broadly  speaking,  these  substances  are  contained  in  largest 
quantities  in  the  richest  food.  A  considerable  proportion  of  the  xanthin  bases 
are  excreted  as  uric  acid,  and  it  is  common  knowledge  that  rich  foods  tend 
to  increase  uric  acid  in  the  urine.  Endogenous  uric  acid,  on  the  other  hand, 
is  derived  from  the  patient's  own  tissue  metabolism.  Birds  excrete  nearly 
all  their  nitrogenous  waste  as  uric  acid  ;  man  excretes  his  mainly  as  urea, 
and  only  to  a  minor  extent  as  uric  acid.  Sometimes,  however,  too  much  of  his 
nitrogenous  metabolism  stops  short  at  the  stage  of  uric  acid,  instead  of  the 
latter  being  nearly  all  converted  into  urea  ;  he  then  excretes  an  abnormal  total 
quantity  of  uric  acid,  with  the  result  that  it  may  be  precipitated  in  crystalline 
form.  One  repeats,  that  this  does  not  necessarily  constitute  gout,  however  ; 
it  occurs  in  certain  healthy  subjects,  in  leukcemia,  in  pernicious  anaemia,  during 
the  course  of  certain  fevers,  and  in  some  cases  of  chronic  heart  disease. 
Perhaps  one  of  the  best  ways  of  avoiding  too  narrow  a  conception  in  regard  to 
this  uric  acid  is  to  remember  that  in  some  respects  the  human  body  is  a  fire  ; 
fires  may  burn  their  coal  well  or  badly  ;  if  well,  the  residue  is  but  a  little  ash  ; 
if  badly,  the  residue  is  not  ash,  but  clinker  ;  uric  acid  is  the  clinker  of  the  human 
body,  and  manj?  different  things  that  make  human  nitrogenous  metabolism 
incomplete,  may  cause  a  deposition  of  this  clinker  in  the  urine.  Gout  is  one 
such  thing  ;  but  excessive  eating,  deficiency  of  exercise,  biliousness,  and  various 
chronic  imperfections  of  the  circulation,  or  digestion,  may  do  so  ;  and  the  same 
may  occur  in  apparently  healthy  subjects,  who  have  never  had  any  untoward 
symptoms  at  all.  Oxalate  of  lime  (see  Oxaluria)  is  very  possibly  derived  in 
part  from  similar  imperfect  combustion  of  carbohydrates  or  fats,  and  it  is 
noteworthy  how  often  crystals  of  uric  acid  and  of  oxalate  of  lime  occur,  either 
together,  or  alternating  with  one  another.  Still  further,  error  of  metabolism 
may  produce  glycosuria  in  association  with  uric-acid  crystals,  so-called  gouty 
glycosuria. 

Besides  being  evidence  of  overloading,  or  of  imperfect  combustion  in  a  general 
sense,  the  occurrence  of  a  uric  acid  deposit  may  be  of  particular  clinical  impor- 
tance in  certain  cases ;  first,  of  frequency  of  micturition  ;  secondly,  of  urethritis  ; 
and,  thirdly,  of  renal  calculus.  Necessity  to  micturate  frequently,  only  small 
quantities  of  urine  being  passed  at  a  time,  is  a  symptom  that  in  young  people 
suggests  cystitis,  possibly  tuberculous  ;  enlargement  of  the  prostate  in  men  over 
sixty  ;  or  some  uterine  or  other  pelvic  malady  in  women.  It  is  important  to 
remember,  however,  that  undue  acidity  of  the  urine,  with  a  tendency  to  deposit 
crystals  of  uric  acid,  or  oxalate  of  lime,  may  produce  the  same  symptom  in 
considerable  degree.  It  is  sometimes  spoken  of  as  irritability  of  the  bladder  ; 
the  highly  acid  urine  irritates  the  vesical  mucosa,  and  it  may  produce  actual 
D  52 


URINE,     ABNORMAL     COLORATION     OF 


cystitis.  The  same  irritation  may  inflame  the  urethral  mucosa,  and  produce 
a  "  gouty  "  urethritis  ;  and,  perhaps,  epididymo-orchitis,  which  may  be  mis- 
taken for  one  of  gonococcal  origin,  unless  pus  films  can  be  shown  to  contain  no 
gonococci. 

If  the  patient  has  suffered  from  renal  colic,  hasmaturia,  or  vesical  pain,  sugges- 
tive of  calculus  in  the  kidney,  ureter,  or  bladder,  the  discovery  of  abundant 
uric-acid  crystals  in  the  urine  affords  confirmation  of  the  diagnosis  of  a  uric-acid 
stone,  particularly  if  they  are  obviously  aggregated  together  into  tiny  calculi  ; 
there  are  generally  red  corpuscles,  excess  of  leucocytes,  and  tailed  epithelial 
cells  from  the  renal  pelvis,  or  pyriform  cells  from  the  deeper  layers  of  the 
bladder  mucosa,  at  the  same  time. 

The  danger  of  diagnosing  glycosuria  in  the  absence  of  sugar,  when  uric  acid  is 
abundant  in  a  urine,  needs  special  mention.  Uric  acid  has  considerable  power 
of  reducing  Fehling's  solution.  It  seldom  gives  the  copious  brick-red  or 
orange-yellow  precipitate  that  is  characteristic  of  abundance  of  sugar,  but  it 
may  give  just  enough  reduction  or  change  of  colour  to  make  it  doubtful  whether 
sugar  is  present  or  not.  More  than  a  few  proposers  for  life  insurance  have 
suffered  unfairly  on  this  account ;  no  such  partial  reduction  should  be  regarded 
as  due  to  sugar,  until  the  presence  of  glucose  has  been  confirmed  by  other  means, 
particularly  the  phenylhydrazine  and  the  fermentation  tests.  Herbert  French. 

URINE,     ABNORMAL  COLORATION    OF.  —  This  may  be  due  to  :    (i)   The 

presence  in  abnormally  large  quantities  of  certain  urinary  pigments,  such  as 
uroerythrin  and  hsematoporphyrin  ;  (2)  The  presence  of  pigments  formed  in  the 
organism,  but  which  are  not  normally  excreted  in  the  urine,  such  as  haemoglobin 
and  the  pigments  of  the  bile  ;  (3)  The  presence  of  pigmentary  substances  derived 
from  drugs  or  foods,  or  administered  directly  by  the  mouth. 

Urines  of  unusual  tints  may  be  classified  conveniently  according  to  the  colours 
which  they  exhibit,  as  follows  :  (I.)  Yellow  and  orange  urines  ;  (II.)  Pink  and 
red  urines  ;  (III.)  Brown  and  black  urines,  including  such  as  are  of  normal  tint 
when  passed,  but  darken  on  exposure  to  air  ;    (IV.)   Green  and  blue  urines. 

I.  Yellow  and  Orange -coloured  Urines. — The  normal  yellow  tint  is  wholly 
due  to  urochrome,  for  other  urinary  pigments  are  present  in  traces  so  minute 
that  their  presence  has  no  obvious  effect.  However  much  it  be  diluted,  normal 
urine  remains  yellow  as  long  as  any  tint  is  visible.  In  some  cases  of  diabetes 
insipidus  the  urine  is  almost  colourless,  and  the  abundant  urine  of  diabetes 
mellitus  usually  exhibits  a  greenish-yellow  tint  which  has  not  yet  been  explained . 
Urobilin,  when  present  in  large  amount,  imparts  a  rich  orange-yellow  colour  ; 
and  when  seen  in  very  thin  layers,  as  near  the  apex  of  a  conical  glass,  urines 
rich  in  urobilin  have  a  pinkish  tint,  due  to  selective  absorption  in  the  middle  of 
the  spectrum.  Such  urines,  when  examined  with  the  spectroscope,  show  a  dark 
absorption  band  near  the  solar  F  line  (-Fig'.  23,  p.  95). 

Urobilimiria — the  excretion  of  excess  of  urobilin — may  result  from  widely 
different  causes,  and  as  a  consequence,  its  clinical  significance  is  not  so  clear  as 
might  be  expected.  The  symptom  is  met  with  in  connexion  with  haemolytic 
diseases,  such  as  pernicious  ancemia,  in  diseases  of  the  liver,  such  as  cirrhosis,  and 
in  cases  in  which  excessive  bacterial  action  is  going  on  in  the  intestine.  The  bulk, 
if  not  the  whole,  of  the  urobilin  of  urine  is  derived  from  the  intestine,  where  it  is 
formed  by  the  action  of  the  bacteria  present  upon  bilirubin.  It  is  present  in 
abundance  in  normal  faeces,  and  in  traces  in  normal  urine. 

Uroerythrin — the  highly  unstable  pigment  to  which  the  colour  of  pink  urate 
sediments  is  due — when  abundantly  present  in  solution  in  the  urine  imparts  to 
it  a  rich  orange-red  colour,  which  may  even  be  mistaken  for  that  due  to  blood. 
The  colour  is  changed  to  a  pale  greenish-yellow  by  addition  of  an  alkali.     Hepatic 


URINE,     ABNORMAL     COLORATION     OF  819 

derangements  of  almost  all  kinds,  including  the  most  trifling  functional  dis- 
turbances, may  lead  to  the  appearance  of  uroerythrin  in  the  urine  ;  but  the  most 
intensely  pink  urate  sediments  are  seen  in  cases  in  which  the  liver  is  the  seat  of 
pronounced  morbid  changes,  such  as  cirrhosis,  or  the  passive  congestion  due  to 
cardiac  disease. 

Choluria. — Urine  which  contains  bilirubin  has  a  rich  orange  colour  with  a 
greenish  tint  at  the  edge  of  the  meniscus.  The  foam  formed  by  shaking  it  has 
a  yellow  colour,  whereas  that  of  bile-free  urine,  even  when  deeply  pigmented, 
is  colourless.  The  colour  of  the  urine  may  be  much  modified  by  the  presence  of 
biliverdin,  in  addition  to  bilirubin,  and  may  approach  to  black  or  dark  green. 

The  presence  of  bile  pigment  may  be  demonstrated  by  Gmelin's  test.  This  is 
best  carried  out  by  allowing  the  urine  to  flow  gently  on  to  the  surface  of  some- 
nitric  acid  in  a  test  tube  ;  on  gently  shaking,  the  familiar  play  of  colours  is  seen 
at  the  junction  of  the  Uquids,  and  the  urinary  layer  often  retains  the  green  tint 
of  biliverdin  for  a  considerable  time. 

Again,  a  green  ring  is  observed  when  tincture  of  iodine  is  allowed  to  flow  on  to 
the  surface  of  the  urine  in  a  test  tube. 

When  the  quantity  of  bile  pigment  present  is  very  small,  the  above  tests  may 
fail  to  reveal  its  presence,  and  Huppert's  test  may  then  be  resorted  to.  A 
precipitate  is  formed  by  the  addition,  to  a  much  larger  volume  of  urine,  of  a 
solution  of  barium  chloride  and  baryta  water,  or  of  calcium  chloride  and  lime- 
water.  The  precipitate,  which  carries  down  any  bile-pigment  which  may  be 
present,  is  filtered  off  and  washed  into  a  test-tube  with  alcohol.  Dilute  sulphuric 
acid  is  then  added,  and  the  test-tube  is  heated  in  a  beaker  of  boiling  water.  If 
bile  pigment  be  present,  the  acidulated  alcohol  acquires  a  rich  green  tint,  due 
to  biliverdin. 

Choluria  is  merely  a  symptom  of  jaundice,  but  the  appearance  of  bile  pigment 
in  the  urine  may  precede  any  yellow  coloration  of  the  conjunctivse  or  skin,  or,  as 
in  cases  of  acholuric  family  jaundice,  the  skin  may  be  tinted  although  the  urine 
is  free  from  bile  pigment.  In  the  very  rare  cases  in  which  a  fistula  exists  between 
the  biliary  and  urinary  tracts,  choluria  of  pronounced  degree  has  been  observed, 
apart  from  any  jaundice. 

Certain  drugs  impart  to  urine  a  tint  which,  although  yellow,  is  abnormal. 
This  is  seen  when  santonin  is  administered,  or  chrysophanic  acid,  which  is  a  con- 
stituent of  rhubarb  and  senna.  In  either  case,  the  urine  turns  pink  on  addition 
of  an  alkali,  but  the  pink  colour  is  far  more  brilliant  after  santonin  than  after 
chrysophanic  acid  has  been  taken. 

II.  Pink  and  Red  Urines.  —  The  conditions  which  lead  to  the  excretion  of  a 
pink  or  red  urine  may  be  classified  as  follows  :  (i)  Hematuria,  in  cases  in  which 
the  blood  pigment  appears  in  the  urine  mainly  as  oxyhaemoglobin  ;  (2)  Hsemo- 
globinuria  —  usually  in  cases  which  do  not  belong  to  the  paroxj^smal  class  ; 
(3)  Hsematoporphyrinuria  ;  (4)  Administration  of  rosaniline  as  a  drug  ;  (5)  Eating 
of  sweetmeats  coloured  with  eosin  ;  (6)  Presence  of  chrysophanic  acid  in  an 
alkaline  urine. 

I  and  2.  Hcsmaturia  and  hcBtnoglobinuria. — -For  the  significance  of  these 
symptoms,  and  the  detection  of  blood  pigment  in  urine,  the  special  articles 
dealing  with  them  may  be  referred  to. 

3.  HcBmato porphyrinuria  is  a  symptom  of  considerable  interest.  The  name 
is  applied  to  a  condition  in  which  urine  is  passed  which  has  a  pink,  port-wine, 
or  nearly  black  colour,  and  which  contains  considerable  quantities  of  the  hcemo- 
globin  derivative,  haematoporphyrin.  In  the  darker  specimens  the  colour  is 
mainly  due  to  other  little-known  pigments  which  accompany  the  hcemato- 
porphyrin.  For  the  recognition  of  the  condition  spectroscopic  examination  is 
necessary.     It  is  most  liable  to  be  mistaken  for  hsemogiobinuria,  but  when  the 


820  URINE,     ABNORMAL     COLORATION     OF 

urine  contains  no  albumin  the  distinction  is  not  difficult  ;  when  albumin  is 
present  in  a  pink  urine,  the  diagnosis  is  more  difficult,  because  the  spectrum  of 
haematoporphyrin  in  the  combination  in  which  it  usually  occurs  in  such  cases 
resembles  that  of  oxyhaemoglobin  somewhat  closely.  However,  the  addition  of 
hydrochloric  acid  changes  the  spectrum  to  that  of  acid  haematoporphyrin  instead 
of  to  that  of  acid  haematin  {Fig.  21,  p.  95). 

If  a  mixture  of  10  per  cent  calcium  chloride  solution  and  lime-water  be  added 
to  the  urine,  the  precipitate  formed  carries  down  all  the  abnormal  pigments,  and 
the  filtrate  is  yellow.  From  the  precipitate  the  haematoporphyrin  may  be 
extracted  with  acidified  alcohol,  and  its  highly  characteristic  spectra  may  be 
observed  and  identified.  The  trace  of  haematoporphyrin  present  in  normal  urine 
escapes  detection  by  such  means,  but  the  increased  quantities  present  in  a 
variety  of  morbid  conditions  may  be  revealed  by  faint  bands,  even  in  cases 
which  do  not  fall  into  the  class  under  consideration,  and  in  which  the  urine 
shows  no  obvious  anomaly  of  pigmentation. 

In  the  great  majority  of  cases,  haematoporphyrinuria  results  from  prolonged 
administration  of  sulphonal  in  medicinal  doses,  and  forms  one  of  a  group  of  toxic 
symptoms  of  much  gravity,  which  often  usher  in  a  fatal  ending.  These  sym- 
ptoms may  only  develop  after  the  drug  has  been  taken  for  months  or  even  years, 
and  even  some  days  after  its  administration  has  been  stopped.  Their  develop- 
ment calls  for  the  free  administration  of  sodium  bicarbonate.  It  is  a  remark- 
able fact  that  such  toxic  effects  of  sulphonal  are  seldom  seen  except  in  women, 
and  the  few  male  cases  on  record  have  mostly  been  of  a  mild  kind. 

Much  more  rarely,  haematoporphyrinuria,  with  deep  red  urine,  is  met  with  in 
cases  in  which  it  cannot  be  ascribed  to  any  drug.  Several  patients  have  been 
sufferers  from  hydvoa  cBStivale,  others  frora  tuberculosis,  and  others  from 
maladies  so  different  from  each  other  that  no  definite  diagnostic  significance  can 
yet  be  assigned  to  the  symptom.  In  such  cases  the  haematoporphyrinuria  does 
not  appear  to  have  the  grave  import  which  it  has  in  sulphonal  cases,  nor  is  there 
manifested  any  special  liability  of  the  female  sex. 

4,  5,  and  6.  Coloration  by  constituents  of  foods  and  drugs. — Rosaniline,  which 
was  at  one  time  employed  in  the  treatment  of  albuminuria,  imparts  a  pink  colour 
to  the  urine  which,  provided  that  it  be  known  that  the  drug  is  being  taken, 
offers  no  diagnostic  difficulty.  Aniline  dyes  have  also,  ere  now,  been  deliberately 
added  to  the  urine  for  the  purpose  of  simulating  haematuria. 

Eosin  has  been  extensively  employed  for  the  coloration  of  pink  sweetmeats 
and  lozenges,  and  the  urine  of  those  who  eat  such  sweetmeats  in  considerable 
quantities  acquires  a  rich  pink  colour,  and  shows  a  brilliant  green  fluorescence. 
The  nature  of  such  pigmentation  can  hardly  be  mistaken  by  any  one  who  is 
aware  of  the  fact  that  eosin  is  so  employed. 

Drugs  which  contain  chrysophanic  acid  are  so  frequently  used  as  aperients 
that  this  compound  may  rank  as  a  common  constituent  of  urine  ;  and  if,  from 
any  cause,  the  urine  be  alkaline,  it  acquires  a  pink  or  red  colour,  which  may 
easily  be  misinterpreted.  However,  the  history  of  the  taking  of  rhubarb  or 
senna,  and  the  fact  that  the  addition  of  an  acid  changes  the  colour  of  the  urine 
to  a  bright  yellow,  renders  the  diagnosis  easy.  The  pink  colour  which  alkalies 
impart  to  the  urine  of  patients  taking  santonin  is  so  fugitive  that  it  does  not 
call  for  consideration  here. 

III.   Brown    and    Black    Urines The    urine    may   be    brown    or   black    in 

the  following  conditions  :  (i)  Jaundice  ;  (2)  Haematuria  ;  (3)  Haemoglobinuria  ; 
(4)  Haematoporphyrinuria  ;  (5)  Indicanuria  ;  (6)  Melanuria  ;  (7)  Alkaptonuria  ; 
(8)  Carboluria  ;  and  after  the  administration  of  certain  other  drugs,  such  as 
salol,  salicylates,  resorcin,  gallic  acid,  and  uva  ursi. 

In  some  of  the  above  conditions  the  urine  has  such  coloration  when  passed  ; 


URINE.     ABNORMAL     COLORATION     OF  821 


but  in  others,  such  as  melanuria  and  alkaptonuria,  the  urine  is  usually  of  normal 
tint  when  freshly  passed,  and  only  darkens  on  standing  in  contact  with  the  air. 

I .  Brown  and  black  jaundiced  urine  is  chiefly  met  with  in  cases  of  long-standing 
icterus,  in  which  the  skin  has  acquired  a  dull  greenish  tint,  and  the  urine 
contains  biliverdin  as  well  as  bilirubin. 

2  and  3.  In  some  of  the  early  recorded  cases  of  black  urine,  the  colour  was 
certainly  due  to  blood  pigment,  and  the  smoky  colour  of  many  urines  which 
contain  blood  pigment  in  the  form  of  methaemoglobin  is  familiar  to  all.  In 
paroxysmal  hcsmoglobinuria  also,  the  urine  is  not  unfrequently  almost  black. 
The  ordinary  tests  for  haemoglobin,  together  with  microscopic  and  spectro- 
scopic examination,  serve  to  reveal  the  nature  of  such  cases  {Figs.  17  et  seq., 

P-  95)- 

4.  That  the  urine  of  hcematoporphyrinuria  may  approach  to  actual  blackness, 
owing  to  the  abundant  presence  of  purple  pigments  which  have  no  characteristic 
spectra,  has  already  been  mentioned  in  the  account  of  that  symptom  above, 

5.  Indicanuria. — Urines  which  contain  much  indican  may  show  no  abnormality 
of  tint ;  but  occasionally,  and  especially  in  extreme  cases,  there  are  present  in  the 
urine,  in  association  with  the  colourless  indoxyl  sulphate,  other  and  higher 
oxidation  products  of  indol,  which  impart  to  it  a  brown  colour,  intensified  or 
developed  on  exposure  to  air. 

This  variety  of  brown  or  black  urine  is  less  well  recognized  than  it  should  be, 
and  it  is  probable  that  the  condition  has  not  infrequently  been  mistaken  for 
melanuria.  Such  urine  is  not  blackened,  as  that  of  melanuria  is,  by  the  addition 
of  ferric  chloride,  nor  by  nitric  acid  in  the  cold,  but  does  blacken  when  heated 
with  nitric  acid.  The  ordinary  tests  for  indican  reveal  its  presence  in  large 
amount.  Thus,  if  a  specimen  of  the  urine  be  heated  with  an  equal  volume  of 
hydrochloric  acid,  and  a  drop  of  a  dilute  solution  of  bleaching  powder,  or  a  drop 
of  nitric  acid,  it  becomes  black.  If,  after  cooling,  the  dark-coloured  liquid  be 
shaken  with  chloroform,  the  latter  takes  up  indigo-blue  and  red  and  acquires  a 
deep  purple  colour  ;  but  the  supernatant  liquid  remains  black.  If  the  chloroform 
extract  be  separated  and  evaporated  to  dryness,  the  indigo  red  may  be  dissolved 
out  of  the  residue  with  alcohol,  whereas  the  indigo  blue,  which  is  insoluble  in 
alcohol,  may  be  taken  up  afterwards  with  chloroform. 

Indicanuria  signifies  abnormal  amount  of  protein  decomposition  in  the 
alimentary  canal,  brought  about  by  intestinal  bacteria  ;  but  it  is  stated  that  it 
may  also  have  its  origin  in  collections  of  putrid  pus,  such  as  putrid  empyemata. 
In  such  a  case,  which  was  recently  under  the  writer's  care,  the  abundant  indican 
disappeared  from  the  urine  when  a  dose  of  calomel  was  given,  and  was  probably 
of  intestinal  origin. 

6.  Melanuria. — This  is  a  symptom  which  is  met  with  in  some  cases  of  melanotic 
sarcoma.  The  urine,  when  freshly  passed,  contains  a  colourless  chromogen, 
melanogen,  and  usually  has  a  normal  tint.  On  exposure  to  air,  it  quickly  darkens, 
owing  to  oxidation  of  the  melanogen  to  melanin,  becomes  brown,  and  eventually 
quite  black.  When  nitric  acid  is  added  to  such  a  urine,  it  causes  prompt  blacken- 
ing, even  in  the  cold,  and  immediate  blackening  also  follows  the  addition  of  a 
solution  of  ferric  chloride.  This  is  the  most  valuable  and  characteristic  of  the 
tests  for  melanuria.  Bromine  water  produces  a  yellow  or  brown  precipitate 
which  quickly  blackens. 

As  a  rule,  melanuric  urines,  when  treated  with  liquor  potassas  and  sodium 
nitroprusside,  yield  a  deep  Prussian  blue  on  acidification  with  acetic  acid,  but 
this  reaction  is  not  due  to  the  melanogen  as  such,  is  yielded  by  some  other  urines, 
and  cannot  be  taken  as  diagnostic  of  melanuria. 

It  is  frequently  stated  that  melanuria  may  be  met  with  apart  from  melanotic 
growths,  in  cases  of  wasting  and  other  diseases.     There  is  little  doubt  that  some 


822  URINE,     ABNORMAL     COLORATION     OF 

of  the  cases  quoted  in  support  of  this  contention,  and  which  were  recorded  before 
the  more  distinctive  tests  for  the  condition  were  known,  were,  in  reality,  examples 
of  indicanuria,  such  as  have  been  described  above,  and  the  writer  has  never  met 
with  true  melanuria  save  in  cases  of  melanotic  sarcoma.  Even  in  such  cases 
it  is  not  seen  so  long  as  the  tumour  is  confined  to  its  primary  seat,  but  only  when 
it  has  invaded  the  viscera,  and  especially  the  liver.  Indeed,  the  quantity  of 
melanogen  excreted  is  apparently  dependent  upon  the  extent  to  which  the  liver 
has  been  invaded,  and  the  amount  of  pigmentation  in  the  growths  of  which  it 
is  the  seat.  Hence  it  usually  happens  that  the  diagnosis  of  the  case  has  already 
been  established  before  the  peculiar  pigmentation  of  the  urine  is  developed. 

7.  Alkaptonuria  is  the  outward  sign  of  a  very  rare  anomaly  of  metabolism 
which  is  almost  always  congenital,  and  persists  through  life  without  any  serious 
detriment  to  the  health  of  its  subjects.  The  peculiar  properties  of  the  urine  are 
due  to  the  excretion  in  it  of  an  aromatic  acid,  homogentisic  or  hydroquinone- 
acetic  acid,  a  product  of  katabolism  of  tyrosin  and  phenylalanin.  It  is,  in  all 
probability,  a  product  of  normal  metabolism,  which  in  normal  individuals  under- 
goes complete  destruction. 

Alkapton  urine  seldom  exhibits  any  abnormality  of  tint  when  passed  ;  but 
quickly  darkens  on  exposure  to  air,  undergoing  changes  through  brown  to  black, 
which  resemble  in  the  closest  manner  those  seen  in  melanuria  urines.  However, 
the  two  conditions  are  readily  distinguished  by  means  of  simple  tests.  When  a 
dilute  solution  of  ferric  chloride  is  added  to  alkapton  urine,  a  deep  blue  colour 
appears  for  a  moment,  and  reappears  after  each  subsequent  addition  of  the 
reagent,  until  oxidation  of  the  homogentisic  acid  is  completed.  Unless  the 
reagent  be  very  dilute,  oxidation  occurs  too  rapidly,  and  the  blue  colour  is 
missed. 

The  addition  of  an  alkali  causes  very  rapid  darkening,  with  absorption  of 
oxygen,  and  heat  increases  the  rate  of  blackening. 

As  homogentisic  acid  is  a  powerful  reducing  agent,  alkapton  urines  give  some 
of  the  reactions  of  glycosuria.  Fehling's  solution  is  freely  reduced  with  the  aid 
of  heat,  but  the  blackening  effect  of  the  alkaline  reagent  gives  a  peculiar  appear- 
ance to  the  reaction.  No  black  precipitate  is  obtained  with  Nylander's  reagent, 
but  the  alkali  therein  causes  conspicuous  darkening.  The  safranin  reaction  is 
not  obtained,  and  alkapton  urine  is  optically  inactive.  An  ammoniacal  solution 
of  silver  nitrate  is  rapidly  reduced,  even  in  the  cold,  a  reaction  which  is  made 
use  of  for  the  quantitative  estimation  of  homogentisic  acid.  It  is  because 
alkaptonuria  is  so  rare,  rather  than  because  its  recognition  presents  any  special 
difficulty,  that  its  properties  are  not  widely  known  and  not  infrequently  fail 
of  recognition. 

Ochronosis,  i.e.,  a  blackening  of  the  cartilages,  and  deep  pigmentation  of 
regions  of  the  skin,  a  bluish-black  coloration  of  the  ears,  and  pigment  spots  on 
the  conjunctivae,  is  sometimes  the  outcome  of  alkaptonuria  ;  but  there  is  a 
group  of  cases  in  which  similar  pigmentation  results  from  the  application  of 
carbolic  acid  to  chronic  ulcers,  over  long  periods  of  years.  There  is  also  some 
reason  to  believe  that  the  lesions  of  joints  which  sometimes  accompany  ochronosis 
may  also  be  results  of  alkaptonuria. 

8.  Carboluria. — A  darkening  of  the  urine,  increased  by  exposure  to  air,  is 
frequently  seen  after  the  administration  of  certain  drugs  which  contain  phenol, 
in  carbolic  acid  poisoning,  and  as  the  result  of  outward  application  of  carbolic 
acid.  A  carbolic-acid  compress  applied  to  the  head  of  a  child  for  the  destruction 
of  pediculi  quickly  induces  carboluria,  and  the  taking  of  salol  is  another  common 
cause.  The  urine  has  a  smoky  tint,  or  in  cases  of  carbolic  acid  poisoning  may 
be  actually  black.  In  the  slighter  cases  it  is  best  described  as  brown  with  a 
greenish  tinge,  and  the  meniscus,  when  seen  from  the  side,  appears  black. 


URINE.     ABNORMAL     COLORATION     OF  823 

There  is  no  direct  chemical  test  for  carboluria,  and  the  diagnosis  is  usually 
based  upon  the  knowledge  that  phenol,  or  some  derivative  or  compound  thereof, 
has  been  administered  or  applied.  After  boiling  the  urine  for  some  time  with 
Fehling's  solution,  a  slight  reduction  is  observed  ;  but  this  is  in  no  way  comparable 
with  that  seen  with  alkapton  urine.  Indirect  evidence  is  obtained  by  the  addition 
of  a  solution  of  barium  chloride,  which  in  cases  of  carboluria  produces  a  very 
slight  precipitate  or  none  at  all.  If,  however,  the  urine  be  first  boiled  with 
hydrochloric  acid,  a  precipitate  is  obtained  such  as  is  yielded  by  normal  urines. 
This  is  due  to  the  fact  that,  in  the  presence  of  abundant  phenol  and  oxidation 
derivatives  thereof,  the  sulphates  of  the  urine  are  for  the  most  part,  or  even 
wholly,  combined  as  aromatic  sulphates,  which  yield  no  precipitate  with  barium 
salts,  whereas,  when  the  aromatic  sulphates  are  broken  up  by  hydrochloric  acid 
a  precipitate  of  barium  sulphate  is  thrown  down. 

The  diagnosis  of  the  other  varieties  of  brown  or  black  urine  which  have  their 
origin  in  the  administration  of  drugs,  is  based  upon  the  fact  that  salicylates,  or 
other  drugs  capable  of  producing  such  pigmentation,  have  been  taken. 

IV.  Green  and  Blue  Urines — In  some  cases  of  jaundicej  the  bile  pigment 
excreted  is  so  largely  in  the  form  of  biliverdin  that  the  urine  has  a  dark  green 
colour  :  but  with  this  exception,  practically  all  green  urines  met  with  in  practice 
owe  their  colour  to  the  taking  of  methylene  blue,  either  as  a  drug  or  in  sweetmeats. 
\Yhen  the  dose  is  small,  the  tint  may  be  a  rich  green  ;  but  after  larger  doses, 
the  urine  is  frankly  blue.  It  is  not  always  easy  to  account  for  the  origin  of  such 
coloration  of  urine,  for  the  patient  may  be  quite  unaware  that  he  has  taken 
methylene  blue  in  any  form,  although  examination  of  his  urine  may  leave  no 
doubt  that  he  has  done  so.  Sweetmeats  are  sometimes  coloured  with  this 
pigment,  as  they  are  with  eosin,  and  it  is  sometimes  used  to  correct  the  colour 
of  white  sweetmeats.  Again,  a  pill  of  methylene  blue  has  before  now  found 
its  way,  either  by  accident  or  design,  into  a  supply  of  pills  of  another  kind. 
Absence  of  a  known  cause  does  not,  therefore,  by  any  means  exclude  this 
kind  of  pigmentation  ;  and  experience  shows  that  unless  it  can  be  shown,  by 
careful  examination,  that  the  colour  of  the  urine  is  not  due  to  methylene  blue, 
it  is  needless  to  search  for  any  other  causation. 

Although  the  green  urine  which  follows  the  taking  of  methylene  blue  may 
appear  perfectly  hmpid,  the  blue  pigment  is  not  held  in  solution  but  in  suspension, 
and  is,  to  a  large  extent,  removed  even  by  a  single  filtration.  The  green  colour 
of  the  filtrate  is  greatly  reduced,  and  the  filter  paper  shows  a  blue  stain.  The 
pigment  upon  the  filter  yields  a  blue  solution  in  chloroform,  and  if  the  chloroform 
solution,  or  the  blue  extract  obtained  by  shaking  the  urine  with  chloroform, 
be  shaken  with  liquor  potassae  in  a  test  tube  the  chloroform  is  decolorized,  and 
the  supernatant  alkaline  liquid  acquires  a  pink  tint.  The  original  urine,  or  the 
chloroform  extract,  show's  an  absorption  band  in  the  red  of  the  spectrum  which 
may  be  mistaken  for  that  of  indigo  blue. 

There  is  no  reason  to  think  that  indigo  blue  ever  produces  a  green  or  blue 
coloration  of  urine  similar  to  that  due  to  methylene  blue.  By  the  spontaneous 
breaking  down  of  indoxyl  glycuronic  acid,  usually  in  alkaline  urines,  indigo  blue 
may  be  set  free,  and  may  form  a  dark  blue  sediment,  or  may  impart  a  blue  colour 
to  the  phosphatic  film  upon  the  surface  ;  and  when,  in  the  earlier  years  of  the 
last  century,  indigo  blue  was  somewhat  frequently  employed  as  a  drug  in  the 
treatment  of  epilepsy,  a  dark  purple  colour  of  the  urine  of  patients  so  treated 
was  observed,  but  under  no  circumstances  are  indigo  pigments  spontaneously 
formed  in  quantities  sufficient  to  bring  about  such  a  result.  A.  E.  Garrod. 

URINE,   ACETONE  IN.— (See  Acetonuria.) 

URINE,  ALBUMIN  IN.— (See  Albuminuria.) 


824 


VEINS.      VARICOSE     ABDOMINAL 


URINE,  ALBUMOSE  IN.— (See  Albumosuria.) 

URINE,  BACTERIA  IN.— (See  Bacteriuria.) 

URINE,  BENCE-JONES'  BODY  IN.— (See  Albumosuria.) 

URINE,  BILE  PIGMENT  IN. — (See  Urine,  Abnormal  Coloration  of.) 

URINE,  BLACK. — (See  Urine,  Abnormal  Coloration  of.) 

URINE,  BLOOD  IN.— (See  Hematuria  ) 

URINE,  CASTS  IN. — (See  Albuminuria.) 

URINE,  CYSTINE  IN.— (See  Cystinuria.) 

URINE,  DIACETIC  ACID  IN.— (See  Acetonuria.) 

URINE,  DIAZO-REACTION  IN.— (See  Diazo-Reaction.) 

URINE,  EXCESS  OF.— (See  Polyuria.) 

URINE,  F^CES  IN. — (See  F^ces  Passed  per  Urethram.) 

URINE,  FAT  IN.— (See  Chyluria.)  ■ 

URINE,  GAS  IN.— (See  Pneumaturia.) 

URINE,  GLUCOSE  IN.— (See  Glycosuria.) 

URINE,  HEMOGLOBIN  IN.— (See  H^emoglobinuria.) 

URINE,  INCONTINENCE  OF. — (See  Micturition,  Abnormalities  of.) 

URINE,  INDICAN  IN.— (See  Indicanuria.) 

URINE,  MUCUS  IN.— (See  Mucus  in  the  Urine.) 

URINE,  OXALATE  DEPOSIT  IN.— (See  Oxaluria.) 

URINE,  OXYBUTYRIC  ACID  IN.— (See  Acetonuria.) 

URINE,  PHOSPHATES  IN.— (See  Phosphaturia.) 

URINE,  PUS  IN.— (See  Pyuria.) 

URINE,  RETENTION  OF. — (See  Micturition,  Abnormalities  of.) 

URINE,  SUGAR  IN.— (See  Glycosuria.) 

URINE,  SUPPRESSION  OF.— (See  Anuria  ) 

URINE,  URATE  DEPOSIT  IN.— (See  Urate  Deposit  in  the  Urine.) 

URINE,  URIC  ACID  DEPOSIT  IN.— (See  Uric  Acid  Deposit  in  the  Urine.) 

UTERUS,  PROLAPSE  OF. — (See  Prolapse  of  the  Uterus.) 

VAGINAL  DISCHARGE.— (See  Discharge,  Vaginal.) 

VARICOSE  ABDOMINAL  VEINS.— (See  Veins,  Varicose  Abdominal.) 

VARICOSE  THORACIC  VEINS.— (See  Veins,  Varicose  Thoracic.) 

^VEINS,  VARICOSE  ABDOMINAL.— The  point  at  which  distention  of  veins 
becomes  varicosity  is  arbitrary  ;  most  conditions  that  produce  undoubted  vari- 
cosity of  the  veins  of  the  abdominal  wall  in  some  cases,  merely  dilate  them  in 
others.  When  this  dilatation  is  considerable  (Plate  XVI),  it  nearly  always  has 
much  diagnostic  significance,  particularly  if  the  direction  of  blood-flow  is  reversed. 
Veins,  however,  may  seem  to  be  dilated  when  they  are  but  unduly  visible  owing 
to  wasting  of  the  subcutaneous  fat ;  or  they  may,  in  very  rare  cases,  be  simply 
varicose,  like  veins  in  the  leg,  owing  to  idiosyncrasy  or  hereditary  predisposition. 
In  neither  of  these  cases,  however,  is  the  blood-current  in  them  reversed.  To 
test  the  direction  of  blood-fiow,  part  of  a  vein  should  be  chosen  where  there 
are  no  side  branches,  and  the  blood  should  be  expressed  from  it  by  means  of  two 


PLATE     XVI. 


VARICOSE      ABDOMINAL      VEINS 


A  case  of  obstruction   lo  the  inferior  vena  cava  by  malignant  disease. 


INDEX    C1F    DIAGNOSIS 


VEIXS,      VARICOSE     ABDOMINAL  825 

fingers  pressed  down  on  the  vein  close  together,  and  then  drawn  asunder,  whilst 
pressure  over  the  vein  is  maintained  by  each  ;  when  a  length  of  the  distended 
vein  has  been  emptied  in  this  way,  one  of  the  two  fingers  is  taken  off,  and  the 
time  taken  by  the  vein  in  re-filling  is  noted  ;  the  procedure  is  repeated,  the 
other  finger  being  taken  oft'  this  time  ;  it  will  generally  be  obvious  whether  the 
vein  fills  from  below  upwards  or  from  above  downwards.  Normally,  the  blood 
flows  from  above  downwards  in  the  veins  of  the  lower  two-thirds  of  the  abdominal 
wall ;  when  the  blood-flow  is  from  below  upwards,  there  is  almost  certainly  an 
obstruction  to  the  inferior  vena  cava,  the  blood,  which  is  unable  to  return  by  it, 
finding  a  collateral  circulation  via  the  azygos  veins  or  the  superior  vena  cava. 

Obstruction  to  the  inferior  vena  cava  is  due  to  one  or  other  of  three  main 
groups  of  conditions,  namel}'  : — ■ 

1.  Great  general  increase  in  the  intra-abdominal  tension,  owing  to  such  condi- 
tions as  :    ascites  ;    ovarian  cyst ;    great  splenic  or  hepatic  enlargement. 

2.  Thrombosis  without  external  obstruction. 

3.  Obstruction  by  compression  from  without,  yet  without  there  being  obvious 
increase  in  the  intra-abdominal  tension  ;  such  local  obstruction  to  the  inferior 
vena  cava  results  mainly  from  carcinoma  or  sarcoma,  adjacent  to  the  vena  cava, 
especially  secondary  growths  in  the  retroperitoneal  glands. 

When  the  obstruction  of  the  inferior  vena  cava  is  due,  not  to  the  vein  itself 
being  thrombosed  or  invaded  by  new  growth,  but  to  the  general  intra-abdominal 
pressure  becoming  so  great  that  the  vein  is,  so  to  speak,  flattened  out,  the  vari- 
cosity of  the  veins  upon  the  abdominal  wall  is  but  a  late  symptom,  and  the 
diagnosis  will  be  made  from  the  cause  of  the  great  abdominal  distention, 
generally  the  result  of  Ascites  [q.v.),  or  a  big  tumour.  If  there  is  marked 
varicosity  of  the  superficial  veins  earl}^  in  a  case  of  ascites,  the  probability  is 
that  both  are  due  to  malignant  disease. 

When  the  inferior  vena  cava  is  obstructed  by  "  simple  "  thrombosis,  the 
probability  is  that  the  clotting  will  not  have  started  there,  but  will  have 
extended  to  it  from  branches  either  in  the  legs  or  in  the  pelvis.  QJdema  of  the 
legs  will  be  a  prominent  symptom  ;  and  if  a  clear  history  is  obtainable,  it  may 
generally  be  ascertained  that  one  leg  became  oedematous  and  painful  before  the 
other  ;  when  this  is  so,  it  is  always  very  suggestive  of  thrombosis  starting  in  the 
saphenous  or  femoral  veins  (see  (Edema,  Asymmetrical)  ;  the  other  leg  becom- 
ing affected  later  when  the  clot  has  spread  up  through  the  iliac  veins  of  the  one 
side  to  the  inferior  vena,  and  thence  down  the  iliac  veins  of  the  other  side.  The 
higher  the  thrombus  extends,  the  higher  up  the  back  will  the  oedema  spread  ; 
and  when  the  renal  veins  have  been  reached,  albuminuria,  with  tube  casts,  and 
even  hasmaturia,  will  be  marked  features  of  the  case.  Ascites  may  also  be 
present.  Distention  or  varicosity  of  the  veins  of  the  abdominal  wall  will  be  of 
assistance  in  distinguishing  such  a  case  from  one  of  acute  or  subacute  nephritis, 
besides  which,  there  will  be  no  oedema  of  the  eyelids  or  face. 

If  there  is  no  very  tense  distention  of  the  abdomen  ;  if  the  way  the  case  began 
does  not  suggest  thrombosis  in  one  leg,  or  in  the  pelvis,  extending  upwards  ; 
and  if,  nevertheless,  there  is  marked  varicosity  of  the  veins  of  the  lower  part  of 
the  abdominal  wall,  with  the  blood-flow  in  them  reversed,  so  as  to  be  from  below 
upwards,  the  history  being  a  relativel}-  short  one, — the  probability  is  that  the 
inferior  vena  cava  is  being  obstructed  b}'  something  that  is  in  immediate  contact 
with  it.  There  will  very  likely  be  symmetrical  oedema  of  the  legs,  and  possibly 
albuminuria  and  hsematuria.  It  is  surprising  how  seldom  an  aortic  aneurysm, 
or  other  non-malignant  mass,  obstructs  a  large  vein  sufficiently  to  produce  this 
collateral  varicosity  ;  hence,  the  presumption  is  that  such  varicosity  indicates 
malignant  disease.  It  is  worthy  of  note  that  carcinoma  o^f  the  kidney  is  prone 
to  extend  into  the  renal  veins,  and  thus  into  the  inferior  vena  cava  by  a  process 


826  VEINS,      VARICOSE     THORACIC 

of  direct  extension — sometimes  the  malignant  clot  reaches  as  far  as  the  right 
auricle,  and  produces  a  pedunculated  polypus  in  the  latter.  In  such  cases  there 
has  generally  been  hsematuria  or  other  renal  symptom  before  evidence  of  inferior 
vena-caval  obstruction  arose,  whereby  cases  of  growth  in  the  kidney  invading 
the  inferior  vena  cava  may  be  distinguished  from  cases  of  secondary  growth  in 
the  retroperitoneal  glands,  which  if  they  produced  hsematuria  at  all,  would  do 
so  by  first  obstructing  the  inferior  vena  cava,  and  thence  involving  the  renal 
veins.  In  such  cases  there  are  often  other  synaptoms  pointing  to  primary 
growth  in  some  organ  whose  lymphatics  drain  into  the  retroperitoneal  glands  ; 
the  testes  and  ovaries  should  not  be  overlooked  in  this  respect. 

It  is  often  said  that  cirrhosis  of  the  liver  leads  to  varicosity  of  the  veins  around 
the  umbilicus — the  so-called  caput  meduscs.  It  is  a  very  rare  condition  indeed, 
the  great  majority  of  cases  of  cirrhosis  of  the  liver  causing  no  distention  of  the 
superficial  abdominal  veins  until  such  time  as  the  general  intra-abdominal 
tension  has  been  greatly  increased  by  the  tenseness  of  the  ascites  which  occurs 
late.  Not  even  the  telangiectases  that  occur  so  commonly  in  men  past  middle 
age  around  the  lower  part  of  the  chest,  in  a  line  with  the  attachments  of  the 
diaphragm,  indicate  cirrhosis ;  they  are  quite  as  common  in  cases  of  emphysema 
without  cirrhosis. 

In  short,  varicosity  of  the  superficial  abdominal  veins  generally  indicates 
either  thrombosis  of  the  inferior  vena  cava,  secondary  to  direct  spread  of  throm- 
bosis up  to  it  from  veins  in  the  pelvis  or  in  the  leg,  or  else  stenosis  of  the  vena 
cava  by  secondary  malignant  disease.  Herbert  French. 

VEINS,  VARICOSE  THORACIC— Much  of  what  has  been  said  above  about 
varicose  abdominal  veins  applies  also  to  those  of  the  thorax.  The  veins  on  the 
chest  wall  may  merely  be  unduly  visible ;  but  if  they  are  really  distended,  there 
is  probably  obstruction  to  one  or  other  innominate  vein  or  else  to  the  superior 
vena  cava  ;  and  the  suspicion  that  this  is  so  becomes  a  certainty  if  the  blood 
current  in  the  distended  veins  can  be  shown  to  be  from  above  downwards  instead 
of  from  below  upwards.  If  the  distention  is  bilateral,  and  associated  with  oedema 
of  both  arms,  and  both  sides  of  the  neck,  face  and  head,  it  is  the  vena  cava  that 
is  obstructed  ;  if  the  distention  is  unilateral,  with  oedema  of  the  corresponding 
arm,  but  little  if  any  of  the  neck  or  face,  the  obstructed  vessel  is  probably  one 
innominate  vein.  The  superficial  varicosity  may  be  only  slight  {Fig.  73,  p.  235), 
but  sometimes  it  is  extreme. 

In  arriving  at  a  diagnosis  of  the  cause  of  the  venous  obstruction,  malignant 
disease  within  the  thorax  will  be  uppermost  in  one's  mind — especially  mediastinal 
sarcoma,  starting  in  the  thymus  or  in  the  lymphatic  glands.  It  is  onl}-  when 
the  history  and  course  are  too  long  for  primary  or  secondary  malignant  neoplasm, 
that  other  causes  of  venous  obstruction  will  be  regarded  as  more  likely,  such  as 
thrombosis  extending  to  an  innominate  vein  or  to  the  superior  vena  cava  from  a 
whitlow,  boil,  or  other  inflammatorj^  affection  of  the  hand,  arm,  axilla,  head,  face, 
neck,  shoulder,  or  front  of  chest ;  or  chrome  fibrous  mediastinitis,  sometimes  tuber- 
culous or  gummatous  but  often  rheumatic  in  origin,  and  resulting  from  repeated 
attacks  of  pericarditis  and  pleurisy,  with  matting  together,  not  only  of  the  pleurae 
to  the  diaphragm  and  pericardium,  but  also  of  all  the  structures  in  the  superior, 
posterior,  and  anterior  mediastina  to  one  another  ;  or,  far  less  commonly,  to 
aneurysm  of  the  thoracic  aorta,  or  a  non-malignant  mediastinal  tumour,  such  as 
a  hydatid  cyst,  a  dermoid  cyst,  or  a  large  congenital  fibroma,  which  may  have 
been  quiescent  within  the  chest  for  many  years  before  starting  to  enlarge  and 
obstruct  structures  in  its  neighbourhood  ;  the  latter  conditions,  except  aneurysm, 
are  rarities,  and  although  an  aortic  aneurysm  does  sometimes  obstruct  the 
superior  vena  cava  sufficiently  to  cause  distention  or  varicosity  of  the  veins 


VERTIGO  827 


upon  the  chest  wall,  such  varicosity  is  so  much  more  marked  in  a  case  of  intra- 
thoracic malignant  disease  that  one  may  say  that  when  the  diagnosis  lies 
between  neoplasm  and  aneurysm  the  presence  of  marked  distention  of  the  veins 
of  the  chest  wall  indicates  the  former  rather  than  the  latter,  though  the  converse 
of  this  is  not  true.  Herbert  French. 

VERTIGO,  popularly  known  as  dizziness  or  giddiness,  depends  upon  a  dis- 
turbance of  the  sense  of  equilibrium.  In  slight  cases  the  trouble  is  perceptible 
to  the  suiferer  either  as  the  apparent  movement  of  motionless  objects  (objective 
vertigo),  or  his  own  body  may  appear  to  be  moving  in  relation  to  surrounding 
fixed  structures  (subjective  vertigo).  In  more  severe  cases  it  may  lead  to  reeling 
or  staggering,  and  unless  the  patient  can  grasp  some  fixed  support  he  may  fall 
to  the  ground. 

The  equilibrium  of  the  body  is  maintained  by  the  co-ordinated  action  of 
various  groups  of  muscles,  and  the  nervous  mechanism  for  this  co-ordination  is 
situated  in  the  cerebellum.  Afferent  impulses  are  brought  to  the  cerebellar 
centres  from  the  muscles,  skin,  joints,  eyes,  and  the  semicircular  canals.  The 
cerebellum  is  also  connected  with  the  motor  centres  of  the  cerebral  hemisphere, 
and  thus  the  requisite  contraction  of  the  necessary  muscles  is  ensured.  Dis- 
turbances of  equilibrium  may  therefore  be  the  result  of  a  lesion  in  the  cere- 
bellum itself  or  in  one  of  the  afferent  tracts. 

True  vertigo  depends  mainly  upon  interference  with  the  afferent  impulses  from 
the  semicircular  canals  or  from  the  eyes.  The  importance  of  the  visual  impulses 
in  the  maintenance  of  equilibrium  is  shown  by  the  frequent  occurrence  of  nys- 
tagmus during  attacks  of  vertigo,  even  when  this  is  due  to  a  labyrinthine  lesion. 

Occasionally  vertigo  may  be  the  result  of  altered  cutaneous  impulses  such 
as  are  present  in  some  cases  of  anaesthesia  of  the  soles  of  the  feet.  Some  people 
experience  a  slight  feeling  of  giddiness  on  stepping  on  to  some  soft  material 
such  as  turf  or  india-rubber  pavement  after  walking  on  a  hard  road.  Unusual 
cutaneous  impulses  are  the  probable  explanation. 

Interference  with  the  afferent  impulses  from  the  muscles  themselves,  such  as 
occurs  in  locomotor  ataxy,  will  lead  to  reeling  and  staggering  rather  than  to 
true  vertigo.  The  ocular  impressions  correct  the  false  sensations  from  the 
muscles,  and  hence  loss  of  equilibrium  is  more  likely  to  occur  in  the  dark,  or 
when  these  impressions  are  cut  off  by  covering  the  patient's  eyes. 

Vertigo  is  sometimes  divided  into  "  general  "  vertigo  and  "  special  "  vertigo. 
In  the  latter,  objects  appear  to  move,  or  the  patient  tends  to  fall  in  a  definite 
direction.  Special  vertigo  points  to  a  lesion  of  a  particular  semicircular  canal. 
Thus,  if  there  is  a  lesion  of  the  external  semicircular  canal,  objects  appear  to 
move  in  a  horizontal  plane,  and  the  patient  tends  to  fall  towards  the  affected 
side.  When  the  superior  canal  is  the  source  of  the  trouble,  objects  rotate  in  a 
vertical  plane,  and  the  patient  will  fall  in  a  forward  direction.  Temporary 
vertigo,  even  of  a  very  severe  nature,  may  be  produced  readily  in  a  healthy 
individual  by  prolonged  movements  of  rotation  or  of  swinging.  In  this  case 
the  cause  of  the  giddiness  is  probably  unequal  pressure  in  the  endolj^mph  in  the 
different  semicircular  canals.  The  dizziness  with  which  niany  people  are  affected 
when  near  the  edge  of  a  high  cliff  is  most  likely  ocular  in  origin,  and  depends 
upon  the  sudden  cessation  of  visual  impulses  from  near  objects.  Some  persons 
are  exceedingly  susceptible  to  alterations  in  these  impressions,  and  travelling  by 
train  or  the  movement  of  a  boat  may  be  sufficient  to  cause  a  considerable  degree 
of  dizziness. 

Vertigo  may  also  be  of  toxic  origin.  Alcohol  and  tobacco  are  familiar  examples, 
but  the  dizziness  associated  with  ptomaine  poisoning,  and  in  some  cases  of 
gastric  disturbance,  is  also  probably  of  this  nature. 


828  VERTIGO 

Vertigo  is  not  infrequentlj'  of  cerebral  origin,  either  with  or  without  some  gross 
lesion.  Thus  it  occurs  in  migraine,  and  is  also  a  frequent  aura  of  an  epileptic 
fit.  '  Attacks  of  vertigo  occurring  in  elderly  people  with  atheromatous  arteries 
or  suffering  form  chronic  nephritis  or  arteriosclerosis  must  always  be  regarded 
as  of  serious  import,  since  an  attack  of  giddiness  may  be  the  precursor  of  cere- 
bral haemorrhage  or  thrombosis.  Severe  vertigo  may  be  one  of  the  syntiptoms 
of  a  cerebral  tumour.  It  is  more  likely  to  be  present  when  the  growth  is  in  the 
cerebellum,  especially  if  the  middle  lobe  is  involved.  A  tumour  involving  the 
auditory  nerve  in  its  intracranial  course  will  also  give  rise  to  this  symptom.  A 
cerebral  or  cerebellar  abscess  may  also  cause  vertigo,  but  in  this  case  there  may 
also  be  suppuration  in  the  middle  ear,  and  the  giddiness  may  be  of  labyrinthine 
origin. 

Vertigo  naay  be  of  ocular  origin.  It  is  especially  likely  to  occur  when  there 
is  some  lesion  of  the  nerves  or  muscles  leading  to  diplopia. 

Laryngeal  vertigo  is  a  very  rare  condition,  where  spasm  of  the  glottis  is  accom- 
panied by  severe  giddiness  which  causes  the  patient  to  fall  down,  and  he  may 
lose  consciousness  for  a  few  seconds.  Complete  recovery  ensues  in  a  short  time, 
but  the  attacks  are  likely  to  recur.     This  trouble  may  be  of  an  epileptic  nature. 

Vertigo  is,  however,  most  commonly  of  aural  origin,  and  is  a  frequent  symptom 
of  diseases  of  the  ear,  especially  of  the  internal  ear  or  labyrinth.  In  its  most 
intense  form  it  is  one  of  the  symptoms  of  "  Meniere's  disease."  Its  onset  is  then 
sudden,  and  so  severe  that  the  patient  falls  to  the  ground  and  even  loses 
consciousness.  Associated  with  the  giddiness  are  severe  tinnitus,  and  unilateral 
or  bilateral  deafness,  while  nausea,  vomiting,  and  pallor  of  the  face  are  frequently 
present.  The  vertigo  passes  off  after  a  few  hours  or  days,  but  impairment  of 
hearing  and  tinnitus  persist.  The  attacks  tend  to  recur.  Meniere's  disease  is 
probably  caused  by  a  sudden  increase  in  pressure  in  the  endolymph,  and,  in 
some  cases  at  any  rate,  appears  to  be  due  to  haemorrhage  into  the  semicircular 
canals.  True  Meniere's  disease  is  very  rare  ;  but  the  occurrence  of  the  symptoms, 
viz.,  vertigo,  deafness,  and  tinnitus,  in  a  less  acute  and  sudden  form,  is  by  no 
means  uncommon.  They  may  be  present  without  any  obvious  lesion  of  the 
middle  or  external  ear,  though  sometimes  there  is  some  abnormality  in  one  of 
these  portions  of  the  auditory  apparatus. 

Syphilitic  disease  of  the  internal  ear  may  produce  symptoms  closely  resembling 
those  of  Meniere's  disease,  in  that  giddiness,  tinnitus,  and  labyrinthine  deafness 
are  associated,  the  onset  being  quite  sudden.  Vertigo  is,  however,  occasionally 
absent.  The  trouble  is  usually  unilateral,  and  may  occur  in  the  secondary  or 
tertiary  stages.  The  diagnosis  will  depend  on  the  history  of  syphilis  or  other 
evidences  of  the  disease.  Similar  symptoms  may  occur  in  congenital  syphilis, 
usually  between  the  ages  of  ten  and  fifteen  years,  though  occasionally  much  later. 
Eustachian-tube  obstruction  is  usually  present  also,  but  treatment  of  this  fails 
to  improve  the  hearing,  and  other  characteristic  troubles,  especially-  interstitial 
keratitis,  may  be  found.  Aural  vertigo  may  also  be  associated  with  some  lesion 
of  the  external  or  middle  ear.  Thus  in  the  former  case  there  may  be  a  foreign 
body,  or  even  a  plug  of  impacted  cerumen,  as  the  exciting  cause. 

Vertigo  is  not  infrequently  present  in  chronic  middle-ear  suppuration.  This 
may  be  due  to  labyrinthine  inflammation  or  irritation,  but  a  definite  labyrinthine 
lesion  is  not  necessarily  present.  In  many  cases  the  giddiness  is  caused  by 
pressure  on  the  stapes  or  the  fenestra  rotunda.  Some  patients  with  a  perfora- 
tion of  the  tympanic  membrane  become  giddy  whenever  the  ear  is  syringed. 
Occasionally  the  use  of  unduly  hot  or  cold  lotions  produces  this  trouble.  It 
is  usually  the  result  of  pressure  on  the  stapes,  though  occasionally  the  vertigo 
may  have  the  special  character  associated  with  a  lesion  of  the  external  semi- 
circular canal  {vide  supra).     When  this  is  the  case  there  is  probably  some  erosion 


VESICLES  829 

of  the  bony  external  canal.  Similar  giddiness  may  occur  from  a  like  cause  on 
syringing  the  ear  after  a  radical  mastoid  operation. 

Vertigo  may  occur  in  otosclerosis,  though  it  is  not  common  in  this  disease, 
and  is  always  of  less  importance  than  the  Deafness  {q.v.)  and  Tinnitus  (q.v.). 

When  a  patient  complains  of  vertigo,  the  ears  should  always  be  examined 
carefully.  The  hearing  should  be  tested,  and  if  the  cause  of  the  trouble 
is  in  the  labyrinth,  the  deafness  will  have  the  characters  of  nerve  deafness  (see 
Deafness).  The  onset  of  the  trouble  must  be  investigated  carefully,  and  any 
associated  symptoms  ascertained.  The  eyes  and  ocular  muscles  must  be 
examined,  and  if  nystagmus  is  present  the  character  of  the  movements 
should  be  observed.  A  general  examination  of  the  patient  should  also  be 
made  for  some  general  constitutional  cause  such  as  gout,  albuminuria,  or 
arteriosclerosis.  Philip  Turner. 

VESICLES.  —  One  of  the  primary  lesions,  the  vesicle  may  be  defined  as 
a  circumscribed  epidermal  elevation  varying  in  size  from  a  pin's  head  to  a 
small  pea,  and  containing  serous  fluid,  which  may  become  sero-purulent  or  be 
mixed  with  blood.  Serous  elevations  larger  than  a  small  pea  are  classified 
as  BuLL.^  iq-v-)-  To  bullae,  therefore,  vesicles  bear  the  same  relation  that  papules 
bear  to  tubercles  (see  Papules)  .  The}'  differ  from  bullae,  however,  not  only  in 
size,  but  in  their  mode  of  formation.  They  are  always  the  result  of  an  inflam- 
matory process,  whereas  in  the  case  of  bullae  there  is  a  veritable  cleavage  of 
the  epidermis.  Vesicles,  again,  often  contain  a  number  of  chambers,  at  any  rate  in 
the  beginning,  whereas  bullae  are  from  the  outset  unilocular.  They  may  originate 
as  vesicles,  or  may  develop  from  papules.  Vesiculation  may  be  either  paren- 
chymatous or  interstitial  (Darier).  In  the  one  case,  as  in  varicella,  the  plasma 
accumulates  within  the  Malpighian  cells,  and  the  unicellular  vesicles  which 
are  thus  formed  run  into  each  other.  In  the  other  case,  as  in  eczema,  the 
plasma  accumulates  between  the  Malpighian  cells. 

In  shape,  vesicles  are  usually  rounded,  conical,  or  acuminate  ;  but  they  may  tend 
to  the  oblong  form,  as  in  scabies,  or  they  may  be  both  oblong  and  irregular, 
as  in  dermatitis  herpetiformis.  The  larger  ones  are  occasionally  umbilicated, 
as  in  variola,  and  instead  of  being  tense,  as  is  usual  with  vesicles,  may  be  flaccid, 
as  in  herpes  and  dermatitis  herpetiformis.  At  first,  the  liquid  they  contain 
consists  almost  invariably  of  pure  plasma,  and  is  quite  clear,  or  with  the 
faintest  tinge  of  j-ellow  ;  but  exceptionally  the  fluid  is  from  the  beginning  mixed 
with  blood.  After  a  time  the  clear  fluid  becomes  turbid.  In  some  conditions, 
as  in  varicella  and  miliaria,  they  remain  discrete  and  few  in  number  ;  but  usually, 
as  in  herpes,  eczema,  and  dermatitis  herpetiformis,  there  is  a  plentiful  crop  of 
them,  forming  groups  or  closely-set  clusters.  As  a  rule,  they  are  of  short 
duration  :  either  thev  rupture  and  crust  over,  as  in  eczema,  or  they  dr}^  up  and 
a  crust  is  formed,  as  is  usual  in  herpes  ;  or  they  enlarge  into  blebs,  as  frequently 
occurs  in  dermatitis  herpetiformis  ;  or  they  are  transformed  into  pustules,  as 
in  variola.  On  mucous  membranes  and  the  lips,  and  in  folds  of  the  skin,  they 
break  more  quickly  than  in  other  situations,  and  leave  excoriations.  Since,  as 
already  stated,  vesicles  are  the  result  of  a  more  or  less  inflammatory  process, 
they  usually  give  rise  to  much  burning  and  itching,  though  in  some  conditions, 
as  in  hidrocystoma,  these  symptoms  are  absent. 

The  most  distinctivel}'-  vesicular  aft'ections  are  herpes  simplex  and  herpes  zoster. 
In  simple  herpes  the  face  and  the  genital  organs  are  affected  chiefly.  The 
characteristic  lesion  is  a  cluster  of  transparent  vesicles  varying  in  number  from 
two  or  three  to  twenty  or  more,  seated  on  an  erythematous  patch,  and  surrounded 
by  a  narrow  red  zone.  First,  a  slightly  red  spot  appears  on  the  skin  ;  effusion 
quickly  takes  place  under  the  epidermis,  and  vesicles  are  formed  ;   these  become 


830  VESICLES 

opaque — sometimes  purulent, — shrivel  up,  and  form  yellowish-brown  crusts, 
which  after  a  few  days  become  detached,  usually  leaving  no  scar,  but  a  brownish 
stain  that  slowly  fades  and  disappears.  These  four  stages  in  the  evolution  of 
the  lesion  are  styled  by  Brocq  the  congestive,  vesicating,  desiccating,  and  macular 
stages.  On  mucous  membranes  the  lesion  runs  a  rather  different  course.  Here 
the  vesicles  are  quickly  reduced  to  a  whitish  pulp,  which  presents  the  appearance 
of  a  false  membrane.  When  this  becomes  detached,  it  reveals  a  number  of 
roundish  excoriations,  either  scattered  about  irregularly  or  running  into  each 
other  and  forming  largish  ulcers.  The  favourite  situations  of  the  vesicles 
in  herpes  genitahs  are,  in  raen,  the  prepuce,  especially  its  inner  surface,  the 
meatus,  the  sulcus,  and  the  glans  ;  in  women,  the  labia  and  the  cervix.  In  men, 
the  vesicles  are  usually  discrete,  and  the  patient  complains  only  of  the  itching 
and  burning  ;  but  if  they  are  neglected,  or  irritated  by  the  application  of 
caustics,  there  may  be  severe  and  extensive  ulceration,  with  swelling  of  the 
inguinal  glands.  In  women,  the  vesicles  tend  to  become  confluent,  and  the 
perineum,  the  inside  of  the  thighs,  and  the  mons  veneris  may  be  invaded.  There 
may  be  a  great  deal  of  swelling,  excoriation,  and  discharge,  with  intense  itching 
and  burning,  and,  as  in  men,  there  may  be  enlargement  of  the  neighbouring 
glands. 

In  the  crusted  stage,  facial  herpes  may  resemble  impetigo,  but  the  rapid  course 
it  runs,  its  limited  distribution,  the  facts  that  it  is  not  auto-inoculable,  and  that 
in  impetigo  the  lips  are  seldom  attacked,  should  suffice  to  obviate  the  confusion. 
The  points  which  distinguish  herpes  facialis  from  vesicular  eczema  are  touched 
upon  below. 

The  vesicles  of  genital  herpes  are  too  characteristic  to  be  mistaken  if  they 
are  seen  before  their  real  significance  is  obscured  by  ulceration.  If,  however, 
the  ulceration  is  considerable,  and  especially  if  there  is  much  suppuration,  the 
herpes  may  be  mistaken  for  chancroids.  Generally,  however,  soft  sores  are 
multiple,  have  a  fouler  base,  excavate  more  deeply,  and  the  healing  process  is 
much  slower.  Soft  sores,  further,  are  flattened  at  the  base,  secrete  very  little 
liquid,  and  are  auto-inoculable.  In  some  cases  there  may  be  doubt  as  between 
herpes  genitalis  and  true  chancre,  especially  as,  according  to  Fournier,  a  chancre 
not  infrequentl}'-  develops  in  the  midst  of  a  premonitory  eruption  of  herpes. 
The  points  of  differentiation  are  the  absence,  in  herpes,  of  induration,  the  less 
considerable  and  more  transitory  gland-enlargement,  the  multiplicity,  irregular 
form,  and  small  size  of  the  ulcers,  and  the  intense  burning  and  itching. 

In  herpes  zoster  (zona,  shingles),  clusters  of  vesicles  seated  on  an  erythematous 
base,  appear  in  the  region  of  skin  distribution  of  one  or  more  of  the  posterior 
spinal  nerve  roots,  preceded  or  accompanied  by  neuralgic  pain  and  tenderness 
in  the  part.  The  erythematous  patches,  more  or  less  oval,  with  the  long  axis 
parallel  to  the  underlying  nerve,  come  out  in  crops,  the  number  of  lesions  varying 
from  two  or  three  to  twenty  or  thirty.  Soon  the  surface  of  the  patches  is  studded 
with  papules,  which  are  quickly  transformed  into  vesicles,  from  ten  to  twenty 
on  each  patch,  sometimes  discrete,  sometimes  running  into  each  other  to  form 
bullre.  An  important  diagnostic  feature  of  the  eruption  is,  that  in  the  great 
majority  of  cases  it  is  unilateral,  and  appears  much  more  frequently  on  the 
right  side  than  on  the  left.  In  rare  cases,  however,  it  forms  a  complete  girdle 
round  the  body.  The  usual  limitation  to  one  side  of  the  body,  the  distribution 
in  one  or  more  nervous  territories,  and  the  preceding  or  accompanying  neuralgia, 
usually  suffice  to  distinguish  herpes  zoster  from  erythema  multiforme  and 
from  dermatitis  herpetiformis.  Another  important  point  in  diagnosis  is  the 
history,  for  zoster  is  not  a  recurring  disease.  These  various  characters  serve 
to  distinguish  it  also  from  herpes  simplex  and  herpes  genitalis.  The  neuralgic 
pain  may  be  mistaken  at  first  for  pleurisy,  but  the  course  the  affection  runs 


VESICLES  831 

soon  clears  up  the  confusion.  I  should  add  that  in  herpes  zoster  the  conjunctiva 
and  the  eyeball  are  frequently  attacked,  and  sometimes  the  mouth,  especially 
the  tongue.  In  rare  cases,  as  Head  has  reported,  the  lesions  on  the  tongue  are 
not  associated  with  an  eruption  on  the  Ups  or  the  palate. 

Although  the  vesicular  stage  is  not,  as  some  authorities  consider,  a  necessary 
phase  in  the  evolution  of  eczema,  the  vesicle  is  undoubtedly  the  most  constant 
of  all  the  primary  lesions  met  with  in  that  condition.  Usually,  following 
sensations  of  itching  and  burning,  an  erythematous  blush  appears,  which  is 
soon  studded  with  numerous  tiny  vesicles.  These  grow  larger  and  often  coalesce, 
but  they  soon  rupture  or  are  broken  by  scratching,  and  a  clear  fluid  exudes,  the 
"  weeping  "  continuing  as  later  vesicles  break.  In  mild  cases,  the  inflammation 
gradually  subsides,  and  as  the  discharge  ceases,  scales  or  crusts  are  formed  ; 
but  much  more  frequently,  fresh  crops  of  vesicles  start  up  around  the  edge  of  the 
earher  patches,  while  new  centres  are  formed  in  other  parts,  until  nearly  the 
whole  cutaneous  surface  may  be  involved.  In  some  cases  papules  are  the 
predominant  feature,  in  others  erythematous  lesions  ;  in  yet  others  pustules, 
and  in  extensive  cases,  the  several  kinds  of  lesions  may  be  all  present  simul- 
taneously. 

From  herpes  in  general,  eczema  is  distinguished  by  the  characteristic  exuda- 
tion, by  the  crowds  of  tiny  vesicles,  which  coalesce  without  forming  distinct 
groups,  by  the  slower  evolution  of  the  disease,  and  by  the  fact  that  as  a  rule 
there  is  some  inflammatory  thickening.  From  herpes  zoster  it  is  differentiated 
by  the  pecuhar  distribution  of  the  vesicles  in  that  affection  (see  above) . 

Doubt  can  seldom  arise  as  between  eczema  and  dermatitis  herpetiformis.  It 
is  true  that  the  earhest  and  perhaps  the  most  characteristic  lesion  of  the  latter 
disease  is  a  vesicular  eruption,  appearing  on  an  erythematous  base  ;  but  the 
disposition  of  the  vesicles  in  herpetiform  groups  should  prevent  confusion 
between  the  two  conditions.  The  vesicles  soon  dry  up  and  form  scabs,  but, 
later,  they  tend  to  coalesce  into  bullae,  which  scarcely  ever  burst  spontaneously 
but,  as  their  contents  thicken,  slowly  shrink,  and  finally,  if  left  to  themselves, 
shrivel  up  to  a  thick  brown  scab.  The  "  weeping  "  of  eczema  is  therefore  absent 
in  dermatitis  herpetiformis,  of  which,  further,  multiformity  is  a  more  pronounced 
feature — erythematous,  vesicular,  pustular,  papular,  and  urticarial  elements 
being  mingled  together  in  all  stages  of  evolution. 

The  vesicles  of  impetigo  contagiosa  are  distinguishable  from  those  of  eczema 
by  the  larger  size  and  discrete  character  of  the  former,  and  by  their  tendency 
to  dry  and  form  yellowish  crusts  without  breaking,  or  as  soon  as  they  have 
broken.  Even  when  the  lesions  run  together  and  large  crusts  are  formed,  there 
will  be  discrete  vesicles  and  papules  which  will  point  to  the  true  nature  of  the 
affection. 

Miliaria  rubra  may  sometimes  resemble  the  vesicular  stage  of  eczema,  but 
here  again  the  lesions,  though  numerous,  remain  discrete  :  they  do  not  run 
together  to  form  patches,  they  do  not  rupture,  and  there  is  no  "  weeping." 
Miharia  of  all  forms  is  a  very  transitory  affection,  and  instead  of  the  intense 
itching  of  eczema,  the  patient  describes  his  sensations  as  those  rather  of  pricking 
and  tingUng.  In  the  form  of  miliaria  which  is  known  as  hidrocystoma,  or 
dysidrosis  of  the  face,  small  vesicles  hke  those  of  miharia  appear  on  the  face, 
but  they  are  so  grouped  as  to  form  patches,  which  show  no  tendency  to  spon- 
taneous involution. 

Scabies  is  another  affection  in  which  the  vesicles,  hke  those  of  impetigo  and 
of  miharia,  are  discrete.  Sometimes  the  lesions,  usually  consisting  of  papules 
and  pustules  as  well  as  of  vesicles,  take  on  an  eczematous  character,  but  they 
are  not  locahzed  as  are  those  of  eczema,  and  instead  of  being  small,  acuminated, 
or  circular,  they  tend  to  be  hnear.    In  uncleanly  persons,  the  burrows  between  the 


832  VESICLES 

fingers  and  elsewhere  which  mark  off  scabies  from  all  other  affections,  can  hardly 
be  overlooked.  When  they  cannot  be  found,  either  because  they  have  not  yet 
been  formed  or  because  they  have  been  laid  open  by  scratching,  the  diagnosis 
of  scabies  must  rest  upon  the  irregularit}^  of  the  lesions — vesicles,  bullae,  and 
pustules  being  mingled  Avith  the  marks  of  the  finger-nails  and  the  results  of 
secondary  inoculations — and  upon  the  distribution,  the  parts  most  affected 
being  those  where  the  skin  is  least  thick,  namely,  the  webs  between  the  fingers 
and  toes,  the  front  of  the  wrist,  inside  the  umbilicus,  on  the  lower  abdomen, 
the  genitaha,  the  nipples  in  women,  and  the  axillary  folds.  The  face  nearly 
always  escapes,  except  in  infants  in  arms. 

Another  vesicular  condition  in  which  the  hands  are  specially  attacked  is 
cheiropompholyx ,  in  which  numerous  minute  vesicles  deeply  imbedded  in  the  skin, 
and  showing  through  the  epidermis  like  boiled  sago-grains,  are  sj^mmetrically 
distributed  on  the  extremities — always  on  the  hands,  and  frequently  also  on 
the  feet.  The  general  features  of  the  affection — the  limitation  of  the  vesicles 
to  the  extremities  and  their  proneness  to  unite  and  form  buUas  which  dry  up, 
the  tendency  to  recovery  followed  by  repeated  recurrence,  and  the  constant 
association  of  the  eruption  with  the  summer  season — are  sufficientlj^  distinctive, 
and  the  diagnosis  is  seldom  in  doubt.  In  some  slight  cases  there  is  a  general 
resemblance  to  certain  subacute  and  limited  cases  of  eczema  in  which  the 
lesions  may  present  the  sago-grain  aspect  ;  ^  but  instead  of  rupturing  and 
"  weeping,"  the  vesicles  in  cheiropompholyx  tend  to  run  together  into  bullae, 
which  shrink  and  crust  over.  This  formation  of  bullae  by  coalescence  of  vesicles 
differentiates  the  condition  also  from  pemphigus. 

In  erythema  multiforme  the  vesicle  can  seldom  be  difficult  of  interpretation, 
even  in  erythema  iris,  or  as  it  is  also  styled,  erythema  vesiculosum.  In  one  form 
of  this  affection  a  small  red  spot  appears,  upon  which  is  formed  a  vesicle  that 
is  quickly  surrounded  by  a  zone  of  redness.  When  the  central  vesicle  dries 
up  it  leaves  a  small  scab,  and  a  ring  of  secondary  vesicles  soon  appears  on  the 
red  zone.  On  the  separation  of  the  central  scab,  the  skin  beneath  is  seen  to  have 
a  blue,  congested  appearance.  The  whole  process  may  be  repeated  time  after 
time  until  the  concentric  rings  of  vesicles  and  reddened  skin  suggest  comparison 
with  a  target.  In  the  form  of  erythema  iris,  which  sometimes  is  infelicitously 
called  herpes  iris,  a  large  central  bulla  is  encircled  by  vesicles  of  considerable 
size.  Outside  the  first  ring  of  vesicles  another  circle  may  develop,  and  outside 
the  second,  sometimes  a  third.  The  symptoms  of  so-called  vesicular  erythema 
multiforme  are  so  characteristic  that  the  affection  can  hardly  be  mistaken  for 
anything  else. 

Lichen  planus  is  so  characteristically  a  papular  affection  that  the  absence 
of  vesicles  is  one  of  the  points  which  distinguish  it  from  eczema.  In  some 
cases,  however — very  rarely  in  adults,  and  rather  less  infrequently  in  children — 
vesicles  appear,  but  never  so  as  to  confuse  the  diagnosis.  In  lichen  urticatus 
a  vesicle  appears  on  the  summit  of  the  small  wheal,  and  the  condition  may 
offer  some  resemblance  to  eczema ;  but  the  individual  lesions  do  not  tend  to 
run  together  nor  to  spread  centrifugally,  as  in  eczema,  and  the  itching  is 
usually  more  intense. 

The  vesicular  form  of  secondary  syphilis  is  so  rare,  that  by  some  authorities 
its  existence  is  not  recognized,  and  Stelwagon,  who  has  never  met  with  a  case, 
justly  points  to  the  possibility  of  its  being  due,  at  any  rate  occasionallj^,  to  drug 
idiosyncrasy.  The  vesicles  are  reported  as  occurring  in  several  forms  :  they 
may  be  minute,  eczematoid,  disseminated  and  grouped,  or  larger,  irregularly 
scattered,  or  disposed  in  herpetiform  groups  ;  and  cases  have  been  reported 
which  simulate  herpes  zoster.  The  vesicles  in  syphilis  are  usually  associated 
with  papules,  and  they  have  a  papular  base,  the  disappearance  of  which  leaves 


VESICLES 


S33 


a  long-persisting  dark  stain.  The  papular  base  and  the  slow  evolution  are 
important  diagnostic  points  ;    and  usually  other  signs  of  syphilis  will  be  present. 

In  lymphangioma  circumscriptum,  even  more  than  in  vesicular  syphilis,  the 
significance  of  the  vesicles  can  hardly  be  missed.  In  circumscribed  areas  of 
the  skin  there  is  an  eruption  of  clusters  of  small,  deep-seated,  thick-walled 
vesicles,  straw-coloured,  sometimes  marked  with  red  striae,  and  filled  with  a 
clear  alkaline  fluid  which  contains  a  few  lymph  corpuscles.  The  affection, 
which  consists  in  the  over-growth  and  dilatation  of  lymph-vessels  and  the  form- 
ation of  new  ones,  is  probably  congenital,  though  not  generally  noticed  until 
early  childhood. 

Varicella — to  come  to  the  eruptive  fevers — is  an  essentially  vesicular  affec- 
tion :  only  occasionally  do  the  vesicles  develop  into  pustules.  They  are  usually 
preceded  by  reddish  spots  of  shght  elevation,  and  the  commonest  situations 


-Small-po.x  :   showing  distribution  of  the  eruption. 

F>-o!ii  a  photograph  by  Dr.  D.  S.  Davies. 


are  the  face,  chest,  shoulders,  back,  and  scalp,  but  they  may  also  be  found 
on  the  mucous  membrane  of  the  palate,  mouth,  or  lips.  As  a  rule  the  rash  comes 
out  within  twenty-four  hours.  Often  there  is  but  trifling  systemic  disturbance. 
In  the  infrequent  cases  in  which  the  varicellar  eruption  laecomes  pustular,  it 
may  possibly  be  confused  with  a  pustular  syphilide  ;  but  in  the  syphilide 
the  lesions  are  pustular  from  the  outset,  or  develop  out  of  papules,  and  although 
the  lesions  of  varicella  start  as  papules,  these  are  almost  invariably  small  and 
evanescent.  The  absence  of  itching  in  syphilis  is  another  point  of  difference. 
In  exceptional  cases  of  strophulus  (see  under  P.a.pules)  the  vesicle  on  the 
summit  may  develop  until  it  becomes  visible  macroscopically,  and  it  may  then 
be  confused  with  varicella  ;  but  the  cases  are  so  rare  as  to  be  negligible. 

It  is  with  small-pox  that  chicken-pox  is  most  often  confused.     In  small-pox, 
the  vesicles  are  usually  multilocular  ;  in  chicken-pox  they  are  usually  unilocular. 
^  '  53 


834  VESICLES 

In  small-pox  they  are  frequently  umbilicated  ;  in  chicken-pox  they  are  never 
umbilicated,  and  seldom  even  dimpled.  The  differences  between  the  two 
exanthems  in  respect  of  the  rash  and  the  lesions  generally,  as  summarized  by 
Ricketts  in  "  The  Diagnosis  of  Small-pox/'  are  these  :  In  variola,  the  rash 
is  most  abundant  on  the  face  and  limbs,  and  least  abundant  on  the  abdomen  and 
chest  {Fig.  213)  ;  in  varicella,  the  abdomen  and  chest  are  covered  as  thickly  as 
the  face,  if  not  more  thickly.  In  variola,  the  rash  is  much  more  abundant  on 
the  back  than  on  the  abdomen ;  in  varicella,  the  abdomen  and  the  back  receive 
equal  attention.  In  variola,  the  rash  is  more  abundant  on  the  shoulders  than 
across  the  loins,  and  on  the  chest  than  on  the  abdomen  ;  in  varicella,  the 
distribution  as  between  these  parts  is  indifferent.  In  variola,  the  rash  favours 
the  limbs  and  is  distributed  centrifugally  ;  in  varicella  it  tends  to  avoid  the  limbs, 
and  when  it  invades  them  is  centripetal.  In  variola  the  rash,  unlike  that  in  vari- 
cella, favours  prominences  and  surfaces  exposed  to  irritation,  and  tends  to  avoid 
protected  surfaces  and  depressions.  As  to  the  lesions  generally,  in  variola  they 
are  deep-seated  and  have  an  infiltrated  base  ;  are  generally  circular  in  outline 
and  homogeneous  in  character  ;  whereas  in  varicella  they  are  superficial  and 
liave  no  infiltrated  base,  are  frequently  irregular  in  outline,  or  else  oval  or  elon- 
gated, and  are  not,  as  a  rule,  homogeneous. 

Vaccinal  eruptions  may  consist  (i)  of  tiny  vesicles  or  small  superficial  papules, 
or  of  a  combination  of  those  elements  ;  or  (2)  of  a  small  papule  with  a  vesicular 
or  pustular  head.  In  the  second  case  the  eruption  may  simulate  modified 
small-pox,  but  almost  always  the  vaccinal  lesions  are  more  superficial  than  those 
of  the  mildest  cases  of  small-pox,  and  show  a  preference  for  the  trunk. 

In  eruptions  due  to  the  use  of  bromides,  iodides,  and  other  drugs,  the  vesicle 
is  but  one  of  the  elements,  and  the  nature  of  the  affection  is  usually  indicated  with 
sufficient  distinctness  by  the  history  of  the  case,  the  remission  that  occurs  when 
the  drug  is  v.'ithheld,  and  the  recurrence  that  takes  place  when  its  administra- 
tion is  resumed.  Vesicles  that  follow  the  bites  or  stings  of  gnats,  mosquitoes,  etc., 
are  always  easily  recognizable  from  the  history,  and  from  the  central  punctum 
to  be  seen  in  the  lesions  ;  nor  can  there  be  any  doubt  as  to  the  significance  of 
those  due  to  such  accidental  causes  as  frostbite  and  pressure  from  splints. 

Malcolm  Morris. 

VISION,  DEFECTS  OF. — This   subject   may   be  considered    in   the    following 

order  : — (A)  Normal  vision,  (B)  Amblyopia,   (C)  Partial  blindness,    (D)  Complete 

blindness,    (E)  Colour  blindness,   (F)  Abnormal  sensations  of  size,    (G)  Day-  and 

Nigh  I-  b  lin  dness. 

A. — Normal   Vision. 

I.  Visual  Acuity. — The  act  of  vision  comprises  the  perception  of  form,  colour, 
and  brightness ;  and,  in  vision  with  two  eyes,  the  perception  of  space  and  distance. 
These  faculties  are  possessed  by  all  parts  of  the  retina,  though  in  varying  degrees, 
and  they  are  of  varying  importance.  It  is  necessary  to  distinguish  between 
peripheral  and  central  vision  ;  or,  in  other  words,  between  merely  seeing  a  thing 
and  looking  at  it.  An  object  is  seen  by  any  portion  of  the  retina  that  has  visual 
perception;  but  an  object  is  only  looked  at  when  its  image  falls  upon  a  particular 
portion  of  the  retina,  the  yellow  spot,  which  is  situated  at  the  posterior  pole  of 
the  globe  on  the  outer  side  of  the  optic  disc.  The  act  of  so  directing  the  eye 
that  the  image  of  a  given  object  shall  fall  upon  the  yellow  spot,  is  termed 
"  fixation."  The  vision  obtained  by  the  fixation  of  the  eye  is  termed  "  central 
vision,"  and  owing  to  the  anatomical  structure  of  the  retina  at  the  yellow  spot, 
the  vision  here  is  the  most  acute  of  which  the  eye  is  capable,  though  its  area  is 
very  limited.  In  the  normal  eye,  central  vision  is  capable  of  distinguishing 
two  points  or  parallel  lines,  which  are  separated  by  a  space  which  subtends  an 


VISIOX,     DEFECTS     OF  835 

angle  of  i' — approximately  the  diameter  of  a  sixpenny-piece  at  200  feet — and 
it  is  on  this  basis  that  ordinary  test-types  are  constructed.  Central  vision, 
however,  though  acute,  is  very  limited  in  extent,  and  it  is  estiniated  that  the 
field  of  acute  vision  is  only  about  the  size  of  the  thumb-nail  held  at  arm's  length, 
all  vision  outside  this  area  being  comparatively  blurred  and  indistinct.  This 
limitation  of  the  field  of  acute  central  vision  is  barely  appreciated  under  ordinary 
circumstances,  owing  to  the  rapidity  with  which  the  retina  receives  consecutive 
visual  impressions,  and  the  constant  niovements  of  the  eyes.  Compared  with  the 
visual  acuity  of  the  central  portion  of  the  field  of  vision,  peripheral  vision  is 
relativelv  poor,  though  it  is  of  extreme  value  in  a  different  way.  To  appreciate 
the  importance  of  peripheral  vision  it  is  only  necessary  to  try  to  walk  about 
looking  through  a  roll  of  paper  or  music  ;  though  central  vision  is  unimpaired, 
and  the  smallest  object  can  be  seen  distinctly,  locomotion  is  almost  impossible, 
owing  to  the  inability  to  see  where  one  is  going  or  to  ascertain  one's  position  in 
relation  to  surrounding  objects,  the  peripheral  portion  of  the  field  of  vision  being 
responsible  for  the  automatic  appreciation  of  these  conditions.  On  the  other 
hand,  a  person  from  some  cause  deprived  of  central  vision,  can  see  to  get  about 
quite  well,  and  has  useful  vision  for  many  purposes,  though  he  is  unable  to  read 
or  write,  recognize  people  when  looking  directly  at  them,  or  do  any  work  in 
which  fine  vision  is  required. 

2.  Colour  Vision. — A  person  with  normal  colour  vision  can  recognize  six  or 
seven  distinct  colours  in  the  solar  spectrum,  and  is  able  to  appreciate  many 
hundreds  or  thousands  of  varieties  of  colour  caused  by  mixtures  of  them,  and 
the  colour  perception  of  th-e  normal  person  is  most  acute  in  the  central 
portion  of  the  field  ;  but  the  field  of  vision  for  colours  has  by  no  means 
the  same  boundaries  as  the  field  of  vision  for  white.  The  fields  of  vision 
ior  all  colours  are  smaller  than  that  for  white,  and  the  fields  for  red,  green, 
and  blue  vary  in  extent  among  themselves.  The  field  for  blue  is  the 
largest,  for  red  is  next  in  point  of  size,  and  the  field  of  vision  for  green  is 
the  smallest  of  all,  being  roughly  only  about  half  to  a  third  the  diameter  of 
the  field   for  white. 

3.  Brightness  Perception. — The  central  and  peripheral  portions  of  the  field  of 
vision  vary  very  much  in  their  perception  of  brightness.  In  ordinary  illumina- 
tion the  central  portion  of  the  field  is  the  most  efficient,  but  in  a  very  weak 
illumination  the  peripheral  portion  has  a  higher  efficiency  than  the  central  part  : 
in  other  words,  there  is  in  very  dim  lights  a  relative  central  scotoma  or  loss  of 
vision.  This  fact  has  long  been  known  to  astronomers,  who  have  found  that 
in  counting  stars  of  low  magnitudes,  vision  is  much  better  if  the  particular 
constellation  or  group  of  stars  is  not  looked  at  directly,  the  Pleiades  being  a 
Avell-known  example  ;  more  of  these  stars  can  be  counted  when  the  vision  is 
directed  to  a  point  a  little  above  or  below  them  or  to  one  side,  whereas  direct 
vision  is  comparatively  dim  and  confused  ;  and  the  same  holds  good  of  vision 
ior  any  object  in  a  dim  light.  Walking  along  a  country  road  on  a  dark  night,  it 
will  be  found  that  a  foot-path  or  track  can  be  seen  more  easily  if  the  gaze  is 
■directed  forwards  and  not  at  the  ground  itself.  These  facts  concerning  vision 
may  be  correlated  with  the  actual  anatomical  structure  of  the  retina  itself.  It 
is  found  that  in  the  region  of  the  yellow  spot — the  area  of  the  retina  endowed 
"with  acute  vision — the  cones  are  very  numerous,  with  few  rods  ;  towards  the 
periphery  of  the  retina  the  cones  become  fewer  and  the  rods  more  numerous. 
It  is  now  generally  held  that  the  function  of  the  cones  is  to  work  in  light  of 
considerable  brilliance,  that  they  are  capable  of  extremely  acute  vision  for 
small  objects,  and  are  also  concerned  in  the  perception  of  colour.  The  rods,  on 
the  other  hand,  have  no  perception  of  colour  ;  their  perception  of  form  is 
poor  compared  with  that  of    the    cones ;    but  in  very  weak  lights  their  visual 


S36  VISIOX,     DEFECTS     OF 

acuit^•  is  greater  than  that  of  the  cones.  In  support  of  this  theory  may  be 
mentioned  the  fact  that  the  retinse  of  nocturnal  animals  are  more  fullv  pro- 
\-ided  Avith  rods  than  cones. 

B. — Amblyopia. 

Amblyopia  is  the  term  applied  to  defective  vision  in  which  there  is  little  or 
no  e\-idence  of  any  ocular  condition  which  might  account  for  the  visual  defect. 
It  is  not,  therefore,  employed  where  there  is  any  obvious  intra-ocular  or 
intracranial  lesion.  The  commoner  forins  of  amblyopia  are  (i)  Amblyopia 
ex  anopsia  ;  (2)  Urgemic  ;  (3)  With  nystagmus  ;  (4)  Alcohol,  tobacco,  lead, 
quinine,  organic  forms  of  arsenic  such  as  atoxyl ;  (5)  Migraine  ;  (6)  Cortical 
or  crossed  amblyopia  ;    (7)   \Yith  hysteria. 

1.  Amblyopia  ex  Anopsia,  is  usually  associated  with  a  squinting  e^-e,  which 
may  or  may  not  have  been  put  straight  by  operation.  It  is  still  open  to  dis- 
cussion whether  the  amblyopia  in  such  conditions  is  due  to  the  loss  of  use  by 
reason  of  the  squint,  or  whether  the  squint  is  due  to  the  \-isual  defect ;  but 
the  fact  remains,  that  in  many  squinting  eyes  the  \-isual  acuity  is  very  much 
below  normal,  though  objectively  the  eye  exhibits  no  abnormal  s\Tnptoms. 

2.  Uraemie  Amblyopia  or  Amaurosis,  may  be  recognized  by  its  association 
with  renal  disease,  whether  complicated  by  pregnancy  or  not.  It  is  charac- 
terized by  its  comparatively  sudden  onset,  \-ision  failing  either  partiallj'  or 
completely  ^^dthin  a  few  hours.  The  failure  of  %dsion  may  be  accompanied  by 
well-marked  retinitis  in  both  eyes  ;  but  in  many  cases  this  is  absent  and  the 
discs  appear  quite  normal.  The  failure  of  ^'ision  lasts  for  from  thirt^'-six  to 
fortv'-eight  hours,  and  then  slowly  disappears,  the  whole  attack  lasting,  as  a 
rule,  under  a  week.  In  the  majority  of  cases,  unless  there  is  some  definite 
injury  to  the  optic  nerve  or  retina  as  the  result  of  retinitis,  the  \asion  recovers 
entirely.     In  some  cases  of  uraemia  the  blindness  is  complete. 

3.  Amblyopia  with  Nystagmus  is  usually  associated  with  evidence  of  visual 
affections  in  very  early  life.  At  birth,  fixation  is  not  developed,  and  the  higher 
visual  acuit\'  is  only  acquired  after  the  first  few  months  of  infant  life.  Any 
affection  of  the  e^-es,  therefore,  that  obscures  the  \-ision  during  the  earlier  weeks 
or  months  of  hfe,  prevents  the  due  development  of  central  vision  and  leads  to  a 
permanent  amblyopia,  as  a  rule  associated  with  nystagmus.  Such  affections 
are  ophthalmia  neonatorum,  which  leaves  more  or  less  corneal  opacity  ;  perfora- 
tion of  the  cornea  -n-ith  anterior  polar  cataract  as  the  result  of  this  ophthalmia  ; 
congenital  defects,  such  as  a  persistent  hyaloid  arterv  or  macular  coloboma  ; 
and  any  retinitis  or  choroiditis  affecting  the  region  of  the  3-ellow  spot. 

4.  The  Amblyopia  due  to  Lead,  Alcohol,  Tobacco,  Quinine,  or  Atoxyl,  is  usually 
described  as  a  toxic  amblyopia,  and  the  SAinptoms  are  somewhat  similar  in  all  the 
varieties.  In  tobacco  amblyopia  there  is  a  central  loss  of  vision  for  colours,  green 
only  in  the  earlier  stages,  subsequently  green  and  red,  and  in  extreme  cases 
even  a  central  scotoma  for  white  ;  total  blindness  is  practically  unknown.  The 
patient  also  states  that  he  sees  better  in  a  duU  than  in  a  bright  light,  and  that 
he  is  incapable  of  reading  or  ^\Titing,  or  distinguishing  silver  from  gold  coins. 
The  ocular  signs  are  usually  ver}^  slight,  being  limited  to  some  redness  and 
blurring  of  the  optic  disc  in  early  cases,  or  pallor  of  the  outer  side  of  the  disc 
in  later  stages.  Alcoholic  amblyopia  resembles  in  most  of  its  symptoms  the 
amblyopia  due  to  tobacco,  though  vision  for  red  is  usually  lost  before  vision 
for  green.  Amblyopia  due  to  lead,  quinine  or  atoxyl  is  rare,  but  it  is  also  usually 
characterized  by  a  central  scotoma  associated  with  some  slight  optic  neuritis  or 
atroph}'. 

5.  The  Amblyopia  of  Migraine  is  usually  transitory,  and  may  occur  either  in 
the  form  of  a  central  scotoma,  hemianopia,  or  monocular  blindness.     It  is  more 


VISION.     DEFECTS     OF  837 

rarely  seen  in  the  form  of  a  quadrant  hemianopia  or  a  ring  scotoma.  In  all 
cases  the  diagnosis  is  comparatively  easy,  as  the  amblyopia  seldom  lasts  more 
than  a  few  minutes,  and  is  followed  later  by  the  characteristic  headache  and 
sickness  of  migraine. 

6.  Amblyopia  has  also  been  described  as  due  to  disease  of  the  Visual  Cortex, 
and  rare  cases  have  been  described  of  a  Crossed  Amblyopia,  or  defect  of  vision 
in  one  eye  due  to  disease  of  the  visual  cortex  of  the  other.  The  loss  of  vision 
is,  however,  usually  associated  with  some  slight  defect  of  vision  in  the  opposite 
eye,  and  hemianopia  is  much  more  commonly  the  symptom  of  disease  of  the 
visual  cortex. 

7.  Hysterical  Amblyopia  may,  like  other  hysterical  affections,  take  various 
forms,  such  as  loss  of  visual  acuity,  a  loss  of  colour  vision,  or  diminution  in  the 
visual  field.  The  characteristic  form  of  the  visual  field  in  hysteria  is  either  a 
spiral  contraction  or  an  extreme  concentric  limitation.  The  symptoms,  however, 
vary  very  much  at  different  examinations,  a  point  of  much  importance  in 
diagnosis.  In  certain  cases  there  may  be  a  functional  loss  of  vision  in  one  or 
both  eyes,  which  can  be  recognized  as  hysterical  by  the  employment  of  Snellen's 
coloured  types  or  some  other  device  for  deceiving  the  patient. 

C. — Partial    Blindness. 

This  may  be  (i)  Definite,  or  (2)  Indefinite. 

I.  Definite:    (a)  Hemianopia;   (b)   Central  scotoma ;   (c)  Peripheral  constriction. 

{a).  Hemianopia  (see  Hemianopsia). 

(b).  Central  Scotoma. — A  scotoma  is  a  local  defect  in  the  visual  field,  and,  from 
its  position,  may  be  either  central  or  peripheral  ;  it  may  also  be  negative  or 
positive.  A  negative  scotoma  is  one  where  the  defect  of  vision  exists,  but  where 
the  patient  notices  nothing  abnormal.  The  best  example  of  a  negative  scotoma 
is  the  blind  spot  in  the  field  of  vision  caused  by  the  entrance  of  the  optic  nerve. 
This  area  is  blind,  but  the  individual  is  not  conscious  of  any  visual  defect. 
Scotomata  of  this  character  exist  where  there  is  some  injury  of  the  visual 
layers  of  the  retina  itself,  or  of  the  optic  nerve  or  tract. 

A  positive  scotoma  is  one  in  which  the  visual  defect  is  noticed  as  a  black  or 
coloured  spot  or  cloud  which  obscures  the  vision  in  some  part  of  the  visual  field. 
Such  positive  scotomata  are  due  to  lesions  of  the  retina,  such  as  haemorrhages 
or  patches  of  pigment  which  do  not  destroy  the  visual  layers.  Vision  still 
remains  ;  but  it  is  obscured  by  some  unusual  opacity  in  the  retina  itself  or  in 
the  adjacent  portion  of  the  vitreous. 

Scotomata  frequently  exist  in  the  peripheral  portion  of  the  field  of  vision 
without  being  noticed,  as  they  are  of  little  importance  in  direct  vision,  and  are 
not  discovered  unless  carefully  looked  for.  A  central  scotoma,  on  the  other 
hand,  is  noticed  at  once,  however  minute,  because  it  affects  direct  vision  and 
produces  a  considerable  defect  in  the  visual  acuity.  A  central  scotoma  may 
be  either  relative  or  absolute,  and  may  exist  for  colours  only  or  for  objects. 
Central  loss  of  vision  for  colours,  more  particularly  red  and  green,  is  associated 
with  tobacco  and  alcohol  poisoning.  The  colours  cannot  be  recognized  in  small 
objects  when  directly  looked  at,  though  a  red  or  green  object  in  the  peripheral 
portion  of  the  field  of  vision  will  be  recognized  as  such.  This  scotoma  is 
associated  with  greater  or  less  diminution  of  the  general  visual  acuity,  and  vision 
in  such  cases  is  generally  better  in  a  dull  than  in  a  bright  light. 

Absolute  central  scotomata  are  met  with  in  disseminated  sclerosis,  in  certain 
forms  of  hereditary  optic  atrophy,  and  may  persist  after  the  acute  affection  of  the 
optic  nerve  known  as  retrobulbar  neuritis,  or  in  rare  cases  after  severe  attacks 
of  migraine.  In  nearly  25  per  cent  of  all  cases  of  disseminated  sclerosis  a 
central   scotoma  exists,  and   the  diagnosis  in  such  a  case  will  be  confirmed  by 


VISION,     DEFECTS     OF 


its  association  with  the  general  symptoms  of  the  disease  and  with  other 
ocular  symptoms,  such  as  optic  atrophy,  paralysis  of  accommodation,  paralysis 
of  the  extrinsic  ocular  movements,  or  nystagmus.  There  is  usually  some 
pallor  of  the  optic  disc,  though  this  is  no  indication  as  to  the  amount  of  visual 
defect.  The  diagnosis  of  a  hereditary  optic  atrophy  depends  to  a  great  extent 
upon  the  history  of  a  similar  affection  among  family  relations  and  its  usual 
period  of  incidence,  namely,  early  adult  life.  It  is  associated  with  either  neuritis 
or  atrophy  of  the  optic  disc.  Retrobulbar  neuritis  usually  occurs  in  young  adults, 
commonly  attacks  one  eye  only,  and  is  sudden  in  its  onset,  vision  failing  from 
normal  to  no  perception  of  light  in  a  few  hours.  In  the  great  majority  of  cases 
vision  commences  to  return  after  the  lapse  of  a  day  or  two,  and  is  ultimately 
restored  in  a  fortnight  or  three  weeks.  If  any  defect  remains  it  is  usualh' 
central,  and  is  due  to  some  injury  to  those  axial  fibres  of  the  optic  nerve  which 
supply  the  macular  region.  Central  scotomata  after  migraine  are  rare,  but  may 
be  ascribed  to  that  cause  when  there  is  a  definite  history  of  sudden  loss  of  sight 
associated  with  the  characteristic  hemicrania  and  vomiting.  It  is  to  be  noted 
that  central  scotomata  are  not  always  easy  to  map  out  on  a  chart,  owing  to 
the  patient's  loss  of  power  of  fixation ;  a  careful  use  of  the  perimeter  by 
an  experienced  observer  is  necessar^^  A  small  central  scotoma  may  cause 
considerable  failure  of  vision,  even  though  it  is  too  small  to  chart  on  the  ordinary 
perimeter.  Scotomata  may  also  be  paracentral,  in  the  immediate  neighbour- 
hood of  the  fixation  point  but  not  actually  upon  it,  or  ma}'  take  an  annular  or 
ring  form. 

(c).  Peripheral  constriction. — Peripheral  constriction  of  the  visual  field  occurs 
commonly  in  affections  such  as  acute  or  chronic  glaucoma,  optic  atrophy,  dissemi- 
nate choroido-retinitis,  retinitis  pigmentosa,  and  various  functional  conditions.  The 
constriction  of  the  visual  field  in  glaucoma  is  usually  most  marked  on  the  nasal 
side,  and  can  be  recognized  from  its  association  with  the  acute  sj^mptoms  of 
glaucoma,  the  circumcorneal  injection,  steamy  insensitive  cornea,  dilated  fixed 
pupil,  hazy  vitreous,  and  general  symptoms  such  as  trigeminal  neuralgia,  head- 
ache, and  sickness.  In  chronic  glaucoma  it  will  also  be  associated  with  atrophy 
and  cupping  of  the  optic  disc  {Plate  VIII,  Fig.  V) .  Central  vision  may  remain 
quite  good,  even  though  the  field  of  vision  is  extremely  limited.  The  field  of 
vision  is,  as  a  rule,  most  limited  in  retinitis  pigmentosa,  where  the  failure  of  sight 
will  be  found  to  be  associated  with  night-blindness  and  characteristic  ophthalmo- 
scopic appearances,  a  small,  ill-defined,  Avaxy-looking  disc,  slender  vessels,  and 
diffuse  superficial  pigmentation  of  the  periphery,  the  retina  in  patches  resembling 
Haversian  bone  corpuscles.  This  condition  often  occurs  in  two  or  more  members 
of  the  same  family,  and  ma}'  exist  where  the  parents  have  been  first  cousins. 
A  limitation  of  the  field  similar  to  that  of  retinitis  pigmentosa  is  often  met  with 
in  cases  of  disseminate  choroido-retinitis  {Plate  VII,  Fig.  G)  and  consequent  optic 
atrophy  ;  but  may  be  distinguished  from  it  bj^  abundant  evidence  in  the  eye 
of  deeper  changes  in  the  retina  and  choroid.  Constriction  of  the  field  of 
vision  ma}'  also  occur  in  certain  functional  states,  but  may,  as  a  rule,  be 
recognized  by  its  variable  character  and  the  absence  of  all  evidence  of  organic 
ocular  or  general  nervous  disease. 

2.  Indefinite. — A  defective  visual  acuity  may  exist  with  no  evidence  of  any 
ocular  or  nervous  disease  (see  Amblyopia,  p.  836).  Defective  vision  may  also  be 
due  to  errors  of  refraction,  to  opacities  of  the  cornea,  aqueous,  lens,  or  vitreous, 
to  affections  of  the  choroid  and  retina,  and  to  lesions  of  the  optic  nerve. 
Opacities  of  the  cornea  can  easily  be  recognized  on  illumination  of  the  eye 
with  a  strong  light  concentrated  by  a  lens,  and  intra-ocular  causes  of  defective 
vision  can  be  discovered  by  ophthalmoscopic  examination.  Detailed  differ- 
ential diagnosis  of  all  the  ocular  causes  of  diminished  vision  requires  a  special 
knowledge  of  ophthalmology. 


VISION,     DEFECTS     OF  839 

D. — Complete  Blindness. 

Total  loss  of  vision,  blindness,  or  amaurosis,  may  be  (i)  Bilateral,  (2)  Uni- 
lateral. 

1.  Bilateral  Blindness. — Total  blindness  in  both  eyes  may  be  congenital  or 
acquired.  Congenital  blindness  may  be  due  either  to  absence  of  the  eyes  them- 
selves, congenital  anophthalmos,  or  to  congenital  defects  in  the  development  of 
the  eyes  themselves.  Nearly  90  per  cent  of  all  cases  of  total  blindness  in  the 
United  Kingdom  are  due  to  the  ophthalmia  of  the  new-born.  Such  cases  can  be 
recognized  by  the  history  of  profuse  inflammation  or  discharge  shortly  after 
birth,  by  the  diffuse  opacity  on  the  surface  of  the  cornea,  associated,  in  some 
cases,  with  thinning  and  protrusion  of  the  anterior  part  of  the  eye,  and  more 
or  less  nystagmus. 

Total  blindness  may  also  be  caused  by  bilateral  inflammatory  affections  of  the 
eyes,  such  as  iritis  with  blockage  of  the  pupils  and  consequent  glaucoma,  or 
ultimate  shrinking  of  the  eyes,  bilateral  primary  glaucoma,  optic  atrophy,  or 
lesions  of  the  optic  chiasma.  It  is  seldom  due  to  lesions  of  the  optic  tracts,  as 
this  would  only  be  caused  by  a  bilateral  lesion  totally  destroying  the  optic  tract 
on  both  sides. 

Total  blindness  of  a  transient  nature  may  also  occur  in  renal  disease,  and  is 
termed  urcemic  amaurosis.  This  condition  is  recognized  by  its  association  with 
the  symptoms  of  renal  disease,  whether  in  pregnancy  or  not,  and  by  its  sudden 
onset  and  short  duration,  the  whole  attack  as  a  rule  lasting  not  more  than  four 
or  five  days.  In  the  majority  of  cases  there  is  some  evidence  of  renal  retinitis, 
though  in  others  the  eyes  are  normal.  The  pupils  usually  react  to  light,  though 
occasionally  the  light  reflex  is  absent. 

Another  form  of  transient  blindness  occasionally  met  with,  is  apparently  due 
to  spasm  of  the  retinal  arteries.  In  these  cases  the  loss  of  vision  may  last  only  a 
few  hours,  and  during  its  continuance  it  will  be  found  that  the  retinal  arteries  are 
of  a  very  slender  calibre.  It  is  to  be  noted  that  no  cataract  ever  causes  total 
blindness.  Provided  that  the  rest  of  the  eye  is  normal,  a  patient  with  the  densest 
cataract  can  always  perceive  light,  and  also  has  the  power  of  projection,  or  the 
recognition  of  the  direction  from  which  the  ray  of  light  is  coming. 

2.  Unilateral  Blindness. — It  is  evident  that  unilateral  blindness  must  be 
due  to  some  lesion  in  the  eye  itself,  or  between  the  eye  and  the  optic  chiasma. 
Lesions  of  the  optic  tract  above  the  chiasma  do  not  cause  monocular  blindness, 
but  Hemianopsia  {q.v.).     Monocular  blindness  may  be  either  sudden  or  gradual. 

Gradual  blindness  may  be  due  to  any  of  the  inflammatory  affections  of  the  eye 
mentioned  above,  or  to  such  progressive  diseases  as  optic  atrophy  or  glaucoma. 
Sudden  blindness  in  one  eye  may  be  due  to  one  of  the  following  causes  :■ — 
Detachment  of  the  retina  [Plate  VIII,  Fig.  T) 
Embolism  of  the  central  artery  [Plate  VIII ,  Fig.  S) 
Thrombosis  of  the  central  vein  [Plate  VIII,  Fig.  0) 
Vitreous  haemorrhage 
Acute  glaucoma  [Plate  VIII,  Fig.  V) 
Injury  to  the  optic  nerve  due  to  an  accident  or  fracture  of  the  base  of  the 

skull 
Compression    of   the    optic   nerve  from   haemorrhage   or    dilatation    of    the 

nasal  sinuses 
Retrobulbar  neuritis 
Migraine. 
The    diagnosis    of    the    majority    of    these    causes    is    simple,    owing   to    the 
characteristic  ocular  or  ophthalmoscopic  appearances.     The  only  cases  which 
present  any  obscurity  are  those  in  which  there  is  sudden  loss  of  vision  without 


840  VISION,     DEFECTS     OF 

any  visible  ocular  changes.  These  cases  are  usually  due  to  retrobulbar 
neuritis,  an  acute  affection  of  the  optic  nerve  of  obscure  origin,  characterized  by 
sudden  loss  of  sight,  with  some  pain  and  tenderness  on  movement  of  the  eye. 
The  loss  of  vision  as  a  rule  lasts  for  not  more  than  twenty-four  or  thirty-six  hours, 
and  coincidently  with  the  return  of  vision,  more  or  less  definite  neuritis  appears 
at  the  optic  disc  [Plate  VII,  Fig.  K).  In  the  majority  of  cases  vision  entirely 
returns,  but  if  there  is  a  permanent  defect,  it  usually  takes  the  form  of  a 
central  scotoma. 

Blindness  due  to  compression  of  the  optic  nerve  by  dilatation  of  the  accessory 
nasal  sinuses  can  only  be  recognized  after  a  thorough  examination  of  the  nasal 
passages  ;  sinus  disease  of  any  duration  is  always  accompanied  by  certain  well- 
defined  appearances  in  the  nose  itself. 

Monocular  blindness  may  also  occur  in  migraine,  but  in  these  cases  it  is  of 
extremely  short  duration,  seldom  more  than  ten  minutes  or  a  quarter  of  an 
hour,  and  is  followed  by  the  characteristic  headache  and  sickness. 

E. — Colour    Blindness. 

Defects  in  colour  vision  may  be  either  congenital  or  acquired.  In  congenital 
colour  blindness  there  is  inability  to  recognize  in  the  spectrum  the  six  or  seven 
definitely  distinct  colours  which  may  be  apparent  to  a  normal  eye.  The 
commoner  cases  of  colour  blindness  are  those  who  can  only  see  three  colours 
in  varying  shades  of  black  and  white,  or  people  who  can  only  distinguish  two 
colours,  the  spectrum  being  made  up  of  yellow  and  blue,  the  one  gradually 
passing  into  the  other.  Red,  orange,  yellow,  and  green  are  seen  as  one  colour, 
blue  and  violet  as  the  other.  Scarlet  and  grass- green  appear  very  similar  to 
these  persons. 

Cases  of  congenital  colour  blindness  can  be  recognized  by  examination  with 
coloured  wools,  as  in  Holmgren's  test,  or  with  much  more  precision  and  certainty 
in  a  dark  room  by  means  of  a  lantern  with  properly  coloured  glasses. 

Acquired  loss  of  colour  vision  may  also  occur  in  tobacco  blindness  or  in  optic 
atrophy. 

Colour  Defects. 

Rainbow  Vision. — Objects,  especially  lights,  may  be  seen  surrounded  by  a 
ring  containing  the  colours  of  the  spectrum.  The  causes  of  this  are,  as  a  rule, 
either  conjunctivitis — in  which  there  is  a  thin  film  of  mucus  on  the  surface  of  the 
conjunctiva — or  glaucoma.  The  diagnosis  in  the  two  cases  should  present  no 
difficulty,  because  the  rainbow  vision  of  glaucoma  will  be  associated  with  the 
other  important  symptoms  of  this  disease,  viz.,  steaminess  or  lack  of  brilliancy 
in  the  cornea,  a  shallow  anterior  chamber,  dilatation  of  the  pupil,  and  some 
limitation  of  the  field  of  vision,  especially  on  the  nasal  side. 

Erythropsia,  or  red  vision,  occurs  after  prolonged  exposure  to  white  or  violet 
light  in  conditions  such  as  electric  or  snow  blindness.  It  is  accompanied  by 
much  inflammation  and  redness  of  the  eyes,  conjunctival  discharge,  and 
intolerance  of  light.  It  may  also  occur  in  slight  vitreous  or  retinal  haemorrhages, 
though  in  severe  vitreous  haemorrhages  vision  is  entirely  abolished.  Erythropsia, 
and  in  some  cases  blue  vision,  may  occur  aftei  cataract  extraction,  and  appears 
to  be  due  to  some  fatigue  of  the  retina. 

Xanthopsia,  or  y»llow  vision,  may  occur  in  jaundice  or  in  poisoning  by  santonin, 
amyl  nitrite,  cannabis  indica,  or  picric  acid. 

G. — Abnormal    Sensations    of    Size. 

Objects  may  appear  rapidly  to  increase  or  diminish  in  size  in  the  preliminary 
stages  of  an  attack  of  epilepsy  ;  and  this  variation  in  size  of  objects  is  a  fairly 
common  symptom  in  the  slight  delirium  of  infantile  febrile  disorders.     Micropsia, 


VOMITING  841 


or  abnormal  diminution  in  the  size  of  objects,  also  occurs  to  many  normal  people 
during  the  act  of  reading.  The  book  appears  suddenl}'  to  recede  to  a  great 
distance,  and  it  and  the  type  appear  extremely  minute,  though  absolutely  clear. 
No  satisfactory  cause  has  yet  been  adduced  for  this  phenomenon.  It  may  be 
relieved  bv  a  momentary  rest,  and  is  of  no  pathological  significance.  A  similar 
condition  may  be  produced  by  the  use  of  certain  drugs,  particularly  cannabis 
indica  and  its  products. 

G. D.\Y-BLINDNESS      AND      NiGHT-BLINDNESS. 

Day-blindness,  or  hemeralopia,  is  caused  most  commonly  by  tobacco  poisonings 
it  being  probable  that  this  condition  is  due  to  a  direct  poisoning  of  the 
retinal  cones,  which  are  endowed  with  the  faculty  of  effective  vision  in  lights 
of  high  brilliancy.  In  snow-blindness,  also,  vision  improves  directly  the  light 
begins  to  fail,  and  defective  vision  in  bright  light  is  a  common  symptom 
of  albinism.  Except  in  the  case  of  albinos,  the  retina  may  show  no 
abnormal  signs. 

Night-blindness,  or  nyctalopia,  occurs  most  frequently  in  retinitis  pigmentosa, 
in  which  on  ophthalmoscopic  examination,  the  characteristic  appearance  of  a 
small  ill-defined  optic  disc,  thin  thready  arteries  and  veins,  and  the  characteristic 
spider-like  pigment  cells  may  be  seen  at  the  peripherj^  of  the  fundus.  It  also 
occurs  in  cases  of  disseminate  choroido-retinitis,  and  in  scurvy.  Patients  suffering 
from  high  myopia  may  also  suffer  from  defective  vision  in  dim  lights. 

Herbert  L.  Eason. 

VISION,  DOUBLE.— (See  Diplopia.) 

VOICE,  ABNORMALITIES  OF  THE. — (See  Speech,  Abnormalities  of.) 

VOMITING.  —  Strictly  speaking,  the  term  vomiting  implies  the  return  and 
expulsion  from  the  mouth  of  part  or  the  whole  of  the  stomach  contents. 

There  are  several  conditions  in  which  vomiting  ma}-  be  simulated  closely, 
although  the  vomited  matter  has  never  reached  the  stomach.  It  will  be  con- 
venient to  deal  with  these  before  discussing  the  causes  and  differential  diagnosis 
of  true  vomiting  or  gastric  regurgitation. 

In  certain  diseases  of  the  oesophagus,  food  may  be  swallowed  and,  after  a 
varying  interval  of  time,  brought  up  again.     These  conditions  are  : 


Malignant  disease 
Fibrous  stricture 
Spasm 


Pressure    from    without,    as     by 

aneurysm,  new  growth,  etc. 
"  Idiopathic  "  dilatation 
Diverticula — "  pressure  "   pouches. 

If  the  obstruction  be  of  long  standing,  and  near  the  lower  end  of  the  oesophagus, 
the  interval  between  taking  food  and  its  regurgitation  may  be  prolonged  consider- 
ably, especially  in  cases  in  which  the  lumen  has  undergone  much  dilatation. 
This  may  occur  with  fibrous  stricture,  slow-growing  carcinoma,  or  the  very  rare 
cases  known  as  "  idiopathic  "  dilatation  of  the  oesophagus. 

A  "  pressure  "  pouch  produced  by  a  hernia-like  protrusion  of  the  mucous 
membrane  through  the  muscular  coats  of  the  upper  part  of  the  oesophagus, 
becomes  filled  gradually  and,  in  addition  to  dysphagia  caused  by  the  pressure 
it  exerts  on  the  oesophagus  below,  may  simulate  vomiting  when  its  contents 
are  voided. 

The  dift'erential  diagnosis  of  these  oesophageal  causes  of  vomiting,  or  rather 
regurgitation,  is  usually  easy.  The  returned  matter  is  practically  unaltered, 
and  is  undigested.  .  It  may  be  diluted  freely  with  mucus.  Blood  may  be  present, 
and  even  portions  of  growth  in  cases  of  carcinoma.       In  oesophageal  pouches. 


842  VOMITIXG 


food  may  be  retained  for  long  periods  and  returned  unchanged.  The  most 
important  point  to  recognize  is,  that  in  such  oesophageal  conditions  the  returned 
matter  is  alkaline  or  neutral  in  reaction.  The  diagnosis  is  confirmed  by 
examination  -with  a  bougie,  or  by  the  .r-rays  after  administration  of  bismuth 
emulsion. 

Further,  certain  individuals  ma}"  acquire  the  power  of  voluntarily  causing  a 
regurgitation  of  portions  of  the  stomach  contents  into  the  mouth,  which  ma}-  be 
ejected  or  again  swallowed,  sometimes  after  further  mastication.  There  is  no 
accompan3"ing  nausea.  This  condition,  known  as  "  rumination  "  or  "  Mery- 
ciSM  "  (i].v.),  must  be  distinguished  from  vomiting. 

^lention  must  also  be  made  of  conditions  in  which  the  mechanism  of  degluti- 
tion is  deranged,  and  in  which  swallowing  is  interfered  with  to  such  an  extent 
that  the  food  or  drink  is  returned.  This  may  occur  in  cases  of  bulbar  paralysis, 
myasthenia  gravis,  etc.  Again,  in  diphtheritic  paralysis  the  return  of  fluids 
through  the  nose,  owing  to  the  paralysis  of  the  soft  palate,  may  be  mistaken  for 
vomiting.  A  similar  mistake  has  been  made  in  cases  the  writer  has  met  with  of 
bronchiectasis  in  which,  during  the  act  of  coughing,  large  quantities  of  pus  have 
gushed  up,  not  only  from  the  mouth  but  also  throiigh  the  nose. 

The  regurgitation  of  milk  in  healthy  breast-  or  bottle-fed  infants  after 
a  heart}-  meal  is  met  with  frequenth",  and  is  often  wrongly  regarded  as 
vomiting.  It  is  due  to  simple  overfilling,  or  sometimes  to  too  rapid  feeding  ; 
air  that  has  been  swallowed  is  belched  up,  and  drives  out  some  of  the 
milk  with  it. 

A  brief  account  of  the  mechanism  of  vomiting  will  facihtate  a  classification  of 
its  causes.  The  parts  concerned  are  the  muscular  coats  of  the  stomach;  the 
sphincter  at  the  cardiac  orifice  ;  the  diaphragm,  and  the  abdominal  muscles  ; 
the  vomiting  centre  situated  in  the  medulla  ;  the  efferent  ner^e  fibres  in  the 
vagus  supplying  the  musculature  of  the  stomach ;  the  phrenics  to  the  diaphragm  ; 
and  the  spinal  nerves  supplying  the  abdominal  muscles. 

In  the  act  of  vomiting,  the  waUs  of  the  stomach  contract,  the  diaphragm  is 
pushed  violenth-  downwards  in  fuU  inspirator}-  position,  while  powerful  contrac- 
tions of  the  abdominal  muscles  take  place.  At  the  same  time  the  cardiac 
sphincter  is  relaxed,  and  the  gastric  contents  are  expelled,  chief!}-  as  the  result 
of  the  pressure  thus  exerted  on  the  stomach  by  the  diaphragm  and  the  abdominal 
muscles,  aided  to  some  extent  by  reversed  peristalsis.  The  pyloric  sphincter  is 
usually  closed,  but  it  may  become  relaxed,  in  which  case  bile  and  intestinal 
contents  may  enter  the  stomach  and  be  found  in  the  vomit.  The  vomiting 
centre  may  be  excited  to  action  by  stimuli  reaching  it  from  the  stomach  itself, 
by  afferent  fibres  in  the  vagus,  or  from  other  parts  by  many  different  afl'erent 
channels.  The  centre  ma}-  also  be  thrown  into  action  by  toxic  substances  acting 
on  it  directly. 

In  retching,  forcible  contraction  of  the  stomach  wall,  and  of  the  diaphragm  and 
abdominal  muscles  takes  place  as  in  vomiting,  but  there  is  no  relaxation  of  the 
sphincter.  In  the  condition  known  as  ivaterbrash  or  pyrosis,  in  which  a  quantity 
of  clear  fluid  is  brought  up  into  the  mouth,  usually  on  rising  in  the  morning,  the 
complete  act  of  vomiting  does  not  occur  ;  relaxation  of  the  cardiac  sphincter 
takes  place  without  obvious  attendant  muscular  contraction  of  the  stomach 
or  of  its  auxiliaries,  the  diaphragm  and  the  abdominal  muscles. 

It  is  obvious  from  the  above  that  the  causes  of  vomiting  must  fall  into  two 
great  groups  :  (I)  Those  acting  directly  on  the  vomiting  centre,  such  as  certain 
poisons,  e.g.,  apomorphine  ;  (II)  Those  acting  refiexly  on  the  centre.  The  second 
group  is  a  ven,-  large  one,  as  it  includes  practically  aU  the  pathological  states 
of  the  stomach,  many  visceral  diseases,  disturbances  of  special  senses,  etc.,  as 
will  be  seen  later. 


VOMITING 


843 


I. — Central    Causes. 


Certain  drugs — 

Apomorphine 

Tobacco 

Antesthetics 
Uraemia 
Diabetes 
Acute  yellow  atrophy  of  the  liver 


Addison's  disease 

Onset  of  acute  infections,  especially 
in   children 

Pregnancy 

Recurrent,  periodic  or  cyclical  vomit- 
ing in  children. 


There  may  be  some  doubt  as  to  whether  Addison's  disease,  pregnancy, 
and  recurrent  vomiting  should  be  included  in  this  group,  as  their  pathology 
is  not  fully  known.  The  vomiting  of  pregnancy  may  be  partly  reflex  ; 
but  there  is  strong  evidence  that  a  toxic  element  exists,  and  is  probably 
the  chief  exciting  cause.  The  differential  diagnosis  of  these  conditions 
presents  little  difficulty.  The  examination  of  the  urine  will  give  evidence 
of  the  existence  of  renal  disease  in  ursemic  vomiting,  and  the  onset  of 
drowsiness  and  coma  in  a  diabetic  patient  may  be  attended  by  vomiting. 
Persistent  vomiting  occurring  in  a  case  of  jaundice  of  apparently  the 
common  catarrhal  variety  should  arouse  suspicion  of  its  proving  acute 
yellow  atrophy.  The  size  of  the  liver  should  be  determined  carefully,  and 
any  diminution  noted  ;  the  urine  should  be  examined  for  leucin  and  tyrosin. 
Vomiting  associated  with  asthenia,  characteristic  pigmentation  of  skin  and 
buccal  mucosa,  and  a  persistent  low  blood-pressure  would  be  diagnostic  of 
Addison's  disease.  The  form  of  vomiting  met  with  in  young  children,  termed 
"  periodic,"  or  "  cyclical,"  is  very  severe,  and  is  accompanied  by  great  wasting. 
The  S3^mptoms  pass  off  after  a  few  days,  but  tend  to  recur  at  intervals  of  months. 
The  urine  during  the  attacks  often  contains  acetone  and  diacetic  acid,  and 
the  condition  may  be  regarded  as  an  autointoxication,  probably  an  acidosis 
(see  Acetonuria).  The  vomiting  so  frequently  met  with  as  one  of  the  earliest 
symptoms  in  specific  fevers,  especially  in  children,  is  chiefly  due  to  the  direct 
action  of  the  specific  toxin  on  the  cerebral  centre,  though  reflex  action  may 
also  have  a  share  in  it.  The  diagnosis  does  not  usually  present  difficulty; 
the  acute  onset,  vomiting,  general  malaise,  headache,  pyrexia,  sore  throat, 
rash,  etc.,  speedily  give  the  clue  to  the  cause  of  the  vomiting.  In  older 
patients,  scarlet  fever  is  the  commonest  specific  fever  to  begin  with  nausea 
and  vomiting. 

We  must  next  consider  the  chief  characteristics  of  the  vomiting  due  to  reflex 


II. — Reflex    Vomiting. 


Gastric  Causes. 

Irritating  articles  of  food  (hard, 
indigestible  substances) 

Emetics,  such  as  zinc   sulphate, 
mustard,  etc. 

Poisons  :    Corrosives,  irritants 

Gastritis  : 

{a)   Acute  :    (i)   Simple, 

(ii)   Phlegmonous 
(6)   Chronic 

Dilatation  and  "  hour-glass  "  con- 
traction 


Pyloric  obstruction  : 

Malignant  disease 

Fibrous  stricture 

"  Hypertrophic  stenosis  "  in  infants 

Pressure  on  pylorus  from  without 
Venous    congestion,    as     in     morbus 

cordis,  portal  obstruction,  cirrhosis 

of  liver 
Ulcer 
Malignant  disease. 


844 


VOMITING 


2.  intestinal,  Peritoneal,  and  General  Visceral  Causes. 


Intestinal  obstruction 

Appendicitis 

Intestinal  worms 

Following    administration   of 

enemata 
Henoch's  purpura 
Peritonitis 
Biliary  colic 
Renal   colic — movable   kidney 

("  Dietl's  crises  ") 
Acute  pancreatitis 
Certain  conditions  of  the  female 
genital  organs  : 

Pregnancy 

Retroversion  of  the  uterus 

Ovarian  disease 

Extra-uterine  gestation 

Affections  of  the  Central  Nervous  System. 

Special  Senses  : — 

Offensive  smells,  tastes,  repulsive  sights. 
Brain  : — 

Concussion 

Cerebral  tumour  or  abscess 

Meningitis 

Hydrocephaly 

Cerebral  haemorrhage 

Thrombosis  of  cerebral  sinuses 
Spinal  Cord  : — ■ 

Tabes  dorsalis,  gastric  crises. 


Phthisis — vomiting  may  be  of  central 
origin   or  due   to   irritation  of   the 
bronchi  or  fauces 
Irritation  of  the  fauces  or  bronchi  by 
direct    stimulation,    or    by    severe 
coughing  : 
Pertussis 
Bronzhiectasis 
Fibroid  lung 
Shock  —  blows   on    the    epigastrium, 
injury   of   a   testicle,    a  kick   upon 
the  internal  semilunar  cartilage  of 
the  knee,  etc. 


Middle-ear   disease  ;     Meniere's 

disease 
Migraine 
Epilepsy 
Sea-sickness 
Functional  or  hysterical  vomiting. 


Certain  general  lines  may  be  laid  down  of  great  importance  in  the  accurate 
diagnosis  of  the  cause  of  vomiting.  Attention  should  be  paid  to  its  relation  to 
food,  if  any,  and  at  what  interval  after  a  meal  it  occurs  ;  whether  preceded  or 
not  by  pain  ;  whether  attended  or  not  by  nausea.  The  absence  of  nausea  is  a 
point  of  great  significance  ;  this  is  usually  present  in  vomiting  due  to  abnormal 
states  of  the  alimentary  tract  and  visceral  organs,  but  is  often  absent  in  diseases 
of  the  brain. 

The  vomited  matter  should  be  inspected  carefully,  and  its  quantity  and 
general  character  noted.  Alcohol,  and  certain  poisons  such  as  carbolic  acid  and 
prussic  acid,  may  be  recognized  by  their  smell,  or  a  faecal  odour  may  be  dis- 
tinguished. Blood  may  be  present,  either  dark  or  bright  red,  or  dark  brown, 
resembling  coffee-grounds.  Slight  streaks  of  blood  are  common  with  severe 
vomiting,  and  are  usually  due  to  rupture  of  small  vessels  in  the  oesophagus  or 
pharynx.  In  whooping-cough,  blood  is  often  mixed  with  mucus  from  the 
respiratory  passages,  and  the  contents  of  the  stomach  are  ejected  during  the 
paroxysms.  The  condition  of  the  food  remains  should  be  noted  carefully  ;  the 
presence  of  substances,  such  as  currants  or  seeds,  taken  it  may  be  many  hours 
or  some  days  previously,  would  point  to  motor  insufficiency  of  the  stomach, 
either  with  or  without  pyloric  obstruction  ;  shreds  of  meat  returned  unaltered 
some  hours  after  a  meal  indicate  deficient  protein  digestion. 

The  reaction  should  be  ascertained  :  in  corrosive  poisoning  this  may  be  strongly 
acid  or  alkaline  according  to  the  toxic  agent.     It  need  hardly  be  said  that  in 


VOMITING  845 


any  case  of  suspected  poisoning  the  vomit  should  be  kept  for  analysis.  Micro- 
scopical examination  may  show  sarcinse  [Fig.  92,  p.  267),  yeast  cells,  the  Oppler- 
Boas  bacillus,  or  cell  elements  from  a  malignant  growth.  Intestinal  contents 
may  be  mixed  with  the  vomit.  Bile  is  often  present  in  severe  or  protracted 
vomiting,  and  is  readily  recognized  by  its  colour  and  the  usual  tests.  Relaxation 
of  the  pyloric  orifice  in  such  cases  allows  of  the  return  of  the  duodenal  contents 
into  the  stomach.  F cecal  matter,  when  present,  is  recognized  by  the  characteristic 
odour  and  the  brownish  coloration  it  imparts  to  the  vomit ;  it  usually  occurs 
as  the  result  of  intestinal  obstruction.  Gastro-colic  fistula  may  give  rise  to 
faecal  vomiting. 

I.  Gastric  Causes. — Most  corrosive  and  irritant  poisons  cause  vomiting  immedi- 
ately after  swallowing,  accompanied  by  intense  burning  pain  in  the  epigastrium. 
The  vomit  contains  food,  blood,  mucus,  and  may  have  the  characteristic 
odour  of  the  poison.  With  some  irritant  poisons,  e.g.,  arsenic,  or  phosphorus, 
the  vomiting  may  come  on  later  and  resemble  that  of  an  acute  gastritis. 
The  diagnosis  will  depend  largely  on  the  chemical  analysis  of  the  vomit,  and 
the  associated  signs  and  symptoms. 

In  acute  gastritis  there  is  repeated  vomiting,  usually  very  severe,  and  attended 
by  nausea  and  abdominal  pain.  Vomiting  occurs  shortly  after  taking  food,  and 
causes  some  relief  of  pain.  The  vomited  matter  consists  at  first  of  food  ingested, 
later,  of  mucus  and  bile.  There  are  often  accompanying  diarrhoea  and  febrile 
disturbances,  especially  in  children.  In  the  phlegmonous  form  the  constitutional 
symptoms  are  exceedingly  grave  ;  pus  is  rarely  found  in  the  vomit,  bile  is  often 
present. 

In  chronic  gastritis  the  vomiting  is  associated  with  nausea  and  epigastric  pain. 
There  is  usually  much  flatulence.  The  vomited  matter  consists  of  partially 
digested  food,  mucus,  and  a  considerable  quantity  of  sour-smelling  fluid.  Hydro- 
chloric acid  is  usually  reduced  greatly  in  amount,  or  may  be  absent.  When 
dilatation  of  the  stomach  is  present,  the  quantity  of  fluid  ejected  is  often  very 
large  ;  portions  of  food  taken  many  hours  previously  may  be  returned.  Fer- 
mentation takes  place  in  the  stagnant  gastric  contents,  so  that  the  vomit,  when 
collected  in  a  glass  vessel,  often  shows  an  uppermost  layer  of  brown  froth,  a 
middle  greenish-grey  layer  of  fluid  containing  streaks  of  mucus,  and  below  this 
a  semi-solid  deposit  containing  food  remains,  sarcinse  {Fig.  92,  p.  267),  yeast 
cells,  and  bacteria  ;  chemical  tests  show  the  presence  of  lactic  acid  and  a 
diminution  or  absence  of  free  or  active  hydrochloric  acid. 

"  Hour-glass  "  contraction,  due  to  transverse  constriction  of  the  stomach  by 
fibrous  tissue,  may  be  a  cause  of  vomiting  which  resembles  in  most  respects  that 
associated  with  dilatation. 

The  vomiting  due  to  pyloric  obstruction  in  adults  presents  no  characteristics 
other  than  those  associated  with  the  dilatation  of  the  stomach  which  usually 
results  from  it.  The  absence  of  free  hydrochloric  acid  in  the  vomit  would  favour 
the  diagnosis  of  carcinoma,  the  presence  of  free  hydrochloric  acid  that  of  fibrous 
stricture  ;  the  presence  of  the  Oppler-Boas  bacillus  is  regarded  by  many  as  dia- 
gnostic of  carcinoma.  Persistent  vomiting  in  young  infants,  especially  if  breast- 
fed, attended  with  wasting  and  constipation,  should  always  arouse  suspicions 
of  the  existence  of  "  hypertrophic  stenosis  of  the  pylorus."  The  vomiting  in  these 
cases  is  very  forcible,  the  milk  being  pumped  up  violently,  often  very  shortly 
after  a  feed,  and  with  little  alteration.  Visible  gastric  peristalsis  and  the  presence 
of  a  small  tumour  in  the  epigastrium  would  complete  the  diagnosis. 

Vomiting  due  to  gastric  ulcer  (non-malignant)  is  very  common.  Pain  occurs 
soon  after  taking  food,  and  is  relieved  by  vomiting,  which  usually  occurs  within 
an  hour.     The  vomit  consists  of  food,  more  or  less  digested,  according  to  the 


846  VOMITING 


time  which  has  elapsed  after  a  meal.  It  almost  always  contains  at  least  the 
normal  quantity  of  free  hydrochloric  acid,  and  blood  may  be  present  in  varying 
quantity. 

With  malignant  disease — carcinoma  of  the  stomach — though  the  general 
character  of  the  vomit  may  be  very  similar  to  that  in  simple  ulcer,  there  is 
usually'  a  great  diminution  or  complete  absence  of  free  hydrochloric  acid,  and 
lactic  acid  and  the  Oppler-Boas  bacillus  are  often  present.  Sarcinse  may  be 
present  also  when  there  is  accompanying  dilatation.  Occasionally  portions  of 
the  growth  may  be  found  in  the  vomited  matter.  In  both  simple  and  malignant 
ulcer,  blood  may  be  detected  in  the  vomit  microscopically  or  spectroscopically 
(see  Blood  per  Anum)  when  it  is  not  recognizable  by  the  naked  eye. 

2.  Intestinal,  Peritoneal,  and  General  Visceral  Causes. — In  intestinal  obstruction 
vomiting  sets  in  after  an  interval,  the  length  of  which  may  depend  on  the 
situation  of  the  blocking.  The  vomiting  is  severe  and  persistent ;  the  contents 
of  the  stomach  are  returned  first,  and  later,  mucus,  bile,  and  intestinal  contents. 
Faecal  vomiting  should  be  recognized  at  once  by  its  odour  ;  obvious  pieces  of 
fsecal  matter  are  rarely  distinguishable,  but  the  vomit  may  have  a  brownish 
colour.  The  vomiting  is  more  severe  the  higher  the  obstruction  is  in  the 
intestinal  canal. 

Vomiting  is  commonly  present  in  appendicitis,  but  in  slight  cases  does  not 
persist  after  the  onset.  In  the  severe  forms  of  the  disease  the  vomiting  may 
be  a  prominent  symptom,  and  resemble  that  met  with  in  intestinal  obstruction  ; 
it  is  sometimes  f^cal  in  character. 

Intestinal  worms  are  a  cause  of  vomiting  in  children,  probably  owing  to  the 
reflex  irritation  they  set  up.     Occasionally  a  round-worm  is  found  in  the  vomit. 

Enemata  in  certain  individuals  cause  vomiting,  and  rare  cases  have  been 
described  in  which  the  fluid  injected  per  rectum  has  been  returned  by  the 
mouth. 

Vomiting  is  a  common  symptom  in  the  condition  known  as  Henoch's  purpura, 
and  may  be  due  to  either  gastric  or  intestinal  stimulation.  The  vomit  may 
contain  blood  due  to  haemorrhages  from  the  mucous  membrane  of  the  stomach. 
It  is  usually  accompanied  by  abdominal  pain,  sometimes  of  an  acute  and  agoniz- 
ing character  closely  simulating  that  occurring  with  intestinal  obstruction,  these 
symptoms  being  due  to  haemorrhage  into  the  intestinal  wall  or  the  mesentery, 
which  occasionally  simulate  or  even  give  rise  to  intussusception.  Recurrent 
attacks  of  vomiting  and  abdominal  pain  associated  with  a  purpuric  eruption 
in  a  boy  or  girl  would  point  to  the  existence  of  this  not  uncommon  disease. 

In  acute  peritonitis,  vomiting  is  an  early  symptom,  and  causes  great  pain  ; 
rarely  the  vomit  may  have  a  fascal  odour.  The  history,  together  with  the 
rigidity  and  immobility  of  the  abdominal  wall,  generally  indicate  the  need  for 
early  laparotomy. 

In  biliary  and  renal  colic,  the  vomiting  accompanying  the  attacks  of  agonizing 
pain  presents  no  special  features.  The  pain  in  the  thorax  and  upper  part  of  the 
abdomen,  and  the  onset  of  jaundice,  distinguish  biliary  colic  from  that  due  to 
renal  calculus,  in  which  the  pain  is  in  the  loin  or  lower  abdomen,  shooting  down 
towards  the  groin  and  testicle.  Jaundice  is  absent  if  the  stone  is  in  the  cystic 
duct. 

Acute  pancreatitis  may  simulate  intestinal  obstruction  closely,  in  that  it  is 
attended  by  nausea  and  vomiting,  constipation,  and  severe  abdominal  pain. 
The  vomit  is  not  faecal  in  character ;  there  is  usually  localized  tenderness  over 
the  region  of  the  pancreas.  The  diagnosis  is  seldom  made,  however,  until 
laparotomy  is  performed  on  account  of  the  urgency  of  the  symptoms,  when 
typical  fat  necrosis  will  be  found  in  the  omentum. 

The  other  visceral  causes  of  vomiting  call  for  no  special  notice. 


WEIGHT,     LOSS     OF  847 


3.  Affections  of  the  Central  Nervous  System. — It  has  been  pointed  out  that  in 
most  of  the  preceding  conditions  nausea  accompanies  vomiting,  and  this  brings 
us  to  a  most  important  distinction,  namely,  that  in  intracranial  disease  a  special 
type  of  vomiting  is  met  with,  generally  known  as  "  cerebral  vomiting."  In 
this,  nausea  is  absent,  vomiting  occurs  suddenly  and  often  without  warning, 
and  bears  no  relation  to  the  ingestion  of  food.  The  whole  or  part  of  the 
stomach  contents  are  returned.  Vomiting  of  this  type,  especially  if  accompanied 
by  headache  or  ocular  changes,  should  arouse  grave  suspicion  of  the  existence 
of  organic  cerebral  disease,  such  as  tumour,  abscess,  meningitis,  or  sinus 
thrombosis.  "  Cerebral  vomiting  "  may  also  occur  in  hydrocephaly  due  to 
increased  intracranial  pressure. 

Cerebral  hcsmorrhage  may  be  attended  by  vomiting,  more  often  when  the 
cerebellum  is  the  part  affected  than  when  other  parts  of  the  brain  are  involved. 

In  Meniere's  disease  vomiting  may  follow  the  attack  of  vertigo.  Nausea  and 
vomiting  frequently  accompany  the  severe  headache  associated  with  attacks  of 
migraine. 

Functional  or  hysterical  vomiting  is  not  attended  by  nausea  or  pain  ;  portions 
of  a  meal  are  brought  up,  usually  fluids  ;  and  although  the  vomiting  may  be  a 
frequent  occurrence,  the  general  state  of  nutrition  often  remains  good.  Other 
hysterical  manifestations  are  generally  present  in  these  patients.  Cases  have 
been  recorded  in  which  the  vomit  contained  faecal  matter. 

The  gastric  crises  in  tabes  are  attacks  of  vomiting  accompanied  by  severe 
epigastric  pain.  The  attacks  usually  last  for  several  days,  and  tend  to  recur  at 
intervals  of  weeks.  Nausea  may  be  absent.  During  the  intervals  digestion 
may  be  carried  on  normally.  The  diagnosis  depends  on  the  presence  of  the 
characteristic  Argyll  Robertson  pupil  and  the  loss  of  the  knee-jerk. 

The  influence  of  anaemia  upon  vomiting,  and  the  manner  in  which  gastric 
ulcer  may  be  simulated  thereby,  has  been  discussed  in  the  article  on  Anemia. 

H.  Morley  Fletcher. 

WALKING,  PECULIARITY  IN.— (See  Gait,  Abnormalities  of.) 

WEIGHT,  LOSS  OF. — Loss  of  weight  sooner  or  later  accompanies  all  cases 
of  cancer,  phthisis,  starvation  from  lack  of  food  or  from  inability  to  swallow,  and 
similar  conditions  ;  but  in  most  such  cases  there  are  other  definite  symptoms 
pointing  to  the  diagnosis.  The  present  article  is  concerned  chiefly  with  those 
cases  in  which,  without  any  other  very  definite  symptoms,  the  patient  has 
recently  been  losing  weight.  In  the  case  of  children,  the  commonest  causes  are 
malnutrition  from  injudicious  feeding,  the  eating  of  sweets  between  meals, 
gastro-intestinal  infections,  and  latent  tuberculosis  (see  Marasmus). 

If  the  patient  is  an  adult  and  the  loss  of  weight  has  been  considerable,  the 
first  suspicion  will  almost  certainly  be  that  there  is  either  phthisis  pulmonalis, 
deep-seated  or  latent  carcinoma  or  sarcoma,  or  tuberculosis  other  than  pulmonary. 
All  the  systems,  including  the  rectum,  and,  if  need  be,  the  vagina,  will  need 
careful  routine  examination.  Any  sputum  that  may  be  obtainable  should  be 
examined  for  tubercle  bacilli ;  the  physical  signs  at  the  apices  of  the  lungs  should 
be  watched  with  extreme  care,  particularly  if  there  is  any  difference  in  the  amount 
of  subcutaneous  fat  on  the  two  sides  in  this  region  ;  the  ;ir-rays  may  be  of  value 
in  detecting  mottling  [Fig.  27,  p.  120)  at  one  or  other  apex  when  the  mischief  is 
too  far  from  the  surface  to  give  abnormal  physical  signs  to  percussion  or  aus- 
cultation. Von  Pirquet's  skin  reaction,  or,  if  it  is  thought  advisable,  Calmette's 
ophthalmic  reaction  to  tuberculin  may  be  tested.  Von  Pirquet's  is  nowadays 
preferred  to  Calmette's  reaction  on  account  of  the  occasional  ill-effects  of  the 
latter  upon  the  eye.  Those  who  believe  that  the  opsonic  index  to  tubercle 
bacilli  is  of  diagnostic  significance  would  have  it  estimated  before  and  after 


WEIGHT,     LOSS     OF 


inoculations  with  small  or  moderate  doses  of  tuberculin  ;  the  family  history 
might  be  of  assistance  in  indicating  the  likelihood  of  a  lung  lesion,  whilst  the 
personal  history  as  to  the  drinking  of  much  unsterilized  milk  would  indicate  the 
possibility  of  infection  by  so-called  surgical  tuberculosis  in  the  lymphatic  glands, 
abdomen,  a  joint,  or  the  spinal  column. 

Notwithstanding  the  most  careful  investigations,  however,  doubt  as  to  the 
cause  of  the  loss  of  weight  in  not  a  few  cases  remains  until,  in  the  course  of  time, 
the  patient  either  recovers  the  lost  ground  and  gets  quite  well,  or  else  develops 
other  signs  or  symptoms  of  growth,  tuberculosis,  or  other  definite  disease. 

Young  persons  may  lose  weight  as  the  result  of  change  of  surroundings,  for 
instance  from  active  out-door  school  life  to  work  in  a  city  office.  Care  and 
anxiety  ;  the  undertaking  of  serious  responsibilities  ;  sorrow  ;  love  ;  too 
strenuous  a  life  of  pleasure  ;  irregularity  of  meals  ;  too  long  hours  of  work  ; 
these  are  amongst  the  everyday  causes  of  what  at  the  time  may  appear  to  be 
serious  loss  of  weight. 

Any  affection  of  the  alimentary  tract  sufficient  in  degree  to  interfere  with  the 
proper  digestion  and  absorption  of  food  may  produce  loss  of  weight,  especially 
if  there  is  cause  for  sapraemia  at  the  same  time  ;  one  may  mention  in  this  connec- 
tion loss  of  appetite  from  too  much  smoking,  excessive  drinking,  monotony  of 
food  or  of  existence,  carious  teeth,  ill-fitting  tooth  plates,  pyorrhoea  alveolaris, 
dyspepsia,  flatulence,  the  abuse  of  purgatives,  and  the  constipation  which 
results  therefrom  ;  gastric  or  duodenal  ulcer  ;  inflammatory  or  ulcerative  affec- 
tions of  the  bowel  of  the  nature  of  colitis  in  its  many  forms.  The  wasting  is 
seldom  severe  in  any  of  these ;  but  especially,  for  instance,  in  cases  in  which 
gastric  symptoms  are  prominent,  it  may  be  very  difficult,  for  the  time  being, 
to  tell  whether  the  mischief  should  be  labelled  merely  dyspepsia,  or  actual 
carcinoma  ventriculi.  Analyses  of  the  gastric  juice  were  at  one  time  thought 
to  be  valuable  in  deciding  between  simple  and  malignant  affections  of  the 
stomach,  but  this  is  by  no  means  always  the  case.  If,  under  observation  and 
treatment,  the  patient  succeeds  in  gaining  weight,  or  even  ceases  from  losing 
more  over  a  period  of  some  weeks,  the  argument  is  against  carcinoma  ;  but  if 
doubt  remains,  and  it  is  desired,  if  possible,  to  adopt  surgical  measures  before 
any  carcinoma  has  passed  the  stage  of  radical  curability,  it  will  often  be  wise 
not  to  postpone  laparotomy  too  long  as  a  means  of  settling  the  diagnosis.  It 
is  too  late  if  one  waits  until  there  is  a  tumour. 

Any  malady  which  produces  sleeplessness  or  pain,  or  both,  may  lead  to  serious 
loss  of  weight,  and  thus  to  difficulty  in  the  diagnosis.  A  thoracic  aneurysm,  for 
instance,  may  erode  the  vertebrae  and  produce  severe  intrathoracic  pain,  which 
in  turn  produces  insomnia,  and  may  thus  cause  so  much  loss  of  weight  that 
neoplasm  may  be  suspected. 

Chronic  microbial  infections  may  not  in  themselves  be  obvious,  and  yet  they 
may  produce  loss  of  weight  by  interfering  with  the  general  nutrition  ;  one  sees 
this  in  many  persons  who  have  returned  from  the  tropics  after  infection  there 
by  dysentery,  yellow  fever,  malaria,  dengue,  and  so  forth.  At  home,  chronic 
infections  of  joints,  of  the  skin,  the  alimentary  tract,  the  uterus,  and  genital 
organs  may  produce  loss  of  weight  in  a  similar  wa^^  One  would  mention  here 
in  particular  a  malady  that  has  only  been  recognized  of  recent  years,  though  it 
is  now  known  to  be  common,  namely  coli  ba,cilluria  (see  Bacteriuria),  the 
diagnosis  of  which  is  only  possible  on  bacteriological  examination  of  the  urine, 
though  it  may  be  suggested  by  the  discov^ery  in  the  latter  of  a  trace  of  albumin 
and,  on  microscopical  examination,  of  variable  numbers  of  pus  corpuscles. 

Liver  affections  exert  a  prominent  influence  upon  general  nutrition,  and  the 
loss  of  weight  exhibited  by  some  sufferers  from  cirrhosis  of  the  liver  is  familiar, 
though  in  the  early  stages  the  patient  may  be  fat,  and  towards  the  end  loss  of 


WEIGHT,     LOSS     OF  849 


weight  may  be  masked  by  a  false  increase  due  to  ascites.  Pernicious  anagmia 
is  only  diagnosable  with  certainty  by  means  of  blood  examination  (see  Anemia), 
though  it  may  be  suggested  by  the  lemon-yellow  colour  of  the  patient  ;  but  one 
marked  feature  of  the  malad}'  is,  that  although  the  patient  does  not  at  first 
decrease  much  in  bulk,  the  tissues,  from  conversion  into  or  replacement  bj^  fat, 
become  of  less  specific  gravity  than  normal,  so  that  the  patient  diminishes 
materially  in  weight. 

The  effect  of  alcohol  upon  body  weight  is  variable,  some  persons  becoming 
exceedingly  stout,  others  not  changing  much,  and  others  becoming  extremely 
thin.  Broadly  speaking,  it  is  spirit  drinkers  who  decrease  in  weight,  and  in 
some  cases  serious  doubts  may  arise  as  to  whether  the  loss  in  such  a  patient  is 
due  to  the  alcoholic  habits  only,  or  whether  there  is  not  some  new  growth  or 
tuberculous  affection  as  well,  ^^'llen  alcoholism  leads  to  peripheral  neuritis 
there  is  rapid  and  extreme  loss  of  weight  as  the  result  of  the  muscular  atrophy, 
and  the  sanre  appUes  to  other  conditions  of  multiple  peripheral  neuritis  (see 
Atrophy,  Muscular). 

Certain  drugs  have  the  power,  especially  in  certain  individuals,  of  reducing 
weight  materially,  even  though  the  diet  remain  the  same  ;  the  best  known  of 
these  is  thyroid  extract,  whilst  a  long  way  second  comes  fticus  vesiciilosiis.  It 
will  seldom  happen  that  either  of  these  is  being  taken  accidentally,  so  that  the 
diagnosis  of  loss  of  weight  due  to  them  is  generally  obvious. 

Old  age  is  very  apt  to  be  associated  with  loss  of  weight  ;  it  is  very  difficult 
sometimes  to  be  sure  whether  the  loss  of  Aveight  that  may  be  complained  of  in 
a  patient  of  sixty  or  seventy  years  of  age  is  merely  senile,  or  whether  it  is  due  to 
underh-ing  gro-wth. 

Diabetes,  especially  diabetes  melhtus  in  young  subjects,  may  have  loss  of 
weight  for  its  earhest  and  most  prominent  symptom  ;  but  the  diagnosis  is 
sufficiently  easy  when  the  urine  has  been  examined. 

Addison's  disease  is  another  affection  in  which,  besides  the  progressive  asthenia, 
loss  of  weight,  though  by  no  means  essential,  is  sometimes  a  marked  feature. 
There  may  or  may  not  have  been  sjmcopal  or  gastric  attacks  ;  the  diagnosis 
depends  almost  entirely  upon  the  discovery  of  abnormal  pigment  deposits  in 
the  form  of  patches  or  spots,  not  onty  upon  the  skin  of  the  neck,  hmbs,  and 
trunk,  but  also  beneath  the  mucous  membranes,  particularly  of  the  mouth, 
where  they  are  generally  best  seen  inside  the  hps,  or  within  the  cheeks.  The 
blood-pressure  is  sometimes  very  low  in  these  cases,  and  if,  on  actual  measure- 
ment, it  is  found  to  be  70  or  80  mm.  Hg,  this  fact  tends  to  confirm  the 
diagnosis. 

Just  as  the  administration  of  thyroid  extract  diminishes  weight,  so  may  loss 
of  weight  be  a  prominent  feature  in  cases  of  Graves'  disease — exophthalmic 
goitre  ;  sometimes,  indeed,  it  may  be  the  first  symptom  to  attract  attention, 
especially  in  those  cases  in  which  there  is  no  exophthalmos.  Tachycardia, 
nervousness,  fine  tremor  of  the  outstretched  fingers,  and  sjTnmetrical  but  not 
extreme  enlargement  of  the  thjToid  gland,  would  confirm  the  diagnosis. 

Anorexia  nervosa  is  a  disease  in  which  wasting  from  disincKnation  to  eat  any 
kind  of  food  except  in  the  smallest  quantities  is  the  most  prominent  sjnnptom  ; 
the  patient  is  nearly  always  a  girl,  or  young  woman,  betAveen  the  ages  of  fifteen 
and  twenty-five  ;  there  may  or  may  not  be  other  e\ddence  of  functional  nerve 
disorders.  A  patient  who  has  been  perfectly  robust  until  pubertj'-  or  shortly 
afterwards  begins  to  lose  all  appetite,  and  the  body  wastes,  until  from  being 
eight  or  nine  stone  the  weight  declines  even  to  so  little  as  four  or  three  and  a 
half  stone,  though  the  height  may  be  5  ft.  4  in.  or  more.  One  sometimes 
sees  girls  of  5  ft.  10  in.  or  more  weighing  less  than  five  stone  as  the  result, 
not  of  any  organic  disease,  but  of  the  simple  functional  absence  of  appetite 
o  54 


850  WHEALS 

— anorexia  nervosa.  In  arriving  at  the  diagnosis  it  is  important  to  exclude  - 
the  possibiht}-  of  some  deep-seated  tuberculous  lesion^  especiall}'  phthisis  pulmo- 
nahs  or  tuberculous  peritonitis  (tabes  mesenterica).  One  of  the  best  means  of 
excluding  these  is  the  thermometer,  for  in  anorexia  ner\'osa  there  should  be  httle 
if  anj'-  p\Texia.  Yery  careful  examination  of  all  the  systems,  including  von 
Pirquet's  and  perhaps  Calmette's  tubercuhn  reactions,  will  lead  to  negative 
findings,  and  the  diagnosis  ■\viU  be  confirmed  b}^  the  rapid  increase  in  weight 
that  will  accrue  when  measures  for  the  treatment  of  the  functional  disease  by  the 
Weir-iMitcheU  method  are  adopted.  Herbert  French. 

WHEALS.— The  characteristic  lesion  of  urticaria  ma}'-  be  defined  as  a  flattish, 
evanescent  elevation  of  the  skin,  the  result  of  an  oedema  of  the  derma.  It  may 
be  regarded  also  as  a  special  variety-  of  the  papule  or  the  nodule.  It  is  related 
to  er^-thema,  and  is  the  expression  of  angioneurotic  excitation,  internal  or 
external,  which  causes  a  dilatation  of  the  vessels  that  permits  an  exudation  of 
plasma.  Reaction  follows  in  the  form  of  a  spasmodic  contraction  of  the  capil- 
laries. The  fluid  is  not  therefore  immediately  taken  up  by  the  vessels,  but  as 
soon  as  the}'  return  to  their  normal  condition,  the  wheal  disappears,  as  a  rule 
\vithout  leaving  any  tiace.  In  colour,  wheals  are  usually  pale  in  the  centre,  with 
a  red  peripher\- ;  but  they  may  be  uniformly  rose-red,  or  naay  have  a  whitish 
peripherj- ;  or,  as  the  result  of  hemorrhage  into  them,  they  ma}'  be  purphsh. 
In  size  they  vary  from  a  pin-head  upwards.  The  smaller  ones  may  take  the  form 
of  conical  or  acuminate  papules,  frequently  surmounted  by  a  tiny  vesicle.  As 
a  rule,  they  are  flat  or  ver}'  sUghtly  raised  ;  but  the  larger  ones,  when  not  the 
result  of  coalescence,  are  hemispherical.  They  may  also  be  linear  in  shape,  and 
several  inches  in  length,  and  by  running  together,  may  form  roughh'  circular 
plaques.  They  usually  appear  suddenly,  and  last  only  a  few  hours,  but  may 
be  succeeded  by  others.  They  are  always  accompanied  by  itching  or  burning, 
which  may  be  intense. 

It  is  not  necessary,  in  a  work  on  diagnosis,  to  give  a  detailed  description  of  the 
different  forms  of  urticaria  ;  the  only  other  affection  in  which  wheals  appear  is 
urticaria  papulosa  (stiophulus),  the  differential  diagnosis  of  which  has  been 
given  under  Papules.  The  sudden  onset,  the  presence  of  the  wheals,  the 
usually  fugitive  character  of  the  eruption,  the  irregular  distribution,  and  the 
severe  itching,  make  up  a  chnical  picture  which  is  generally  unmistakable.  In 
bullous  tirticaria,  however,  in  which  the  wheal  is  crowned  or  is  replaced  by  a 
bleb,  the  afiection  may  be  confused  with  pemphigus  or  with  the  erythematous 
stage  of  dermatitis  herpetiformis  ;  btit  its  true  nature  is  indicated  by  the  history 
of  the  case,  the  course  of  the  eruption,  and  the  almost  invariable  presence  at 
some  points  of  t}-pical  lesions.  In  cases  in  which  the  constitutional  symptoms 
are  pronounced,  the  rash  may  be  mistaken  at  first  for  that  of  scarlet  fever,  or 
even  for  erj'sipelas  ;  but  the  course  of  the  lesions  will  quickly  correct  the  error. 

^Mlen  wheals  are  due  to  such  local  and  accidental  causes  as  the  bites  of  insects, 
or  contact  with  the  stinging-nettle,  the  diagnosis  is  furnished  b}'  the  history,  and 
in  insect  bites  bj^  the  central  punctum.  Malcolm  i\I orris. 

WIND. — (See  Flatulence  ;    and  INIeteorism.) 
WORMS,  INTESTINAL.— (See  Parasites,  Intestinal.) 
WRIST-DROP. — (See  Paralysis  of  the  Extremity,   Upper.) 
XANTHELOPSIA.— (See  Vision,  Defects  of.) 
YELLOW  VISION.— (See  Vision,  Defects  of.) 


GENERAL     INDEX 

Entries  in  hcnvij  capitals  {e.g.  ACETONURIA)  denote  niain  articles  in  the  text.  Small 
heavy  type  {e.g.  Abscess)  is  employed  partly  to  indicate  [/roups  of  entries,  and  partly  as  an 
assistance  to  the  eye   ivhen  rjlancinrj  down  the  columns   to  locate  a  reference  rapidly. 


PAGE 

ABDOMEX,  anatomical  areas 

(Fig.  189)          .  .          . .  721 

-  bulfint;  in  visceroptosis  (Fig. 

4ir          1-18 

-  distention  of 473 

(see  Swelling,  Abdominal) 

in     acute      hsemorrhagic 

pancreatitis      . .          . .  646 
peritonitis         ..131,472,644 

-  -  in  ascites  . .          . .          . .  50 

-  -  atonic  constipation        .  .  143 

-  -  carcinoma             . .          . .  152  i 

-  -  causes  of  enormous        . .  465 
in  cirrhosis  of  liver         .  .  134 

-  -  cystic  disease  of  kidneys. .  15 

-  -  witli  gas  (see  ileteorism) 

-  -  Hirsclisprung's  disease 

148,  151,  713 

-  -  from  hydatid  disease     . .  719 

iu  intestinal  colic           . .  473 

obstruction         134,  152,  571 

-  -  from   meteorism.  .          .  .  716 

orthopnoea  in      .  .          .  .  465 

ui  pseudo-leutaemia  infan- 
tum         42 

-  -  from  splenic  enlargement  688 

in  tuberculous  peritonitis  152 

typhoid  fever      . .          . .  90 

volvulus                . .          . .  152 

-  eczema  marginatum  on     . .  275 

-  fullness  of,  in  colic            . .  134 

-  immobility  in  peritonitis  . .  472 

-  Jacquet's  erythema  of      . .  446 

-  lesions  of,  causing  pleuritic 

efiasion             . .          . .  123 

-  lichen  scrofulosorum  of     . .  529 

-  lineae  albicantes  on            . .  402 

-  lympliatic  drainage  of       . .  738 

-  muscles,  paralysis  of          .  .  181 

-  new    growth    in,    intestinal 

obstruction  from             . .  431 

meteorism  in  . .          . .  432 

secondary     nodule     at 

umbilicus     . .          . .  524 

glands  along  thoracic 

duct          . .          . .  421 
in  neck     . .          . .  421 

-  pediculosis  of          . .          . .  447 

-  pendulous  in  cretinism       .  .  259 

-  -  hepatoptosis  from           . .  406 
--  pit.vriasis  rosea  of  . .          . .  658 

-  prominent  in  rickets          . .  695 

-  -  in  Hanot's  cirrhosis       . .  411 

-  prurigo  ferox  of      . .          .  .  531 

-  retraction    of,    at    onset   of 

perforative  peritonitis   . .  472 
in  tixberculous  meningitis  612 

-  rigid  (see  Rigidity  of  Abdo- 

men) 

-  rub  over  liver  or  spleen  in  ""^ 

peritonitis            . .          . .  431 

-  scabies  of        . .  . .     447,  832 

-  seborrhceic  dermatitis  of    . .  447 

-  swellings  in,  in  chronic  peri- 

tonitis      .  .          .  .          . .  472 

-  syphilitic  roseola  on           . .  675 

-  tenderness  in  (see  Tenderness, 

General  Abdominal) 


PAGE  , 

Abdominal     aortic    pulsation,  j 

undue      (see     Pulsation,  i 

undue  Abdominal  Aortic)  i 

-  aneurysm    (see    Aneurysm, 

Abdominal)  | 

-  angina  (see  Angina,  Abdo- 

minal) 

-  conditions,  hiccough  in    . .     342 

-  crises  of  locomotor  ataxy  . .     562 

-  cysts,  diagnosis  from  ascites       53 

-  disease,  chloasma  in  . .     574 
facies  in    . .          .  .        133,  258 

-  neuralgia      - .  . .  .  .     4 1 3 

-  pain  (see  Pain,  Abdominal) 

-  reflexes  (see  Reflexes,  Abdo- 

minal) 

-  swelUng  (see  Swelling,  Ab- 

dominal) 

-  tumours,    great    abdominal 

distention  from   .  .  . .     467 

due  to  aneurysm  . .     299 

benign  in  pyloric  obstruc- 
tion      . .  . .  . .     353 

from  carcinoma  of  colon      367 

causing    acute     intestinal 

obstruction      . .  . .     152 

asymmetrical  oedema..     456  ' 

portal  obstruction,  i 

ascites  with. .  . .       59 

in  chronic  intussusception     148 

colic  . .  . .  . .     134 

constipation    from    pres- 
sure of  . .  . .     148 

from  gastric  carcinoma         299 

inferior    vena    cava     ob- 
struction by    . .  . .     459 

in  intussusception        152,  196 

large,    ortliopnoea    from       467 

linese  albicantes  in         . .     402 

-  -  in  malignant  pyloric  ob- 

struction . .  . .     353 

multiple  causes  . .  . .       55 

in  tuberculous  peritonitis    56 

-  -  paraplegia  due  to  . .     561 
pressure  by,  causing  albu- 
minuria            . .  . .       17 

dyschezia     . .  . .     150 

jaundice        .  .  .  .     362 

paralysis  of  anterior 

crural  nerve         .  .      541 
pseudo-elephantiasis  from    456 

-  -  from  twisted  ovarian  cyst     153 

-  wall,  fibro-Upomata  of      . .     716 

Hodgkin's  disease  affecting  715 

infiltration  by  appendicular 

abscess  . .  . .  . .     715 

IjTnphosarcoma  afiecting      715 

oedema  of,  with  redness, 

in  tuberculous  peritonitis  691 

swellings    in    distinction 

from     intra-abdominal 
swellings  . .  . .     715 
thickenings    of,    in    peri- 
tonitis . .          . .          . .       56 

tuberculous  infiltration  of      56 

tumours  of  . .  . .     716 

Abductor      hallucis,      nerve 

supply  of         . .  . .     542 


PAGE 
Abductor  minimi  digiti,  nerve 

supply     of       . .         542,  550 

-  paralysis    simulating    acute 

asphyxia  . .  . .  . .     185 

-  poUicis,  effects  of  paralysis  of  127 

nerve  supply  of  . .     550 

Abductors  and  external  rota- 
tors of  hip,  spinal  nerve 
roots  supplying  . . 

Abortion  in  lead  poisoning  . . 

-  infective  peritonitis  after  . . 

-  spasmodic  pelvic  pain  in  . . 

-  tendency  to,  in  plumbism. . 

-  threatened,  simulating  ecto- 

pic gestation 

-  uterine  hjemorrhage  from  758, 436 

-  tubal,   absence  of  products 

of   conception  in   uterine 
discharge  in 
of       uterine      contrac- 
tions in 

cervix  uteri  closed  in     . . 

collapse  due  to    . . 

diagnosis     from     uterine 

abortion 

-  -  pelvic  liaBmatocele  from 
ruptured,     acute     abdo- 
minal pain  from 

coma  from       . .        137,  140 

general  peritonitis  simu- 
lated by 

hsemorrhage  per  vagi- 

nam  with     .  .         646 

leucocytosis  with 

resembling     dysmenor- 

rhcea .  . 
signs  of  internal  bleed- 
ing from       .  .         646 

spasmodic  pelvic  pain  in  509 

sudden  pelvic  pain  due  to     760 

Abscess  in  adhesions  between 
bladder  and  appendix  . . 

-  albumosuria  in       . . 

-  anaemia  in    . . 

-  diagnosis  of  gumma  from 

-  leucocytosis  with     . . 

-  alveolar,  toothache  with   . . 

-  -  bleeding  gums  from  86 
development  at  root  of  a 

carious  tooth  .  . 

diagnosis  from  actinomy- 
cosis of  lower  jaw 

necrosis  of  jaw 

enlarged     lymph     glands 

from 

furred  tongue  with 

necrosis  of  jaw  from 

-  -  pointing  between  gum  and 

cheek    . . 

on  the  cheek  .  . 

on  the  chin 

in  submaxillary  region 

pyrexia  with 

swelling  of  face  from 

— of  gums  in 

of  the  lower  jaw  from 

trismus  froTn 

-  of  antrum  of  Highmore 


643 

77 

644 

509 


436 


700 

760 
760 
760 

760 
760 

646 


646 


760 
646 


220 


60 


632 
20 
39 

449 
400 

747 
J  S7 

747 

748 
747 

747 
747 

747 

747 
747 
747 
747 
747 
746 
747 
747 


747,  801 
502 


852 


ABSCESS,    APPENDICULAR— ABSCESS,    HEPATIC 


Abscess,    contd. 

-  appendicular,  abdominal  ri- 

gidity from  . .  . .     645 

-  -  due  to  actinomyces       . .     736 

-  -  acute  peritonitis  from   . .       55 

-  -  albumosuria  -with  . .       20 

ansemia  with       . .  . .       39 

B.  coli  communis  in     711,  713 

felt  per  rectum   . .        638,  736 

-  -  fever  and  rigors  from  . .     632 

-  -  gas  in       . .  . .        711,  713 
infiltration  of  abdominal 

wall  by  . .  . .     715 

pelvic  swelling  due  to  . .     757 

--  -  leucocytosis  in    . .  . .     400 
pus  in  stools  from  . .     601 

-  -  rectum  obstructed  by  . .       638 

-  -  resonance  over   . .  . .     713 

-  -  rigors  from  . .  . .     648 
rupture  into  bladder    313,  624 

631,  632 
simulated     by     movable 

kidney  . . 

by  phantom  tumours . . 

swelling  in   right  lumbar 

region  from 
urethral  passage  of  faeces 

from 

-  axillary,  due  to  whitlow  . . 

pain  on  moving  arm  with 

pyrexia  with 

simulating  hepatic  abscess    779 

lipoma  . .  . .         731,  732 

tuberculous  . .  . .     731 

-  of  bone,  age  incidence  of  750,j752 

-  -  bursting  into  joint  . .     750 

denuding  whole  bone     . .     750 

diagnosis  from  endosteal 

sarcoma 
periosteal  sarcoma     .  . 

-  -  high  leucocytosis  in 

limitation  by  epiphyses . . 

localized  swelling  from  . . 

-  -  necrosis  of  bone  in 
occurrence  in  the  end  of 

long  bone 

osteomyelitis  from 

pain  and  tenderness  over 

popliteal  .  . 

pyaemia  from 

pyrexia  in 

-  -  secondary  arthritis  from 

infection  in 

septic  embolism  from     . . 

sinus  formation  from 

red  and  (Edematous  in 

skin  over . . 

tender  spot  in     . . 

tubercuUn  in  diagnosis  of 

tuberculous 

-  -  tyiJhoidal 

-  -  upper    end    of   tibia    the 

commonest  site   of 

-  -  V.  Pirquet's  reaction  in . . 

-  -  s-rays  in  diagnosis  of 

-  breast  (see  Abscess,  Mammary) 

-  cerebellar,  from  bronchiec- 

tasis . .         . .         . .     644 

headache  in         . .         565, 651 

head  retraction  from   641,  643 

hypothermia  in  . .  . .     346 

-  -  knee-jerks  increased  in.  .     565 
optic  neuritis  in  . .  .  .     565 

-  -  from  otitis  media  565,  644 

-  -  paraplegia  from  . .  . .     565 
pyrexia  in            . .  . .     565 

-  -  pyrexia  absent  with       . .     644 
simulating  cerebellar   tu 

mour 

superior    longitudinal 

sinus  thrombosis     . .     651 

-  -  slow  pulse  with  . .  . .     644 
sometimes  no  leucocytosis 

with 644 


729 
721 

727 

264 
731 
731 
731 


756 
763 
750 
750 
750 
751 

752 
750 
750 
762 
750 
750 
378 
752 
750 
751 
750 
752 
752 
752 
752 
752 

752 
752 
752 


Abscess,  cerebellar,  contd. 

vertigo  due  to     . .  . .     828 

vomiting  in         . .        565,  651 

-  cerebral,  aphasia  in  685,  686 

bradycardia  from  . .       98 

from  bronchiectasis        98,  547 

coma  from  . .        136,  137 

convulsions  from  . .     172 

from  frontal  sinus  disease     547 

with   fungating   endocar- 
ditis       547 

giddiness  in         . .  . .     341 

headachefrom326,  327,686,  847 

hemianopsia  from  . .     335 

hemiplegia  from 

82,  138,  340,  341 

hyperpyrexia  in. .  . .     344 

hjrpertension   of  cerebro- 
spinal fluid  in . .  . .     338 

hypothermia  in  . .         346, 547 

increased       intracranial 

pressure  in       .  .  . .     686 

leucocytosis  in     . .  . .     400 

due  to  mastoid  disease  . .     547 

-  -  occasional  latency  of      . .     341 
optic  neuritis  in,  341,  547,  565 , 

686 
otitis  media  causing    340,  341 


547 
609 
594 
341 
648 
614 
173 


623 

470 
326 
828 


643 


paralysis  from 

prolonged  pyrexia  in 

pupil  changes  with 

pyrexia  in 

recurring  rigors  in 

septicaemia  from 

signs  of     . . 

simulating  superior  longi- 
tudinal sinus  tlirombosis  651 

slow  pulse-rate  in  547,  771 

slow  respiration  in  . .     547 

temperature  in  diagnosis 

from  cerebral    tumour 

temporosphenoidal,      dis- 
charge through  ear 

unilateral  headache  in  .  . 

vertigo  due  to 

vomiting  in 

341,547,651,086,844,  847 

-  of  chest  wall  . .     194 

due  to  abscess  of  liver      478 

caries  of  rib     . .  . .     478 

pyaemic . .  .  .  . .     478 

simulated  by  empyema 

193,  478 

-  cholecystic  (see  Gall-bladder, 

Empyema  of) 

-  femoral,    femoral    swelling 

due  to      . .  . .  . .     732 

-  gas-containing,  from  bacillus 

coli 

-  -  in  subphrenic  abscess 

501,  578,  712,  720,  721 

-  in  heart,  from  periostitis  . .     650 

-  hepatic,  ama3ba  coli  in  wall 

279,  704 
amcebic,  absence  of  amoebae 

in  pus  of  . .  .  .     704 

dysentery  with  . .     279 

anaemia  in  . .  . .       39 

"  anchovy  sauce  "  sputum 

from   ..     176,  323,  704 

bursting  through  hang 

323,  409,  704 
"  chocolate     and    milk " 

appearance  of  pus  in. .     279 

-  -  compression  of  lung  by. .     667 
from  active  congestion 

of  liver         ..         371,  407 

enlarged  gall-bladder  278,  279 

hydatid  disease  . .     415 

dome-shaped   dullness   at 

right  base  of  lung  in  . .     324 

empyema  from  . .  . .     120 

enlargement  of  liver  from 

408,  651 


578 


Abscess,  hepatic,  contd. 

exercise,    insuflBcient,     in 

etiology  of 

exploration  in     . . 

following  dysentery 

323,  651, 

fullness,  sense  of,  from  . . 

gumma,  growtli,   or  cyst 

preceding 

-  haemoptysis  from  317, 
history    of    residence    in 

tropics  in 

infection  through  hepatic 

artery  causing 

-  -  jaundice  in     362,  366,  371 
with  enlarged  liver  in 

-  large  single 

-  age  incidence  of 

from  extension  from 

neighbouring   sup- 
puration  . . 

injury  to  liver 

non-dysenteric  intes- 
tinal ulceration   . . 

race  incidence  of 

specific  fevers  a  very 

rare  cause  of 

from        suppuration 

ro\ind  a  gall-stone 

of  a  hydatid 

leucocytosis  with 

279,  369,  400, 

malaise  from 

-  multiple    . .        ..       369, 
absence      of     enlarged 

liver  in 

jaundice  with  .  . 

patlis  of  infection  in. . 

suppurative  cholangitis 

causing 

pylephlebitis  causing 

nausea  in 

pain  in  axilla  from 

chest  from 

epigastrium  in . . 

hypochondrium  from  499 

shoulder  from 

pleurisy  from 

with  effusion  from 

peritonitis  from  . . 

pointing  in  chest-wall  . . 

-  -  polymorplionuclear     leu- 

cocytosis in     . . 

fi-om  pylephlebitis 

pyrexia  from         324,  362, 

redness    and    sweUing    of 

hypochondrium  from . . 
relative  leucocyte  count  in 

diagnosis  from  malaria 
residence    in    tropics    in 

etiology  of        . .        371, 
rigors  from    324,  362,  648, 

-  -  rupture      through      dia- 

phragm, abundant  spu- 
tum in. . 

into  intestine   . . 

lung,  foul  taste  from  . . 

sputum    not   usually 

foul  in 

-  -  -  stomacli 

simulated     by    phantom 

tumour 
by  subphrenic  abscess 

-  -  simulating  axillary  abscess 

empyema         . .         119, 

large  gall-bladder 

situation  of 

skodaic  resonance  due  to 

sterile  pus  in     . . 

subphrenic  abscess  from 

sweating  from     . . 

swelling  of  chest  wall  from 

tenderness  from . . 

in  chest  from  . . 


704 
371 

279 
324 

704 

369 
651 
363 
369 
408 


408 
408 


408 
408 


408 
408 

402 
651 
372 

408 
372 
369 

369 
369 
371 
651 
779 
486 
,651 
651 
123 
651 
644 
478 

369 
649 
651 

715 

402 

407 
651 


704 
409 
774 

704 
409 

721 
723 
779 
779 
278 
722 
667 
323 
501 
651 
194 
651 
779 


ABSCESS,    HEPATIC— ABSCESS,    PROSTATIC 


853 


Abscess,  hepcUic,  contd. 

-  -  tropical 3G9 

absence  o£  bile  in  urine 

in 369 

albuminui'ia  in  . .  409 

amceba    dysentcrioa    in 

369,  408 

in  lining  wall  of  liver  408 

pus  from      . .  . .  408 

aufemia  in        . .  . .  408 

"  anchovy-paste  "    pus 

in       .'.          ..          . .  408 
bacteria  in  pus  from. .  408 

-  -  -  bronchitis  secondary  to  409 

bulging  of  ribs  in         . .  409 

chest     measurement 

increased  on  affected 
side  in           . .          . .  409 
common  site  of           .  .  408 

-  -  -  diagnosis  from  malaria 

369,  408 

-  -  -  difficulty    of    diagnosis 

in  chronic  cases       . .  409 

-  -  -  dome-shaped     area     of 

dullness  above  liver  in  409 
emaciation  in  . .          . .  369 

-  -  -  empyema  secondary  to  409 
extension  upwards  be- 
tween layers  of  coron- 
ary ligament           .  .  400 

-  -  -  fluctuating   swelling   in 

epigastrium  in         . .  369 

fluctuation   excessively 

rare  in          . .          . .  409 
gangrene  of  lung  secon- 
dary to         . .          . .  409 
histpry  of  dysentery  in  369 

-  -  -  ictoroid   tinge   of   con- 

junctivae in. .  . .  369 

jaundice  in       . .  . .  408 

not   common  .  .  369 

liver  enlarged  in        408,  409 

leueocytosis  absent  in  408 

mistaken  lor  recurrent 

attacks   of    influenza  408 
obliteration     of     inter- 
costal spaces  in       . .  409 

occasional  good  health 

in  spite  of     . .          . .  408 
leueocytosis  in        369,  408 

-  —  yellow  colour  of  pus 

m 408 

oedema  and  redness  over  409 

pain     in    right    hypo- 

chondrium  in  . .  369 

on  jarring  patient  in  409 

in  left  shoulder  in    . .  409 

right  shoulder  in     369,  409 

palpability        . .  . .  409 

pleurisy    secondary    to  409 

pneumonia     secondary 

to 409 

profuse  sweats  in      369,  408 

pulse  rapid  in  . .         369,  408 

pus    sterile     in     long- 
standing      . .  .  .  408 

pyrexia  in        .  .         369,  408 

rigiditj'   of  rectus  over  409 

rigors  in  .  .         369,  408 

rupture  into  lung        .  .  369 

simulating  empyema  .  .  369 

enlarged  gall-bladder  369 

severe  prostration  in. .  369 

tenderness    in    hepatic 

area  in  . .  . .  409 

thirst,  anorexia  in  febrile 

stage  of        . .  .  .  409 

tongue  dry,  furred  in  369,409 

urine  scanty  and  high- 
coloured  in  . .  . .  409 

variability  of  pain  in. .  409 

vomiting  in      .  .  .  .  369 

wasting  in        . .  . .  408 

.r-rays  in  diagnosis  of. .  409 


Abscess,  hepatic,  contd. 

upward    enlargement    of 

liver  in. .         . .          . .  406 

value  of  leucocyte  count  in 

diagnosis  of  malaria  from  401 
vomiting  in         . .          . .  371 

-  -  wasting  with       . .          . .  69 

-  iliac,  diagnosis   from  psoas 

abscess      . .          . .          . .  739 

limping  gait  in  . .          .  .  739 

-  -  pyuria  from         . .         624,  632 

-  -  rupture  into  bladder  631,  632 

spinal  caries  with           . .  632 

swelling  in  iliac  fossa  in  632 

-  inguinal,  causes  of              . .  739 

-  ischiorectal,  felt  per  rectum  638 
from  foreign  body          . .  655 

-  of  kidney  (see  Abscess,  Eenal) 

-  lachrymal,  epiphora  from. .  250 

-  of  lung,  embolic      . .          . .  649 

foul  breath  in      . .          . .  99 

leueocytosis  in     . .          .  .  400 

pleurisy  with       .  .          . .  649 

rapid  breathing  from     . .  649 

signs  of  bronchitis  with  649 

simulating  empyema     .  .  119 

stinking  sputum  in        .  .  176 

-  mammary 744 

purulent    discharge    from 

nipple  in           .  .          . .  202 

tachycardia  in    .  .          . .  98 

tuberculous,    absence   of 

cocci  in  pus  in            . .  744 

fever  in. .          . .          . .  744 

diagnosis     from    carci- 
noma            . .          . .  744 

enlarged  axillary  gland 

in 744 

long  duration  of         . .  744 

microscopic  section   of 

wall  in  diagnosis  of  744 
paui  slight  in  . .          . .  744 

-  mastoid,  discharge  through 

auditory  meatus             . .  470 

from  otitis  media           .  .  98 

pain  in  the  ear  from       . .  230 

tachycardia  in     . .          .  .  98 

-  mediastinal  (see  Mediastinitis, 

AcuteJ 

-  miliary  in  new-born           . .  601 
of  the  spine    . .          . .  785 

-  myocardial  .  .          .  .          .  .  241 

-  omental,    from    perforative 

gastric  ulcer        . .          . .  724 

-  orbital,  producing  diplopia  200 

-  ovarian,  pyrexia  due  to    . .  621 

-  parametric,  felt  per  rectum  634 
femoral  swelling  from    . .  738 

-  pelvic,  acute  onset  of        . .  760 

bearing-down  pain  in     . .  474 

bulging     into     posterior 

fornix 76 

into  rectum     . .          .  .  760 

diagnosis  from  cellulitis  760 

fixation  of  uterus  by     . .  760 

hfematuria  from            305,  313 

in  hip  disease      .  .          .  .  739 

intraperitoneal    . .          . .  760 

mucus  per  rectum  in      . .  474 

pelvic  swelling  due  to  757,  760 

from     puerperal      septic 

infections         . .          . .  760 

pus  in  stools  from           . .  601 

pyuria  from         .  .         624,  632 

rupture  into  bladder 

624,  631,  632 
into  rectum     .  .          . .  760 

-  -  due  to  salpingo-oophoritis  760 

septicoemia  from            . .  614 

signs  of  local  peritonitis  in  760 

tenderness    in    the    back 

from      . .          . .         785,  786 

-  pericolitic,  swelling  in  right 

lumbar  region  from       . .  727 


Abscess,  pelvic,  contd. 

-  perigastric,    inflammation 

round  umbilicus  with     . .     716 
pus  in  the  stools  from  . .     601 

-  perinephric  . .        . .     499 
abscess  of  liver  from  ex- 
tension from    . .  . .     408 

acute  general  sj'mptoms  in  392 

-  -  diagnosis  from  renal  tu- 

mour    . .  . .  . .     391 

fluctuation  in     . .  . .     392 

oedema  of  skin  over       .  .     392 

pain  in      . .  . .  . .     392 

the     left     hypochon- 

drium  in      . .  . .     499 

lumbar  region  in        . .     500 

right  hypochondrium  in    500 

prominence  in  loin  in    391,  392 

pus    in    the    stools    from 

rupture  of        . .  . .     601 

recurring  rigors  in        . .     648 

renal  tumour  in  . .  . .     500 

-  -  temperature  in     . .  . .     392 
tenclerness    in     the      back 

from      . .  .  .         785,  786 
thickening  of  skin  over. .     392 

-  periosteal  (see  Abscess  of  Bone) 

-  peru-ectal,   acute  peritonitis 

from  . .  . .  . .       55 

-  perl-urethral,    oedema    and 

fluctuation  in  . .  . .     767 

scrotal  swelling  due  to  . .     767 

tenderness  in       . .  . .     767 

urinary  flstula  from       . .     442 

-  popliteal : 

communicated  pulsation  in  762 

flexion  of  knee  in  . .     762 

from  necrosis  of  femur   .  .     Y62 

painful  swelling  due  to  761,  762 

raising  of  pulse  and  tem- 
perature in      . .  .  .     732 

suppurating  lymph  glands     762 

from  tuberculous  knee  . .     762 

-  post-pharyngeal,      age-inci- 

dence of  . .         .  .        673,  707 
digital  diagnosis  of         . .     707 

-  -  dysphagia  from  . .  .  .     225 

obstruction  to  larynx  by      710 

orthopnoea  from  . .     465 

stertor  from        . .  .  .     707 

stridor  from        . .  . .     710 

-  prostatic      510 

acute  peritonitis  from  .  .       55 

difficulty  of  micturition  in 

511,  631 

-  -  felt  per  rectum       632,  638,  678 

frequency  of  micturition  in  511 

gonorrhceal  . .  . .     631 

hsematuria  due  to  . .     632 

from  instrumentation   631,  678 

-  -  pain  in  penis  510,  511,  513,  515 

perineum  in     .  .  . .     516 

painful  erections  with    . .     515 

perineal  sinus  from        . .     678 

ft-om  posterior  urethi'itis       678 

prostate  felt  per   rectum 

to  be  inflamed  in        . .     678 

from  prostatic  calculus  . .     632 

pyrexia  with        . .         207,  511 

pyuria  from  rupture  of  624,  632 

recent  urethral  infection  in  678 

retention  of  urine  in     207,  631 

-  -  rigors  from  207,  631,  648 

-  -  rupture  into  bladder      631,  632 

rectum  . .         631,  632 

urethra  .  .      631,  632 

septic  arthritis  from       .  .   .375 

sequela  of  gonorrhoea     . .     515 

septic  urethritis  .  .     515 

soft  area  in  enlarged  in- 
flamed gland  on  rectal 
examination  in  . .     511 

fluctuating  area  with.  .     207 

tuberculous  . .  . .     632 


854                    ABSCESS,  PROSTATIC— ACHOLURIC 

JA  UN  DICE 

Abscess,  prostatic,  conid. 

Abscess,  splenic,  conld. 

Abscess,  subphrenic,  contd. 

urethral  passage  of  faeces 

peritonitis  from  . . 

644 

simtilating  empyema 

119 

from 

264 

-  subcutaneous 

400 

hepatic  abscess 

723 

from  urethritis     . .        631 

678 

in  pyaemia 

649 

hydropnenmothorax  . . 

712 

Teaereal   infection 

631 

-  subdiaphragmatic  (see   Ab- 

 pneumothorax 

721 

-  psoas,  anaemia  in             

39 

scess,  Subphrenic^ 

skodaic  resonance  due  to 

667 

causing  swelling   in  Uiac 

-  submammary,  from  tubercu- 

 from  splenic  lesions 

720 

fossa 

733 

losis  of  ribs 

744 

succussion  sounds  in 

711 

diagnosis    from    femoral 

post-typhoidal  periostitis 

from  suppuration  in  liver 

720 

hernia   . . 

739 

of  ribs  . . 

744 

swelling  of  chest  wall  from 

194 

iliac  abscess     . . 

739 

-  submaxillary            . .        419, 

744 

tenderness  in  back  from 

7S6 

dullness  on  prarcussion  over 

739 

-  sub-periosteal  (see  Abscess  of 

of  epigastrium  from    . . 

720 

extending      under     Pon- 

Bone) 

hypochondrium  from  . . 

720 

part's  ligament 

733 

-  subphrenic : 

in  the  spine  from 

785 

in  Scarpa's  triangle    . . 

733 

abdominal  swelling  from 

715 

tympanitic  note  over     . . 

501 

femoral  spelling  due  to . . 

733 

not  moving  with  res- 

 ar-rays  in  diasnosina 

fluctuation  in       . .        733, 

739 

piration  in 

501 

501,  578,  712, 

721 

impulse   on   coughing   in 

aficecting  umbilicns 

716 

-  testicular 

732,  733, 

7.?  9 

air  in 

712 

acute  pain  in  testicle  from 

680 

kyphosis  with 

733 

apparent  upward   exten- 

 aiiection    of    epididymis 

lardaceous  disease  from . . 

414 

sion  of  Uver  dullness  in 

406 

first  in  urethral  cases 

080 

pointing  over  vertebra . . 

785 

from  appendicitis  119,  720, 

721 

diaPTirBis  frnin  onmrna 

680 

position  external  to  femo- 

 E.  coli  causing  gas  in 

711 

tuberculosis  of  t^estis  . . 

680 

ral  vessels 

739 

bulging  of  epigastrium  from 

720 

due  to  epididymo-orchitis 

518 

pus    in    the   stools    from 

hypochondrium  from. . 

720 

gonorrhoeal 

680 

rupture  of 

601 

from  carcinoma  of  colon 

578 

haematogenous     . . 

680 

pyuria  from  rupture  into 

of  duodenum  . . 

578 

from  instrumentation     . . 

680 

bladder             . .        624, 

632 

of  stomach 

578 

metastatic 

680 

reducibility 

739 

causing  pleurisy . . 

122 

in  mumps 

680 

rigidity  of  spine  in        733, 

739 

coin-sound  on  percussion 

pyrexia  and  rigois  in 

680 

rupture  into  bladder    631, 

632 

over 

501 

in  scarlet  fever    . . 

680 

ureter    . . 

633 

commoner  on  left  side    . . 

721 

scrotal  sinus  from 

680 

simulated    by    distended 

communicating  with  duo- 

 sores  from       . .         679 

680 

ilio-psoas  bursa, 

734 

denal  or  gastric  ulcer 

712 

swellin<^  of  testis  in 

518 

femoral  hernia 

733 

with  duodenum 

711 

from  torsio  testis 

680 

saphena  varLx. . 

733 

with  stomach  . . 

711 

in  typhoid  fever  . . 

680 

in  spinal  caries            564, 

632, 

compressing  lung    324,667, 

721 

from  urethritis    . .         518, 

679 

739, 

785 

constitutional  disturbances 

720 

—  thyroid,  in  pyaemia 

792 

swelling  of  chest  wall  from 

194 

diaphragm  pushed  up  by 

721 

-  urethral,  pain  in  perinerun  in 

516 

iliac  fossa 

632 

displacing  heart  upwarcfc 

Absinthe,  coma  due  to 

137 

inguinal  region           632, 

739 

712, 

721 

-  palpitation  due  to..        525, 

527 

right  Uiac  fossa  from. . 

730 

due  to  duodenal  ulcer  528, 

720 

-  tremor  from            . .         795, 

797 

tenderness  of  spine  in   739, 

785 

721 

Academy  headache    . . 

329 

-  -  tuberculous 

564 

empyema  from  . . 

120 

Acanthosis      nigricans,      sore 

-  rectal,  characters  of,  as  felt 

complicating    . . 

720 

fingers  from 

266 

per  rectum 

635 

exploring  needle  only  to 

-  relation  to  prurigo  f  erox    . . 

531 

foreign  body  causing 

635 

be    used    immediately 

Acarus,  pruritus  caused  by    . . 

588 

rectal  tenderness  from  . . 

635 

before  operation  in    . . 

501 

Accentuated  heart  soimds  (see 

-  renal,  from  infarct. . 

625 

from  FaUopian  tube  lesions 

720 

Heart  Sounds.  Accentuated^ 

infective  peritonitis  from 

644 

fibroid  lung  and  bronchi- 

Accessorius,  nerve  supply  of. . 

543 

injury  to  kidney 

625 

ecta.«is  from 

324 

Accessory  rib  (see  Pdb,  Cervical, 

-  -  leucocytosB  with 

400 

foul  taste  from    . . 

774 

-  sinus    dilatation,    unilateral 

palpable  tumour  due  to 

391 

gas-containing501,578, 720 

,721 

exophthalmos  in            254, 

255 

polyturia  in 

626 

from  gastric  ulcer  119,  721, 

578. 

inflammarioTi,  polvpi  with 

255 

pyelonephritis     . . 

625 

720 

suppuration,      cavernous 

pyuria  in..          ..         623, 

625 

general  account  of       501, 

720 

sinus  thrombosis  due  to 

253 

from  renal  calculus 

309 

history  of  appendicitis  in 

501 

earache  from    . . 

230 

tuberculous 

394 

duodenal  ulcer  in 

501 

Accommodation,  paralysis  of. 

urine  normal  in  localized 

gastric  ulcer  in 

501 

after  diphtheria  . . 

77 

cortical 

626 

due  to  hydatid  cyst 

721 

in  disseminated  sclerosis 

838 

-  retropharyngeal 

673 

iTiiTnnhiliTincr  diaphraxJin 

721 

ACCOUCHEUR'S  HAND  {Fig.  1)    3 

cyanosis  from      . . 

185 

from  intestinal  obstruction 

721 

in  tetany  . . 

17S 

diagnosis  of 

465 

from  kidney  lesions 

720 

Acetabulum,'  osteo-arthritic . . 

784 

by  digital  examination 

466 

laparotomy  in  diagnosis  of 

501 

Acetic  acid  in  gastric  juice    . . 

333 

in  spinal  caries 

673 

leucocytosis  with  501,  720 

721 

test  for  albuminuria 

5 

extreme  dyspnoea  from . . 

642 

liver  not  pushed  down  in 

501 

phosphaturia  . .         20S 

574 

laryngeal  obstruction  from 

642 

onset  of  pain  in 

501 

ACETONURIA,  CAUSES  OF.. 

4 

orthopnoea  in 

465 

opening  into  pericardium 

711 

-  in   cyclical    vomiting    of 

retraction  of  head    from 

642 

pain    in    left   hypochon- 

infanr.s      . .           . .         426, 

813 

-  -  simulating  meningitis     .  . 

642 

drium  in 

499 

-  iQ  diabetes  . .          . .         292 

583 

sore  throat  from 

670 

right  hypochondrium  in 

501 

Achillis-jerk  (see  Ankle-jerk) 

tenderness  in    the    back 

from  pancreatic  lesions. . 

720 

-  in  locomotor  ataxy . . 

562 

from 

786 

physical  signs  of. .        720, 

721 

Aching   in   loin  from  vesical 

the  spine  in      . . 

785 

pleurisy  above     . .         122 

501 

carcinoma  (and  see  Pain 

-  scrotal         

767 

secondary  to    . .         720 

721 

in  Loin) 

620 

fistula  from 

679 

pneumothorax  from   ..577 

578 

carcinoma  coli     . . 

393 

from  peri-urethral  abscess 

pyrexia  with          501,  720 

721 

hypernephroma   . . 

.S95 

679 

,  767 

rapid  pulse  with . .         720 

721 

kidney  tumour    . .         307 

395 

due  to  stricture   . . 

679 

rigors  with           . .         648 

,721 

polycystic  kidneys 

396 

tuberculous  epididymis . . 

767 

rupture  into  lung 

774 

pyelitis     . . 

625 

due  to  urethritis . . 

679 

septic  aspect  with 

720 

renal  calculus 

627 

-  spinal,   tenderness  in   back 

sex  incidence  of  . . 

721 

tuberculosis     . . 

626 

from 

786 

shifting  of  level  of  fluid  in 

721 

-  in  testis  in  tuberculous  disease  519 

-  splenic,  exceedingly  rare  . . 

C92 

shortnes  of  breath  with 

"721 

Acholiuic  jaundice     . .         361 

372 

A  CHONDROPLA  SI  A  —A  DOLESCENCE 


85: 


Achondroplasia,  bowed  legs  in    212 

-  bridge  of  nose  depressed  in     212 

-  bulging  forliead  in  . .  . .     212 

-  distinguished  from  rickets .  .     214 

-  dwarfism  due  to  (Fiff.  64)         212 

-  enlargement  of  bones  in    . .     214 

-  lordosis  in     .  .  .  .  .  .      212 

-  prominent  joints  in  . .     212 

-  shape  of  lingers  in  .  .  .  .      212 

-  sliort  lower  limbs  character- 

istic in      .  .  . .        212,  214 

-  small  contracted  pelvis  in. .     212 

-  strong  muscular  power  in. .  212 
Achorion  schonleinii  in  favus  270 
Achylia  with  diarrhoea  .  .     196 

-  in  functional  dyspepsia  .  .  354 
Acid  dyspepsia  Csee  Dyspepsia) 

-  faeces  in  pancreatitis  .  .     117 
Acidity  of  urine,  effect  of  phos- 
phates in          .  .  . .     572 

in  general  bacterial  affec- 
tions . .  .  .       83 
Acidosis            . .          .  .  .  .         4 

-  in  cyclical  vomiting  of  chil- 

dren .  .  .  .        420,  843 

Acids,  strong,  gangrene  from        282 

-  cesophageal  stenosis  from  . .     222 

-  reduced  total,  in  gastritis  . .     352 

-  sore  throat  from     . .  . .     671 

-  of  stomach  contents,  test  for     355 

-  stomatitis  from  .  .  .  .  815 
Acne  rosacea  in  alcoholism 

59,  368,  797 

association  of  phlyctenular 

ulceration  of  cornea  with     806 

causes  of  .  .  . .  .  .     268 

in  cirrhosis  of  liver         . .     368 

diagnosis  from  A.  vulgaris 

268,  531 

granulosis  rubra  nasi . .     714 

lupus  erythematosus  . .     268 

seborrhceic  eczema     . .     268 

tertiary  syphilides      . .     268 

-■  -  leprous  nodules  simulating    450 

permanent  flushing  in    . .     268 

skin  changes  in   . .  . .     26S 

-  vulgaris,  absence  of  cachexia 

with 604 

-  -  age-incidence  of  .  .         531,  603 

-  -  in  bromidism  .  .  . .  112 
chronic  nature  of  eruption     604 

-  -  comedones  in  . .  604,  609 

convex  shape  of  pustule  in     601 

diagnosis  from    acne 

rosacea  .  .         268,  531 

from    large    acuminate 

syphilide       . .  . .     604 

drug  eruptions  .  .     603 

pustular  syphilides     .  .     603 

small-pox         . .        603,  609 

sycosis  vulgaris  . .     603 

-  -  distribution  of        531,  604,  609 

in  iodism  .  .  . .  . .     112 

the  lesions  of       .  .  .  .     530 

papules  of  .  .         528,  530 

pustules  in  .  .  . .     603 

septicaemia  from. .  . .     698 

simulated    by    xanthoma 

diabeticorum   . .  .  .     805 

tendernessof  scalp  from  780,781 

spine  from        . .  . .     784 

Aconite,  ptyalism  due  to  . .  590 
Acromegaly  (Fig.  88) . .        . .     753 

-  abnormal    growth    of    sub- 

cutaneous tissue  in         . .     262 

-  amenorrhoea  in        . .  .  .       23 

-  bony  changes  of      . .  .  .     263 

-  bull^  tongue  in      . .  . .     263 

-  changes  in  face  in  (Fig.  88) 

262,  263,  391,  749 

-  diagnosis  from  leontiasis  ossea  749 

-  -  osteo-arthropathy  . .     391 

-  enlarged  bones  of  liands,  feet, 

and  head  m  262, 391,  585, 749, 753 


Acromegaly,  conld. 

-  enlarged  fingers  in  . .  . .     128 

lower  jaw  in         .  .263,  749,  753 

pituitary  body  in    335,  585,  749 

ridges  of  insertion  of  mus- 
cles and  ligaments  in . .     753 

superciliary  ridges  in  749,  753 

-  headaclie  in..  ..  ..     749 

hemianopia  in  (Fig.  102)  335,  749 

-  irritability  in  . .  . .     300 

-  muscular  debility  in  . .     749 

-  periosteal  thickening  in     . .     753 

-  polyuria  in  .  .        583,  585 

-  teeth  in        263 

-  .r-rays  in  diagnosis  of         . .     585 
Acroparaesthesia : 

-  age  and  sex  incidence  of    . .     493 

-  in  alcoholism  . .  .  .     493 

-  becoming  worse  in  bed       . .     493 

-  definition  of . .  ..  ..     493 

-  of  hands  and  feet    . .  . .     493 

-  occupation  incidence  of     . .     493 

-  in  paroxysmal  tachycardia     772 
Actinomyces  (Plate  XII,  Fig.  S, 

p.  696) 810 

-  characters  of  pus  due  to    .  .      786 

-  Gram-staining         .  .  . .     736 

-  microscopical  recognition  of     736 

-  relation  to  barley    . .  . .     705 

cotton       . .  .  .  . .     705 

Actinomycosis  bleeding  gums 

from         .  .  . .  86,  88 

-  of  cfecum  and  appendix    . .     736 

-  distinction  from  mycetoma      810 

-  hsemoptysis  from    . .  . .     705 

-  of  jaw  .  .  . .  87,  748,  810 

with    carious  teeth        . .     748 

cellulitis  of  neck  in        . .     748 

-  -  diagnosis  from  abscess  .  .     748 

-  -  sinuses  from         .  .  .  .     748 

-  liver,  rarity  of         . .  . .     415 

local  enlargement  from  .  .     415 

ray    fungus    in    pus    in 

(PtoeA'//,.S'i(7..S',p.696)  415 

"  sulphur  granules  "  in  415,  748 

trabeculate  abscess  from      415 

-  of  lung         322 

haemoptysis  in       . .     317,  705 

-  mycelium  in  pus  in. .         415,  748 

-  simulating  spinal  caries     . .     786 

-  sites  of  election  in  . .  .  .     810 

-  in  tailors  and  seamstresses      705 
"  Acute  abdomen  "   in  acute 

pancreatitis  . .  . .     431 

Acute  nephritis  (see   Bright's 
Disease  Acute ;  and  Nephritis) 

-  poliomyelitis  (see  Poliomyelitis, 

Acute) 

-  rheumatism  (see  Eheumatism) 

-  yellow  atrophy  of  Uver  (see 

Liver,  Acute  Yellow  Atrophy 
of) 
Adamson,    re    Jacquet's    ery- 
thema      . .  . .  . .     446 

-  re  pemphigus  neonatorum        446 

-  re  seborrhceic  dermatitis  of 

infants      . .  . .  .  .     446 

Addison's  ansemia  (see  Pernicious 
Anaemia) 

-  disease,  amenorrhoea  in    . .       23 
arsenical  poisoning  simu- 
lating   . .  . .  . .       38 

-  -  asthenia  in  38,  843,  849 

-  -  bronzing  of  skin  in        .  .     574 
cancer  of  one  capsule  not 

causing. .  .  .  . .      307 

coma  in    . .  . .  . .     136 

eosinophilia  in    .  .  38,  248 

gastric  attacks  in  . .     849 

headache  in         . .  . .     329 

hypothermia  in  . .  . .     345 

loss  of  weight  in  . .     849 

low  blood-pressure  in 

96,  329,  843,  894 


Addison's  disease,  conld. 

not  produced  by  uni- 
lateral suprarenal  disease  690 

periodic  acute  diarriioea  in  196 

pigmentation  of  skin  and 

buccal  mucosa  in     843,  849 

simulated  by  exophthal- 
mic goitre        . .          .  .  792 

-  -  syncope  in           . .          38,  849 

vomiting  in         . .           38,  843 

Adductor  brevis,  nerve  supply  542 

-  femoris,  spinal  nerve  root 

supplying  . .          . .          . .  543 

-  longus,  nerve  supply  of     . .  542 
tendon,  ossification  of  . .  763 

-  magnus,  nerve  supply  of  . .  542 

-  obliquus      hallucis,      nerve 

supply  of . .          . .          . .  542 

poUicis,  nerve  supply  of . .  550 

paralysis  of          . .          .  .  127 

-  transversus    halluois,  nerve 

supply  of . .          . .          . .  542 

poUicis,  nerve  supply  of  550 

Adem'n  bases,  uric  acid  from. .  817 
Adenitis,  acute   cervical    (see 

I-ymphatic  Glands,  Cervical) 

Adenoids,  anosmia  from       . .  668 

-  a  cause  of  deafness.  .          .  .  190 

-  cure  of  enuresis  by  removal  of  248 

-  with  enlarged  tonsils          .  .  670 

-  epistaxis  due  to        250,  251,  252 

-  headache  from        .  .          . .  327 

-  insomnia  from         . .          .  .  357 

-  loss  of  taste  due  to  774,  775 

-  mouth-breathing  causing  .  .  072 

-  night  terrors  due  to  357,  448 

-  obstruction  to  nose  by      .  .  668 

-  otitis  media  from  . .          . .  230 

-  removal  of,  palate  paralysis 

after          640 

-  rhinitis  from             .  .          .  .  204 

-  snoring  due  to        .  .          . .  669 
stertor  from            . .          . .  707 

Adenoma  of  liver  (see  Liver, 
Adenoma  of) 

-  of  prostate    (see    Prostate, 

Adenoma  of) 

Adherent  pericardium  (see  Peri- 
cardium, Adherent) 

Adhesions,  appendicular,  pain 

in  right  iliac  fossa  from. .  501 

-  intestinal,  in  peritonitis    . .  5G 

-  perigastric,      influence      of 

movement  on  pains  due  to  486 

-  peritoneal,    causing    consti- 

pation      .  .          . .          . .  147 

from  gall-stones . .          . .  280 

-  from  hernia          . .          .  .  152 

-  -  intestinal  obstruction  from 

151,  152 

-  jaundice  from     . .          . .  361 
loculation  of  ascites  by . .  717 

-  pleural,  pain  and  tenderness 

in  the  back  from       . .  789 

pneumothorax     rendered 

partial  by        . .          . .  577 

-  in  shoulder  joint  simulating 

circumflex  nerve  paraly.sis  552 
Adiposis  dolorosa,  age  and  sex 

incidence  of         . .          . .  478 

alcoholism  causing         .  .  455 

congenital  syphilis  causing  455 

extreme  fatness  in  453,  454,  455 

-  -  hyperaesthesia  in            .  .  455 

neuralgic  pam  in  arm  in  492 

pain  in  the  chest  from  . .  477 

parts  affected  in . .          . .  455 

-  -  symmetrical    painful    de- 

posits of  fat  in  .  .  478 
thyroid   treatment  of  no 

effect  in            . .          . .  455 

Adolescence,  albuminuria  of  19 

-  erythema  nodosum  in        . .  450 

-  rounded  spine  of     . .          . .  183 


ADRENAL  RESTS— ALBUMINURIA 


Adrenal  rests 

395 

Age  incidence  of  disease,  contd. 

Age  incidence  of  disease,  contd. 

causing  nephroma 

307 

Henoch's  purpura 

tuberculides 

603 

in  pathogenesis  of  maUg- 

90,  380,  600, 

846 

tuberculous  arthritis 

385 

nant  renal  tumours    . . 

395 

hereditary  optic  atrophy 

838 

cystitis.  .          .  .         312, 

628 

in  iiidney,  hypernephroma 

of  high  blood-pressure  . . 

96 

dactyhtis 

751 

from 

690 

Hirschsprung's  disease  152 

718 

meningitis 

642 

AdrenaUn  in  cystoscopy 

630 

Huntington's  chorea 

156 

peritonitis        . .          56, 

691 

-  irrigation  of  bladder  with  . . 

307 

hysteria    . . 

710 

ulcer  of  tongue 

814 

^gophony  in  pleural  effusion 

ichthyosis 

530 

umbilical  hernia 

524 

193, 

332 

—  —  insomnia  . .          . .        356, 

359 

undue  aortic  pulsation  .  . 

592 

Aerophagia 

267 

intermittent  hydrarthrosis 

387 

urticaria  . . 

531 

Africa,  bUharzia  in     . . 

313 

intussusception  . .        636, 

736 

valvular  heart  disease  . . 

507 

"  After-pains  "  of  labour 

509 

iodide  and  bromide  erup- 

 vesical  calculus  . .        513, 

628 

Agar-agar  in  constipation     . . 

143 

tions 

603 

von  Jaksch's  disease     . . 

694 

Age  incidence  of  disease  : 

jaundice   . .          .  .362,  363 

365 

xerodermia  pigmentosum 

804 

of  acne     . .            268,  531, 

603 

joint  pains  of  acute  rheu- 

- in  diagnosis  of  systolic  bruits 

103 

acne  rosacea 

268 

matism  . . 

507 

-  influence  on  heart  sounds . . 

1 

acquired  spastic  paralysis 

155 

keratomalacia 

807 

on  child-bearing. . 

707 

acroparesthesia  . . 

493 

kraurosis  vulvae.  . 

770 

on  size  of  pupU    . . 

594 

acute   intestinal  obstruc- 

 leukoplakia  of  vulva     .  . 

770 

Ageustia  (see  Taste,  Loss  of) . . 

774 

tion 

151 

hchen  scrofulosorum 

529 

Agglutination    reaction     (sea 

mastitis 

743 

Little's  disease   . . 

154 

Serum     Reaction ;      and 

yellow  atrophy 

302 

lupas  erythema to.~us   449, 

781 

TTidal's  Test) 

adiposis  dolorosa 

478 

vulgaris               449,  808, 

812 

Agrapllia,  definition  of 

685 

aneurysm. .          . .        223, 

786 

lymphangioma     circum- 

- hemiplegia  with 

685 

angina  pectoris    . . 

482 

scriptum 

833 

-  lesions  producing    . . 

685 

anorexia  nervosa 

849 

macular  choroiditis 

462 

Ague  ("see  Malaria)    . .          34, 

371 

aortic  aneurysm 

538 

mediastinitis 

484 

"  Ague-cake  "  spleen. . 

693 

lesions,  various 

107 

mitral  disease     . .         103 

110 

Air-swallowing 

267 

ateleiosis  . . 

217 

myocardial  affections      61 

103 

-  borborygmi  due  to. . 

97 

bacilluria 

615 

myxoedema 

460 

Alar  chest  in  phthisis . . 

191 

baldness   .  . 

84 

new  growths  of  testis    . . 

766 

Albinism,  diagnosis  from  leuco- 

bath  pruritus 

588 

normal        Cheyne-Stokes 

dermia 

575 

bladder  tuberculosis     312, 

628 

breathing 

124 

-  hemeralopia  in 

841 

bromide  eruption 

603 

odontomata 

749 

-  nystagmus  in 

453 

bronchopneumonia 

321 

osteitis  deformans 

753 

-  photophobia  in 

574 

carcinoma  of  bladder  311, 

514, 

osteo-arthritl? 

214 

Albumin    in  serous  discharge 

630 

osteogenesis  imperfecta. . 

214 

in  chronic  otitis  media . . 

468 

bowel    .  .          . .   91, 146 

150 

osteomalacia 

214 

ALBUMINURIA 

5 

breast    .  . 

745 

oxaluria    .  . 

471 

-  from  abdominal  aneurysm 

8 

pancreas 

266 

Paget's  disease   . . 

802 

-  accidental     .  . 

19 

penis 

676 

pain  in  herpes     . . 

496 

-  with  albumosuria    . . 

20 

stomach             .  .299,  351 

,713 

pancreatitis          . .         153 

266 

-  from  arteriosclerosis 

1,8 

thyroid  gland  .  . 

791 

parenchymatous  goitre. . 

791 

-  withbacUluria  83,  84,  576, 615 

,848 

tongue  . . 

812 

peliosis  "rheumatica       380 

600 

-  boiling  test  for,  nucleoproteid 

urethra . . 

209 

periosteal  sarcoma 

756 

fallacy  of           . .          .  .471 

472 

cerebral  embolism 

173 

Pinguecula 

256 

phosphate  faUacy  of  . . 

574 

hsemorrhage    . .         138, 

173 

polyuria  of  diabetes 

584 

-  from  burns  and  scalds 

16 

cervical  caries 

708 

popUteal  exostosis 

763 

-  in  cerebral  haemorrhage 

chancre  of  the  tongue  . . 

813 

post-pharyngeal  abscess 

98,  138,  337, 

503 

chloroma 

599 

673, 

707 

-  cerebrospinal  fluid  in  menin- 

 chorea 

156 

priapism 

585 

gitis           

643 

chronic  abscess  of  bone . . 

752 

progressive  muscular  atro- 

- chronic  alcoholism. . 

16 

cirrhosLs    . . 

410 

phy       

165 

bronchitis     and     emphy- 

 coh  bacilluria 

82 

prostatic  enlargement   . . 

440 

sema     . . 

246 

congen.  syphiUtic  deafness 

190 

prurigo  ferox 

532 

laryngeal  paralysis 

539 

coughs,  various  . . 

176 

psoriasis    .  . 

533 

peritonitis 

56 

cystic  disease  of  kidneys 

310 

pyometra.  . 

211 

pyuria 

623 

epididymis 

767 

rectal  carcinoma 

636 

-  with  chyluria 

126 

dermatitis  herpetiformis 

114 

polypi  and  papillomata 

93 

-  in  cirrhosis  of  the  liver 

16 

diabetes    . . 

292 

renal  tuberculosis 

309 

-  contracted  granular  kidney 

14 

diverticulitis 

152 

retrobulbar  neuritis 

838 

-  after  convulsions     . .        169, 

172 

embryoma  of  kidney     . . 

307 

rheumatic  nodules 

452 

-  from  corrosive  poisoning    . . 

297 

endocarditis 

237 

purpura            . .         380 

,600 

-  cystic  kidneys         . .          .  .  8 

,  390 

epistaxis  . . 

251 

tonsUhtls 

671 

-  in  cystitis 

628 

erythema  nodosum 

450 

rhinoscleroma 

805 

-  diabetes  mellitus     . . 

16 

exophthalmic  goitre    772, 

792 

rickets 

214 

-  diphtheritic 

13 

faecal  tumours     . . 

692 

rodent  ulcer 

449 

-  disproportionate      to      the 

femoral     and     inguinal 

sarcoma  of  breast 

746 

amount  of  pus  in,  in  pye- 

hernia . .          . .  733,  740 

,  742 

jaw        

748 

litis  and  pyelonephritis.  . 

628 

fibro-adenoma  of  breast 

744 

testis 

520 

-  in  eclampsia 

647 

filariasis    . . 

126 

scrofula    . . 

808 

-  from  enlarged  prostate          8,  16 

fragilitas  ossium 

269 

scurvy -rickets 

753 

-  with  epistaxis 

251 

Friedreich's  ataxy  70,  131 

164 

spinal  caries 

785 

-  in  exophthalmic  goitre 

16 

functional  aphonia 

538 

splenomegalic  cirrhosis.  . 

639 

-  febrile 

17 

gaU-stones 

135 

polycythcemia 

581 

-  and  Fehling's  test   .  . 

290 

gastralgia .  . 

485 

spondylitis  deformans  . . 

787 

-  in  fungating  endocarditis  . . 

237 

gastric  ulcer 

298 

Stokes-Adams'  disease  . . 

172 

-  gonorrhoea    . . 

16 

glaucoma . . 

257 

subperiosteal  abscess     .  . 

750 

-  gout  

16 

gout          

381 

sjTjhDis  of  aortic  valve.  . 

237 

-  haematuria    .  . 

306 

Hanot's  cirrhosis          369 

410 

syphilitic  epiphysitis     . . 

752 

-  ^ith  heart  failure    . . 

61 

heart  failure        . .             61,  62 

pseudo-paralysis 

387 

-  high  blood-pressure          .252 

526 

hsematuria 

306 

testicular  atrophy 

78 

-  from  invasion  of  kidney  by 

hemiplegia           . .         337 

338 

trigeminal  neuralgia 

495 

malignant  growth  of  colon 

393 

A  LB  UMIN  URIA—A  MENORRHCEA . 


857 


Albuminuria,  contd. 

-  lardaceous  disease  39, 197, 414,  696 

-  lead  poisoning        . .     16,  38,  77 

-  lympliadenoma        . .  . .       17 

-  meduUaiy  softening  . .     343 

-  mercurialism  . .  . .       16 

-  mitral  regurgitation  . .     239 

-  morphinism  .  .  .  .       16 

-  from  movable  kidney         .  .         8 

-  in  mumps     . .  . .  . .       16 

-  myocardial  affections         .  .       18 

-  nephritis  (Bright 's  Disease) 

1, 13,  63,  303,  331,  454,  466 

-  after  noctiu'nal  emission    . .       19 

-  witli  ffidema  . .  . .     457 

-  from  ovarian  cyst  .  .  . .         8 

-  pelvic  tumours 

-  physiolofiical 

effect  of  calcium  on 

polyuria  in 

-  with  pleural  effusion 

-  pneumonic   .  . 

-  polym'ia  with,  causes  of 

-  in  portal  obstruction 

-  pregnancy     . . 

-  prolonged,  cachexia  from 

-  in  pyelitis     .  . 

-  pyelonephritis 

-  rareness  in  chlorosis 

-  from  renal  calculus 
embolism  . . 

-  -  enlargement 

and  with  pus  .  . 

without  pus     . . 

tuberculosis 

tumoiu-     .  . 

-  repeated  pregnancies 

-  retinitis  in  (see  Eetinitis) 

-  with  tube-casts 

-  scarlatinal    . . 

-  in  secondary  syphilis 

-  shortness  of  breath  with 

-  slight  with  coli  bacUluria 

-  in  snake-bit 

-  from  stricture  of  the  urethra  8,  16 

-  suppui'ative  nephritis         . .     646 

-  syphilitic      . .  . .  13,  86 

-  in  thrombosis  of  inferior  vena 

cava  . .  . .  61,  825 

-  treatment  by  rosanilin       .  .     820 

-  with  tropical  abscess  of  liver     409 

-  without  tube-casts. .  ..       16 

-  with  uremia     329,  350,  464,  647 

-  froni  uterine  fibromyomata         8 
prolapse   .  .  . .  . .         8 

-  in  vasomotor  neuroses       . .       16 

-  vertigo  with  . .  .  .     829 

-  in  yellow  fever  . .  301,  373 
Albuminuric  retinitis  (see  Retinitis) 
Albumoses,  a  source  of  fallacy 

in  test  for  albumin         .  .         6 
ALBUMOSURIA    with    albu- 
minuria      . .  . .  .  .     20 

-  Bence- Jones' .  .  ..  ..21 

-  in  Bright's  disease  . .  . .  12, 20 

-  haematogeuous         . .  .  .       20 

-  in     malignant     disease     of 

bones         . .  . .  . .       21 

-  pyogenic       .  .  . .  . .       20 

-  tests  for        .  .  .  .  20,  21 
Alcoholism 

-  acne  rosacea  from  .  .         268,  797 

-  acroparaesthesia  from         . .     493 

-  active    congestion    of    liver 

from  . .  . .         371, 407 

-  acute,  Babinski's  sign  in    . .       82 
subnormal  temperatmre  in    344 

-  adiposis  dolorosa  from      .  .     455 

-  albuminuria  in        . .  . .       16 

-  amenorrhoea  from  . .  .  .       23 

-  anorexia  in  .  .        238,  243 

-  aortic  aneurysm  in  538,  564 
disease  fi-om           236,  237,  238 

-  arteriosclerosis  from  . .     238 


19 

19 

..   584 

121,  122 

13 

584 

300 

8 

115 

625 

626 

41 

:,  16 

237 

689 

15 

8 

8,  16,  310,  626 
16,  367 
16 

8 
674 
371 
101 
576 
458 


Alcoholism,  could. 

-  ataxy  from  .  . 

-  brachial  neuralgia  in 

-  in  bronzed  diabetes 

-  central  scotoma  from        836, 

-  cirrhosis  of  liver  from 

59,  300,  368,  409, 

-  colic  from     . . 

-  colom*  blindness  from     836, 

-  coma  due  to  .  .137,  344, 

-  convulsions  in         . .         169, 

-  cramps  in     .  .         . .  78,  179, 

-  delirium  from 

-  Dercum's  disease  from 

-  diarrhoea  in 

-  diminished  appetite  in 

-  disturbed     pancreatic     and 

hepatic  functions  in 

-  dwarfing  of  one  lobe  of  liver  in 

-  dyspepsia  from 

-  d.ysphagia  from 

-  enlarged  heart  in  232,  238,  243, 

-  effect  on  blood-pressure 

-  fatty  heart  from      . .         238, 

-  -  liver  from  . . 

-  fibroid  heart  due  to 

-  Hushing  in    . . 

-  furred  tremulous  tongue  in  136, 

-  and  gangrene  of  the  lung   . . 

-  gastritis  in  .  .  . .         297, 

-  general  symptom-s  of       300, 

-  hsematemesis  in      .  .         243, 

-  liEemorrhoidal  bleeding  in . . 

-  headache  in 

-  hiccough  in  . . 

-  hippus  in      .  . 

-  hypothermia  from  344, 

-  infantile  convulsions  due  to 

-  infantilism  from 

-  insomnia  in 

-  irritability  in 

-  jaundice  in  . . 

-  Korsakow's  syndrome  in  . 

-  leucopenia  in 

-  lipomatosis  from     . . 

-  and  Little's  disease 

-  loss  of  appetite  in  238, 
weight  due  to  848, 

-  medullary  degeneration  in225, 

-  moral  deterioration  from  .  . 

-  morning  vomiting  in 

238,  243,  297, 

-  myocardial  changes  from  . 

-  nerve  deafness  from 

-  obesity  due  to 

-  optic  disc  changes  from 

-  pachymeningitis  from 

-  pains  in  the  limbs  in 

-  palpitation  in  .  .         525, 

-  pancreatitis  due  to         ..116, 

-  parsesthesia  from    . . 

-  passive  vacant  aspect  in 

-  peripheral  neuritis  from 

60,  165,  285,  492,  505, 

-  pharyngitis  in 

-  polyuria  from  . .  581,  583, 

-  priapism  caused  by 

-  in  prognosis  in  pneumonia 

-  pupil  reflex  in 

-  purpura  in  . .  . .        596, 

-  restlessness  and  insomnia  in 

-  signs  of         .  .  .  .  59, 

-  simulated   by   disseminated 

sclerosis    .  . 

-  -  by  nervousness    .  . 

-  simulating  new  growth 
tuberculosis 

-  speech  lost  in 

-  tachycardia  from    . . 

-  talipes  due  to 

-  temporary  glycosuria  in 

-  tinnitus  increased  by 

-  tremor  in    136,  238,  258,  795, 

-  urethral  stricture  from     . . 


136 
837 
346 
172 
238 
195 
455 
197 
49 

292 
404 
354 
225 
245 
238 
241 
414 
238 
268 
243 
287 
352 
368 
295 
243 
328 
342 
595 
346 
170 
215 
358 
360 
243 
25 
401 
455 
154 
243 
849 
343 
797 

797 
238 
191 
849 
836 
563 
78 
527 
153 
797 


599 
136 
584 
586 
194 
594 
599 
797 
797 

565 
797 
849 
849 
682 
773 
131 
292 
793 
797 
440 


Alcoholism,  contd. 

-  venous  stigmata  from 

-  vertigo  from 

-  weakness  of  the  limits  from 
Alexia  (Word  Blindness) 
Algidity  in  malaria     . . 
Alimentary  albumosuria 

-  glycosuria,     distinguished 

from  diabetes  mellitus  . . 
Alkali  added  to  santonin,  pink 

urine  from 
Alkalies,  cachexia  from 

-  in  diabetic  coma 

-  gangrene  from 

-  CESophageal  stenosis  from . . 

-  sore  throat  from 

-  stomatitis  from 

Alkaline    faeces    in    gall-stone 
obstruction 

-  urine  with  bacteriuria 

effect  of  phosphates  in  . . 

Alkaptonuria,  alkali  test  for  290, 

-  black  urine  from    .  .        820, 

-  due  to  congenital  errors  of 

metabolism 

-  dark  colom-  of  urine  in 

-  dar-kening  of  urine  on  expo- 

sure .  .  .  .  821, 

-  ferric  chloride  test  for 

-  general  account  of  .  . 

-  homogentisic  acid  in 

-  hydroquinon^-acetic  acid  in 

-  liquor  potassae  test  for      290, 

-  ochronosis  with       . .         575, 

-  optical  inactivity  in 

-  reactions    with    Kylander's 

reagent 

-  reduction  of  Fehling's  solu- 

tion in      .  .  .  .         2 

-  relation     to     tyrosin     and 

phenylalanin  katabolism 

-  no  safranin  reaction  in 

-  silver  nitrate  test  for 

-  simulated  by  melanuria    .  . 
ALLOCHEIRIA 

-  fimctional     . . 

-  m  tabes  dorsalis 
Alloxuric  bases,  uric  acid  de- 
rived from 

ALOPECIA  (and  see  Baldness) 

-  areata 

-  -  diagnosis  from  favus 

-  -  -  ringworm  of  scalp 

tinea  decalvans 

"  exclamation    -    mark  " 

hairs  m 

relation  to  pseudopelade 

of  Brocq 

-  cicatrisata    . . 

-  from  head  injury    . . 

-  in  syphilis    . . 

Altitudes,  polycythsemia  at  high 
Alum,  extreme  thirst  due  to . . 
Alveolar  abscess  (see  Abscess) 

-  echinococcus     disease     (see 

also  Hydatid  Disease)    . . 

-  sarcoma  of  kidney  .  . 
Amaurosis  from  hcemorrhage 

-  pregnancy    . . 

-  urfemic  . .  . .         836, 
Amblyopia,  causes  of . . 

-  in  disseminated  sclerosis    . . 

-  hj'Steria 

AIVIENORRH(EA,blood  altera- 
tions and  . . 

-  causes  of 

-  in  chlorosis  . .  41, 

-  continued,  in  ectopic  gestation 

-  with  deficient  ovarian  activity 

-  double  ovarian  tumour 

429,  691, 

-  hy]Derinvolution  of  uterus. . 

-  ia  myxoedema 

-  pregnancy  . .  350,  437,  758, 


797 
827 
797 
684 
35 
20 

584 

819 
115 
137 

282 
222 
671 
815 

117 
83 

572 
822 
822 

822 
290 

822 
822 
822 
822 
822 
822 
822 
822 

822 


90,  822 

822 
822 
822 
822 
21 
22 
665 

817 

84 

84 

272 

274 

274 

244 


782 
85 
80 
450 
579 
789 


416 
395 

140 
839 
839 
836 
800 
800 

24 

22 

303 

760 

707 

759 
706 
430 
759 


AMERICA,    YELLOW   FEVER   IN— ANESTHETICS 


America,  yellow  fever  in 

372 

Aruemia,  corvtd. 

Ancemia,  coritd. 

Ajnido-oxrbutjric  acid  in  urine 

4 

—  catising  amenorrhoea 

23 

-  sterility  due  to        . . 

706 

Ammonia"  anosmia  from 

669 

-  in  cerebral  embolism 

138 

-  in  StOl's  disease     . . 

4,  8 

-  co-efficient     in      urine      in 

-  chlorotic,  ascites  in 

64 

-  suggesting  empyema  in  broncho- 

phosphorus poisoning    . . 

373 

in  tape-worm  infection  568, 

570 

pneumonia  of  children  . . 

39 

-  corrza  from.  . 

203 

-  in  chronic  lead  poisoning  . . 

507 

-  from  syphilis           .  .         459 

604 

-  olfactory  neuritis  from 

669 

-  colour  index  in 

20 

-  tachycardia  from   .  . 

772 

-  poisoning  by 

674 

—  cord  changes  from. . 

667 

-  with  thymic  infantOism    . . 

215 

-  sore  throat  from     .  . 

671 

-  delirium  from 

195 

-  due  to  toxins 

36 

-  varying  amounts  of,  in  urine 

574 

-  diazo-reaction  in    . . 

198 

-  tropical 

115 

Ammonio-maprnesium     phos- 

-  dilatation  of  lieart  in 

528 

-  in  tropical  abscess  of  hver 

408 

pihate  ia  urine  (Fig.  155) 

573 

-  displaced  cardiac  impulse  in 

330 

-  tuberculosis . .          . .         459 

616 

Ammonium  sulphide,  reduction 

-  earache  from 

230 

-  tuberculous  peritonitis 

719 

of  oxyhsemoglobin  by  . . 

314 

-  enlarsed  spleen  with,  in  kala- 

-  -with  undue  aortic  pulsation 

592 

test  in  carbon  monoxide 

azar  (Plate  XII,  Fig.  H, 

-  uterine  haemorrhage             36 

42S 

poisoning 

138 

p.   696)     

34 

-  vomiting  due  to     . . 

847 

for  lead 

77 

-  eosinophilia  with     . . 

249 

simuiatinsr  eastric  uleer . . 

847 

AMNESIA         

25 

-  fatty  heart  in         . .           62, 

241 

AN>ESTHESIA  (andsee  Sensa- 

- from  toxsemia 

20 

liver  in     . . 

414 

tion,  Abnormalities  of) 

Amniotic    bands,    oedema    of 

-  functional  bruits  in    104,  106 

791 

-  of  arm  in  Erb's  palsy 

552 

arm  or  leg  from  . . 

455 

thrill  with 

791 

-  bedsore  secondary  to 

285 

Amoeba  coli  (Fig.  12) 

91 

-  in  funo-ating  endocarditis 

-  below  lesion  in  fractures  of 

in  dysentery 

196 

9,  lO;  76,  .593,  .598,  613,  616 

700 

spine  (Fig.  180)  . .     484 

663 

-  dysenteriae  in  liver  abscess 

-  from  ga-stric  ulcer  . . 

298 

-  in  brachial  neuritis 

492 

369, 

408 

-  haematemesis 

459 

palsy 

552 

-  histolytica  (Fig.  12) 

91 

-  hiemoglobinuria 

315 

-  Brown-Sequard  paralysis  540 

664 

Ampulla  of  Vater.  ball- valve 

-  with  lipemoperitoneum 

717 

-  from  Cauda  equina  lesions . . 

74 

obstruction  by  stone  in . . 

650 

-  headache  in . . 

329 

-  cervical  rib  .  .          . .         493 

554 

carcinoma  of 

366 

-  in  HodgMn's  disease 

-  in  circumflex  nerve  paralysis 

552 

fatty  stools  from  cancer  of 

265 

303,  4.59,  617,  649,  695 

715 

-  combined   scleroses   of    the 

jatmdice  from  catarrh  of 

361 

-  hypochlorhydria    with,     in 

cord          . .          . .        164, 

667 

Amphoteric  reaction  of  urines 

572 

"gastric  carcinoma            37, 

351 

-  with  compression  paraplegia 

Amputation,  neurosis  leading  to  -157 

-  hysterical  symptonxs  from . . 

784 

494 

786 

Amyl  nitrite  poisoniag,  xan- 

- idiopathic    (see    Pernicious 

-  definition  of 

660 

thopsia  in 

840 

Anaemia)  . . 

616 

-  in  diagnosis  of  cause  of  ataxy 

66 

Amyloid  disease  (see  Lardaceous 

-  insomnia  in. .          . .        356, 

359 

-  dissociative  in  syringomyelia 

Disease) 

-  in  lardaceous  disease 

696 

75,  112,  128,  285,  554,  563 

664 

Amyotrophic  lateral  sclerosis 

-  leukamia       .  .          .  .          459 

649 

in  haematomyelia 

664 

absence  of  anaesthesia  iu 

5G5 

-  liver  ctrrliosis 

696 

from  lesion  of  optic  thala- 

 ankle-clonus  in 

565 

-  low  blood-pressure  in 

329 

mus 

666 

BabmsM  s  sign  in        82 

565 

-  in  lymphadenoma  . . 

738 

medullary  softening 

666 

bladder  spasm  in 

443 

-  lymphatic  leuksemia 

599 

-  from  dorsal  myelitis  (Fig.  179) 

663 

condition  of  reflexes  in 

554 

-  lymphosarcoma       . .         366 

715 

-  of  feet,  vertigo  with 

827 

contractures  in          162, 

164 

-  malaria          .  .          .  .         459 

698 

-  functional  paraplegia 

567 

cord  changes  of 

554 

-  malignant  disease  of  stomach 

691 

-  glove     and     stocking,     in 

iibriUary  contractions  in 

158 

growths     .  .          .  .          459 

616 

hysteria                 157,  342, 

506 

impotence  in  . . 

346 

—  in  mediastinal  growth 

483 

in    peripheral    neuritis 

increased  knee-jerks  in 

565 

—  menorrhagia  from  .  . 

430 

(Fig.  175) 

660 

muscular  paralysis  from 

73 

-  in  mercury  poisoning         37 

797 

-  hysterical    69,  157,  342,  506, 

509, 

normal  sensations  in . . 

554 

-  miners',  occult  hasmorrhage  in 

94 

548,  549,  567,  666 

798 

I-iaralysis  of  arm  in     . . 

554 

-  multiple  serositis  in 

124 

paral3'sis  of  one  arm  in  . . 

549 

-  -  -  l-iaraplegia  from         561, 

565 

-  with  negative  blood  picture 

36 

of  one  leg  in    . . 

541 

primary 

565 

-  nerve  deafness  in   . . 

191 

-  in  inflammation  of  posterior 

pupils  "normal  in 

554 

-  neuralgia  from 

134 

spinal  root  ganglia 

494 

reflexes  in 

565 

-  noises  in  the  ears  from 

794 

-  from  inJTiry  to  cervical  roots 

simulated  by  myelitis 

74 

-  cedema  of  legs  from          459 

461 

(Fig.  178) 

663 

-  -  -  simulating  sjTrngomyelia 

73 

-  at  onset  of  phthisis 

620 

to  3rd,  4th,  and  5th  sacral 

slow  onset  and  course  of 

565 

-  ovarian 

707 

roots  (Fig.  178) 

663 

spastic  rigidity  with   . . 

163 

-  pains  in  limbs  from 

503 

-  in  Klumpke's  palsy 

553 

spasticity  of  leg  in 

159 

-  palpitation  in          .  .         525, 

528 

-  of    leg   in    paraplegia   from 

taUpes  in 

131 

-  from  parasites 

spinal  caries 

558 

wastingof  hand  muscles 

94,  249,  459,  568 

570 

-  in  leprosy     .  .              75,  450, 

575 

in     . . 

565 

-  with  parenchymatous  goitre 

792 

-  -  diagnostic  importance  of 

424 

AN>EMIA         

26 

-  from  pediculosis  capitis     . . 

419 

-  musculospiral  paralysis 

552 

-  abnormal  leucocytes  in     . . 

28 

-  pernicious    (see    Pernicious 

-  neuromyosits 

504 

-  in  ankylostomiasis       94,  459 

570 

^.nsemia) 

-  pain  mth     . . 

475 

-  aortic  disease 

233 

-  in  jilumbism      77,  136,  144, 

798 

-  from  peripheral  neuritis 

-  aplastic  (see  Aplastic  Anae- 

- pioUdlocjrtosis  in     .  . 

620 

66,  551,  562, 

661 

mia; 

-  with  positive  blood  pictures 

30 

-  in  paralysis  from  cervical  rib 

554 

-  ascites  with             . .     54,  62 

,  64 

-  from  post-partumhEemorrhage  459 

-  pernicious  anaemia 

667 

-  Babinski's  sign  in  .  . 

82 

-  pseudo-leukaemia  infantum 

-  sciatic  nerve  paralysis 

542 

-  ia  Banti's  disease  . .        694, 

696 

459, 

694 

-  sciatica 

487 

-  from  bleeding  gums 

85 

-  from  pyorrhoea  alveolaris 

87 

-  due  to  spinal  hagmorrhage 

787 

-  blood  changes  in  severe     . . 

27 

-  pyrexia  in   . . 

32 

-  from  transverse  cord  lesions 

164 

various  kinds  of    26  et 

set]. 

-  pyrexial  periods  in 

620 

-  in  transverse  myelitis 

484 

-  in  bothriocephalus  infection 

-  in  renal  disease 

172 

-  trigeminal  neuralgia 

496 

459,  568,  569, 

570 

-  from  sarcoma 

459 

-  ulnar  paralysis 

128 

-  Bright's  disease  13, 14, 90, 126 

,303 

—  scurvy-rickets 

753 

Anaesthetics,  "acetonuria  after 

4 

-  cachexia                  .  .114,  115 

4.59 

-  in  septicaemia 

650 

-  coma  due  to            . .         137 

346 

-  canter-rhythm  of  heart  in . . 

639 

-  shortness  of  breath  in 

100 

-  deaths     from     lymphatism 

-  capillary  sensation  in  severe 

106 

-  splenic  (see  Splenic  -AnaRmia) 

under        . .     "    . . 

423 

-  from  carcinoma  of  colon   . . 

147 

-  in  splenomegalic  cirrhosis 

-  delirium  from 

195 

duodenum 

725 

369,  693, 

694 

-  in     determining     cause     of 

pancTeas    . . 

724 

-  from  starvation 

459 

dystocia    . . 

228 

ANESTHETICS— ANEURYSM,    THORACIC   AORTIC 


859 


Ancesthclics,  cnntd. 

Aneiin/.im.  mnld. 

Aneurysm,  thoracic  aortic,  conld. 

-  in    diagnosis  of    abdominal 

-  cirsoid  (I'hiie  XIV) 

764 

diagnosis  from  prominent 

aneurysm . . 

786 

-  external  iliac,  bruit  over  . . 

741 

subclavian  artery  . . 

764 

congenital  abnormality  of 

decreased  by  compress- 

 dissecting,  anginal  pain 

genital  organs .  . 

705 

ing  common  iliac    . . 

741 

on  formation  of 

482 

hysterical  joint   . . 

389 

delayed  femoral  pulse  in 

741 

dullne.ss  over   . . 

790^ 

spasm    . . 

133 

diagnosis     from     psoas 

dysphagia  from           222, 

483 

pancreatic  swellings 

724 

bursa 

741 

ear  in  detecting  pulsa- 

 phantom   tumour           53, 

721 

sarcoma  of  pelvis    .  . 

741 

tion  in 

764 

-  disappearance   of  phantom 

expansile  pulsation  in 

741 

embolism  from 

286 

tumour  under 

761 

iliac  swelling  due  to    . . 

735 

from  embolism 

367 

-  general,  Babinski's  sign  in 

82 

inguinal  swelling  due  to 

741 

erosion  of  rib  cartilages  by 

482 

-  hypothermia  from  .  . 

346 

x-rays  in  diagnosis  of. . 

741 

-  sternum  by  . .         194, 

182 

-  vomiting  from 

843 

-  femoral,     femoral    swelling 

-  -  -  -  vertebrae  by 

Anal  fissure  (see  Anus,  Fissure  of) 

due  to 

732 

476,  482,  784, 

848 

-  fistula  (see  Anus,  Fistula  of) 

-  -  gangrene  from     . .         282 

287 

fusiform 

238 

-  prolapse,  haem.orrhage  in  . . 

93 

of  lung  in 

288 

gangrene  of  fingers  from 

287 

-  sphincter  (see  Sphincter  Ani) 

-  of  heart  from  syphilis 

241 

girdle  pain  in  . . 

482 

-  ulcer 

636 

systolic  bruit  in  . . 

102 

hsematemesis  from     294, 

29G 

Analgesia  from  cord  lesions  . . 

662 

-  hepatic,  ascites  with 

59 

haemoptysis  from 

-  from  cervical  rib     .  . 

128 

from  emboUsm        59,  367, 

368 

176,  317,  318, 

322 

-  definition  of  superficial  and 

-  -  jaundice  with           59,  362 

368 

hard  work  in  etiologv 

deep          

660 

-  innominate,  T-rays  in  diag- 

of      .  .          . .         300 

538 

-  from  lesion  of  the  medulla 

666 

nosis  of  (Fig.  131) 

483 

heart  displaced  by 

ssa 

-  peripheral  nerve  lesions 

662 

-  internal  iliac,  felt  per  rectum  638 

impaired  resonance  from 

322 

-  in  syringomyelia  (Fig.  182) 

665 

-  popliteal  (Plate  XIII) 

762 

insomnia  due  to 

848 

-  tabes  dorsalis  (Fig.  183) 

bruit  over 

762 

loss  of  w-eight  from    479 

848 

498,  507,  562,  662,  664 

665 

compression     of    femoral 

mistaken  for  asthma  . . 

582 

Anangioplasia    (Fig.  66)      215, 

216 

artery  in  diagnosing  .  . 

762 

hysteria 

777 

Anarthria        

685 

delayed  tibial  pulse  from 

762 

intercostal  neuralgia 

Anasarca  (see  Ascites,  Oidema) 

diagnosis  from  sarcoma. . 

762 

478, 

777 

"  Ancliovy-sauce  "     pus     in 

expansile  pulsation  ui     .  . 

762 

mode  of  production  of 

tropical  abscess  of  liver.  . 

408 

gangrene  from    . . 

287 

pain  m 

482 

sputum     . .          .  .         176, 

323 

oedema  of  leg  from 

456 

muscle  atrophy  in  arm 

Anconeus,  nerve  supply  of  .  . 

550 

pain  in  leg  from. . 

762 

from . . 

74 

Aneurysm,  abdominal  aortic 

swelling  due  to    . . 

761 

neoplasm  simulated  by 

-  -  -  absence  of  pulsation  in 

764 

varicose  veins  from 

762 

1S5, 

848 

albuminuria  from 

8 

x-rays  in  diagnosis  of     .  . 

762 

oedema  from    . . 

anaesthetic  in  diagnosis  of  786 

-  pulmonary,  in  phthisis     318, 

319 

of  face,  neck,  and  arms 

blanching  due  to 

692 

rarity  of  tuberculous  focus  in  786 

from            456,  458, 

461 

diagnosis    from    undue 

-  subclavian,  causing  oedema 

orthopnoea  from       465, 

467 

aortic  pulsation  592,  728 

764 

of  arm 

456 

pain  in  abdomen  from 

646 

erosion  of  vertebrae  by 

728 

osteo-arthropathy  in 

891 

back  from       222,  296, 

322, 

expansile  pulsation  with 

simulating  brachial  neuritis  492 

474,  475,  476,  482 

789^ 

299,  486 

786 

-  thoracic  aortic : 

chest  due  to    478,  482 

848 

hasmatemesis  from    294, 

299 

absence  of  bruits  over 

476 

intercostal  due  to  478 

47» 

haematoma  due  to 

692 

pain  with 

482 

in  left  arm  from 

494 

Jaundice  from. . 

368 

age  incidence  of  223,  538 

786 

-  -  -  -  from  pleurisy  over  .  . 

482 

leakage  from    . .         G92 

728 

alcohol  m  etiology 

538 

palpitation  from 

526 

pain  in  abdomen  from 

angina  pectoris  due  to 

paralysis  of  vocal  cord 

299, 368 

692 

482 

778 

from  . . 

538 

back  from        299,  486 

728 

aortic  regurgitation  from 

paraplegia   from 

561 

epigastrium  from    486 

646 

107,  235 

238 

preponderance  in  men 

483 

rarity  of            .  .         592, 

728 

apical  rales  from 

322 

pressure  signs  with 

235 

rupture  into  stomach 

299 

blood  per  anum  from . . 

90 

pulsatile  tumour  from 

sex  incidence  of 

728 

bronchiectasis  . . 

324 

235,  476,  564,  763 

790- 

simulating  peritonitis. . 

646 

carotid   pulses  unequal 

pulsation  in  back  from 

-  -  -  -  indigestion   . . 

351 

with 

236 

296, 

475 

S3T3hilitic  history  in  486, 

728 

chest-wall  bulged  by  193 

,235 

pulses  unequal  with   . . 

.593. 

systolic  bruit  over 

368 

clubbed  fingers  from  . . 

128 

pupils  unequal  in 

595 

.r-rays   in   diagnosis   of 

collapse  from  rupture  of 

482 

-  -  -  rarity  apart  from  syphilis 

483 

(and  see  A'-rays)     . . 

486 

of  lung  due  to 

482 

rupture  into  air-passages 

482 

-  arterio-venous  of  orbit      255 

764 

coma  from       . .        137, 

140 

bronchus      . .         318, 

322 

exophthalmos  due  to  254,255 

compression  of  bronchi 

heart . . 

482 

loud  murmur  with 

255 

by   .  .    236,  322,  324 

482 

lung 

318 

pulsation  of  eye  with .  . 

255 

cord  by 

561 

oesophagus   . . 

482 

-  artery,  internal,  erosion  from 

heart  by 

482 

one  of  the  great  veins 

482 

chronic  tympanic  suppiu:- 

lung  by         .  .          222 

296 

-  pericardium .  . 

482 

ation 

468 

oesophagus  by 

peritoneum  .  . 

482 

-  axillary,  due  to  embolism  . . 

732 

474,  482 

841 

plevu-a 

482 

due  to  injury 

732 

phrenic  nerve  by    . . 

482 

spinal  canal .  . 

482 

unequal  radial  pulses  from 

732 

superior  vena  cava  by 

trachea 

318 

-  carotid,  unequal  pupils  in . . 

595 

234,  236,  461,  746,  825 

,826 

severe    pain    in    chest 

pulsation  in  exophthalmic 

of  trachea  by  465,  482 

,  710 

from  rupture  of 

482 

goitre     .  . 

244 

of  vagus  nerve  by  482 

,  772 

sex  incidence  of          538 

786 

-  cerebral,  acute 

699 

confusion  with  phthisis 

322 

signs  of  descending    . . 

222 

convulsions  from 

172 

cough  due  to    .  .          175 

,176 

simulated  by  spinal  caries  786 

-  -  diabetes  insipidus  in 

585 

danger  with  bougie    . . 

222 

sites  of  rupture  of 

iia 

due  to  embolism  . . 

699 

diagnosis    from    carci- 

 slight  ha?moptysis  of  grave 

headache  from    . .        327, 

328 

noma  of  oesophagus 

296 

import  in 

322 

sensations  in  head  from . . 

328 

dyspepsia     . . 

476 

stridor  from     . . 

7ia 

-  of  coeliac  axis  artery 

368 

enlarged      bronchial 

sudden  death  from    . . 

107 

abdominal  pain  from . . 

368 

glands 

422 

syphilis  in  etiology  of 

jaimdice  m 

368 

mediastinal  growth  296,483 

223,  296,  300,  322,  538 

,  78& 

86o 


ANEURYSM,    THORACIC  AORTIC— ANUS 


Aneurysm,  tJioracic  aortic,  conld 

Angioneurotic  oedema,  corttd. 

Anorexia  nervosa,  contd. 

systolic  bniit  over 

'l05 

relation  to  ililroy's  disease 

460 

"Weir-ilitchell    treatment 

tachycardia  from       773, 

773 

self-induced  oedema  simu- 

in diagnosis  of 

850 

tenderness  of  the  spine 

lating    

457 

Anosmia,  various  causes  of  668 

669 

in      ..          ..         78i 

789 

Angiokeratoma  affecting  fingers 

266 

Ajiosteoplasia,  dwarfism  due  to 

212 

tbrOl  due  to     . . 

790 

Angiosarcoma  of  kidney 

395 

Ante-partum  haemorrhage     . . 

436 

thrombosis  in  . . 

280 

Angular    curvature    (see    Ky- 

Anterior chamber  in  glaucoma 

840 

transverse  myelitis  from 

5G4 

phosis  :   Lordosis) 

in  differentiating  conjuncti- 

 Taricose      chest     veins 

-  gyrus,  visual  word  centre  in 

vitis,  iritis,  and  glaucoma 

257 

from  . .          . .        236, 

826 

(Fig.  185) 

683 

Anterior  crural  nerve,  paralysis 

'Wa'ssermann  reaction  in 

786 

-  word  bUndness  from  lesion  of 

684 

of 

541 

.T-rays   in   diagnosis   of 

Anidrosis,  causes  of    . . 

714 

muscles  supplied  by  . . 

542 

(Fi^.  74),  223,  296,  322,422, 

465, 

Aniline  dye  workers,  bullae  in 

110 

spinal  roots  supplying 

542 

474,  476,  5S2,  593,  7S6, 

790 

-  methsBmoglobinaemia  from 

187 

—  neuralgia,  with  sciatica  . . 

488 

Angina,  abdominal,  benefit  of 

Anicle,  fractures  near,  causing 

diminished  knee-jerk  in 

488 

diuretin  in           .  .        351, 

486 

talipes     . . 

132 

distribution  of  pain  in 

488 

vasodilators  in. . 

351 

-  haemophiUc  arthritis  of 

388 

-  pohomyelitis  (see  PohomyelitisJ 

-  -  diasrnosis  from  indigeston 

351 

-  osteo-arthritis   of    . . 

384 

-  thoracic  nerve,  muscles  sup- 

flatulence  in        . .        351, 

486 

-  synovitis  of  . . 

486 

phed  by 

550 

-  -  hfematemesis  in  . . 

351 

-  tuberculous  disease  of 

385 

spinal  roots  derived  from  550 

induced  by  exertion 

486 

-  ulceration  in  vaws . . 

449 

-  tibial  nerve,  distribution  of 

659 

paroxysmal  epigastric  pain 

ANKLE  CLONUS 

44 

Anteversion  (see  Uterus) 

in 

486 

-  in  amyotrophic  lateral  sclero- 

Anthelmintics in  diagnosis    . . 

249 

tenesmus  in 

486 

sis 73, 

565 

Anthraoosis 

319 

thick  peripheral  vessels  in 

351 

-  birth  palsies 

558 

Anthrax,  bacteriology  in  diag- 

 vomiting  in 

351 

—  Brown-Sequard  paralysis  . . 

540 

nosing      . .          .  .459,  603 

746 

—  ludovici,  bacteriology  of    . . 

459 

-  disseminated  sclerosis 

342 

-  constitutional  symptoms  in 

603 

dysphagia  due  to 

225 

-  with  exaggerated  knee-jerks 

397 

-  diagnosis  of 

603 

oedema  of  face,  neck,  and 

-  in  hemiplegia 

337 

from  carbuncle   . . 

603 

arms  from       . .         459, 

461 

-  method  of  obtaining 

44 

chancre     . . 

603 

ptyaUsm  due  to  . . 

590 

-  in  neurasthenia 

787 

-  gangrene  from 

282 

stomatitis  with  . . 

590 

-  paraplegia  from  spinal  caries 

558 

-  hsemoglobinuria  from 

315 

trismus  simulated  by     . . 

801 

-  positional,  in  normal  person 

160 

-  itching  and  burning  in 

603 

-  maligna 

674 

-  in  primary  lateral  sclerosis 

567 

-  malignant  pustule  of         603 

,  746 

-  pectoris,  from  acute  aortitis 

778 

-  spastic  paralysis 

547 

-  occupation  incidence  of   603, 

746 

age  and  ses  incidence  of 

482 

paraplegia 

494 

-  oedema  of  face,  neck,   and 

-  -  aortic  aneurysm .  .         482 

778 

-  syringomyelia 

554 

arms  from           . .        459, 

461 

disease      "  233,  237,  582 

778 

-  Tooth's  peroneal  atrophy. . 

560 

round  lesion  in    . . 

746 

atheroma     and     arterio- 

- transverse  myelitis 

14 

-  rigors  in 

647 

sclerosis  with  . .         482 

582 

Anl(!e-jerl<S,  absent  in  multiple 

-  septic  fever  in 

603 

brought  on  by  emotion  482 

,778 

neuritis 

488 

-  ulceration  of  the  leg  from. . 

811 

exertion     350,  481,  482, 

778 

-  diminished  in  sciatica 

487 

Antimony,  diarrhoea  from     . . 

197 

touch    . . 

778 

-  exaggerated  in  hysteria     . . 

541 

-  haematemesis  from.  .        294, 

297 

from      coronary      artery 

in  spastic  paralysis 

539 

-  ptyaUsm  due  to 

590 

sclerosis 

778 

-  in  hemiplegia 

337 

Antipyrin,  purpura  from 

596 

diagnosis  of 

482 

-  locomotor  ataxy     . . 

.562 

-  tinnitus  from 

794 

from  indigestion 

350 

Anl<ylosis,  after  gonorrhoea  . . 

377 

Antitoxic  serum  rashes  (see  Serum) 

pseudo-angina .  . 

482 

-  from  joint  disease  . . 

167 

Antrum  of  Highmore 

faintness  and  coUapse  in 

481 

-  in  rheumatoid  arthritis 

379 

affections    of,    a;-rays    in 

false 

482 

-  after  septic  arthritis 

375 

diagnosis  of . . 

502 

fatal          

482 

Anl<y!ostomiasis,  albuminuria 

pain  in  face  from 

749 

due  to  fibroid  heart 

241 

in  .  . 

17 

due  to  carioas  tooth 

502 

flatulencewith267,350,481 

,779 

-  blood-count  in        . .           33 

570 

discharge     of    pus    from 

high  blood-pressure  in  350, 

582 

-  cachexia  in. . 

115 

nose  in         .  .204,  502 

,  749 

from     hypertrophy     and 

-  eosinophilia  in 

249 

foul  taste  from    . . 

774 

dilatation  of  the  heart 

778 

-  melasna  in    . . 

570 

lieadache  from    . . 

327 

mental  anguish  in 

481 

-  occult  hemorrhage  with    . . 

94 

tender  swollen  gums  in. . 

502 

from  myocardial  affections 

18 

-  oedema  of  legs  in    .  .459,  461 

570 

—  empyema  of,  illustrated 

205 

pain  in  arm  and  neck  in 

-  progressive  asthenia  in     . . 

570 

menins-itis  from 

642 

350,  481 

482 

-  severe  anaemia  in  37,  94,  459 

,  570 

subjective  smell  sensa- 

 chest  in               478,  481 

582 

-  shortness  of  breath  in 

570 

tions  from    . . 

669 

from  pericarditis . . 

480 

-  skin  eruptions  in     . . 

570 

symptoms  and  diagnosis 

polynria  after        481,  581 

582 

Ankylostomum  duodenale    . . 

570 

204 

502 

precordial  tenderness  from 

778 

illustrated 

94 

exploration  of      . .         502 

,749 

with  progeria 

218 

Anode,  meaning  of     . . 

633 

-  -  neoplasms  of        .  .          205 

749 

sense  of  impending  death  in 

481 

Anophthahnos,  congenital     . . 

839 

sarcoma  of  (see  Sarcoma) 

from  syphOis       . .           62 

237 

Anorexia  in  acute  polymyositis 

504 

transillumination  of  (Fig.  6 

2) 

varying  duration  of  attack 

481 

yellow  atrophv  of  liver  . . 

370 

205,  502 

749 

-  vasomotor  ("see  Pseudo-angina) 

-  alcoholism          '      238,  243, 

368 

ANURIA          

45 

-  Vincent's  Csee  Vincent's  Angina) 

-  with  bacteriuria 

84 

-  distinction  from  retention . . 

440 

Angioma  of  larynx,  hemoptysis 

-  in  carcinoma  of  colon 

147 

-  non-obstructive 

48 

in 

318 

-  -  stomach    . .          .  .        299, 

351 

-  obstructive  . . 

45 

-  liver 

414 

-  catarrhal  jaundice.. 

365 

-  from  rapid  emptying  of  dis- 

- nose,  epistaxis  due  to 

250 

-  dyspepsia     . . 

49 

tended  bladder    .  . 

440 

—  vulva 

768 

-  gastritis 

352 

Anus,  boil  near,  pain  in  perin- 

Angioneurotic   oedema    (Fiy. 

-  from  intestinal  parasites    . . 

568 

eum  from .  . 

516 

128.) 457-8 

-  nervosa                           50, 

849 

-  carcinoma  of  (see  Carcinoma^ 

albuminuria  in    . . 

17 

absence  of  pyrexia  in 

850 

-  cond_vlomata  round 

769 

as^-mmetrical 

455 

age  and  sex  incidence  of 

849 

-  congenital  absence  of 

637 

diagnosis    from   urticaria 

746 

amenorrhoea  with 

23 

narro\\-ness   of,    constipa- 

 electrical  reactions  in    . . 

634 

severe  loss  of  weight  in    69 

849 

tion  from 

150 

-  -  of  face  (Fiy.  128,  p.  458) 

746 

-  -  simulating  tuberculosis  .  . 

850 

-  fissure  of,  dyspareunia  from 

221 

hsemoglobinuria  in 

315 

carcinoma  of  stomach 

508 

excruciating  pains  during 

legs            

459 

tabes  mesenterica 

850 

defcBcation  from 

636 

ANUS— APPETITE,    ABNORMAL 


86i 


Arms,  fissure  of,  contil. 

pain  in  the  penis  from  513,  515 

perineum  from  . .     516 

-  fistula  of,  bleeding  in         .  .        92 

-  irritation   of,   from   thread- 

worm infection    .  .  .  .      5G0 

-  lymphatic  drainage  of        . .     738 

-  pain  in,  from  vesical  carci- 

noma       . .  . .  . .     442 

-  pigmented,     in     Addison's 

disease      . .  . .  . .     574 

-  protoscope   examination    in 

stricture  of  .  .  . .     150 

-  pruritus  of  .  .  . .  . .     588 

-  syphilitic  eruption  round  440,  447 

-  ulcer  of  636 

Anxiety,  loss  of  weight  due  to     848 

-  professional     cramps     pro- 

voked by 177 

Aorta,  aneurysm  of  (see  Aneurysm) 

-  atheroma    of,    jiain    in    left 

arm  from  .  .  .  .  .  .     494 

-  erosion  of,  by  carcinoma  of 

the  oesophagus     . .  . .     295 

-  nerves  corresponding  to  the     481 

-  site  of  bifurcation  of  . .     728 

-  tenderness  in  the  chest  from 

affections  of         . .  . .     776 

Aortic  area,  systolic  bruits  over    105 

-  disease,  absence  of  bruit  in      526 

-  -  albuminuria  with  . .       18 

anaemia  in  .  .  . .       38 

aneurysm  with    . .  . .     223 

angina  pectoris  with      582,  778 

bruit   often   brought   out 

on  exertion  in . .  . .     526 

capillary  pulsation  in     . .     106 

causes  of  . .  . .         106,  236 

cerebral  embolism  from  138, 155 

collapsing  pulse  in  106,  247,  526 

-  -  congenital  . .        236,  238 

-  -  diastolic  bruit  in . .  ..     106 

-  -  displaced  cardiac  impulse  in  332 

due  to  endocarditis         . .     236 

enlarged  left  ventricle  in       232 

right  ventricle  in        . .     245 

essential  signs  of  stenosis 

105,  235 

excessive  pulsation  in 

247,  592,  764 

-  -  Mint's  murmm-withl08,109,234 

general  account  of         . .     233 

hasmoptysis  from  . .     320 

heart  failure  from  . .     464 

insomnia  in  . .  . .     359 

liver  congestion  in  . .     407 

with  mitral  disease  . .     237 

mitral  regurgitation  from     239 

noises  in  the  ear  from     . .     794 

orthopnoea  from  . .  . .     464 

pain  dowm  left  arm  in    481,  494 

palpitation  in      ..525,526,626 

precordial  pain  in  . .     481 

-  -  and  pulmonary  incompe- 

tence distinguished     . .     247 
pulsating  noises  in  head  in    359 

-  regurgitation,      Corrigan's 

pulse  in     . .  . .  . .     106 

-  -  from  endocarditis  . .     106 
hypertrophy  of  the  heart  in  359 

-  -  rupture  of  valve  from   236,  238 

-  -  signs  of     . .  . .  . .     240 

situation  of  bruit  due  to       790 

syphilitic  . .     18,  62,  223 

systolic  bruit  over  mitral 

area  in. .  . .        102,  103 

-  -  thrill  due  to         . .  . .     790 
water-hammer  pulse  in . .     IOC 

-  ring,  dilatation  from  aneurysm  238 
Aortitis,  acute,  angina  pectoris 

due  to      . .     '     . .         481, 778 

-  pain  in  the  back  from       . .     789 

-  rheumatic    . .  . .  . .     481 

-  due  to  syphilis        . .  . .     481 


Ape's  hand  (see  Claw-hand) 
Aperients,  constipation  due  to     144 

-  in  diagnosis  of  nature  of  con- 

stipation . .  . .  . .     142 

Apex  beat  (see  Heart  Impulse) 
Apliasia,  from  cerebral  abscess 

685,  686 

embolism  . .  . .     685 

haemorrhage         . .  . .     685 

syphilis 173 

thrombosis  . .  . .     685 

-  -  tumour     .  .  .  .  685,  686 

-  definitions  of  . .         682,  685 

-  diagnosis  from  loss  of  speech 

due  to  mental  defects     . .     682 

-  difficulties  of  analysing      . .     683 

-  with  hemiplegia      . .         336, 685 

-  impaired  intelligence  with        683 

-  internal  and  external  speech 

in  relation  to       . .         683,  685 

-  motor,  anarthria  distinct  from  685 

Eroca's  area  and  . .     685 

consciousness    of    speech 

mistakes  in  . .  . .     685 
intellectual  processes  intact  685 

-  sensory,  intellect  impaired  in   683 
lesions  producing  . .     683 

-  temporary,  in  epilepsy       . .     686 
in    general    paralysis     of 

the  insane        . .  .  .     682 

-  -  health 686 

migraine   . .         . .  . .     686 

Aphonia,  from  laryngeal  palsy    687 

-  hysterical   224,  342,  506,  538,  687, 

710,  798 
cough  normal  with         538,  687 

-  -  painless     . .  . .  . .     538 

recurrent  . .  . .     687 

sex  and  age  incidence  of     538 

-  -  sudden  onset  in  . .  . .     688 

recovery  from. .  . .     688 

voice  reduced  to  a  whisper    687 

Aphrodisiac    drugs,    priapism 

from  586 

Aphthous  stomatitis,  bleed- 
ing gums  in  (and  see 
Stomatitis) 

Aplastic  anaemia 

ascites  in. . 

bleeding  gums  in 

blood  changes  in 

fatty  heart  from . . 

leucopenia  in 

myelocytes  in 

simulating  pernicious 

Apomorphine,  vomiting  from 

Apoplexy  (see  Haemorrhage, 
Cerebral) 

-  pulmonary  . . 
Appendicitis 

-  abdominal  rigidity  due  to . .     736 

-  acute  diarrhcea  in  . .  . .     196 

-  adhesion  to  ovary  and  tube  in  737 

-  bladder  symptoms  in  438,  032,  736 

-  in  children   . .  . .  . .     134 

constipation  from  .  .144,  729,  736 


31 

62,  64 

.   85 

64 

62 

.  401 

29 

42 

843 


320 


cystitis  from 

cystoscopic         appearances 

when  appendix  adherent 

to  bladder 
diagnosis      from      enlarged 
tender  ovary   . . 

-  gall-stones 

-  indigestion 

-  ovarian  cyst  with  twisted 

pedicle  . . 

-  pain     due     to     retained 

testicle . .  . .        523, 

-  from  pyosalpinx 

-  renal  colic 

-  renal  tumour 

-  suppurating    gall-bladder 

-  suppurative  pylephlebitis 

-  typhoid  fever 


313 


632 

737 
500 
350 


Appendicitis,  diagnosis,  contd. 

from  ureteric  calculus 

311,027,033 
vesical  disease     . .  . .     632 

-  drawing  up  of  right  leg  in . .     73G 

-  dysmenorrhcea  from  . .      737 

-  empj'ema  from        .  .  .  .     120 

-  faeculent  vomiting  in        . .     846 

-  furred  tongue  due  to        .  .     736 

-  gangrenous,     severe    shock 

and  collapse  in  . .  .  .     484 

-  gas-production  in   . .  .  .     231 

-  general  peritonitis  from    431,  644 

-  haematuria  in  305,  313,  032 

-  haemoptysis  from   . .  . .     123 

-  indicanuria  in         . .         349,  500 

-  inguinal  abscess  due  to     .  .     739 

-  intestinal  obstruction  from 

151,  152 

-  jaundice  from         . .  . .     362 

-  kinking  of  bowel  after      .  .     147 

-  leucocyte  count  in  diagnosis 

from  typhoid  fever        .  .     401 

-  leucocytosis  with    . .  . .     736 

-  micturition  frequent  with 

438,  632,  736 

-  multiple  ulcers  of  stomach  in    304 

-  pain  in  the  back  in . .  .  .     476 

epigastric,  in       . .  .  .     484 

hunger,  in  . .         350,  50O 

-  -  in  loin 393 

-  -  pelvis  from  . .  . .     508,  632 

-  -  right  hypochondrium  in .  .      500 
right  iliac  fossa  in 

313,  501,  729,  736,  780 
spasmodic,  in      . .  . .     509 

-  pelvic  abscess  from  . .     632 
swelling  due  to    . .          . .     757 

-  plem-itic  effusion  from       . .     122 

-  pneumaturia  from  .  .  .  .      576 

-  pregnancy  with        .  .  .  .     761 

-  pulmonary  emboli  from    . .     123 

-  pulse-rate  in  .  .         032,  736 

-  pylephlebitis  after 

59,  362,  370,  614,  649 

-  pyrexia  from 

133,135,313,632,729,  736 

-  pyuria  in     . .  . .         313,  632 

-  rectal  and  vaginal  examina- 

tions in    . .  . .        729,  736 

-  right-sided  abdominal  rigid- 

ity in        . .  . .  .  .     632 

-  rigors  after  . .  . .  . .     370 

-  rupture  of  abscess  into  bladder  632 

-  septicaemia  from     . .  . .     614 

-  signs  of         . .  . .  . .     135 

-  simulated  by  dysmenorrhcea    220 

-  -  ovarian  pains       .  .  .  .      729 

pyelitis 646 

salpingitis  . .  . .     729 

scybala 729 

spastic  constipation       . .     145 

tuberculous  caecum        . .     736 

-  subpiurenio   abscess  from 

119,  122,  501,  720,  721 

-  swelling  in  right  iliac  fossa  in     736 

-  tenderness  in  the  right  iliac 

fossa,  due  to      .  .500,  736,  780 

-  undue      abdominal      aortic 

pulsation  suggesting      . .     592 

-  vomiting  from  729,  736,  844,  846 
Appendicular  abscess  (see  Ab- 
scess, Appendicular) 

-  colic,  discussion  of  . .  . .     134 
Appendix,  actinomycosis  of  . .     736 

-  palpable  per  rectum  . .     638 

-  in  right  inguinal  hernia  742 
APPETITE,     ABNORMAL  ..       49 

-  excessive,  in  diabetes     292,  507 
from  intestinal  parasites     568 

-  increased  in  pregnancy     . .     293 

-  loss  of,  in  cirrhosis  of  liver  59,  300 

gastritis    . .  . .  . .     352 

lardaceous  disease  . .       48 


852 


APPETITE— ARTHRITIS,    GONORRHCEAL. 


Appetite,  loss  of,  coiitd. 

Arsenic,  contd. 

Arteriosclerosis,  contd. 

pyelonephritis 

48 

-  blood  per  anum  from 

9? 

-  noises  in  the  ear  in . . 

794 

renal  tuberculosis 

48 

-  contractures  due  to 

165 

-  cedema  of  legs  from 

461 

-  -  rheumatoid  arthritis 

39 

-  coryza  from 

203 

-  orthopnoea  in 

464 

—  -  uraemia     . .          .  .          45, 

350 

-  diarrhoea  from        . .         197, 

579 

-  pain  in  the  back  from     . . 

789 

-  perverted 

50 

-  in      distinguishing      lichen 

-  palpitation  in 

525 

in  cachexia  aquosa 

115 

planus     from     pityriasis 

-  pancreatitis  from    . . 

116 

insanity    . . 

50 

rubra  pilaris 

530 

-  from  plumbism       .  .         144, 

507 

Apple-jelly  nodules  in  lupus  vul- 

- fatty  heart  from      .  . 

62 

-  polyuria  with 

583 

garis  20-4,  2-48,  603,  655,  808 

812 

-  foul  taste  in  mouth  from.  . 

774 

-  in  progeria  . . 

218 

Aran-Duchenne  type  of  paraly- 

- haematemesis  from            294 

297 

-  ptyalorrhoea  wdth   . . 

592 

sis  of  hand 

554 

-  in  hair          . .          . .             3S 

,  87 

-  reduplicated  sounds  in 

639 

Arcus  senilis    . . 

343 

-  leucopenia  from 

401 

-  renal  changes  of 

14 

Argyria  from  silver  nitrate   .  . 

575 

-  loss  of  smell  sensation  from 

668 

-  sense  of  fullness  in  head  in 

329 

Argvll  Robertson  pupils       134, 

562 

-  in  Manchester  epidemic     . . 

576 

-  simulating  cerebral  tumour 

328 

-  -"-  in  tabes     134,  285,  466, 

493, 

-  muscular  hyperaesthesia  from 

165 

-  in  Stokes-Adams'  disease  97, 

172 

498,  507,  562, 

847 

-  -  inco-ordination  in 

506 

-  systolic    bruit    over    mitral 

dolorosa 

507 

-  nasal  catarrh  from . . 

668 

area  in     .  .          . .         102, 

103 

Arm,  angioneurotic  oedema  of 

459 

-  peripheral   neuritis   from 

-  urine  in 

240 

-  athetosis  of  . . 

536 

38,  76,  165,  285,  492 

551 

-  uterine  prolapse  causing 

11 

-  atrophy  from  arthritis 

72 

marked  hyperaesthesia  in 

506 

-  vertigo  due  to 

828 

-  monoplegia  of,  m  dissemin- 

 paralysis  early  in 

506 

-  vomiting  in . . 

328 

ated  sclerosis 

547 

-  pigmentation  of  skin  from 

Arterio-venous  aneurysm  (see 

from  embolism  in  internal 

411,  423, 

574 

Aneurysm) 

capsule 

546 

-  poisoning  by,  acute           .  .87,  92 

Arthritis,  acute  rlieumatic(and 

-  multiple  benign  sarcoid  of 

451 

chronic            . .         75,  77, 

297 

see  Rheumatism,  Acute) 

-  muscular    atrophy    of   (see 

-  polycythaemia  from          579, 

580 

absence  of  suppuration  in 

374 

Atrophy.  Muscular) 

-  ptyalism  due  to 

590 

diagnosis  from  acute  ne- 

- myoma  cutis  of      . . 

805 

-  purpura  from 

596 

crosis  of  bone . . 

375 

-  cedema  of,  after  amputation 

-  reaction  of  syphilides  to  . . 

604 

suppurative  artliritis 

375 

of  breast  . . 

456 

-  swelling   of    eyes   and   face 

gonorrhceal   arthritis . . 

376 

from  aneurysm  .  . 

456 

caused  by 

459 

rheumatoid  arthritis . . 

378 

heart  failure 

458 

-  toxic  symptoms  produced  by 

297 

septic  arthritis 

375 

mediastinal  growth       296, 

456 

Arseniuretted  hydrogen  poison- 

 traumatic  arthritis     . . 

375 

-  pain  in,  from  aneurysm     . . 

222 

ing,  bile  changes  in 

374 

tuberculous  arthritis . . 

375 

in  cervical  pachymeningitis 

128 

haemoglobinuria  from 

314 

drenching  sweats  in 

375 

-  paralysis  of 

545 

jaundice  in      . .         362, 

374 

enlargement     of     lymph 

-  -  from  cervical  rib 

593 

Arterial  affections  (see  Arterio- 

glands in 

418 

hysterical . . 

54S 

sclerosis  and  Atheroma) 

-  -  history  of  chorea  in 

374 

-  -  importance  of  hislory  in 

545 

-  tension  (see  Blood-pressure) 

recurrent  tonsillitis  in. . 

374 

~  -  infantile    . . 

70 

-  thrombosis  (see  Thrombosis) 

mainly  of  larger  joints  .  . 

374 

-  -  in  Little's  disease 

154 

Arteries,  defective,  in  cerebral 

past  rheumatic  history  in 

374 

monoplegic,  from  embolism 

haemorrhage         .  .         138 

563 

permanent  stiffness  rare  in 

374 

in  internal  capsule     . . 

546 

-  forcibly  pulsating  in  aortic 

red  blush  of  skin  over    374 

.375 

from  multiple  neuritis   . . 

550 

disease 

233 

-  -  rheumatic  nodules  in     . . 

375 

neuritis  in  leprosy  ("#1(7. 14  4) 

551 

-  thick  and  tortuous  in  chronic 

-   -  salicylates  in 

375 

in  paralysis  agitans 

548 

nephritis  . . 

303 

severity  of  pain  in 

374 

peripheral  nerve  distribu- 

Arteriosclerosis, abdominal  an- 

 slight  degree  of  wasting  in 

375 

tion  (Plate  XD 

551 

gina  in     .  . 

351 

synovial  effusion      in    . . 

374 

spastic,  in  brachial  mono- 

- accentuated    aortic    second 

therapeutic  test  in 

375 

plegia    . . 

546 

sound  in  .  . 

639 

"  travelling  "  character  of 

374 

-  -  -  from   cerebral    abscess 

heart  sounds  in  . . 

1,  2 

-  -  vesicles  on  skin  in 

375 

or  tumour    . . 

547 

-  albuminuria  with   .  . 

8 

rheumatoid  (see  Rheuma- 

  from  encephalitis 

547 

-  alcohol  causing 

238 

toid  Arthritis) 

—  -  -  internal  capsular  lesions 

546 

-  angina  pectoris  in..         482, 

582 

—  secondary,  diagnosis  from 

various  causes  of          455, 

458 

-  aortic  regurgitation  in      106 

107 

rheumatic  fever     377, 

378 

weakness  of,  in  paralysis 

systolic  bruit  in  . . 

106 

early  operation  in 

377 

of  serratus  magnus     . . 

551 

-  apoplexy  with 

173 

high  temperature  in  . . 

377 

Werdnig-HofEmann  type 

158 

-  cardiac  hypertrophy  with 

sudden  onset  in 

377 

-  predilection  of  psoriasis  for 

447 

232,  245,  331,  359 

639 

^-rays  in  diagnosis  of. . 

378 

-  professional  cramp  of 

177 

-  Oheyne-Stokes     respiration 

-  atrophy  of  muscles  with    . . 

346 

-  syringomyelia  affecting     . . 

664 

in 124, 

125 

-  chronic,  from  gonorrhoea   .  . 

278 

-  tremor  of,  in  disseminated 

-  cyanosis  from 

186 

pyorrhwa  alveolaris 

278 

sclerosis    .  . 

800 

-  cystic  kidneys  with           49 

396 

rheumatic,  effects  of  move- 

 in  Friedreich's  ataxy     . . 

799 

-  diabetes  witla 

282 

ment  on  pains  of 

507 

general   paralysis   of   the 

-  displaced  cardiac  impulse  330 

331 

-  congenital  syphilitic,  absence 

insane   . . 

796 

-  epistaxis  in . . 

251 

of  pain  in 

386 

Graves'  disease  . . 

797 

-  gangrene  from 

286 

favourite  site  in  knee 

386 

-  -  mercurial. . 

797 

-  haematuria  in 

305 

impairment    of    move- 

- wasting  of,  in  syringomyelia 

-  haemoptysis  in 

318 

ment  very  slight  in 

386 

285 

,665 

-  headache  in              327,  328, 

329 

simulating  tuberculous 

386 

Arnica  causing  bullae. . 

110 

-  heart  failure  in       . .         461 

464 

-  contractures  from   . . 

390 

-  sore  fingers  from    . . 

266 

-  high  blood-pressure  with   18 

64, 

-  diagnosis  from   the   distor- 

Arnold's branch  of  the  vagus, 

96,    186,    239,    240,    251, 

329, 

tion  of  joints  in  muscular 

relation  to  cough 

174 

331,   433,   464,   582,   639 

paralysis  . . 

390 

Arrhythmia,      shortness      of 

-  hypothermia  in 

345 

-  egg-shell  crackling  in 

177 

breath  with 

101 

-  infantilism  from 

216 

-  in  erythema  nodosum 

450 

Arsenic,  acute  gastritis  from 

845 

-  insomnia  in. .          .  .         356, 

359 

-  flonorrhoeal 

376 

-  albuminuria  from    .  . 

17 

-  laryngeal  paralysis  with    .  . 

539 

anltylosis  with  deformity  in  377 

-  amblyopia  from 

836 

-  medullary  softening  due  to 

343 

-  -  contractures  from 

167 

-  an:emia  from 

37 

-  menorrhagia  in 

428 

diagnosis      from      acute 

-  analysis  of  vomit  for 

845 

-  metrorrhagia  from 

433 

rheumatism     . . 

376 

-  ascites  from 

62 

-  mitral  regurgitation  from  239 

240 

general  account  of 

376 

-  bleeding  gums  in  . .         . .  8 

5,  87 

-  monoplegia  from     . . 

546 

gleet  with 

376 

ARTHRITIS,  GONORRHCEAL— ASCITES 


863 


Arthritis,  gonnrrhceal,  eonld. 

Arthritis,  contd. 

Articulation  (see  Speech,  Abnor- 

 gonococci  in    fluid    from 

-  syphilitic,  monarticular     . . 

380 

malities  of) 

joint  in. . 

37C 

-  -  swelling  and  tenderness  in 

386 

Arytenoid  cartilage,  perichon- 

 ophthalmia   from 

370 

synovitis  in 

386 

dritis  of,  sore  throat  from 

670 

opsonic  index  in  diagnosis 

376 

tertiary,   enlargement    of 

-  joints,  fixation  of    .  . 

537 

pyrexia  in 

377 

joint  in . . 

386 

Asafoetida,  foul  taste  from     . . 

774 

rarity  of  suppuration  in 

377 

gumma  of  end  of  bone  in 

386 

Ascarislumbricoides(i^ijr.  153)  569 

salicylates  witliout  effect  in  377 

-  -  thickening      of      synovial 

eosinophilia  with 

249 

severe  muscular  atrophy  in 

370 

membrane  in   . . 

386 

in  gastric  contents 

846 

simulating   gout.. 

383 

-  in  sjTingomj'elia         .  .      388 

,563 

gastro-intestinal  and  ner- 

 progressive     muscular 

-  tabes  dorsalis 

388 

vous  disorders  from  . . 

569 

atropliy 

377 

-  -  disorganization  of  joint  in 

388 

impaction  in  bile-duct  . . 

364 

tuberculous  artluritis.. 

377 

monarticular 

387 

increased  appetite  with. . 

49 

subcutaneous  nodules   in 

375 

-  talipes  from .  . 

132 

jaundice  from      . . 

361 

urethral  discharge  with 

376 

-  transient     impairment      of 

length  of  . . 

364 

vertebral  .  . 

785 

movement    in    joints    in 

-  -  no  blood  changes  with  . . 

33 

-  gouty  (see  also  Gout)        381 

,  383 

early  tuberculous          385 

380 

ASCITES          

50 

-  -  sodium  urate  in  joints  in 

-  transparency    of    bones    to 

-  abdominal  swelling  from  467,  715 

(Fig.Wl) 

380 

ir-rays  (Fig.  110) 

380 

simulating 

717 

tophi  about  joints  in     .  . 

507 

-  traumatic,    conversion  into 

-  in    acute    peritonitis    from 

-  gummatous  . . 

386 

tuberculous 

386 

Bright's  disease     . . 

14,  63 

-  in  lia?mophiUa 

388 

diagnosis      from      acute 

-  albuminuria  with    . . 

9,  17 

-  hsmoptysis  with              318 

319 

rlieumatic  arthritis     .  . 

375 

-  from  bronchitis  and  emphy- 

- in  Henoch's  purpura 

90 

-  tuberculous  . .          365,  385 

386 

sema 

246 

-  hysterical,  absence  of  mus- 

 age  incidence  of . . 

385 

-  in  cancerous  peritonitis 

.     57 

cular  atrophy  in 

389 

anaimia  in            .  .     36,  39 

386 

-  from  carcinoma  of  colon    .  . 

366 

-  -  -  bony  outgrowths  in   . . 

389 

-  -  of  ankle    . . 

385 

of  stomach 

366 

grating  in 

389 

talipes  from 

132 

-  in  child,  dystocia  due  to    . . 

227 

heat  in. . 

389 

-  -  in  association  with  tuber- 

- chlorotic  antemia    . . 

64 

swelling  in 

389 

culous  peritonitis 

691 

-  chylous,  in  sub-acute  nephritis  126 

symptoms  of  arthritis  in 

389 

contractures  from 

167 

-  cirrhosis  of  the  liver        301 

.  368. 

-  -  coldness  of  joint  in 

389 

diagnosis  from  acute  rheu- 

410, 411,  693,  696,  826 

disappearance  under  anaes- 

matism 

375 

-  compression  of  lung  by     324,  668 

thesia    . . 

389 

syphilitic  synovitis     . . 

386 

-  constipation  with  . .  ' 

148 

tenderness  of  joint  in     . . 

389 

disease  of  ilium    second- 

- chylous 

58 

-  of  infants,  acute 

378 

ary  to  . . 

737 

in  subacute  nephritis     . . 

126 

-  infective,  anaemia  in 

36 

of  elbow    . . 

385 

-  diagnosis  of 

716 

in  children,  pneumococcal 

375 

foot  simulated  by  tabetic 

from    conditions    simula- 

 diagnosis  from  gout 

382 

arthritis 

388 

ting  it  . . 

52 

-  -  epitrochlear  gland  enlarged 

frequent  absence  of  general 

gravid  uterus 

52 

in 

422 

symptoms  in  . . 

366 

hydramnios 

759 

in  Malta  fever 

507 

pyrexia  in 

386 

ovarian  cyst         .  .          759,  761 

mixed  infection  in 

377 

of  hip,  relative  frequency  of  385 

phantom  tumour 

433 

from  pyorrhcea  alveolaris 

87 

history  of  injury  in 

386 

-  difficulty  of  estimating  size 

-  in  mtermittent  hydrarthrosis 

387 

hysterical  hip  simulating 

166 

of  liver  in 

406 

-  localized  in  displacement  of 

knee  simulating 

166 

-  "  dipping  "  for  liver  in 

410 

semilunar  cartilase 

388 

impaired     movement     a 

-  from  distoma  hepaticum 

364 

-  monarticular,  of  secondary 

sign  of  .  .          .  .         385, 

386 

-  dullness  in  flanks  from 

759 

syphilis    . . 

386 

insidious  onset  of 

385 

-  encysted,  account  of 

719 

character      of     Charcot's 

of  knee,  absence  of  bony 

diagnosis  from  ovarian  cyst  761 

disease  .  . 

387 

outgrowth  in  . . 

386 

-  eosinophilia  with    . . 

249 

of  osteo-arthritis 

384 

pulpy  sensation  in 

386 

-  fibroid  lung  and  bronchiec- 

 sweUing  due  to  gout 

382 

relative  frequency  of. . 

385 

tasis  from 

324 

-  multiple,    in    children    ("see 

lameness  in 

385 

-  fibroma  of  ovary  with 

759 

Still's  Disease) 

muscular  wasting  in 

366 

-  in  Hanot's  cirrhosis 

411 

-  nervous  mimicry  in 

389 

-  -  niglit  startings  in 

385 

-  hfemorrhagic            . .          . . 

718 

-  osteosynovial    membrane 

occasional  absence  of  pain 

385 

-  heart  displaced  by             330,  332 

thickened  in         . .       384, 

390 

twinge  of  pain  in  early 

385 

-  due  to  hydatid  disease 

719 

-  pain  in  the  chest  in 

478 

occurrence    without    im- 

- in  von  Jaksch's  disease 

42 

-  in  peliosis  rlieumatica 

599 

pairment  of  movement 

385 

-  jaundice  with 

58, 

-  pneumococcal,  after  injuries 

pain  in     . . 

385 

-  knee-elbow  position  in  diag- 

of joints    .  . 

375 

percentage      distribution 

nosis  of     . . 

717 

seneral  account  of 

375 

amongst  various  joints 

385 

-  linete  albicantes  in . . 

402 

-  -  In  otitis  media    . . 

375 

rarity  of  lardaceous  dis- 

- loculated      .  .          .  .  56,  717,  719 

pus  in  joints  in   . . 

375 

ease  from 

366 

-  mediastinitis 

484 

great  tenderness  of  joints  in  375 

phthisis  in 

366 

-  in  mitral  regurgitation 

238 

-  rheumatoid  (see  Elieumatoid 

tuberculosis  elsewhere  in 

366 

stenosis     . . 

764 

Arthritis) 

relative  frequency  amongst 

-  nephritis      . .          . .            14,  48 

-  in  scarlet  fever 

376 

the  various  joints 

385 

-  oedema  of  legs  from 

461 

-  septic           

375 

sacro-iliac  joint,  difficulty 

-  orthopncea  from     .  .         465 

,  467. 

-  -  of  ankle,  talipes  from  .  . 

132 

of  diagnosis  of 

386 

-  with  ovarian  tumour  367,393,759 

albumosuria  in    .  . 

20 

shoulder   . . 

385 

cyst  \\ith  twisted  pedicle 

759 

-  -  ankylosis  from     .  . 

375 

simulated  by  gonorrhoeal 

-  palpitation  from      .  . 

526 

-  -  fixation  from 

375 

arthritis 

377 

-  pelvic  sweUing  due  to 

759 

hue  of  skin  over  . . 

375 

occupation  neuroses   .  . 

178 

-  with  peritonitis       . .           56 

.  718 

irregular   temperature   in 

375 

slow  progress  of  . . 

385 

-  in  pernicious  anaemia          6 

2,  64 

leucocytosis  in     . . 

375 

swelling  in 

385 

-  physical  signs  of     . . 

50 

septicaemia  from . . 

698 

usually  monarticular     . . 

366 

-  with  pleural  effusion 

121 

sources  of  infection  of    . . 

375 

wrist 

385 

-  from  portal  gland  enlarge- 

 suppuration  in     .  . 

375 

-  with  typhoid  fever.  .          375 

376 

ment 

366 

-  simulating  paralysis 

545 

Artliritism,  pruritus  in 

588 

-  pressure onportal vein  301 ,366,669 

-  spinal,  pain  in  back  from. . 

476 

Artichokes,  oxaluria  from 

471 

-  in  pseudoleukjemia  infantum 

42 

-  suppurative  in  pyaemia 

649 

Articular     rheumatism      (see 

-  pylephlebitis 

301 

causing  anajmia  . . 

39 

Eheumatism) 

-  resonance  in  umbilical  area  in  759 

864                                     ASCITES— ATROPHY,    MUSCULAR 

Ascites,  contd. 

Astigmatism,  contd. 

Atony  of  bladder  wall,  difficult 

-  with    secondary    carcinoma 

-  tenderness     in    mid-orbital 

micturition  in 

440 

of  liver 

413 

region  in 

498 

-  bowel,   illustrated  . . 

144 

-  in  severe  blood  diseases     . . 

122 

temporal  region  from    . . 

783 

-  constipation  from  . . 

149 

-  simulated      by      distended 

vertex  from 

783 

-  gastric,  dyspepsia  from     . . 

354 

bladder     . .          .  .        717, 

730 

Astley  Cooper,  re  bladder  in 

flatulence  in 

267 

gall-bladder 

717 

hernia 

742 

-  post-dysenteric 

144 

intestines 

717 

irritable  breast  of  • 

479 

Atoxyl,  optic  atrophy  from .  . 

836 

gastrectasis 

717 

Astringents,  dryness  of  mouth 

Atrophic  brachial  pajsy,  peri- 

 haemoperitoneum 

717 

due  to 

789 

pheral  nerve  distribution 

mesenteric  cyst  . . 

717 

-  extreme  thirst  due  to 

789 

and  (Plate  XI,  p.  663)  . . 

551 

ovarian  cyst 

717 

-  vaginal  casts  due  to 

211 

Atrophic  rhinitis  (see  Rhinitis, 

pregnancy 

717 

Ataxic  paraplegia  (see   Para- 

Atrophic) 

retroperitoneal  lipoma  . . 

717 

plegia,  Ataxic) 

Atrophy,  acute  yellow  (see  Liver, 

-  skodaic  resonance  due  to  . . 

668 

ATAXY          

64 

Acute  TeUow  Atrophy  of) 

-  in  splenic  ansmia    .  .            64 

,411 

-  cerebellar,  intention  tremor 

-  of  bone  in  tabetic  artluitis 

388 

-  splenomegalic  cirrhosis 

693 

in 799, 

800 

-  ears  in  lupus  erythematosus 

658 

-  subacute  nephritis  . . 

126 

-  in  cerebellar  lesions 

69 

-  eyes  from  iritis' 

839 

-  -nith  telangiectases 

59 

-  from  cerebellar  tumour     . . 

643 

-  leg,  vrith  peroneal  atrophy 

128 

-  in  thrombosis  of  portal  vein 

58 

-  combinedsclerosesof  cord  493 

,667 

in  mycetoma 

810 

-  tuberculous  peritonitis  with 

-  choreiform  movements  with 

799 

-  from  supraclavicular  nerve 

56,  152,  618 

691 

distinguished  from 

156 

paralysis  .  . 

552 

-  tumours  of  liver  ^ith 

366 

-  contracture  with     . . 

162 

-  transverse  myelitis  at  lum- 

- varicose  abdominal  veins  from  825 

-  in  disseminated  sclerosis  341 

565 

bar  enlargement. . 

563 

-  vena  cava  obstructed  by 

-  distinguished  from  paralysis 

545 

ATROPHY,   MUSCULAR 

68 

459.  461 

825 

-  Friedreich's      (see      Fried- 

 from  acute  poliomyelitis  555 

,558 

-  from  vena  cava  thrombosis 

825 

reich's  Ataxy) 

in  alcoholism 

79 

-  in  venous  congestion  of  liver 

407 

-  gait  in          . .          . .           66 

277 

of  arm,  various  causes  of 

549 

Ascitic  fluids,  analyses  of      .  . 

57 

-  in  Huntington's  chorea     . . 

156 

in  brachial  neuritis     . . 

492 

characters  of       ..          ..52,59 

-  illustrated  (Fig.  206) 

799 

from  cervical  rib 

554 

endothelial  cells  in 

718 

-  from  spinal  new  growth     . . 

68 

multiple  neuritis 

550 

mitotic  figures  in  cells  of 

718 

-  tabes             . .    285,  498,  562 

665 

in     arsenical     peripheral 

Asexual  ateleiosis 

218 

dolorosa    . . 

507 

neuritis 

506 

Aspergillosis,  haemoptysis  in  317 

,705 

-  test  for  minor  degrees  of  . . 

65 

with  arthritis 

-  of  lung 

322 

-  from  thrombosis  of  posterior 

183,366,376,379,386 

634 

-  in  mycetoma 

809 

inferior  cerebellar  artery 

666 

associated  -with  scars     . . 

132 

Aspergillus,  varieties  of 

705 

Atelectasis,   fibroid  lung    and 

in  bulbar  paralysis 

Asphyxia,  acute,  from  bilateral 

bronchiectasis  from 

324 

224,  641,  686 

687 

abductor  paralysis 

185 

Ateleiosis,  asexual  (Fig.  69)  217 

,218 

cachexia  . . 

634 

-  borborygmi  in 

97 

-  hypothyroidism  in .  . 

216 

callus  causing 

75 

-  causes  of     . . 

288 

-  sexual           .... 

218 

claw-hand  with  . . 

127 

-  convulsions  in 

169 

how  diagnosed   . . 

215 

from   disuse         . .         390 

634 

-  local,  in  Eaynaud's  disease 

490 

Atheroma    (and    see  Arterio- 

 facial  paralysis  with 

536 

-  raised  blood-pressure  in   . .  64,  96 

sclerosis) 

1 

in  Friedreich's  ataxy      70 

164 

-  retraction  of  the  head  in  . . 

641 

-  abdominal  angina  from     351 

486 

fibrillar  contractions  in 

-  tetanus  causing 

162 

-  and  angina  pectoris 

582 

157,  1.58 

159 

Assam,  kala-azar  in  . . 

34 

-  aortic  systolic  bruit  with 

Of  hands  in  amyotropliic 

Astereognosis  in  brain  lesions 

68 

61,  105,  106 

235 

lateral  sclerosis  131,  159 

565 

-  in  disseminated  sclerosis  . . 

665 

-  ascites  in 

61 

bulbar  paralysis        '  . . 

687 

-  tabes  dorsalis 

665 

-  cerebral,  recurrent  transient 

from  cervical  rib 

554 

Asthma 

hemiplegia  from  . . 

340 

peroneal  atrophy 

128 

-  bronchitis  and  emphysema 

-  in  diabetes  meUitus 

811 

progressive   muscular 

from          . .          . .         186 

.582 

-  gangrene  of  the  leg  from  . . 

810 

atrophy 

127 

simulating            ..180,249 

,467 

-  hsematemesis  in 

299 

ulnar  paralysis 

127 

-  cardiac,  from  fatty  heart  . . 

241 

-  headache  from 

326 

with  herpes  zoster 

494 

-  Charcot-Leyden  crvstals  in 

-  pulmonary,  in  mitral  stenosis 

in  hysteria          . .         166 

548 

117, 

179 

245,  317,  320 

323 

inflammation    near    pos- 

- clubbed  fingers  in  .  . 

128 

haemoptysis  from           317 

323 

terior  root  ganglion  of 

-  constipation  in 

149 

-  Stokes-Adams'  disease  from 

97 

cervical  nerves  from  .  . 

494 

-  coryza  with  .  . 

203 

-  after  syphilis          . .        233, 

238 

in  Jacksonian  epUepsy  . . 

161 

-  Curschmann's  spirals  in   . . 

179 

bruits  in  .  . 

105 

joint  affections   . .           72 

384 

-  cyanosis  in  . . 

186 

-  thrill  due  to 

790 

lower  neurone  types  dis- 

- differential  diagnosis  of     . . 

582 

-  thrombosis  and  embolism  from  286 

tinguished  from  others 

634 

-  drugs  relieving 

582 

-  rdcer  of  leg  from     . . 

810 

in  myasthenia  gravis     . . 

687 

-  dyspnoea  the  essential  sym- 

- unequal  pulses  from 

593 

from  neoplasms   . . 

72 

ptom  of    . . 

582 

-  vertigo  due  to 

828 

of  one  leg 

541 

-  eosinophilia  in          179,  249, 

582 

Athetosis  (and  see  Contractions) 

153 

ovarian     . . 

24 

-  insomnia  in             . .         .356, 

359 

-  accoucheur's  hand  in 

3 

paralysis  of  arm  with     . . 

549 

-  orthopnoea  in 

465 

-  bilateral 

154 

in  peripheral  neuritis 

-  other  diseases  mistaken  for 

582 

-  in  birth  palsies 

155 

285,  390,  462,  488,  559,  562, 

849 

-  polycythsemia  in               579, 

580 

-  congenital  diplegia             799 

800 

peroneal    . .          .  .         127 

128 

-  poljTiria  after 

581 

-  from  cortical  lesions 

336 

paralysis  of  arm  in     . . 

554 

-  shortness  of  breath  from  . . 

579 

-  facial  paralysis  with 

536 

from  pohomyeHtis          128 

585 

-  spasmodic  dyspncea  from . . 

249 

-  hemiplegia  with  155, 157,  336 

799 

progressive  (see  Progressive 

-  uraemia  mistaken  for 

582 

-  inf  antCe  hemiplegia  with  .  . 

68 

Muscular  Atrophy) 

-  s-rays  in  diagnosis  of 

582 

-  primary  or  idiopathic 

154 

or    pseudo  -  hypertrophy 

Astigmatism,  headache  due  to 

Athletes,  albuminuria  in 

19 

in  myopathy  .  . 

555 

327,  498, 

783 

-  aortic  disease  in    . .        237, 

244 

in  sciatica 

487 

-  monocular  diplopia  in 

198 

-  cardiac  impulse  in  . . 

332 

slight  in  osteo-arthritis . . 

384 

-  neuralgia  in 

498 

-  enlarged  left  ventricle  in  . . 

232 

spondyhtis  deformans    . . 

-  ophthalmoscopic  appearance 

-  semimembranosus  bursa  in 

762 

svringomyelia     ..285,  554, 

665 

of  (Flate  Vim    .. 

463 

Atmospheric  conditions  caus- 

- -  taUpes       . .          . .        130, 

132 

-  pain  in  mid-orbital  region  in 

498 

ing   shortness    of   breath. 

101 

thenar,  in  Tooth's  neuro- 

- tenderness  of  forehead  from 

783 

epista.xis  due  to  . . 

251 

muscular  paralysis 

132 

ATROPHY,    MUSCULAR- 

-BACK. 

865 

Atrophy,  Muscular,  conld. 

Babinski's  sign,  conld. 

Bacillus  influenzcp,  contd. 

of     toiigue      in     bulbar 

Brown-Sd^iuard  paralysis 

540 

acute  tonsUlitis  from 

670 

paralysis           ..224,641 

686 

children 

557 

bronchopneumonia  from 

321 

from  traiisvei-se  myelitis 

563 

with    compression    para- 

 in  the  circulating  blood . . 

650 

with  tuberculous  hip     18.3, 

386 

plegia    

786 

importance  of  examining 

-  -  in  ulnar  iiaralj'sis 

127 

in   disseminated  sclerosis 

sputum  for 

702 

varieties  of  primary 

158 

174,  539,  .542,  547, 

800 

laryngitis  from    . . 

670 

of    prOL'ressive    neuro- 

 with  exaggerated  knee  jerks 

397 

pharyngitis 

G70 

muscular 

158 

I'^riedreich's  ataxy            82, 

559 

small  size  of 

702 

-  optic  (see  Optic  Atrophy) 

hemiplegia           . .         164, 

337 

in   sputum 

321 

-  of  the  skin  in  sclerodermia 

781 

in  paralysis  of  legs 

82 

-  lactis  aerogenes  in  bacilluria 

616 

ATROPHY,  TESTICULAR    .. 

78 

paraplegia  from  spinal  caries 

558 

-  of  leprosy     . . 

75 

from  epididymitis 

454 

primarylateral  sclerosis. . 

567 

-  mallei  in"  buUae 

112 

-  -  after  Konorrluea .  . 

454 

upper  extremity     . . 

547 

in  glanders 

603 

impotence  from  . . 

347 

paraplegia 

494 

sputum     . . 

704 

obesity  in            . .        453, 

454 

with  pyramidal  tract  lesion 

546 

-  paratypliosus  A  and  E 

697 

from  orchitis       . .        454, 

519 

spastic    paralysis    of  one 

-  pneumonife     (see     Bacillus 

-  Tooth's  peroneal  (see  Tooth's) 

leg         

539 

Priedlander) 

Atropine  harmful  in  glaucoma 

257 

subacute    combined    de- 

- producing  lactic  acid  in  the 

-  infantile  convulsions  from 

170 

generation  oC  the  cord 

493 

vagina 

210 

-  in  iritis 

257 

syringomyelia 

554 

-  proteus  vulgaris  in  bacilluria 

616 

-  relief  of  eye-strain  by 

498 

in  talipes. . 

131 

-  pyocyaneus,  pemphigus  neo- 

Attic,   tympanic,     caries     of 

transverse  myelitis 

74 

natorum  from     .  .          Ill 

113 

ossicles  from  supyiuration  in 

470 

BaciUfemia,  account  of 

650 

in  tlie  circulating  blood. . 

650 

Auditive,  definition  of 

685 

Bacilluria  (see  Bacteriuria) 

coloured  sweat  due  to    . . 

714 

Auditory  aura  of  epilepsy     . . 

80 

Bacillus  aerogenes  capsulatus, 

in  empyemata     . . 

119 

-  meatus,   ivory   exostosis   in 

emphysema  due  to 

231 

green  or  blue  sputum  from 

704 

(see  also  External  Audi- 

- coll  communis,    bacteriuria 

in  impetigo 

113 

tory  Meatus) 

754 

due  to       . .          . .          83, 

615 

nephritis  due  to. . 

83 

-  nerve,  deafness  from  injury 

a  cause  of  vaginal   dis- 

- tetani  (Plate  XII,  p.  696) 

of,  in  fractured  base 

468 

charge 

211 

162,  463,  652 

802 

from  lesion  of  . . 

190 

in  cerebrospinal  fluid  . . 

340 

-  tuberculosis  (Plate  XII,  Fig. 

-  -  degeneration  in  tabes 

190 

circulating  blood 

650 

K,  p.  696) 

814 

tumour  of,  vertigo  due  to 

828 

cystitis  due  to      83,  264 

438 

in  ascitic  fluid     . . 

57 

-  word  centre .  . 

683 

in  empyemata . . 

119 

carbol-fuchsin  stain  for. . 

700 

AURA  in  epilepsy 

faeculent  abscesses 

264 

cerebrospinal  fluid        340, 

643 

SO,  81,  171,268,669,774 

,828 

gas  production  by 

cystitis  due  to         83,  312 

442 

-  flushing  as  au 

268 

231,  577,  578,  711 

713 

in  discharge  from  eye    . . 

808 

-  in  intracranial  new  growth 

80 

in  groin  abscess 

739 

examination  for  in  haemo- 

- Jacksonian  epilepsy 

174 

infection     of     pericar- 

ptysis   . .          . .        316 

317 

-  perverted  taste  as  an 

774 

dium    by 

711 

in  gum  scrapings 

87 

-  spasm  of  the  glottis  as  an. . 

828 

meningitis  due  to 

642 

laryngitis  from   . .        226 

670 

-  vertigo  as  an 

828 

nephritis  due  to 

83 

meningitis  due  to 

172 

Auricle,  single  cardiac 

184 

in  pleuritic  effusion    . . 

123 

metliods  of  concentrating 

701 

Auriculo-temporal  nerve,  skin 

pneumaturia  caused  by 

576 

nephritis  due  to  . . 

83 

distribution  of     . . 

659 

pneumothorax  from   . . 

577 

pharyngitis  from 

670 

Auriculo-ventricular  bundle  of 

pyelitis  due  to . . 

625 

pyelonephritis  due  to   . . 

83 

His,  lesions  of      ..          ..97,78 

pyelonephritis  due  to . . 

83 

in    sputum     in    phthisis 

Australia,    hydatid    cysts    in 

prostatitis  due  to 

83 

(Plate  XII,  Fig.  K)    87 

185, 

58,  323,  719 

720 

subcutaneous     emphy- 

319, 577,  578,  700,  701 

712 

Austria,     impetigo      herpeti- 

sema due  to 

231 

in  laryngitis      226,  670 

672 

formis  in . . 

113 

In  subphrenic  abscess . . 

711 

tonsillitis  from    . .        670 

672 

Automatism,  post-epileptic  25 

169 

ureteritis  due  to    82,  83 

515 

■ in  ulcer  of  tongue 

814 

Autophonia 

190 

-  diphtheriee 

181 

ureteritis  due  to . . 

83 

Axilla,  abscess  of  (see  Abscess, 

associated  with  foul  breath 

99 

in  urine  136,  310,  394,  513 

,628 

^\_xillary) 

in    cutaneoas    diphtheria 

602 

Ziehl-Neelsen    method  of 

-  bromidrosis  of 

714 

diagnosis          77,  203,  226, 

469, 

staining  lor      .  . 

700 

-  eczema  marginatum  of 

275 

602,641,672,673 

,807 

-  typhosus  in  bacilluria 

616 

-  erythrasma  of 

276 

diphtheria 

641 

bile  passages 

371 

-  glands  enlarged  in  (see  Lym- 

 of  ear 

469 

blood        . .          . .         610 

,650 

phatic  Glands,  Axillary) 

larynx 

466 

cerebrospinal  fluid 

340 

-  liairy,     in      infants,      with 

meningitis  due  to 

642 

cystitis  due  to     . . 

83 

hypernephroma  . . 

690 

in  the  throat      . .        185 

224 

in  empyemata     . . 

119 

-  hygroma  of  . . 

732 

vaginal  discharge  due  to 

211 

meningitis  due  to 

642 

-  lipoma  of     . . 

732 

-  dysenterife   . . 

91 

in  periosteal  abscess 

752 

simulating  tubercle 

732 

-  enteritidis    of    Gaertner    in 

pure  cultui-e  in  periosteal 

-  pediculosis  of 

447 

zymotic  diarrhcea 

426 

abscess  after  typhoid  f  ever752 

-  primary  tumours  of 

732 

-  f  cetidus,  cause  of  bromidrosis 

714 

pyelitis  due  to     . . 

625 

-  scabies  in     . . 

832 

-  Friedlander'S,  bacteriuria  from  83 

recognition  in  faeces 

610 

-  seborrhoeic     dermatitis     of 

447 

nephrhitis  due  to 

83 

vertebral  periostitis  from 

787 

-  sycosis  vulgaris  of  . . 

602 

pyelonephritis  due  to     . . 

83 

-  xerosis  in  normal  urethra   . . 

82 

Axillary  artery,  aneurysm  of 

ureteritis  due  to . . 

83 

Back,  acne  affecting  . .         531 

,604 

(see  Aneurysm,  Axillary) 

-  fusiformis,  acute   tonsUlitis 

-  lichen  scrofulosorum  affecting 

529 

-  swelling  (see  Swelling,  Axillary) 

from 

670 

-  lymphatic  drainage  of 

738 

Azoospermia,  sterility  due  to. . 

706 

laryngitis  from   . . 

670 

-  multiple  benign  sarcoid  of 

451 

Azotic  diabetes,  polyuria  in  583 

,584 

pharyngitis  from 

in  Vincent's  angina  (Plate 

670 

-  myoma  cutis  of 

-  pain  in  (see  Pain  in  Back) 

805 

DABINSKI'S  SIGN    (and  see 
D         Plantar  Reflexes) 

XII,  Fig.  J/)  . . 

627 

-  papular  syphilides  of 

532 

81 

Vincent's  . . 

99 

-  pulsating  tumour  in 

476 

absent  in  hysteria   82,  166 

800 

-  Gaertner's,     in    ptomame 

-  sebaceous  cyst  of    . . 

804 

in  alcoholic  intoxication 

82 

poisoning  . . 

597 

-  seborrhceic  eczema  affecting 

533 

amyotrophic  lateral  sclerosis 

serum  reaction  witli 

597 

-  stiffness  of  (see  Stiffness  of 

73,  554 

565 

in  zymotic  diarrhoea     . . 

426 

Back) 

birth  palsies 

558 

-  influenzae 

203 

-  varicella  affecting  . . 

833 

55 


866 


BACKACHE—BILE    DUCTS 


Backache  in  acute  nephritis. . 

48 

Balanitis,  contd. 

Beer-drinker's  heart   . . 

333 

-  from  endometritis . . 

220 

-  pain  in  the  penis  from 

515 

Beer-drinking,  polyuria  from 

-  in  epidemic  jaundice 

372 

-  penile  sores  ^vith     . .        674, 

675 

581, 

583 

-  sacralgia  in  cervical  catarrli 

509 

-  with  phimosis 

674 

-  excessive,  oedema  from     . . 

458 

in  pj-osalpinx 

632 

-  pyaemia  due  to       ..        624, 

631 

-  explosive  belching  from   . . 

639 

-  from  uterine  congestion     . . 

429 

-  stinking  discharge  in 

674 

-  oxaluria  from 

471 

-  in  variola 

301 

Bald  ringworm 

274 

-  plumbism  from 

136 

-  yellow  fever . . 

372 

-  tongue  in  scarlet  fever 

674 

Beetroot,  oxaluria  from 

471 

Backward  pressure  (see  Heart 

BALDNESS 

84 

Belching,  violent,  in  aerophagy 

267 

Failure.) 

-  from  folliculitis  decalvans  . . 

84 

from  beer-drinking 

639 

Backwardness  in  little's  disease  154 

-  due  to  luptis  erythematosus 

781 

Belladonna,  action  on  heart. . 

773 

Bacteria,  illustrations  of  (Piatt 

-  occipital,  in  rickets . . 

782 

-  anidrosis  from 

714 

XII)         

696 

-  premature    . . 

84 

—  delirium  from 

195 

Bacteriaemia,  account  of 

650 

-  in  progeria  . . 

218 

-  dry  flushed  skin  from 

195 

Bacteriology  of  ascitic  Auids 

57 

-  pseudopelade 

782 

-  dryness  of  mouth  from    . . 

789 

-  of  cerebrospinal  fluid 

339 

-  ringworm  of  scalp  . . 

274 

of  the  tongue  from 

773 

-  in  diagnosing  angina  ludovici 

459 

BaUet-dancers,  cramp  in 

177 

-  extreme  thirst  due  to 

789 

anthrax    . .          . .         459, 

603 

Ballooning  of  rectum 

153 

-  purpura  from 

596 

cause  of  prolonged  pyrexia 

609 

Bandaging,  gangrene  due  to  287 

282 

-  relief  of  constipation  by     . . 

144 

cellulitis   . . 

459 

Bands,  acute  obstruction  from 

-  scaly  eruption  due  to 

655 

cerebral  conditions 

558 

151, 

152 

-  secretions  dried  up  by  /     . . 

789 

coU  baciUuria 

848 

Banti's  disease 

43 

-  tachycardia  from   . .         772, 

773 

corneal  ulceration 

807 

anaemia  in            . .        694, 

696 

-  widely  dilated  pupils  from 

773 

cutaneous  diphtheria     . . 

602 

cirrhosis  of  liver  in        694, 

696 

Bell  sound  (see  Brnit  d'airain) 

empyema . . 

119 

clubbed  iingers  in 

129 

Bell's  palsy,  contracture  from 

165 

encephalitis 

558 

peripheral  neuritis  in     . . 

76 

definition  of        . .        533, 

537 

epididymitis 

766 

relation  to  splenic  anaemia 

411 

facial  asymmetry  from. . 

537 

erysipelas 

459 

spleen  enlarged  in        694, 

696 

Belly,  pendulous,  causing  ante- 

fungating  endocarditis  . . 

613 

Barium  test  for  carboluria  . . 

823 

version  and  dystocia 

227 

glanders   . . 

603 

Barley,relation  to  actinomyces 

705 

Bence-Jones  Albumosuria   .. 

21 

laryngitis              .  .        466, 

673 

Barlow's  disease  (see  Scurvy, 

albumose  in  urine 

5,  6 

meningitis    464,  558,  563, 

643 

Infantile) 

Benzene-cUoroform      method 

paralysis  of  palate 

640 

Barnard,  re  hepatic  abscess . . 

720 

of      measuring      specific 

phthisis   ■. . 

703 

Barrel-shaped  chest  . . 

191 

gravity  of  blood. . 

580 

post-typhoidal  abscess  . . 

74r4 

Baruria 

584 

Benzoic  acid,  reducing  body  in 

ptyaliim  . . 

591 

Bartholin      glands,      normal 

urine  due  to 

290 

pmnilent  rhinitis 

203 

secretion  from    . . 

210 

Beri-beri.  anaesthetic  areas  in 

75 

septicemia 

698 

Bartholinitis,  dyspareunia  from 

221 

-  diet  in  causation  of            75, 

460 

sinus  thrombosis 

558 

-  gonorrhoea  causing    221,  769 

770 

-  muscular  wasting  in 

75 

sore  throats          .  .         671, 

673 

-  pain  in  perineum  from    . . 

516 

-  CBdema  in     . .     "    . .          75 

460 

spinal  meningitis 

464 

Basedow's  disease  (see  Exoph- 

- peripheral  neuritis  in        75, 

460 

urethral  discharges 

631 

thalmic  G-oitre) 

-  relation  to  rice 

75 

Tincent's  angina 

672 

Basisphenoid,     fracture     of, 

-  rigors  in 

647 

-  in  sputum  analyses            702, 

704 

hemianopia  from 

335 

Besnier,  re  pityriasis . . 

530 

BACTERIURIA  "       .. 

82 

-  recurrent  fibrosarcoma  of. . 

204 

Biceps,  atrophy  of      . . 

560 

-  age  incidence  of 

615 

Basophile  cells  in  HodgMn's 

-  clonus  of 

161 

-  albumin  in  urine  in 

615 

disease      . .      41,  76,  303, 

695 

-  jerks  exaggerated  . . 

546 

-  B.  coU  in      . .          . .          83 

615 

characteristics  of  {Plate  II) 

29 

-  nerve  supply  of     . .        542, 

550 

-  B.  lactis  aerogenes  in 

616 

in  leuksmia        . .            3] 

33 

-  spinal  roots  supplying 

556 

-  B.  proteus  Ttdgaris  in 

616 

pernicious  anemia 

'  30 

Bicycling,    menorrhagia   from 

428 

-  E.  typhosus  in 

616 

splenic  anaemia    . . 

64 

Big-toe,  inabihty  to  extend,  in 

-  casts  in  urine  in 

615 

Bath  pruritius 

588 

Tooth's  peroneal  atrophy 

560 

-  cells  in  urine  in   . . 

615 

Baths,  hot,  in  insomnia  with 

.. 

Bilberries,  black  stools  after. . 

89 

-  clinical  symptoms  in 

84 

high  blood-pressure 

359 

Bile  changes  in  arseniuretted 

—  deposit  in  urine,  on   stand- 

Bathing-drawers    area,    erup- 

.-* 

hydrogen  poisoning 

374 

ii^,  in 

615 

tions  in     . .           447,  598, 

653 

-  and  fat  digestion     . . 

265 

-  frequency  of  micturition  in 

616 

Bazin's  disease 

450 

-  in  gastric  contents. .        845, 

846 

-  gastro-intestinal    symptoms 

aggravation      by      anti- 

-  inspissation,   jaundice  from 

in  . . 

616 

syplnhtic  treatment  . . 

451 

361 

364 

-  in  genito-urinary  affections 

83 

colour  of  skin  in. . 

451 

in  fungaiing  endocarditis 

368 

—  inguinal  and  perineal  pains  in 

84 

diagnosis  of  gummata  from  451 

-  iodine  test  for 

819 

-  offensive  urine  in    . . 

015 

nodules  of 

450 

-  in  peritoneal  cavity 

718 

-  pain  in  kidney  or  bladder  in 

616 

ulceration  of  legs  in 

450 

-  phosphorus  poisoning 

373 

-  pneumaturia  from  . . 

576 

Beading  of  ribs  in  rickets   182 

191 

Bile  ducts,  adhesions  round  362 

725 

-  in  pregnancy           . .           82 

615 

Beans,  oxaluria  from. . 

471 

carcinoma  of  (see  Carcinoma) 

-  pyehtis 

625 

Beard,  seborrhoeic  eczema  of 

533 

catarrh  of 

361 

-  pyrexia  due  to   G09,  615,  616 

621 

-  pediculosis  of 

447 

in  acute  yellow  atrophy 

370 

-  rigors  in 

616 

-  ringworm  of  (and  see  Sycosis) 

274 

pneumonia 

372 

-  in  suppurative  nephritis   . . 

646 

association  with  ringworm 

syphihs . . 

371 

-  sweating  in  . . 

616 

of  nails. . 

275 

cicatricial  contraction  of 

-  symptoms  of  cystitis  in      S3 

615 

BEARING-DOWN  PAIN 

473 

361,  362, 

365 

-  in  tuberciilous  cystitis 

442 

Bedclothes,     insomnia     from 

gall-stone  in 

410 

-  urine  acid  in 

615 

improper              . .        356, 

358 

infection  (see  Cholangitis) 

-  urine  characters 

83 

Bedford,   re  safranin  test    . . 

291 

kinking    in    hepatoptosis 

407 

-  without  symptoms . . 

615 

Bedroom,  hygiene  of  the 

358 

obstruction      in      arsenic 

Baker's  cyst    . .          . .        761, 

762 

Bedsore,  acute 

285 

poisoning 

374 

Balanitis  "a  cause  of  priapism 

585 

-  on  the  fingers 

266 

association  of  pressm-e 

-  chancre  with 

675 

-  in  hemiplegia 

811 

on  portal  vein  with 

696 

-  in  diabetes  . . 

675 

-  malignant  disease   . . 

718 

by  carcinoma  of  stomach 

366 

-  enuresis  with 

248 

Bee-sting,  bleeding  gums  due  to 

85 

causes  of          . .         361, 

362 

-  frequency  of  micturition  in 

438 

-  dysphagia  from 

225 

gall-bladder       enlarge- 

- from  gonorrhoea 

674 

-  lumpy    swellings  from 

747 

ment  in 

280 

—  in  gouty  subjects    . . 

675 

Beer,  arsenic  in 

576 

by  kidney  tumour     . . 

367 

-  multiple  shallow  ulcers  in. . 

674 

-  arsenical  neuritis  from 

77 

omental  tumour 

367 

BILE    DUCTS— BLISTERS 


867 


JJila  ducts,  contd. 

-  -  obstruction  by  ovarian  cyst  307 

parasites           . .        3G1,  3G4 

.  in  iihospliorus  poisoning  373 

Ijy  portal  glands          . .  58 

in  snake  poisoning      . .  37-1 

by  spasm         . .          . .  374 

suprarenal  tumour     . .  HG7 

in  toluyleuc  diamine  poi- 
soning          . .          . .  374 

by  uterine  tumour     . .  3G7 

-  -  stenosis,   large   liver   ami 

jaundice  in       .  .          .  .  305 
typlioid  bacilli  in            . .  371 

-  pigments.  Gmelin's  test  for  819 
colour  of  urine  from 

818,  819,  823 

Huppert's  test  for          . .  819 

nitric  acid  test  for           .  .  819 

-  -  yellow-coloured   foam    in 

urine    . .          . .          . .  819 

-  in  snake  poisoning  . .          . .  374 

-  toluylene    diamine    poison- 

ing               374 

Bilharzia  haematobia,  anoemia 

witli           37 

anal  ha'morrhage  in      . .  93 

blood  changes  due  to     . .  33 

cachexia  in           . .          . .  115 

CTStoscopic  appearances  in 

'  (Plale  VI,  Fig.  K,  p.  310) 

313,  514,  630 

eosinophilia  in     . .          . .  249 

geography  of       . .          . .  514 

-  -  hoematuria  in  304,  313,  630 
ova  in  urine  in  (Fig.  13, 

p.  93) 313 

pain  in  groins  from        ..  513 

pyuria  due  to     . .        630,  623 

simulating    vesical    tuber- 
culosis . .          . .          . .  514 

ulceration  of  bladder  from  630 

Biliary  calculus  (see  Calculus, 
Biliary) 

-  colic  (see  Colic,  Biliary) 
Bilious  headache        . .          . .  326 

-  typhoid  (see  Weil's  Disease)  596 
Biliousness,    effect     on     uric 

acid           817 

-  ptyalism  in..          ..          ..  591 

Bilu-ubin          360 

-  origin  of  urobilin  from       . .  818 

Biliverdm         360 

Biot's  breathing  . .  . .  124 
Bird  feeders,  aspergillosis  in. .  705 
lisemoptysis  in     . .          . .  705 

-  foods,  sporotrichosis  from  322 
Bu'd's  test  for  sugars  in  urine  290 
Birds,  uric  acid  excretion  in. .  817 
Birth  palsies  .  .  155,  556,  558 
Bismuth,  black  stools  from  89,  428 

-  and  x-ray   test  in  constipa- 

tion (Figs.  32-35 ) 

141, 142,  145,  146 

gastrectasis          . .          . .  714 

Hirschsprung's  disease   . .  433 

cesophageal  obstruction 

223,  296 

pouch    . .          . .          . .  842 

pneumothorax     . .          . .  578 

pyloric      or       duodenal 

obstruction      . .          . .  571 

stricture     of     intestine, 

(Fig.  38)           . .          . .  146 

test  for  sugar       . .          .  .  290 

visceroptosis        . .        147,  473 

Bitter  taste  in  mouth  in  active 

congestion  of  liver          . .  371 

"  Black-dot  "  ringworm  . .  274 
Black  sputum  in  people  living 

in  smoky  atmospheres    . .  704 

"  Black  vomit  "  in  yellow  fever  301 
Blackening  of  ears  in  ochronosis  822 

Blacksmith's  cramp   . .          .  .  177 


Blackwater  fever,  etiology  of  315 

coma  in    . .          . .          . .  130 

hajmoglobinuria  in          . .  315 

purpura  in           . .          . .  590 

Bladder,     abscesses     opening 

into           . .          . .        024,  631 

-  adhesions,  micturition    fre- 

quent in  appendicitis  with  032 

-  affections,  bearing-down  pain 

from          . .          . .          . .  473 

pain  in  penis  from           . .  510 

pueumaturia  caused  by. .  570 

rectal  examination  in    306, 307 

surgical  emphysema  from  231 

-  air  in            711 

-  appendix  abscess  ruptured 

into           . .          . .          . .  313 

-  atony  of,  difficult  micturition 

in 440 

-  bacillus  coli  infection  of     . .  264 

-  bilharzia   infection   of    (see 

Bilharzia) 

-  blood-clot  in,  causing  diffi- 

culty in  micturition       . .  439 

-  carcinoma  of  (see  Carcinoma 

of  Bladder) 

-  congestion  of,  a  predisposing 

cause  of  cystitis  . .          . .  627 

-  in  cystocele,  simulating  pro- 

lapse of  uterus    . .          . .  587 

-  diseases  of,  pain  in  back  in  470 
the  leg  from     . .          . .  491 

-  displaced  by  hypertrophied 

cervix  uteri          . .          . .  587 

-  distended,  catheter  in  diag- 

nosis of 730 

dystocia  due  to               . .  227 

from  enlarged  prostate  52,  730 

felt  per  rectum    . .          . .  638 

mistaken  for  ovarian  cyst  730 

pregnant  uterus          . .  730 

urachal  cyst    . .          . .  730 

pelvic  swelling  due  to     757,  758 

physical  signs  of             . .  52 

priapism  from     . .          . .  586 

from   retroverted    gravid 

uterus  . .  . .  52,  730,  758 
simulating  ascites  (Fig.  191, 

p.   730)  52,  7*17,  730 

-  enormous    distention    from 

retention              . .          . .  440 

-  evidence  of  bleeding  from . .  305 

-  extroversion  of,  simulating 

prolapse  of  uterus           .  .  587 

-  fistula  causing  pneumaturia  576 

-  gangrene   of,  in   cystitis   . .  627 

-  hernia  of       . .          . .          .  .  742 

pyuria  in           .  .          .  .  632 

-  inflammation  of  (see  Cystitis) 

-  injury,  abnormal  micturition 

from          . .          . .          . .  443 

diagnosis  of          . .          . .  308 

fracture  of  pelvis  causing  308 

free  fluid  in  abdomen  in  308 

lia>maturia  in       . .          . .  304 

-  invaded  by  carcinoma,  faeces 

or  flatus  per  uretliram  . .  632 

of  rectum         . .          . .  313 

urine  per  vaginam      . .  632 

of  uterus          . .          . .  313 

vagina  . .          . .          . .  313 

-  irritability  of           . .          . .  817 
in  oxaluria           .  .          . .  471 

-  involved  in  intestinal  ulcera- 

tion             313 

-  normal  Umits  of      .  .          . .  730 

-  papilloma  (see  Papilloma  of 

Bladder) 

-  pain  (see  Pain  in  Bladder) 

-  paralysis  of  motor  nerves  . .  443 

-  simple  ulcer  of  (see  Ulcera- 

tion of  Bladder) 

-  sounding  for  calculus        . .  629 

-  stammering              . .          . .  439 


Bladder,  contd. 

-  suocussion  splash  in  . .     711 

-  tapped      in      mistake     for 

ascites  . .  . .  . .         717 

-  trouble  (and  see  Micturition, 

Abnormalities  of)  in  cere- 
bellar tumour      .  .  .  .     565 

disseminated   sclerosis   . .     565 

locomotor  ataxy. .  . .     562 

transverse  myelitis         . .       74 

-  tuberculosis    (see    Cystitis, 

Tuberculous) 

-  tumours  (and  see  Carcinoma 

of  Bladiler  ;     and  Papill- 
oma) description  of        . .     513 
pain  in  penis  during  mic- 
turition due  to  . .     512 

renal      enlargement    and 

profuse  hiematuria  from    395 

pedunculated,     retention 

of  urine  from  . .  . .     441 

sudden  stoppage  of  urine 

by  ..  ..         439,  512 

-  ulceration  of  (see  Ulceration 

of  Bladder) 

-  yeasts  in,  pneumaturia  from    570 
Blanching,  haemorrhages  caus- 
ing severe  . .  . .     139 

Bleaching-powder  test  for  indican 

349,821 
Bleb  (see  Bullae) 
Bleeding  from  ear  in  otitis   ..    468 

diagnosis  of  cause  of      . .     408 

from  erosion   of  internal 

carotid  artery  . .     468 
of  lateral  sinus  . .     468 

-  -  fractured  base      138,  467,  468 

injury       . .  . .        467,  468 

malignant  disease  . .     468 

testing  of  hearing  in       . .     468 

BLEEDING    GUIVIS      ..         85,293 

in  alveolar  abscess  86,  87 

asthenia       . .  . .         85,  87 

dermatitis  herpetiformis   80,  88 

dyspepsia  .  .  85,  87 

erytliema  bullosum  80,  88 

gangrenous  stomatitis      80,  88 

liEemophilia  . .  . .       85 

Hodgkin's  disease  . .     302 

infantile  scurvy  . .  . .     115 

phagedsena  oris         . .       86,  88 

pyorrhoea  alveolaris  80,  87 

tartar        .  .  .  .  86,  87 

variola  maligna  . .  . .     301 

-  -  yellow  fever        . .        301,.  373 

-  nose  (see  Epistaxis) 

-  occult(seeHiemorrhage,  occult) 

-  from  slight  causes  in  heemo- 

philia        . .  . .  . .     599 

-  uterine    (see    Menorrhagia  ; 

Metror'rhagia ;  and  Metro- 
staxis) 

-  vulval  from  urethral  prolapse    770 

from  urethral  caruncle  . .     770 

Blepharitis,  ectropion  from..     250 

-  epiphora  in  . .  . .     250 

-  in  Mongolian  idiocy  . .     263 

-  from  nuclear  facial  paralysis     536 
Blindness  (see  Vision,  Defects 

of;  Night-blindness;  and 
AVord-blindness) 

-  with   liysterical    hemianaes- 

the.sia        . .  . .  . .     666 

-  monocular,  in  migraine     . .     836 

-  nystagmus  with      . .  . .     452 

-  optic  nerve,  in  idiocy         . .     557 

-  strabismus  due  to  . .  . .     709 

-  sudden,  various  causes  of..     839 

-  total,  causes  of       . .        839,  840 

-  transient  in  ursemia  . .     839 

-  word,  with  word  deafness        684 

Blinking  tic 159 

Blistering  by  malingerers,      . .     Ill 
Blisters  (see  BuUie) 


868                        BLOOD 

PER    ANNUM— BONES, 

NECROSIS  OF 

BLOOD  PER  ANUM.. 

89 

Blood  examination,  contd. 

Mood-pressure,  low,  contd. 

in  acute    yeUow   atrophy 

m  pernicious  anaemia     . . 

616 

anaemia     . . 

329 

of  liver             . .        302 

370 

relapsing  fever  (Plate  XII) 

698 

asthenia   . . 

96 

adhesive  pylephlebitis    . . 

301 

splenomeduUary      leukae- 

 heart  disease 

329 

anaemia  with       . .            36,  90 

mia 

693 

-  normal  in  functional  albu- 

 due  to  gastric  ulcer  . . 

40 

-  in  fseces  in  carcinoma  of  colon 

minuria    . . 

584 

in  ankylostomiasis 

570 

147, 

393 

-  in  renal  and  arterial  sclerosis 

14 

carcinoma  of  bowel       125 

150 

-  loss  of  (see  Haemorrhage) 

-  tabes  dorsalis 

350 

colon            91,  145,  147, 

367, 

-  occult     ("see     Haemorrhage, 

Bloody  effusion  in  chest  (see 

393,  690,  731 

736 

Occult) 

Chest,  Bloody  Effusion  in) 

rectum  . .          . .        150, 

636 

-  parasites  in  . . 

33 

Blotches,  in  secondary  syphilis 

425 

stomach 

351 

Blood  per  rectum  (see  Blood 

Blows  causing  deafness 

191 

cirrhosis  of  liver 

per  Anum) 

-  purpura  from          .  .         596, 

597 

300,  368,  409 

696 

-  specific  gravity  increased  in 

Blubber  lips    . . 

746 

with  colic 

134 

coUapse     . . 

580 

Blue  line  on  gums  in  lead  poison- 

 coUtis        . .          . .         197 

501 

of,  in  diabetes  insipidus 

584 

ing     38,  77,  136,  139,  144, 

153, 

colour    due   to  action   of 

method  of  measuring 

580 

507,  551,  645 

798 

digestive      juices      on 

-  spirochaeta  obermeieri  in  . . 

373 

-  piU,  polyuria  after. . 

582 

hsemoglobiQ 

428 

-  in  sputum  of  phthisis  (and 

-  vision  from  cataract 

840 

-  -  from  duodenal  ulcer     300, 

500 

see  Haemoptysis) 

176 

Blushing,  definition  of 

268 

dysentery             . .  91 ,  501 

727 

-  in  the  stools  (see  Blood  per 

-  absence  of,  in  cervical  sym- 

 in  enteritis 

444 

Anum) 

pathetic   paral5'sis 

247 

from  gall-stones  . . 

300 

BLOOD-PRESSURE,  ABNOR- 

Bockhart, follicular  impetigo  of 

601 

-  -  gastric  ulcer 

298 

MAL          

95 

Boeck,     re    multiple     benign 

fromhfemorrhoids  in  alco- 

- high,  abdominal  angina  with 

486 

sarcoid 

4.=)1 

holism  . . 

243 

accentuated  heart  sounds 

Boiler-makers,  deafness  in  . . 

191 

Henoch's  purpura          380 

600 

with      . .          . .       1,  3, 

252 

Boiling  test  for  albuminuria 

5 

intussusception 

albuminuria  with            19, 

526 

Boils  (and  see  Pustules) 

148,  152,  196,  636,  727 

736 

alcohol  causing   . . 

238 

-  in  ankylostomiasis  . . 

570 

invagination  of  rectum  . . 

150 

amenorrhoea  with 

24 

-  enlarged  gland  secondary  to 

708 

mesenteric  embolism 

153 

angina  pectoris  vs-ith     350 

582 

-  septic  arthritis  from 

375 

mucomembranous  colitis 

727 

arteriosclerosis  with 

64, 

-  stifii  neck  from 

708 

polypus     . . 

635 

186,  239,  240,  251, 

329, 

-  swelling  of  scrotum  fi'om  . . 

765 

purpura  haemorrhagica  . . 

600 

331,  433,  464,   582, 

639 

Bone  in  embryonia  of  kidne}- 

395 

tuberculous  peritonitis  . . 

719 

asphyxia  . . 

64 

-  enlargement     of     ends     of, 

sigmoid  colon   . . 

731 

cerebral  hsemorrhage  with 

in     hypertrophic     osteo- 

 ulcerative  colitis . . 

727 

96,  98,  138,  173,  337, 

563 

arthropathy 

390 

variola  maligna    . . 

301 

Cheyne- Stokes    respiration 

-  tumours,  albumosuria  in   . . 

21 

-  in  carbon  monoxide  poisoning 

138 

with 

125 

Bones,  abscess  of  (see  Abscess 

-  casts,  renal  . . 

7 

in  chronic  lead  poisoning 

507 

of  Bone) 

-  changes     common     to     all 

cirrhosis  of  the  Uver 

251 

-  in  achondroplasia  . . 

214 

severe  anfemias  . . 

27 

enlarged  heart  with 

526 

-  acromegaly  .  .          .  .          262 

585 

-  Charcot-Leyden  crystals  in 

epistaxis  from     ..        251, 

252 

-  acute  osteo-myelitis 

751 

117, 

118 

errors  of  digital  estimation  of  95 

-  atrophy     of,      in      general 

-  coagulation-time  of 

430 

in  gastric  crisis  of  tabes. . 

485 

paralysis  of  the  insane.  . 

269 

-  deficient    coagulability    of, 

gout          

251 

in  tabetic  arthritis 

388 

menorrhagia  from        428, 

430 

granular  kidney 

-  carcinoma  of 

757 

-  destruction     in     toluylene- 

122,  186,  251,  464 

629 

-  caries  of  (see  Caries  of  Bone) 

diamine  poisoning 

374 

headache  in         . .         326 

329 

-  in  congenital  syphilis  (Fin. 

-  discharge  from  nipple,  causes 

205; 

in  heart  disease  . . 

251 

78)             

259 

Blood-clot  in  bladder,  difficulty 

failure  from    .  .     18,  64 

186 

-  cranial  and  facial,  in  leon- 

in     starting     micturition 

sounds  in  estimation  of 

96 

tiasis  ossea 

753 

with          

439 

influence  of  rest  in  bed  on 

96 

hyperostoses  of,  m  leon- 

-  in  ureter,  colic  from          305, 

395 

insomnia  in         . .         356, 

359 

tiasis  ossea   . . 

749 

-  urine             . .          . .        136, 

305 

laryngeal  paralysis  with 

539 

-  enlarged  locally  (see  Swelling 

Blood-crescents  {Plale  XII,  p. 

lead  colic 

485 

on  a  Bone) 

696;           

373 

massage,  hot  baths,  high- 

-  fracture  of  (see  Fracture) 

Blood-culture  in  diagnosis  of 

frequency  currents  in 

359 

-  gumma  of  (see   Gumma   of 

cause  of  obscure  pyrexia 

medullary  softening  with 

343 

Bone) 

609 

620 

menorrhagia  from 

430 

-  hyperplasia  of,  in  acromegaly 

263 

fungating    endocarditis 

613 

methods  of  lowering     . . 

359 

in     hypertrophic     osteo- 

 septicaemia       . .        598, 

698 

metrorrhagia  from 

433 

arthropathy     . . 

390 

septic  conditions 

648 

mitral  regurgitation  from 

rickets       . .          . .         179 

214 

various     organisms    re- 

239, 

240 

-  injury  of,  swelling  due  to  . . 

750 

coverable  ftom 

650 

stenosis 

64 

-  innocent  tumours  of 

752 

-  diseases                         26  et 

seq. 

in  nephritis                      14 

48, 

-  invaded  by  epithelioma     . . 

814 

cachexia  in 

114 

56,   90,  102,  240,  303, 

454 

-  malignant  disoa^ie  of 

388 

causing     pleurisy     with 

acute  nephritis    . . 

12 

albumosuria  in 

21 

effusion 

122 

chronic  nephritis      64,  96, 

122, 

-  necrosis  of 

751 

peripheral  neuritis  in    . . 

75 

172,186,239,251,331,464 

629 

abscess  in  heart  from     . . 

650 

tenderness   in    the    chest 

noises  in  the  ears  with  . . 

794 

ansemia  with 

39 

from 

776 

ptyalorrhoea  with 

592 

-  -  anosmia  from 

668 

-  distribution    of,    medullary 

reduplicated  heart  sound 

diagnosis  from  sarcoma  751 

763 

centre  for  regulation  of 

619 

with 

639 

-  -  earache  from 

230 

-  examination   in   ankylosto- 

 renal  tube  casts  with     . . 

526 

foul  breath  due  to 

99 

miasis 

570 

retinitis  with 

526 

lichen  scrofulosorum  with 

529 

carcinoma  of  stomach  . . 

351 

sphygmomanometer     in 

obstruction  to  nose  by  . . 

668 

-  -  generalized  lymphatic  gland 

diagnosis  of     . . 

526 

pericarditis  from 

650 

enlargement      . .       416, 

419 

in  uraemia 

350 

from  phosphorus. . 

87 

Hodgkin's  disease 

617 

-  low   with   acute  abdominal 

popliteal  abscess  due  to. . 

762 

instruments  for  . . 

27 

pains  except  lead  colic 

ptyalism  due  to  . . 

590 

in  lymphatic  leukaemia . . 

739 

and  tabetic  crisis 

485 

stomatitis  due  to 

590 

-  -  malaria  {Plate  XII,  p.  696) 

Addison's  disease 

from  syphilis 

237 

371,  615,  693, 

698 

38,  329,  843, 

849 

talipes'from 

132 

BONES— BRIGHT'S    DISEASE 


869 


Bones,  cmul. 

-  node  on        . .  . .  . .     750 

-  in  osteitis  deformans         . .     753 

-  osteogenesis  imperfecta     . .     213 

-  osteomalacia  . .         213, 214 

-  pain  in,  in  sypliilis  (and  see 

I'aiu  in  Bone^     . .  . .     503 

-  in  rickety  dwarfism  . .     21-t 

-  sarcoma    (see    Sarcoma    of 

BoneJ 

-  sinus  in  connection  with    . .     751 

-  spontaneous  fracture  of,  in 

scurvy-rickets      .  .  .  .      753 

in  new  sjrowtli  of        269,  757 

tuberculous  disease  of        2()9 

-  subperiosteal    extravasation 

on,  node  after     . .  . .     750 

-  syrinaromyelia  . .  . .     2S5 

-  swelling    on    (see    Swelling 

on  a  Bone) 

-  syphilis  of,   diagnosis  from 

tuberculous  periostitis  . .     752 

-  tenderness  of,  in  scurvy  and 

rickets      .  .  . .  -i-l,  115 
in  secondary  sypliilis     . .     672 

-  thickening  of,  from  clironic 

osteomyelitis       . .  . .     751 

clironic    periostitis    (Fiff. 

192) 751 

due  to  gumma    . .  . .     752 

in  osteitis  deformans     . .     753 

a-ravs    in     diagnosis     of 

(Fios.  196, 198,  199)  . .     751 

-  transparency   to   a;-rays   in 

rheumatoid  arthritis  (Fig. 
110)  380 

-  tuberculous  disease  of       . .     751 

diagnosis  from  gumma     752 

sites  of  commencement     751 

-  unaffected  by  lupus  vulgaris  SOS 
Bone-marrow  affections,  Bence- 

Jones'  albumosm-ia  in  . .       21 
eosinophUia  in     . .  . .     2i8 

-  splenomegalic  polycythsemia 

a  disease  of         . .  . .     581 

Bony    out-growtlis    in    osteo- 
arthritis and  gout        383,  384 
Boots,  buUie  due  to    . .  . .     110 

-  relation  to  ilorton's  disease     438 

-  tight,     causing     metatarsal 

neuralsia  . .  . .  . .     488 

talipes    .  .  .  .  .  .     132 

whitlow..  ..  ..     445 

BORBORYGMI 96 

-  absent    with    general   peri- 

tonitis 97,431,  644,  645 

-  in  intestinal  colic    . .         473, 645 

obstruction  . .         153, 431 

Boring  epithelioma  of  jaw     . .     749 
Bossing  of  skull  in  rickets     . .     753 
"  Bossy  "  nodules  in  tubercu- 
losis of  testis       . .  . .     519 

BotlniocephaUts     infection, 

albuminuria  in    . .  . .       17 
anemia  in           33,  37,  459,  568 

-  -  cachexia  in  . .  . .     115 

eosinophilia  in     . .  . .     249 

oedema  of  legs  in  459, 461 

-  (see  also  Tape-worm)  (Fig.lol)  568 
B6ttLrer"s  test  for  glycosuria  290 
Bottle-nose  in  cirrhosis  of  liver  300 
Bougie  in  diagnosis  of  calculus 

in  urethra  . .  . .     439 

-  danger  of   passing   in    dys- 

phagia      .  .  .  .  .  .      222 

cesophageal  pouch         . .     842 

urethral  stricture  .  .     439 

-  olive-pointed     flexible,     in 

urethral  stricture  . .     440 

Bovine    cough    in    laryngeal 

paralysis  . .  . .        53S,  539 

-  heart  233 

Bowed  legs  in  achondroplasia  212 
from  rickets        . .  . .     212 


Bowel,  casts  of,  in  membranous 

colitis        . .  . .  . .     444 

Boxing,  enlarged  heart  from      244 

Boj's,  excessive  fatness  of,  in 

hypernephroma  . .  . .     454 

Brachial  artery,  unequal  pulses 

from  atlieroma  of         . .     593 

-  nerves,     table     of     muscles 

innervated  by  550,  556 

-  neuralgia  (see  Neuralgia,  Brachial) 

-  neuritis  (see  Neuritis,  Brachial) 

-  palsy  (and  see  Paralysis  of 

Extremity,  Upper)         .  .      545 

-  plexus     disease,     diagnosis 

from  progressive  muscu- 
lar atrophy  . .  . .       73 

interference  with  by  thjrroid 

gland  tumoiu". .  ..     792 

lesions,  muscular  atrophy  in  74 

palsy  (see  also  Erb's,  Du- 

chenne's,  and  Klumpke's 
Palsies)  . .  . .     552 

paralysis    of     arm    from 

injuries  to         .  .  . .      552 
from  presstire  of  cer- 
vical rib  on         . .          . .     539 

table    of    innervation    of 

muscles  by      . .  . .     550 

Brachialis  anticus  muscle,  nerve 

supply  of  . .  550,  556 

Brachvceplialy   in   Mongolian 

idiocv        263 

BRADYCARDIA  ..97,98 

-  in  aortic  stenosis     . .  . .     235 

-  cerebellar  abscess   . .  . .     644 

-  fattT  heart 241 

-  jauncUce        . .  . .  98,  361,  365 

-  Stokes-Adams'  disease       ..     172 
Brain,   coma  due  to  compres- 
sion of      . .  . .  . .     137 

-  concussion   (see   Concussion 

of  Brain) 

-  cystic,  congenital   . .  . .     558 

-  fatigue  in  neturasthenia      . .     506 

-  injury,  testis  atrophy  after         79 
Clieyne-Stokes'     respira- 
tion after  .  .  . .      125 

coma  after  . .  . .     136 

diagnostic  importance   of 

aura  in  localizing        . .       80 

-  not  coloured  in  jaundice  . .     361 

-  syphilis  of  (see  Syphilis,  Cerebral) 

-  tuberctilous  nodule  in       . .     341 

-  tumom:      (see      Cerebrum, 

Tumour  of) 
Bramwell's  test  of  pancreatic 

infantilism  .  .  .  .     216 

Brassy    cough    in    laryngeal 

paralysis  . .  . .        538,  539 

Braim's  sign  in  pregnancy  . .  437 
Brazil,  ankylostomiasis  in  . .  570 
Bread-crumbling    movements 

in  paralysis  agitans       . .     796 
Breast,  abscess  of,  (see  Abscess, 

Mammary) 

-  atrophy  of,  carcinomatous        745 

-  carcinoma  of  (see  Carcinoma 

of  Breast) 

-  cliauges  in,  in  lactation     . .     743 

the  new-born       . .  . .     743 

in  pregnancy       . .  . .     743 

of  puberty  .  .  .  .      743 

-  cyst  of  (see  Cysts  of  Breast) 

-  cystic  disease  of      . .  . .     744 

-  enchondroma  of       .  .         744,  754 

-  fibro-adenoma  of,  absence  of 

enlarged  axillary  glands  in    744 

age  incidence  of  . .  . .     744 

characters  of         743,  744,  745 

cystic  change  in. .  . .     744 

from  carcinoma  744,  745 

chronic  mastitis  . .     744 

cyst  . .  . .  . .     744 

early  sarcoma      . .  . .     746 


Brea.1l,  fibro-adenoma  of,  contd. 

free  mobility  of  . .          . .  744 

the  only  conmion  innocent 

tumour  of  breast         . .  744 
rarity  of  . .          . .          . .  744 

-  fullness  and  pigmentation  of, 

in  pregnancy       . .          . .  350 

-  hydatid  cyst  of        .  .          . .  202 

-  hypersestllesic  patclies  in,  in 

hysteria    . .          . .          . .  667 

-  linea;  albicantes  on             . .  402 

-  lipoma  of,  rarity  of              . .  744 

-  male,  milk  in           . .          . .  202 

-  mode  of  examination  of     . .  742 

-  multiple  cystic  disease  of. .  744 

-  myoma  cutis  of       . .          . .  805 

-  pain   in   (see    Pain   in    the 

Breast) 

-  redness  of,  in  mastitis        . .  743 

in  tuberculosis   . .          . .  744 

swelling  and  tenderness  in 

mastodynia      . .          . .  479 

-  sarcoma  of  (see  Sarcoma  of 

Breast) 

-  sinus  of,  tuberculous          . .  744 
Breast  swellings,  general  dis- 
cussion of     742,  743,  744,  745 

-  tuberculosis  of         . .          .  ■  744 

-  unilateral    hypertrophy    of, 

from  fibro-adenoma        . .  743 

from   putting   children 

to  the  breast            . .  743 

-  veins  of,  dilated  in  pregnancy 

and  lactation  . .  .  .  743 
Breath,    characteristic    catch 

in  gall-bladder  affections  499 

BREATH,  FOULNESS  OF      ..  98 

with  bronchiectasis        . .  579 

catarrhal  jaundice          .  .  365 

gangrene  of  lung            . .  321 

-  -  gastritis    . .          . .       ...  297 

pyorrhoea  alveolaris       . .  87 

stomatitis             . .          . .  88 

Vincent's  angina             . .  672 

BREATH,     SHORTNESS    OF 

(and  see  Dyspnoea,  Ortho- 

pnoea,    etc.)        . .          . .  100 

in  ankylostomiasis          . .  570 

bronchitis     and     emphy- 
sema    . .          . .          . .  579 

cachexia   . .          . .          . .  115 

fibroid  limg          . .          . .  579 

goitre        . .          . .          . .  792 

Graves'  disease    . .          . .  792 

mitral  regurgitation       ..  103 

stenosis             . .          . .  579 

pericarditis          . .          . .  480 

polycythsemia  in           100,  579 

renal  disease  13,  14,  579 

spasmodic  asthma          . .  579 

subplirenic  abscess         . .  721 

-  smell  of,  in  alcoholic  coma  138 
in  ursemia            . .          . .  350 

-  sounds  (see  Vesicular  JFurmur) 
Breathing,  Cheyne-Stokes  (see 

Cheyne-Stokes  Respiration) 

-  difficulty  in  (see  Dyspnoea, 

etc.) 

-  laboured,  in  convulsions   . .  169 

-  paiioful,  with  gall-stones    . .  486 

in  intercostal  nemralgia  478 

phrenic  neiualgia            . .  478 

with  pleurisy       . .          . .  479 

pneumothorax     . .          . .  ■  480 

-  rapid  shallow,   in  pneumo- 

thorax      . .          . .          . .  577 

-  stertorous,  in  convulsions. .  169 

-  tubular-      (see       Bronchial 

breathing) 
Breathlessness    (see     Breath, 

Shortness  of) 

Bright  eye  in  Bright's  disease  256 
Brlght's  disease,  albuminuria  in 

11, 12,  466 


870 


BRIGHT' S    DISEASE— BRONCHITIS 


Bright s  disease,   could. 

Brigfit's  disease,  acute,  conid. 

Bronchial  hrealhing,  contd. 

albumosuria  in    . . 

12 

after  scarlet  fever 

671 

lobar  pneumonia           186, 

701 

amenorrhcea  in  . . 

23 

simulated  by  angioneu- 

 in  lung  compression 

332 

ansemia  in 

90 

rotic  cedema  (Fig.  128) 

458 

phthisis    . . 

319 

anasarca  -n-ith      . .            4S 

,  54 

by  excessive  drinking 

458 

pleuritic  effusion 

193 

aortic  regnrgitation  in  . . 

107 

after  infusion 

458 

-  glands  (see  Lymphatic  Glands 

ascites  in. . 

63 

transfusion   . . 

458 

Bronchial) 

backward  pressure  in     . . 

48 

by  vena  cava  throm- 

Bronchiectasis, albumimu-ia  in 

18 

bacteriiiria  in 

83 

bosis 

825 

-  albumosuria  in 

20 

bulls  in    . . 

110 

sudden  onset  in 

311 

-  anfemia  in    . . 

39 

Chevne-Stokes  respiration 

symptoms  of   .  . 

48 

-  aneurysm  causing   . . 

324 

ui           . .          .  .         124, 

412 

universal  cedema  in  . . 

460 

-  causes  of 

324 

chlorides  in 

12 

urinary  changes  In     . . 

311 

-  cerebellar  abscess  from 

644 

conjunctival  oedema  of. . 

256 

chronic  (and  see  Granular 

-  cerebral  abscess  from        98, 

547 

contracted  granular  kidney 

Kidneys) 

-  Charcot-Leyden  crystals  in 

118 

in 

14 

albuminuria  in      13,  16, 

454 

-  clubbed  fingers  in     99,  129, 

703 

conTulsions  in     . . 

160 

albuminuric  retinitis  in 

-  cyanosis  from 

186 

diminution  of  total  solids 

303, 

454 

-  (flagnosis  from  gangrene  of 

in  urine  in 

626 

anaemia  in 

303 

lung          ..          ..        321, 

703 

distinguished  from  infarc- 

 big  heart  in     . . 

454 

epithelioma  of  bronchus 

324 

tion  of  kidney 

314 

cardiac  hypertrophy  with 

-  with  fibroid  lung,  diagnosis  of 

324 

physiological      albumi- 

303, 

331 

-  foul  breath  in 

99 

nuria     . . 

19 

chylous  ascites  in 

58 

taste  in     . . 

774 

epistaxis  in         . .          90, 

251 

convulsions  in . . 

160 

-  gangrene  of  lung  in 

287 

general  oedema  in 

466 

cramps  in 

179 

-  haemoptysis  In        . .        318, 

324 

haematemesis  rare  in 

299 

eosinophilia  in  diagnos- 

- heart  failure  from  . .          61, 

186 

haematuria  in       . .        304, 

316 

ing  asthma  from     . . 

249 

-  indicanuria  in 

349 

hiemoglobinuria  in 

315 

epistaxis  in 

295 

-  inspissated  mucus   . . 

324 

hsemorrhage  in   .  .          90, 

598 

general  pains  in  limbs  in 

503 

-  lardaceous  disease  in         10, 

696 

heart  faUure  from            63, 

461 

haematemesis  in         294, 

303 

—  leucocytosis  in 

400 

hypertrophy  of  heart  in  90 

245 

high  blood-pressure  in 

-  from  mediastinal  new  growthl21 

infantile  conrulsions  in. . 

170 

90,  102,  239,  240,  303 

454 

-  monoplegia  due  to. . 

547 

mercury  iniurious  in 

590 

hypothermia  in 

345 

-  multiple  rigors  from 

651 

mitral  regurgitation  from 

irritability  in  . . 

360 

-  no  elastic  fibres  in  sputum  in 

703 

239, 

240 

micturition  frequent  in 

437 

-  orthopncea  in 

464 

morning  headache  in 

327 

noises  in  the  ear  in  . . 

794 

-  osteo-arthropathy  in 

390 

multiple  serositis  in 

124 

of  old  people     . . 

14 

-  part  affected  by      . . 

703 

nerve  deafness  in 

191 

parenchymatous,  obesity 

-  periodical  return  of  symp- 

 nucleoproteid  in. . 

12 

in      . .          . .        453, 

454 

toms  m     . . 

703 

obesity  in            . .        453, 

454 

anaemia  due  to 

30 

cyanosis  from 

579 

oedema  in 

12 

-' polyuria  in         48,  102, 

303, 

-  physical  signs  of    .  .        193, 

703 

of  legs  in          . .         459, 

461 

331,  437 

583 

-  poiycythaemia  in    .  .        579, 

580 

pericarditis  in      . . 

122 

prolonged    first    sound 

-  rigors  in        . .          . .        648, 

651 

phosphates  in      . . 

12 

at  impulse  in 

454 

-  septic  arthritis  from 

375 

polyuria  in 

90 

renal  tube-casts  in 

454 

-  shortness  of  breath  with    . . 

579 

puffiness   and    oedema  of 

retinal  changes  in 

-  simulating  gangrene  of  lung 

288 

face  in  .  . 

746 

102,  103 

240 

-  sputum  in    ..          ..99,176, 

321, 

purpura  in           .  .         596, 

598 

ringing    aortic    second 

651,  703, 

842 

renal  tube-casts  in 

12 

sound  in 

454 

-  vomiting  from         . .        842, 

844 

in  scarlet  fever  . . 

674 

systolic  bruit  over  mitra: 

Bronchiolitis,      Curschmann's 

simulated     by     MOroy's 

area  in         . .        102, 

103 

spirals  in  . . 

179 

disease 

460 

thick  radial  artery  in . . 

240 

Bronchitis,  albumininia  in    .. 

18 

mysoedema 

43 

tortuous  arteries  in . . 

303 

-  ascites  in 

61 

oedema  of  convalescence 

459 

trace  of  albumin  in    . . 

331 

-  asthma  developing  into    1S6, 

582 

stridor  in. . 

709 

urinary  changes  in    240 

331 

mistaken  for 

582 

syphilitic  . . 

86 

vertigo  due  to . . 

828 

-  blood  streaks  in  sputum  of 

176 

tube-casts  in  urine  in   . . 

466 

of  young  people 

13 

-  capillary      

465 

uraemia  with 

48 

subacute,  anaemia  in     . . 

39 

extreme  dyspnoea  from . . 

642 

urea  in      . . 

12 

cachexia  in       . . 

115 

cyanosis  from 

185 

urine  changes  in    12,  16  et 

seq. 

chyluria  in 

126 

retraction  of  the  head  from 

642 

varieties  of  ascites  with . . 

54 

chylous  ascites  with  . . 

126 

sticky  sputum  in 

175 

pleural  effusion  in 

122 

Brightness  perception,  normal 

835 

-  Charcot-Leyden  crystals  in 

118 

various  forms  of .  . 

8 

Brittleness  of  bones    . .        213, 

285 

-  chronic,  clubbed  fingers  in 

128 

weakness  in 

90 

-  of  naiLs,  onychorrhexis 

445 

albuminuria  in    . . 

246 

acute,  anuria  in  . . 

48 

Broca's    area,    aphasia    from 

ascites  in  . . 

246 

bacteriuria  in  . . 

82 

lesion   of  . .          . .        337, 

683 

enlarged  liver  in        .... 

246 

cyanosis  in 

185 

situation  of 

683 

right  ventricle  in       245, 

240 

diagnosis  from  Henoch's 

motor  speech  centre  in 

683 

-  -  fraenum  linguae  abraded  in 

320 

purpura 

600 

Brocq,  re  pseudo-pelade 

heart  failure  in  61,186,464 

,525 

mitral  regurgitation  in 

239 

85,  780, 

782 

oedema  of  legs  m 

246 

occasional    absence    of 

-  re  vesicles  of  herpes 

83 

pains  in  limbs  in. .        503, 

505 

oedema  in    . . 

311 

Bromide  eruption,  characters  of 

603 

palpitation  in 

525 

cedema  in        . .        311, 

457 

diagnosis  from  smaU-pox 

609 

poiycythaemia  in           579, 

580 

of  face  and  of  labia  in 

458 

Bromides,  coma  due  to 

137 

systolic  murmm-  in 

246 

larynx  in     . .         185, 

709 

-  loss  of  taste  due  to . . 

774 

tricuspid  regurgitation  in 

246 

legs  m          . .        458 

461 

-  ptyalism  due  to 

590 

-  complicating  asthma 

467 

lungs  in 

466 

-  vesicles  from 

834 

-  cough  from..          ..        175, 

176 

penis  in 

458 

Bromidrosis,  account  of 

714 

-  cyanosis  in  severe  . . 

186 

scalp  in 

458 

Bromine  test  for  melanuria  . . 

821 

-  distinction  from  asthma    . . 

180 

scrotum  in  . . 

458 

Bronchial  breathing  with  bron- 

- and  emphysema  (see  Emphysema) 

peritonitis  with 

55 

chiectasis              193,  324, 

703 

-  epistaxis  in . . 

251 

polyuria     in;     recovery 

fibroid  lung 

232 

-  fibrinous  or  plastic . . 

704 

from            . .         582, 

583 

growth  of  lung     .  . 

322 

-  libroid  lung  and  bronchiec- 

 scant3'  urine  in 

311 

infarction  of  lung 

321 

tasis  from 

324 

BRONCHITIS,    FCETID— BURNS 


871 


Bronchitis,  conld. 

-  foBtid 

99 

703 

-  -  abundant  foul  sputum 

in 

703 

foul  breatli  iii 

99 

taste  in 

770 

frequently     a     mistaken 

diagnosis 

703 

-  -  indicanuria  in 

319 

leucocytosis  in 

404 

simulating    gangrene 

of 

lung      . . 

287, 

288 

-  hsemoptysis  in  317,  318, 

320 

32 1 

-  in  influenza. . 

505 

-  insomnia  in 

sVe, 

359 

-  in  Malta  fever 

507 

-  orthopnoeain             186, 

404, 

405 

-  pain  in  the  chest  in 

480 

-  periodic  cyanosis  from 

579 

-  physical  signs  due  to 

192 

176 
186 


615 


-  plastic,  casts  in  sputum  in       704 

-  secondary  to  abscess  of  liver     409 
abscess  of  the  lungs        . .     649 

-  shortness  of  breath  from  101,  579 

-  simulated  by  pertussis       . .     705 

-  simulating  asthma. .        249,  467 

-  sputum  in     . .  176,  700,  704 

-  tenderness  in  the  chest  fi'om  778 

-  in  typhoid   fever    ..  ..     697 

-  venoas  congestion  of  liver  in    407 
Bronchophony  in  bronchiectasis  703 

-  in  fibroid  lung         . .  . .     246 

-  with  fibroid  lung  and  bron- 

chiectasis . .  . .     324 

-  in  lobar  pineumonia         186,  701 

phthisis     .  .  .  .  .  .      319 

Bronchopneumonia,   albumin- 

m-ia  in       . .  . .  . .       17 

-  apical,  diagnosis  from  phthisis  321 

-  caseous,  lividity  ia  . .     185 

-  chief  incidence  in  children     321 

-  cough  from. . 

-  cyanosis  from 

-  diagnosis      from      general 

pulmonary  tuberculosis . 

-  diminished  knee-jerks  in   398,557 

-  empyema  uith        . .  39,  119,  186 

-  extreme  dyspnoea  from     . .     642 

-  fibroid  lung  and  bronchiec- 

tasis from  .  .  .  .     324 

-  gangrene  of  lung  in  287,  712 

-  haemoptysis  in        . .         317,  321 

-  hyperpyrexia  in      . .  . .     343 

-  influenzal      .  .  .  .         321,  505 

asthenia  in  . .  . .     321 

relatively  low  fever  in    . . 

sticky  rales  at  bases  in . . 

-  and    laryngeal    obstruction 

-  after  mouth  operations 

-  orthopncea  in 

-  ■^■\t\\  otitis  media    . . 

-  pleurisy  with 

-  pneumococcal 

-  prolonged  pyrexia  in       C09 

-  retraction  of  the  head  in    . . 

-  septic,  diagnosis  of 

gangrene  of  lung  from    . . 

from  lateral  sinus  throm- 
bosis    . .  . .         321 

pneumothorax  from      5 

from  tongue  carcinoma  321,578 

-  shortness  of  breath  in        . .     101 

-  streptococcal  . .  . .     615 
Bronchorrhcea,  haemoptysis  in 

318,  324 

-  identity  with  bronchitis    . .     324 
Bronchus,  anem-ysm  of  aorta 

rupturing  into  140,  318,  322, 482 

-  carcinoma  of  (see  Carcinoma 

of  Bronchus) 

-  empyema    rupturing     into, 

causing  pneumothorax      578 

-  foreign  body  in       . .  . .     466 
fibroid  lung  and  bron- 
chiectasis from        . .     324 


78,  71£ 


Bronchus,  conld. 

-  irruption   of  caseous  gland 

into  466 

-  parasitic  infection  of         318,  325 

-  pressure       of      mediastinal 

growth  on  . .  . .     483 

-  stenosis  of  by  aneurysm 

236,  296,  322,  324,  474,  482 

bronchiectasis  from        . .     324 

carcinoma..         ..  ..     324 

fibroid  lung  from  . .     324 

foreign  body        . .  . .     324 

gangrene  of  lung  from  288,  712 

Hodgkin's  disease  . .     321 

inspissated  mucus  . .     324 

list  of  causes  of    . .  . .     324 

mediastinal  new  growth  324,343 

with  mitral  stenosis       . .     324 

new  growth  118, 185,  322 

-  -  orthopnoea  from  . .  . .     465 
pyopneumothorax     from     712 

-  -  in  syphilis  . .         288,  582 
sypliilitio  disease,  diagnosed 

from  phtliisis  . .  . .     325 

tuberculous    bronchial 

glands  . .  324,  422,  773 

-  ulceration  of,  hfemoptysis  in 

325,  328 
Bronzed  diabetes  (see  Diabetes, 

Bronzed) 
Broom  tops,  polyuria  from   . .     582 
Brown-S6quard  paralysis     . .       68 

character  of         . .  . .     540 

crossed      anaesthesia      in 

(Fig.  181)         . .  . .     664 

diagram  of  physical  signs 

of,  (Fig.  142)    . .         . .     540 

Brows,    prominence    in    acro- 
megaly     . .  . .  . .     263 

Bruising  of  skin  in  jaundice  361, 598 
multiple  in  epilepsy,  simu- 
lating purpura  . .     597 

in  some  normal  people  . .     597 

Bruit  in  aneurysm  of  coeliacaxis  368 

-  d'airain  with  pneumo- 

thorax     ..  ..        193,  577 

simulated    by     drips    in 

thorax  . .  . .     711 

-  de  diahle     . .        . .  41, 105, 106 
associated  with  congenital 

systolic  bruit    10-1,  105,  106 
in  clilorosis  . .  . .     333 

-  over  enlarged  spleen  . .     689 

-  exophthalmic  goitre  . .     244 

-  Flint's,  in  dilatation  of  left 

ventricle  . .  108,  109,  234 

-  functional     41,  102,  104, 105,  106 
systohc     pulmonary,     in 

chlorosis    . .         . .  . .     333 

-  in  fungating  endocarditis 

9.  10,  38,  240,  598,  649 

-  hsemic,  in  chlorosis  . .       41 

-  with  high  blood-pressure  . .     252 

-  mid-diastolio  . .  . .     107 

-  in  mitral  stenosis 

107,  245,  320,  580 

-  myocardial  degeneration   . .     333 

-  over      eye      with      orbital 

aneurysm  . .  . .     255 

-  with  patent  ductus  arteriosus  184 
septum   ventriculorum 

184,  579 

-  presystolic  107,  320,  580 
in  tricuspid  stenosis      . .     110 

-  pulmonary  incompetence  . .     247 

stenosis    . .  .  .129,  184,  247 

systolic,  in  chlorosis       . .     105 

-  rumbling    systolic,    in   con- 

genital pulmonary  stenosis    579 

-  sometimes    absent   in    con- 

genital heart  disease      . .     579 

-  of  stenosed  superior  vena  cava  236 

-  sudden  changes  in,  in  funga- 

ting endocarditis  . .       38 


Bruit,  conld. 

-  of  tricuspid  regm-gitation  . . 

-  in  undue   abdominal  aortic 

pulsation 
BRUITS,  CARDIAC     ..      101, 
witli  acute  cardiac  dilata- 
tion 

endocarditis 

76,  102,  103,  239,  613, 

in  adherent  pericardium 

with  albuminuria 

aortic  disease 

138,233,234,235,230,237, 
aortic  and  mitral  distin- 
guished . . 

in  arterio-sclerosis        102, 

cerebral  embolism         138, 

chronic     bronchitis     and 

emphysema 

nephritis  . .  14,  102, 

chlorosis    .  .  .  .  41, 

congenital  heart  disease 

129,  184,  244,  247, 

in  mitral  regm-gitation  102, 

with  pleural  effusion 

rumbling    or    blattering, 

in  congenital  pulmonary 
stenosis 

-  diastolic 

-  systolic 

Bryant,  re  spinal  cord  centres 
Buboes   (and    see   Lymphatic 

G-lands,  Inguinal)  675, 

Buccal  nerve,  distribution  of 
Bug-bites,  pruritus  from 
Bulb  (see  Medulla  Oblongata) 
Bulbar  paralysis  (see  Paralysis, 

Bulbar) 
Bulging  of  chest   (see  Chest, 

Bulging  of) 
Bulimia 
BULL/E,  

-  affecting  mucous  membranes 

-  in  anthrax    . . 

-  artificially  produced,  value 

of  eosinophiUa  in  detecting 

-  caused  by  malingerers 

-  in  cheiropompholyx         654, 

-  congenital  syphilis  . . 

-  crusts  in 

-  dermatitis  herpetiformis  781, 

-  eosinoplulia  with    . .         114, 

-  in  epidermolysis  bullosa 

110,  113,  266, 

-  erysipelas     . . 

-  erythema  multiforme 

-  extreme  oedema  110, 

-  gangrene     and     Raynaud's 

disease      . .  110,  112, 

-  glanders 

-  herpes  n-is    . . 

-  impetigo       . .  . .        602, 

-  leprosy 

-  pemphigus   . .  . .         602, 
neonatorum 

-  relation  of  vesicles  to 

-  in  scabies     . .  . .        654, 

-  urticaria 

Bullet  wound  of  cord . . 
Burning  sensation  in  antlirax 

drug  rashes 

eczema 

eyes  from  error  of  refraction 

herpes  genitalis  . . 

of  lips  in  Pordyce's  disease 

in  pustular  eczema 

urticaria   . . 

with  vesicular  eruptions 

Burns,  contracture  after 

-  ectropion  and  epiphora  from 

-  hsemoglobinuria  after 

-  hyperpyrexia  after 

-  and  scalds,  albuminuria  in 

-  scarring  after 


239 


592 
013 


671 

243 

18 

240 

234 
103 
563 

246 
103 
333 

579 
238 
121 


579 
106 
101 
566 

738 
659 


49 
110 


249 
111 
832 
446 
829 
831 
249 

445 
746 
531 
112 

283 
603 

832 
608 
654 
654 
446 
829 
832 
835 
650 
603 
426 
831 
328 
830 
403 
602 
850 
829 
168 
250 
315 
344 
16 
709 


BURNS— CALCULUS,     URETHRAL 


Burns,  conld. 

Caisson  disease,  bilateral  par- 

Calculus, renal,  conld. 

-  talipes  equinus  following  . . 

132 

alysis  in   . . 

342 

pleuritic  effusion  from  . . 

123 

-  iilcerarion  of  the  leg  from. . 

810 

Cheyne-Stokesrespirationinl25 

polyuria  due  to  hydrone- 

EurrowB in  skin  in  scabies  608 

831 

deafness  in 

191 

phrosis  from    . .         581, 

583 

Bursa  over  exostosis  . . 

754 

epistaxis  in 

251 

pricking  pain  on  bimanual 

-  lijoid,   simulating  enlarged 

hemiplegia  in      .  .         340, 

342 

examination  in 

306 

"  thyroid  gland 

791 

shortness  of  breatii  in    . . 

101 

pyehtts  from       . .         438 

625 

-  ileo-psoas,  femoral  swelling 

Calcanodynia   . . 

488 

pyonephrosis  from 

from  . . 

734 

Calcification  of  anterior  com- 

309, 396,  626, 

627 

simulated     by     bijj-joint 

mon  ligament  in  spondyU- 

pyrexia  due  to   . . 

621 

disease  . . 

734 

tL3  deformans 

787 

pyuria  from 

simulating  psoas   abscess 

734 

Calcium  chloride  and  physio- 

16, 46,  308,  312,  623,  626, 

627 

-  psoas  (see  Psoas  Bursa) 

logical  albuminuria 

19 

renal  abscess  from  309,  499 

500 

-  sodium  urate  in,  in  gout    . . 

380 

-  deficiency  at  the  menopause 

433 

rigors  ■s\-ith          . .         647, 

650 

-  spinal,  in  porters    . . 

183 

metrorrhagia  from 

433 

sex  incidence  of  . . 

312 

But<;hers'  boys,  scoliosis  in  . . 

181 

-  hypochlorite  test  for  indican 

349 

simulating  enlarged  spleen 

729 

Butchers,  epidemic  jaundice  in 

372 

-  oxalate 

816 

sMa^aphy  in  (Fig.  97) 

-  Weil's  disease  in     . . 

372 

crystals  in  pancreatitis  . . 

116 

309,  500, 

583 

Buttocks    affected  by  eczema 

in  intestinal  sand 

6.52 

tenderness  of  kidney  in 

500 

marginatum 

275 

sources  of  in  body 

817 

ultimate  fate  of.. 

308 

-  bedsore  over 

285 

and   uric    acid,    relation- 

 without  urinary  signs     . . 

500 

-  condyloma  of 

769 

ships  between            816 

817 

varif  rion    in     symptoms 

-  eruptions  on 

446 

in  urine  (and  see  Oxaluria) 

470 

■nith  position  in  kidney 

627 

-  Jacquet's  erythema  of 

446 

—  phosphates,  acid  and  alka- 

- salivary,  ptyalism  due  to. . 

591 

-  lymphatic  drainage  of 

738 

line  reactions  of 

573 

-  ureteral        

627 

-  pemphigus    neonatorum    of 

446 

in  intestinal  sand 

652 

anuria  from          .  .             45 

,  i6 

-  prurigo  ferox  on 

531 

-  salts  in  diagnosis  of  tetany 

179 

coUc  in     . .          . .        135, 

C27 

-  scabies  affecting     . . 

609 

effects     on     coagulation 

diagnosis   from   appendi- 

Butyl chloral  hydrate  poison- 

time of  blood 

430 

citis       . .          . .         311, 

632 

ing,    Cheyne-Stokes    res- 

Calculus, biliary,  colic  in    . . 

135 

vesical       calculus       or 

piration  in 

125 

rigors  in   .  . 

647 

tuberculosis 

627 

purptira  from  . . 

596 

-  impacted,  blood  per  urethram 

villous  papilloma 

514 

Butyric  acid  in  gastric  juice. . 

333 

in  . . 

441 

felt  per  rectum  . .        627, 

638 

Buzzing     in    the     ears    Csee 

-  infantile  convulsions  arising 

vaginam 

627 

Tinnitus) 

from 

170 

frequent  micturition  with 

-  pancreatic,  colic,  etc.,  due  to 

135 

311, 

627 

PACHEXIA 

«J     -  acetonuria  in   . . 

114 

epigastric  pain  with 

486 

h8ematm:iafrom304,311,514,627 

4 

symptoms  of 

725 

history  of  renal  calculus 

-  albuminuria  in 

17 

-  penile  (see  Calculus,  Uretliral) 

in  diagnosis  of 

627 

-  ansemia  with 

37 

-  prostatic,  absence  of  fixation 

—  impacted        47,  51^,  515, 

627 

-  aquosa,  perverted  appetite  in 

115 

of  prostate  on  rectal  ex- 

 cystoscopic  appearances 

514 

-  atrophy  of  muscles  in 

634 

amination  in 

512 

examination  of  ureter  by 

-  bleeding  gums  in    . . 

85 

diagnosis   from  prostatic 

wax-tipped  bougies  in 

-  from  carcinoma 

carcinoma 

512 

cases  of         . .       ... 

514 

57,  459,  575,  731 

745 

effects  of 

512 

hydronephrosis  from 

-  congenital  syphilis 

44G 

grating    felt   on    passing 

135,  395, 

627 

-  constipation  with  . . 

143 

catheter  in      . .         512 

515 

micturition  frequent  in 

514 

-  functional    . . 

508 

of      calculi     felt      per 

palpation  per  rectum  . . 

514 

bruits  in  . . 

106 

rectum  in     . .         512 

515 

renal   pain   from    dila- 

- impotence  from 

347 

pain  in  penis  after  mic- 

tation of  pelvis  in  . . 

514 

-  from  leprosy 

575 

turition  in       . .         513 

515 

symptoms  like  those  of 

-  malaria         .  .          .  .         489, 

575 

perineum  in     . . 

516 

vesical     calculus     or 

-  mediastinal  growth 

483 

prostatic  abscess  due  to 

632 

tuberculosis 

514 

-  neuritis  in    . . 

508 

ulceration  into  urethra . . 

515 

usual  sites  of    . . 

627 

-  cedema  of  legs  in    . .         459 

,461 

-  renal,  aching  in  loin  in 

308 

pain  in  course  of  ureter 

-  pains  in  limbs  from  fever  in 

508 

agglomeration  of  crystals 

from 

627 

-  pigmentation  of  skin  in    . . 

575 

in  urine  in 

471 

after  micturition  in  442 

627 

in  uterine  lesions 

114 

albnminiiriq    -m'th 

16 

in  penis  from 

-  with  pyopneumothorax    . . 

712 

anuria  from . . 

46 

442,  513,  514 

627 

-  sarcoma        . .          . .        459, 

75C 

blood  in  urine  in 

627 

tssticle  from    . . 

524 

-  from  starvation 

459 

causing  anuria    . .            45,  46 

pyuria  from           514,  623, 

627 

-  in  stomach  disease  of  negroes  115 

pleuritic  effusion 

12.0 

sacralgia  from     .  . 

510 

-  syphilis             459,  575,  b04 

658 

Cheyne-Stokes  breathing  in 

124 

2--ray  diagnosis  of  311,  514 

627 

-  tropical  diseases     . . 

459 

coUc  due  to        ..308,  627 

846 

-  urethral        

510 

-  tuberculosis             . .         459 

,731 

crystals  in  urine  in     306 

818 

acute  pain  in  penis  from 

313 

Cacogeustia 

774 

cystin  causing 

187 

behind  urethral  stricture 

677 

Cscum  actinomycosis  of 

736 

diagnosis  from  growth  . . 

395 

bougie  in  diagnosing 

439 

-  carcinoma  of  (see  Carcinoma 

from    oxaluria 

311 

- —  common  sites  of . . 

511 

of  Caecum) 

renal  tuberculosis      310 

626 

discharge  due  to 

206 

-  dilatation     of,     succussion 

enlargement  of  kidney  in 

500 

frequent  micturition  from 

438 

sounds  in 

711 

frequent  micturition  in  308 

438 

hematuria  in     . .         304, 

313 

—  faecal  accimiulations  in 

393 

lia>maturia  in  16,  46,  304, 

308 

impacted              . .         211, 

439 

-  fistula  of,  causing  pneimia- 

after  movement         305 

395 

piain  in  the  penis  during 

ttiria 

576 

hydronephrosis  from 

micturition  in. . 

510 

-  lesions  of,  causing  surgical 

309,  581 

583 

perineum  in     . . 

516 

emphysema 

231 

impaction  in  ureter 

627 

at  tip  of  female  urethra 

-  normal  situation  of 

722 

lumbar  aching  from 

627 

from 

442 

-  sarcoma  of  (see  Sarcoma  of 

pain  from 

46 

palpation  of  stone  in     313, 

511 

Caecumj 

nephritis  from     . . 

8 

passage  of 

511 

-  tuberculosis  of 

736 

pain  in  the  left  hypochon- 

priapism  from    . . 

585 

simulating  appendicitis 

736 

drium  in 

499 

retention  from               313 

441 

swelling     in    right    iliac 

right     hypochondrium 

sudden  urethral  pain  from 

511 

fossa  from 

7.36 

and  back  in 

500 

stoppage  of  micturition 

Caffeine,  diuretic  effect  of  .. 

581 

testicle  in 

524 

in      ..          ..         313 

511 

CALCULUS.     URETHRAL— CARCINOMA     OF    BREAST 


873 


Calculus,  vrelliral,  conkl. 

Cancrum  oris  (Fig.  ll)        88, 

282 

Carcinuma,  contil. 

from  urotlirai  fistula 

678 

bleeding  gums  in              81 

,  88 

-  starting  in  lupus  vulgaris. . 

803 

urethritis  due  to 

766 

|ityalism  due  to  .  . 

590 

a  mole 

803 

visible    by    means    o£ 

Cannabis  indica,  micropsia  from  8H 

a  wart 

803 

urethroscope 

511 

liiiisdiiiiig,  -xautliopsia  in 

840 

from  an  x-ray  scar 

803 

-  vesical..        ..        304,  312 

511 

liri:i|iisai  caused  by 

586 

-  with  thoracic  duct  obstruc- 

- -  absf'uce     of     cystitis     in 

Canter  rhythm  in  cardiac  dila- 

tion, chyluria  in.  . 

126 

earliest  stages . . 

513 

tation 

6:!9 

-  wasting  with 

69 

frequency  of  micturition 

diagnosis  from  redui)lica- 

-  of  antrum  of  Highmore    .. 

205 

iluriui,'  complete  rest 

513 

tion  of  heart  sound 

639 

-  anus 

423 

age  incideuco  of  . .         513 

628 

in  fatty  heart 

639 

eiUarged  inguinal    glands 

behind  prostate  . . 

629 

jipricarditis     .  .         242, 

639 

from      . .          . .        423, 

739 

concealment  in  a  diverti- 

Cantharides causing  bullixj     . . 

110 

pain  in  perineum  from  . . 

516 

culum   . . 

629 

-  hicmaturia  caused  by 

304 

jienis  from 

515 

crystals  in  urine  in 

629 

-  priapism  caused  by 

580 

-  of  bile-ducts          . .         36, 

725 

cystitis  from       . .        513, 

629 

-  ptyalism  due  to 

596 

diagnosis    from    enlarged 

cystoscopy  in  (Plates    V, 

-  used  by  malingerers 

111 

gall-bladder     . . 

278 

VI,  p.  308)               312, 

439, 

Capillary  oozing  in  jaundice. . 

361 

infective  cholangitis  from 

362 

442,  512,  513 

629 

-  pulsation  in  aortic  disease 

jaundice  in 

361 

diajinosis    from    tubercu- 

106, 

233 

-  of  bladder 

513 

lous  cystitis     . . 

628 

Capsicum  used  by  malingerers 

112 

age  incidence  of 

ureteral     calculus    im- 

Caput medusEB  in  cirrhosis    51, 

826 

311,  514,  628, 

630 

pacted 

627 

Carbol-fuchsin  stain    . . 

700 

-  -  anuria  in .  .          .  .             45 

,  47 

effect  of  exercise  on  mic- 

Carbolic acid,  coma  due  to  137 

346 

cystitis  due  to    . . 

627 

turition  with  . . 

438 

diazo-reaction  in . . 

198 

cystoscopy  in  diagnosis  of 

fallacies  in  sounding  the 

ferric  chloride  reaction  in 

(Plate  VI.,  Figs.  F,  G, 

bladder  in 

629 

urine  from 

196 

p.  130)   439,442,512,514,630 

felt  per  rectum  . . 

638 

in  gastric  contents 

844 

diagnosis    from    tubercu- 

 frequency  of  mictm-ition  in 

hsematuria  from . . 

304 

lous  cystitis 

628 

3i2,  438,  513,  628, 

629 

in  hypopyon  ulcer 

807 

enlarged  glands  from 

during     exercise     or 

hypothermia  from 

346 

307,  514,  628, 

630 

jolting 

513 

ochronosis  from  .  .        575, 

822 

pelvic  lymph  glands  felt 

hfematuria  in 

reducing    body   in    urine 

on  rectal  examination 

304,   312,   512,  513, 

629 

due  to  .  . 

290 

628, 

630 

-  -  iiistory  of  renal  colic  in 

513 

scaly  eruption  due  to     . . 

655 

faeces  passed  per  urethram 

633 

pain  after  micturition  in 

used  by  malingerers 

112 

felt  per  rectum    . . 

628 

441,  511,  512, 

513 

Carboluria,  general  account  of 

822 

fragments  in  urine 

306 

in  the  bladder  from  . . 

818 

Carbon    bisulphide,  htemoglo- 

frequency  of  micturition 

penis  from       . .          441 

628 

binuria  from 

314 

in      311,  438,  512,  514, 

630 

perineum  in     . . 

516 

peripheral  neuritis  from 

77 

hfematuria  in          47,  304, 

305, 

priapism  from 

585 

-  dio.xide,  headaches  from    . . 

328 

311,  512,  514,  628 

630 

pyrexia  due  to    . . 

621 

-  naonoxide,  coma  due  to 

137 

hydronephrosis  in 

311 

pyuria  with  512,513,623,626,629 

headache  from    . . 

328 

infiltration     of     base     of 

skiagraphy  in  (i^i(/.  98)  312 

629 

liajmoglobinuria  from     . . 

314 

bladder  in    311,512,513 

630 

stoppage  of  stream  during 

poisoning,  cherry  colour  in 

138 

micturition  frequent  from 

mictm-ition  by 

Carbonate  of  calcium  in  boiling 

311,  438, 

630 

312,  439,  512, 

513 

test  for  albumin  . . 

5 

pain  after  micturition     47 

441 

the  sound  in  diagnosis  of 

Carboxyhsemoglobin,   spectral 

in  penis  from             312, 

441, 

312,  512, 

629 

absorption  band  of 

95 

442,  512,  513,  514 

630 

m-mary  changes  due  to . . 

512 

-  test  for 

138 

in  perineum,  anus,  and 

Calf  muscles,  paralysis  of    . . 

543 

Carbuncle,     diagnosis     from 

vulva  in        . .         442 

516 

talipes  from  fibrosis  and 

antlirax    . . 

603 

pelvic  swelling  due  to    . . 

757 

contracture  of 

132 

cellulitis   . . 

603 

pyelitis,  from 

625 

Callus,  diagnosis  from  sarcoma 

757 

furuncle    . .          . .   _ 

603 

pyonephrosis  from 

626 

-  involvement  of  nerves  in  . . 

75 

ringworm  of  beard 

274 

-  -  pyuriiin   47,  311,  512,  623 

630 

-  swelling  on  a  bone  due  to  . . 

750 

-  enlarged  gland  secondary  to 

708 

rectal  examination  in  307, 

311, 

-  a--rays  in  diagnosis  of 

757 

-  of     face,     cavernous    sinus 

312,  512,  514,  628,  630, 

638 

Calmette's  reaction     .. 

38 

thrombosis  due  to 

253 

renal  growth  simulating 

311 

in  diagnosing  latent  tuber- 

- on  neck,  stiff  neck  from 

708 

pain  from           311,  514, 

630 

culosis  . .          . .        621, 

847 

-  several  suppuration  points  in 

603 

sudden,  profuse,  painless 

negative     in     anorexia 

Carcinoma,  albumosuria  in  . . 

20 

hremorrhage  in 

305 

nervosa 

850 

-  anaemia  in    . .          . .   27,  37 

459 

ulceration  of 

629 

risks  and  fallacies  of     . . 

621 

-  cachexia  from  114,  459,  461, 

575 

ureter  obstructed  by     . . 

311 

-  -  in  tuberculous  peritom'tis 

691 

-  causing  portal  obstruction, 

urethra  obstructed  by   . . 

514 

Calomel,  cure  of  indicanuria  by 

821 

ascites  with 

59 

urethral  passage  of  faeces  in 

264 

-  polyuria   after 

582 

-  diazo-reaction  in     . . 

198 

vaginal  detection  of 

512 

Calves,  Jacquet's  erythema  of 

446 

earache  from 

230 

varieties       . .          . .     306 

630 

-  seborrha?ic  dermatitis  of  .  . 

447 

-  enlarged  liver  from.. 

55 

villus-covered      . .        513, 

630 

CAMIVIIDGE'S    PANCREATIC 

-  eosinophilia  in  some  cases  of 

249 

-  of  breast 

421 

REACTION..                   115, 

117 

-  fatty  heart  in 

241 

absence  of  anfemia  with . . 

37 

in  affections  of  pancreas 

486 

-  felt  in  epigastrium  . . 

723 

-  -  accidental  discovery  in  first 

in  carcinoma  of  liver  60, 

690 

-  kyphosis  JErom 

182 

instance  in  most  cases 

745 

of  pancreas  . .            59 

,  60 

-  leucocytosis  in 

400 

atre  incidence  of . . 

745 

pancreatic  cysts 

725 

-  loss  of" weight  from. . 

817 

atrophic    . . 

745 

pancreatitis       135,  280, 

."64 

-  oedema  of  legs  in  . .        459, 

461 

axillary  glands  in           421 

745 

Campbell,  Harr^',  re  flusliing 

268 

-  prolonged  pyrexia  due  to  . . 

609 

bloody     discharge     from 

Camphor,  eosinophilia  from . . 

248 

-  pyrexia  from 

617 

nipple  in 

202 

-  priapism  caused  by 

586 

-  sallow  pigmentation  of  skin 

cachexia  in  advanced     . . 

745 

-  reducing  body  in  m-ine  due  to 

290 

in  cachexia  of      

575 

diagnosis    from    cyst    of 

Canaliculi,   lachrymal,   conge- 

- secondary,  spontaneous  frac- 

breast  . . 

744 

nital  absence  of  . . 

250 

ture  from 

269 

fibro-adenoma. .        744, 

745 

obstructed,  epiphora  from 

250 

-  simulated  hj  chancre  of  vulva 

769 

mastitis            . .        743, 

745 

Canal  of  Xuck,  hydrocele  of  (see 

rhinoscleroma 

805 

tuberculous  abscess   . . 

744 

Hydrocele  of  Canal  of  Nuck) 

tuberculous  ulcer 

814 

early  fixation  of  , .        743, 

745 

874 


CARCINOMA    OF    BREAST— CARCINOMA    OF    KIDNEY 


Carcinoma  nf  breast,  contd. 

Carcinoma  of  colon,  conld. 

Carcinoma  of  diiodenam,  cotitd. 

en  cuirasse 

802 

diagnosis  from  renal   tu- 

 bile-duct  obstruction  from 

366 

fixation  of  tumour  in    . . 

745 

mour     . . 

303 

copious  vomiting  from  . . 

725 

flat  hand  in  palpating   . . 

745 

of  spastic  constipation 

diagnosis  from  carcinoma 

fungating  througti  skin  . . 

745 

from  . . 

145 

of  pancreas      . .        266, 

725 

gangrene  of  liand  from  . . 

287 

diarrhoea  in           146,  196, 

393 

distended       gall-bladder 

-  -  glands  in  axilla  with 

742 

disorders  of  defaecatiop  in 

501 

from 

725 

importance  of  early  dia- 

 dyschezia  from    . .          ; . 

150 

enlarged     supraclavicular 

gnosis  in 

745 

enemata  in  diagnosis  of. 

735 

gland  in 

421 

indefinite  outline  in 

745 

enlarged   mesenteric   and 

fatty  stools  in     . . 

256 

invading  lung 

322 

retroperitoneal  glands  in 

422 

gastrectasis  from 

725 

large  hard  tumour  in     . . 

745 

examination  under  anaes- 

 hffimatemesis  from 

725 

malignant  peritonitis  from 

718 

thetic     in     suspicious 

jaundice  from         362,  366 

725 

mammary  swelling  due  to 

745 

cases     . . 

501 

loss  of  weight  from 

725 

in  married  women 

745 

explosive  diarrhcea  in    . . 

348 

secondary  in  liver 

279 

mobility  of  tumour  in  very 

faBcal  distention  of  csecum 

simulating  bile-duct   car- 

early stages 

745 

in 

394 

cinoma 

725 

pseudo-elephantiasis    fol- 

 great    abdominal    disten- 

 enlarged  gall-bladder. . 

280 

lowing  operation  for  . . 

456 

tion  from 

152 

gastric  carcinoma 

725 

puckering  the  skin  over  743 

,745 

hepatic  flexure  afliected  bv 

portal  fissure  carcinoma 

725 

retraction  of  nipple  in    . . 

745 

500. 

723 

subphrenic  abscess  from. . 

578 

secondary  deposits  in  bones 

intestinal  distention  from 

367 

suppurative     cholangitis 

182,  269,564,  757,782 

786 

obstruction  from        92, 

151, 

from 

725 

liver  . . 

743 

152,  393,  500,  501,  645,  731 

735 

swelling  in  epigastric  and 

thorax 

743 

jaundice  in          . .         362 

366 

umbilical  areas  from. . 

725 

sex  incidence  of  . . 

745 

laparotomy  in  diagnosis  of 

visible   gastric  peristalsis 

stony  hardness  of           743 

,745 

501, 

735 

from 

725 

suppuration  with 

744 

loss  of  weight  from 

147 

-  of  externa!  auditory  meatus 

469 

supraclavicular  glands  421 

743 

mobility  of 

393 

similarity   to  rodent 

swelling  not  sharply  definec 

745 

movement  with  respiration 

406 

ulcer 

469 

-  of  bronchus           ..       322, 

324 

mucus  in  stools  in       150, 

152, 

-  Of    face,    affection  of   lym- 

- -  fibroid  lung  and  bronchi- 

393, 443,  690 

736 

phatic  glands  from      '   . . 

808 

ectasis  from     . . 

324 

pain  with 

153 

— -  diagnosis  from  lupus  vul- 

- of  bundle  of  His   .. 

98 

in  left  iliac  fossa  in 

501 

garis 

449 

-  of  caecum,   blood  per  anum 

hypochondrium  from  499 

,500 

syphilitic  ulcer 

449 

in 

736 

umbilical  region  in    . . 

524 

pain  from 

808 

constipation  from 

729 

perinephric  infiltration  in 

393 

-  Of  fauces      . .           420,  670, 

673 

fewness  of  symptoms  with 

736 

peritonitis  from  . . 

645 

enlarged  submaxillary  lym- 

 intestinal  obstruction  from 

736 

pneumoperitoneum  due  to 

711 

phatic  glands  in 

420 

involvement  of  bladder  by 

632 

pus  in  stools  from 

601 

-  Of  eyelids 

419 

laparotomy  in  diagnosis  of 

736 

pyuria  from         .  .         624, 

632 

-  of  fingers 

266 

loss  of  weight  from 

736 

rectal  examination  in    . . 

501 

-  of  gall-bladder 

421 

pain  in  the  right  iliac  fossa 

resonance    between  liver 

biliary  colic  in     . . 

279 

from 

729 

and  tumour     . . 

406 

catch  in  breath  on  deep 

pyrexia  from 

729 

over  tumour  in 

393 

inspiration  during  pres- 

 swellmg     in     right     iliac 

sand  with 

653 

sure  over  gall-bladder  in 

409 

fossa  from 

736 

secondary  in  liver 

279 

cholangitis  in 

369 

tumour  of  right  iliac  fossa 

152 

sense  of  rectal  fullness  in 

150 

diagnosis    from    enlarge- 

 urethral  passage  of  faeces 

sigmoid  affected  by        731 

735 

ment  of  gall-bladder  . . 

279 

from 

264 

sigmoidoscope  in  detecting 

enlarged    supraclavicular 

vomiting    and    constipa- 

147, 501, 

735 

glands  in          ..        279, 

421 

tion  from 

729 

simulated  by  diverticulitis 

gall-stones  in      . .        278, 

279 

-  of  Cauda  equina,  muscular 

141, 

152 

jaundice  in 

279 

atrophy  in 

74 

local  inflammatory  lesions727 

nodular  outline  in 

270 

-  of  cervix   uteri  Csee   Carci- 

 omental      tumour      of 

pain  in  the  right  hypo- 

noma  of  Uterus) 

chronic  peritonitis . . 

472 

chondrium  in. . 

499 

-  Of  cheek,  enlarged  glands  in 

419 

spastic  constipation  . . 

145 

pyrexia  in 

279 

-  "  chimney-sweep's  " 

607 

tuberculous  peritonitis 

724 

rapid  enlargement  in    . . 

279 

-  of   clitoris,    enlargement   of 

simulating  enlarged  liver 

406 

rectal  shelf  in 

638 

inguinal  glands  in 

423 

spleen 

729 

secondary  deposits  in  left 

-  of  colon,  abdominal  swelUng 

movable  kidney 

727 

supraclavicular     gland 

278 

with           . .      91,  367,  499, 

524 

tuberculous  infiltration 

146 

in  liver 

278 

absence  of  palpable  lump 

spastic  constipation  with 

145 

tenderness  over  gall-blad- 

in many  cases 

501 

splenic  flexure  affected  bv 

der  in  . . 

499 

tumour  with    . . 

152 

499, 

690 

-  of  gum         

419 

-  -  aching  pain  in  loin  in  . . 

393 

strictiire  due  to  (Fiff.  38) 

146 

bleeding  gums  in               86,  88 

adhesion  to  liver  in 

367 

subcostal  position  of     . . 

393 

-  of    jaw,     connection     with 

age  incidence  of           146, 

150 

subphrenic  abscess  from 

578 

decayed  tooth     . . 

749 

albuminuria  from  invasion 

sweUing     in        umbilical 

microscopic    examination 

of  kidney  by   . . 

393 

region  in 

524 

in  diagnosis  of 

749 

anfemia  from 

147 

tenesmus  due  to 

731 

origin  as  an  ulcer  on  gum 

749 

ascites  with          . .           59, 

366 

transverse  colon   affected 

-  of  kidney     ..        ..       395, 

421 

bile-duct  obstruction  from 

367 

by          

406 

aching  pain  in  loin  in    . . 

395 

bladder  invaded  by       624, 

G32 

tumour  with          91,  146, 

147, 

Clieyne-Stokes    respira- 

 blood  per  anum  in         91, 

147, 

394, 

499 

tion  in  . . 

124 

150,   152,  367,  393, 

731 

vesico-colic  fistula  from. . 

146 

diagnosis  fromrenalcalculus395 

cachexia  due  to  , . 

731 

visible  peristalsis  with    91, 

147 

tuberculo=5is 

395 

colic  from              . .           91, 

147 

vomiting  with     . .        153, 

367 

early  metastases  in 

395 

colloid  degeneration  in  . . 

735 

weakness  and  wasting  with    91 

enlarged    supraclavicular 

common  sites  of  . . 

147 

-  en    cuirasse,    secondary    to 

glands  in 

421 

communication  with  renal 

breast  cancer 

802 

extreme  malignancy  of  . . 

395 

pelvis    . . 

577 

-  Of  duodenum 

421 

liaematuria  in     ..304,  307, 

395 

-  -  constipation  with            91, 

367 

anaemia  from 

725 

increased  haematuria  after 

and  diarrhoea  in 

146 

ascites  with 

59 

movement  in  . . 

305 

CARCINOMA     OF   KIDNEY— CARCINOMA     OF  RECTUM 


875 


826 


825 

395 
395 
826 
395 
395 


674 
673 
226 
325 


674 
466 
670 
710 
226 


Carcinoma  of  kidney,  could. 

inferior  vena  cava  obstruc- 
tion from 

liability    to    spread    into 

renal  veins  and  inferior 
vena  cava 

-  -  nodular    enlargement    of 

kidney  in 

origin  from  adrenal  rests 

polypus  of  heart  due  to. . 

rarity  of  . . 

renal  colic  in 

enlari^eraent  in  391,  394,  395 

symptoms  of       .  .  .  .      307 

-  of  large  intestine  Csee  Carci- 

noma of  Colon) 

-  of  labium  majus     ..        ..    423 

-  of  larynx 420 

cyanosis  from      . .  .  .      185 

diagnosis  from  syphilitic 

laryngitis 

tuberciilous     laryngitis 

dysphagia  from  . . " 

ulceration  unilateral  in. . 

haemoptysis  in     . .        318,  325 

microscopic    examination 

in  diagnosis  of 

oedema  of  larynx  in 

sore  throat  from 

stridor  from 

-  -  ulceration  of,  described. 
unilateraloccurrenceof  325,  673 

-  of  leg  812 

-  of  lip  .  .  .  .  403,  419 

-  of  liver         . .        . .  41,  58,  603 
absence  of  symptoms   in 

50  per  cent  of  cases    ..     412 

age  incidence  of  . .  . .     412 

ascites  in  . .       55,  60,  279,  413 

albumosuria  in    . .  . .       20 

angioma  simulating        . .     414 

from  carcinoma  of  breast      743 

colon 

gall-bladder 

oesophagus 

rectum  . . 

stomach  . .         351, 691 

common  sites  of  primary 

growth  . . 

commonest  liver  tumour 

compression  of  lung  by . . 

death  in  coma  in. . 

diagnosis    from    cirrhosis 

409,  410,  413, 

gumma 

hydatid  disease         413, 

impacted  gall-stone   . . 

syphilis  of  liver         411, 

enlargement  of  the  liver 

often  great  and  rapid  in 

extreme  wasting  in 

frequent  absence  of  sym- 
ptoms of  primary  disease  412 

impalpability  of  nodules     412 

general  account  of         . .     368 

gradual  exhaustion  in    . .     413 

great  enlargement  of  liver  in  279 

green  jaundice  character- 
istic    of  . .        368, 

hard  irregular  edge  of  liver 

nodules  on  liver  in 

hardness  of  liver  in 

jaundice  in  60,  279,  362, 

366,   368,  412,  413 

leucocytosis  in    . .  . .     413 

liver  enlarged  in    338,  363,  368 

movement  with  respiration  412 

-  -  nocturnal  rise  of  tempera- 

ture in 362 

occasional    semi-fluctuant 

feeling  from  softening  in   412 

pain  in  the  epigastrium  in     486 

hepatic  region  in  about 

half  the  cases  . .     412 


690 
278 
223 
636 


279 
412 
667 
413 


370 
415 
413 
413 

412 
413 


413 

412 
412 

279 


Carcinoma  of  liver,  conld. 

right  hypochondrium  in    499 

shoulder  in  . .  . .     412 

primary,  extreme  rarity  of    413 

difficulty    of    diagnosis 

from  secondary        . .     413 

growth  in   portal   area 

in  90  per  cent         . .     412 

rapid  course  of  . .     413 

symptoms    similar    to 

those    of    secondary     413 

progressive   wasting   and 

weakness  in     . .  . .     368 

pyrexia  in  362,  618,  623 

rub  from  peritonitis  over      412 

sense  of  dragging  in  right 

hypochondrium  . .     412 
simulating  large   gall- 
bladder            . .          . .     278 

skin  dry  and  shrivelled  in     413 

skodaic  resonance  due  to     667 

sudden  enlargement  from 

haemorrhage  into       409,  412 

umbilication  of  nodules  in 

279,  3G8,  409,  412 
urinary  changes  in  . .     413 

-  Of  lung,  hasmoptysis  from  .     227 
secondary  . .  . .     313 

-  mammrc  (see  Carcinoma  of 

Breast) 

-  melanotic     . .  . .  . .     802 

-  of  nose         . .         .  .        204,  420 
epistaxis  from     . .  . .     250 

-  of  OBSOphagus  afEecttng  lung     322 
diagnosis     from       aortic 

aneurysm         . .  . .     296 

dysphagia  from  222,  484 

enlarged  cervical  glands  in 

223,  296 

the  first  sign  in  . .     421 

erosion  of  aorta  by       . .     295 

gangrene  of  lung  in        . .     288 

iiEematemesis  in..         294,  295 

haemoptysis  from  . .     318 

invasion  of  bronchus  by      318 

laryngeal  paralysis  in    296,  538 

obstruction  to  trachea  by    710 

opening  into  pericardium     711 

pain  in     . .  . .  . .     296 

paralysis   of    vocal    cord 

from 538 

pneumothorax  from      . .     577 

progressive  dysphagia  in      295 

emaciation  in. .  . .     484 

rapid  wasting  in. .  . .     295 

right  supraclavicular  gland 

enlarged  in       . .  . .     421 

-  -  secondary  in  liver  . .     223 
simulated  by  gastric  car- 
cinoma..         ..          ..     299 

stridor  from         . .  . .     710 

a;-rays  in  diagnosis  of,    . .     296 

-  of    ovary,,    enlarged   supra- 

clavicular glands  in       . .     421 

peritonitis  with  . .  . .       57 

secondary  deposits  in  ribs     776 

simulating  sciatica         . .       74 

-  of  palate     . .        . .        420,  640 

-  palpable  in  inguinal  region      731 

-  of  pancreas 421 

absence  of  cholangitis  with  725 

stercobilm  in  fisces  with    116 

behaviour  of  faecal  fat  in     116 

Cammidge's  reaction  with 

59,  60,  116,  690 
diagnosis  from  duodenal 

carcinoma        . .         266,  725 

pancreatitis      .  .  . .     265 

epigastric  pain  with       . .     486 

tumour  from  .  .366,  500,  724 

fatty  stools  with      59,  364,  365 

gall-bladder   enlargement 

with  59,  265,  280,  363,  366, 
500,  690 


Carcinoma  of  pancreas,  contd. 

glycosuria  with  . .  59,  360 

inflation    of    stomach    in 

diagnosis  . .         39,  366 

jaundice  due  to     280,  362,  363, 

366,  500,  690,  724,  725 

occult  blood  in  faeces  in . .     117 

pain    in    right    hypochon- 
drium in  . .  . .     500 

in  left  hypochondrium       726 

pancreatitis  secondary  to     116 

peritonitis  with  . .  . .       57 

portal  glands  affected  in      366 

position  and  characters  of     366 

secondary  in  liver  60,  279 

supraclavicular  glands  en- 
larged in  . .  . .     421 

transmitted  pulsation  in       59 

wasting,      anaemia      and 

jaundice  with  . .     724 

-  of  penis        ..  423,  677,  803 

age  incidence  of..        676,  677 

deposits  in  femoral  glands   734 

description  of      . .  . .     676 

diagnosis  from  chancre  676,  677 

gumma  . .  . .     677 

inguinal  glands   enlarged 

hi  423,  676,  677 

liability  to  bleed  . .     677 

microscopic    diagnosis   of 

676,  677 
obscured     by     phimosis, 

slitting   up  of   prepuce 

in  diagnosi'i  of  . .  670 
occurrence     on     site     of 

previous  ulceration     . .     677 

pain  due  to         . .  . .     516 

-t  -  site  of  origin  of  . .  . .      676 
sore  due  to          . .  . .     674 

-  Of  perineum  423,  677,  678 

development  from  scar. .     678 

direct     extension     from 

anal  or  vulval  growth  678 
inguinal  glands  enlarged 

from      . .  . .        423,  678 

haemorhage  from  . .     678 

microscopic  diagnosis  of       678 

ulcerated  . .  . .  . .     678 

-  of  peritoneum,  ascites  in  . .      57 
colloid       . .  .  .  .  .        57 

-  Of   pharynx,    enlarged   sub- 

maxillary lymphatic  glands 

in  . .  . .  . .     420 

enlargement    of    cervical 

glands  in  . .  . .     420 

sore  throat  in      . .  .  .     670 

-  of  pleura,  bloody  effusion  in     118 

-  of  prepuce 423 

-  of  prostate 307 

characters  of  441,  512 

enlarged  pelvic  glands  in     307 

haematuria  in      . .         304,  311 

infiltration     of     urethral     • 

mucous  membrane  in        512 

micturition  frequent  with     458 

nodulation  and  fixity  of        307 

pain  in  penis  during  mic- 
turition in        . .         511,  512 

-  -  -  perineum  in      .  ,  .  .      516 

primary     . .         . .  . .     307 

rectal  examination  in  diag- 
nosis of  . .         512,  638 

relative  frequency  of      . .     512 

secondary     deposits      in 

cranial  bones  from     . .     783 

ribs   . .  . .  . .     776 

vertebrae       . .  . .     786 

similar  in  many  ways  to 

adenoma  . .  . .     512 

-  of  rectum    ..        . .         44,  473 
absence     of     satisfaction 

after  stool  in    .  .  .  .      636 

age  incidence  of  .  .  .  .      636 

bearing-down  pain  in    . .     473 


876     CARCINOMA   OF  RECTUM— CARCINOMA    OF  THYROID  GLAND 


Carcinoma  of  rectum,  contd. 

Carcinoma,  contd. 

Carcinoma  of  stomach,  contd. 

bladder  infiltrated  by 

-  Of  splenic  flexure  (and  see 

movement  with  respiration 

406 

313,  624, 

632 

Carcinoma      of       Colon) 

multiple  serositis  in 

123 

cachexia  from     . . 

93 

absence  of  definite  tumour 

-  -  nausea,     vomiting,     and 

characters  of 

636 

in  many  cases  of 

690 

pain   in . . 

351 

constipation  due  to      147, 

636 

alternating  constipation 

early  symptoms  in 

299 

diagnosis    from    polypus 

and  diarrhoea  in 

690 

obstructing  oesophagus 

223 

C35, 

636 

blood   and   mucus   per 

portal  vein 

692 

diarrhoea  in 

636 

rectum  in     . . 

690 

occult  blood  in  vomit  in 

846 

dyscliezia  from   . . 

150 

diagnosis    of    enlarged 

origin  from  simple  ulcer  351,713 

enlarged    supraclavicular 

spben  from. . 

690 

Oppler-Boas     bacilli     in 

glands  in 

421 

intestinal      obstruction 

stomach  in 

explosive  diarrhosa  in    . . 

636 

from  . . 

690 

351,  353,  355,  845 

846 

fsecal  urethral  discharge  in 

local  perforation  of    . . 

690 

pain  aggravated  by  food  in 

264,  313 

633 

growth  usually  annular 

690 

485 

691 

haematuria  in      . .        305, 

313 

resonance  of  tumour  in 

690 

in  epigastrium  in      484 

485 

hiemorrhage  in    . .           92 

636 

secondary    deposits    in 

an  early  symptom  in 

299 

incontinence  of  fsces  in. . 

374 

left     supraclavicular 

left  hypochondrium  in 

499 

infection  of  inguinal,  pel- 

glands in 

690 

and  tenderness  in  the 

vic,  or  lumbar  glands  in 

636 

in  liver  in 

690 

back  from  . . 

789 

with  internal  piles 

636 

tumour    in    left   hypo- 

umbilical  region  in     . . 

524 

jaundice  first  symptom  m. 

363 

chondrium  in 

690 

palpable    in    left    hypo- 

 malignant  portal  glands  in 

366 

-  Of    stomach,    abdominal 

chondrium 

726 

microscope  in  diagnosis  of 

636 

tumour  from 

peritonitis  with  . . 

57 

micturition  frequent  in . . 

438 

299.  351,  485,  713, 

723 

physical  signs  of 

690 

—  -  mucus  in  the  stools  in     . . 

636 

acetonuria  in 

4 

pneumothorax  from     577, 

578 

pain  in  penis  after  mic- 

 age  incidence  of           299, 

713 

ptyalism  in 

591 

turition  in 

513 

aneemia  in         27,  37,  351, 

691 

pyloric  obstruction  from 

712 

rectum  and  bottom  of 

anorexia  in         . .         299, 

351 

pyrexia  with 

299 

back  in 

636 

nervosa  confused  with 

588 

rectal  shelf  in 

638 

peritonitis  with  . . 

57 

appetite  in  diminished  . . 

50 

i-etroperitoneal      glands 

pyuria  from         . .        624, 

663 

ascites  with          . .           59 

366 

enlarged  in 

422 

rapid  emaciation  in 

636 

band  of  resonance  between 

saromae  in  vomit  in  (Fig. 

rectal  examination  in    . . 

636 

liver  and  tumour 

406 

92,  p.  267)        ..         691 

846 

sciatica  simulated  by     . . 

74 

bile-duct     obstruction 

secondary  cervical  gland 

secondary  deposits  in  liver 

from 

366 

from 

223 

from      . .          . .  60,  279, 

636 

blood  count  in    . . 

352 

deposits    at    umbilicus 

simulating  acute  Bright's 

in  vomit  in 

691 

from        351,  526,  716 

718 

disease    . . 

9 

cachexia  in 

299 

growths  in  bone  in     . . 

269 

situation  of 

636 

cardiac  end,  mterscapular 

ia  liver           279,  351, 

691 

stricture  of  rectum  from 

636 

pain  in. . 

474 

lung  . . 

322 

symptoms  of 

93 

tenderness    of    lower 

simulated    by     duodenal 

talipes  from        . .         131, 

132 

dorsal  spines  in  . . 

474 

carcinoma 

725 

ulceration  of  rectum  due  to 

635 

chemical  analysis  in 

299 

dyspepsia 

299 

vesical  irritability  in 

313 

"  coffee-grounds  "  vomit  in 

299 

enlarged  spleen 

690 

villous,  hfemorrhage  in  . . 

93 

copious  vomiting  in 

737 

epithelioma  of  oesopha- 

- Of  ribs         

776 

diagnosis    from    cirrhosis 

gus    

299 

-  of  scrotum  . .        . .       423, 

679 

of  liver 

301 

gastritis 

299 

absence  of  testicular  en- 

 enlarged  gall-bladder . . 

280 

phantom  tumour 

721 

largement  with 

681 

spleen              690,  726 

729 

simulating  enlarged  liver 

406 

characters  of  ulcer       679, 

681 

gastric  ulcer    . . 

846 

omental      tumour      of 

in  coal  miners     . . 

679 

from  dyspepsia 

848 

chronic  peritonitis  . . 

472 

commencement   as   small 

pernicious  anaemia     . . 

351 

subphrenic   abscess  from 

nodule  or  wart 

679 

spleno-meduUary    leuk- 

577, 

578 

diagnosis  from  hernia  testis  681 

femia 

691 

swelling     in     right     iliac 

enlarged  glands  in  groui  in 

diffuse  type         . .       270, 

299 

fossa  due  to     . . 

737 

423,  679, 

765 

dilatation  of  stomach  in 

umbilical  region  in    . . 

524 

extension  to  testicles 

679 

299,  351,  712 

846 

vomiting  in 

gas-workers 

679 

distaste  for  meat  in 

50 

351,  485,  691,  737, 

843 

occupation  incidence  of  679,765 

dysphagia  from  . .         222 

351 

nature  and  time  of    . . 

299 

simulated  by  suppurating 

epigastric  tumour  from 

723 

wasting  in           . .         299, 

737 

sebaceous  cyst 

681 

gastroscojie  in     . . 

299 

-  Of  suprarenal,  ascites  with 

59 

-  -  in  sweeps 

803 

glands  above  left  clavicle 

diagnosis    from    enlarged 

-  of  sigmoid  colon  (and  see 

in           . .            351,  421 

691 

gall-bladder'     . . 

280 

Carcinoma  of  Colon)  blood 

great  pain  due  to 

767 

-  Of  testis       . .        . .       421, 

520 

per  anum  in 

731 

hfematemesis  in     294,  298, 

351 

age  incidence  of . . 

766 

cachexia  from . . 

731 

HCl  absejit  from  vomit  in 

485 

commoner  than  sarcoma 

766 

intpstinal      obstruction 

diminished  in 

dissemination    via     lym- 

from..             501,  731 

735 

351,  485,  691,  845, 

846 

phatics  . . 

766 

involvement  of  bladder 

632 

hysterical  vomiting  con- 

 duration  of 

766 

sigmoidoscopy  in 

501 

fused  with 

508 

lumbar  glands  infected  in 

766 

diagnosis  of . . 

735 

"  mdigestion  "  in 

351 

malignant         peritonitis 

urethral     passage      of 

jaundice  from      . .         362 

366 

from 

718 

fpeces  from   . . 

264 

lactic     acid     in     gastric 

mesenteric  and  retroperi- 

- of   the   sl<in,    characters   of 

contents  in        351,  353 

84G 

toneal  glands,  enlarged, 

(Fig.  210)              . .          803 

811 

laparotomy  in  diagnosis  of 

in 

422 

description  of 

449 

352,  713 

848 

secondary     deposits      in 

distinction  from  syphilide 

803 

leaking 

577 

cranial  bones  from     . . 

782 

haemorrhage  from 

803 

leucocytosis  in     . . 

691 

vertebrae  from 

786 

-  Of  spine,  atrophic  palsy  of  one 

loss  o£  weight  in . . 

351 

supraclavicular    glands 

leg  from  . . 

543 

malignant  portal  gland  in 

366 

enlarged  in 

421 

pain  in  arm  in  491,492,493 

,494 

melsena  in 

351 

thickening  of  cord  in 

520 

mistaken  for  malingering 

508 

mesenteric  glands  enlarged 

-  of  thyroid  gland,   ags   inci- 

 simulating  brachial  neuritis  492 

in 

422 

dence  of  . . 

791 

CARCINOMA   OF    THYROID    GLAND—CARIES    OF    SPINE 


S77 


('arcinoma  of  thyroid  glami,  coyild. 

Carcinoma  of  uterus,  contd. 

Caries,  dental,  contd. 

cervical  glands  enlarged 

simulating  renal  tumour 

393 

ulceration  of  the  tongue 

from  . . 

792 

sterility  due  to  . .         705 

,  706 

from     ..          ..        813, 

814 

paralysis  of  vocal  cords 

ureter  involved  in         625 

626 

-  sicca 

78ft 

from               .  .         538 

792 

uretliral  passage  of  faeces 

-  of  spine        

474 

secondary    deposits    in 

from 

264 

age  incidence  of  . . 

785 

cranial  bones  from 

782 

urinous  vaginal  discharge  in  313 

atrophic  paLsy  of  one  leg 

in   ribs  from 

776 

vesical  irritability  in     . . 

313 

from 

54S 

vertebra?  from 

786 

vesico- vaginal  fistula  in. . 

632 

atrophy  of  one  leg  from 

54.^ 

sex  incidence  of 

791 

-  Of  vagina 

423 

—  cervical 

477 

ulceration    of    trachea 

hsematuria  in      . .        305, 

313 

age  incidence  of . . 

708 

from  . . 

792 

infiltration  of  bladder  in 

313 

characteristic  attitude  in 

708 

-  Of  tongue     . .        . .       419 

812 

inguinal  lymphatic  glands 

diagnosis     from     post- 

- -  age  incidence  of .  . 

812 

enlarged  in    . . 

423 

pharyngeal  abscess . . 

673 

from  leucoplakia  CP?a^<?Zy)  814 

pain  in  perineum  in 

516 

occipital  pain  in 

477 

broncho-pneumonia  in  321 

,578 

urine  per  vaginam  in     . . 

313 

pain  increased  on  move- 

-  -  cervical  glands  enlarged  in 

420 

vesical  irritability  in 

313 

movement      477,  494 

67a 

diagnosis    from    gumma, 

-  of    vertebrae,    paralysis  of 

radicular  pain  in  arm  in 

493 

therapeutic  test  in     . . 

420 

upper  extremity  from    . . 

555 

scoliosis  from  . . 

708 

Wassermann's  reaction 

lumbar,  pain  in  testicle  in 

524 

severe  pain  in  cervical 

in 

420 

-  of  vulva       . .         . .        768, 

771 

spine  in 

673 

distinction  from  syphilis 

813 

difficulty  of  micturition . . 

440 

sore  throat  in  . . 

673 

dysphagia  due  to 

225 

leukoplakia  preceding   . . 

770 

stiff  neck  from 

708 

-  -  earache  from 

230 

Swelling  due  to    . . 

768 

ar-rays  m  diagnosis  of  477 

,708 

foul  breath  from 

99 

Cardiac  asthma  from  fatty  heart 

241 

colicky  pains  in  . . 

134 

taste  from 

774 

-  branches  of  vagus,  relation 

compression  of  cord  by. . 

561 

limited  )irotrusion  -nith 

S12 

to  cough  . . 

175 

without  deformity 

564 

origin     from     superficial 

-  bruits  Csee  Bruits,  Cardiac) 

diagnosis  of  pachymenin- 

glossitis 

813 

-  disease  (see  Heart) 

gitis  from 

563 

position  usually  not  median 

420 

-  displacement  (see  Heart  Im- 

 occipital  headache 

477 

positive  Wassermann's  re- 

pulse, Displaced) 

from  scoliosis  . . 

477 

action  with 

813 

-  dullness  (see  Heart  Dullness) 

dwarfism  from    . . 

214 

relation  to  chronic  glossitis 

812 

-  dyspnoea,  asthma  mistaken 

gait  in      . .          .  .          181 

785 

sex  incidence  of  . . 

812 

for             

582 

hyperfesthesia  from 

667 

simulated  by  tuberculous 

-  failure  (see  Heart  failure) 

iliac  abscess  from 

632 

ulcer 

814 

-  hypertrophy  (see  Heart  En- 

 intercostal  nerve  pain  in 

47S 

situation  of 

812 

larged) 

interscapular  pain  from 

474 

-  -  submaxillary     lymphatic 

-  impulse  (see  Heart  Impulse) 

keratosis  due  to  . . 

785 

glands  enlarged  m 

419 

-  irregularity  (see  Heart,  Irregular) 

knee-jerk  exaggerated   in 

trismus  simulated  by 

801 

-  malformation     (see    Heart, 

paraplegia  from 

558 

-  of  tonsil       

420 

Disease,  Congenital) 

kyphosis  from     . . 

181 

not  common 

672 

-  thrills  (see  Thrills,  Precordial; 

lardaceous  disease  in      10, 

696 

squamous-celled  . . 

670 

Caries  of  bone,    spontaneous 

lordosis  from 

183 

submaxillary      lymphatic 

fracture  in 

269 

loss  of  sphincter  ani  con- 

glands enlarged  in 

420 

tuberculous 

751 

trol  in  . . 

558 

ulceration  of 

672 

-  cervical  (see  Caries  of  Spine, 

mistaken  for  hysteria    . . 

777 

-  -  unilateral 

672 

Cervical) 

intercostal  neuralgia 

777 

-  of  trachea,  stridor  from  . . 

710 

-  dental   (and    see    Neuralgia 

new  growth  simulating 

564 

-  of  urethra 

209 

Minor)  .  .            419,  496, 

497 

pain  in  back  from          476 

785 

painful  micturition  from 

209 

abscess  of  antrum  of  High- 

with   prominence    of 

urethral    obstruction    re- 

more from 

502 

spines  in   . . 

475 

sulting  from    .  . 

767 

alveolar  abscess  from     . . 

747 

epigastrium  from 

485 

-  Of  Uterus,  affecting  body  of, 

bleeding  gums  from 

868 

umbilical  region  in      .  . 

525 

pregnancy  almost  impos- 

 canine,  pain  and  tender- 

 paralysis    of    bowel    and 

sible  with 

436 

ness  in  naso-labial  area 

tympanites  from   com- 

 size  of  uterus  with 

434 

in  {Fig.  132)   . . 

497 

pression  in 

433 

vaginal  discharge  from 

211 

earache  caused  by 

230 

upper  extremity  from 

555 

anuria  in  . .          . .            45 

>  47 

empyema    of    antrum    of 

paraplegia    due    to 

arising  from  fibromyoma 

434 

Higlimore  from         204, 

205 

131,  181,  557, 

561 

bladder  infiltrated  by 

enlarged  glands  from    419, 

708 

Pott's  curvature  in 

564 

313,  624, 

632 

submaxillary  lymphatic 

psoas  abscess  from  632, 739 

785 

diagnosis  from  sloughing 

glands  from .  . 

419 

reflexes  in 

558 

fibroid  . . 

759 

fibrous   epulis  in  associa- 

 relative  frequency  of     . . 

385 

dystocia  from 

229 

tion  with 

748 

rigidity  over  painful  area 

foul  discharge  in           211, 

435 

foul  taste  due  to  . .       99, 

774 

in 

477 

frequent  micturition  with 

438 

headache  irom     . . 

327 

of  the  spine  from      474, 

785 

friable  hardness  of 

435 

loss  of  weight  due  to 

848 

sacralgia  in 

510 

hsematuria  in      . .         305, 

313 

mercurialism  from 

86 

signs  of  tuberculosis  in  . . 

564 

histological  diagnosis     . . 

434 

neuralgia  from    . .        330, 

497 

simulated  by  aneurysm 

786 

metrorrhagia   from        433 

435 

trigeminal  from 

495 

indigestion 

351 

metrostaxis  from 

436 

pain  in  the  lower  jaw  in 

malignant     disease     of 

micturition  frequent  from 

438 

501, 

502 

vertebrrp 

786 

pain  in  inguinal  regions  in 

510 

tooth  in 

496 

plirenic  neuralgia 

479 

ovarian  regions  in 

510 

the  upper  jaw  from    .  . 

502 

rickets  .  . 

785 

radiating  down  legs  in 

510 

ptyalism  due  to  . . 

591 

simulating  torticollis 

167 

pelvic  swelling  due  to    . . 

757 

referred  pain  in  . . 

496 

spontaneous    fracture    in 

270 

pressure    on    rectum    of, 

segmental    areas    in 

stooping  gait  in  . . 

181 

causing  dyschezia 

150 

face  in 

497 

sudden,  paraplegia  in     . . 

270 

pyelitis  from 

625 

relation  to  carcinoma  of 

swelling  in  right  iliac  fossa 

pyonephrosis  from 

626 

jaw        

749 

due  to  . . 

737 

pyuria  from         .  .         624, 

632 

retracted  gums  from 

641 

over  spine  from         194, 

474 

sacralgia  in 

510 

stiff  neck  from    . . 

708 

tenderness    in     spine    in 

sciatica  simulated  by     . . 

74 

stomatitis  from  . . 

815 

181,  474,  784, 

785 

simulating  prolapse 

587 

-  -  swelling  of  the  face  from 

746 

transverse  myelitis  from 

564 

S/S 


CARIES    OF   SPIXE— CEREBRAL    VOMITIXG. 


Caries  of  spine,  contd. 
tuberculous,  relative  fre- 
quency of        . .  . .     3S5 
j--rays  m  diagnosis  of   ISl,  47i 

-  spontaueous   fracture   froni    269 

-  swelling  of  the  face  from  . .     746 

-  of  temporal   bone,   earache 

from  .  .  .  .  . .     230 

Caruia  bases,  uric  acid  from  . .     SI  7 
Carotid  aneurysm  (see  Aneu- 
rysm, Carotid) 

-  artery,  internal,  erosion  from 

chronic  tympanic  suppur- 
ation          4GS 

-  pulsation    in    exophthalmic 

goitre         . .  .  .  .  .      244 

-  pulses,  unequal,  with  aortic 

aneurysm..  ..  ..     236 

Carpal     joints,     hypertrophic 

osteo-arthropathy  in     . .     390 
Carpo-pedal  spasm  (see  Spasm, 

Carpo-pedal) 
Carriers,  typhoid,  infected  bile  in  281 
Cartilags,  blackening  in  ochron- 
osis . .  . .         575, 822 

-  itt  embryoma  of  kidney    . .     393 

-  erosion    of  (see   Erosion   of 

Cartilage) 
CarunculiB    myrtiformes,    red 

and  swollen  in  gonorrhoea     769 
Caruncle,     lu-ethral,     dy^par- 

eunia  from  . .  . .     221 

-  vulval  swelling  due  to  . .  768 
Castellani,  re  dhobie's  itch  . .  275 
Castor  oil,  taste  in  mouth  from  774 
Castration,  obesity  after,  453,  454 
Casts,     intestinal,    simulating 

tapeworm  (Tig.  123)      444,  568 

-  renal,  in  acute  nephritis     12,  311 

albuminuria  with  . .         8 

without  . .  15,  16 

in  arteriosclerosis  . .       15 

bacilluria  . .  . .  . .     615 

and  ceUs,  test  for  in  oedema   457 

with  chyluria       . .  . .     126 

hfemoglobinuria  . .  , .     314 

high  blood-pressure    con- 
ditions . .  . .  . .     526 

importance  in  diagnosis  of 

cause  of  albuminuria . .       61 

with  infarction  of  kidney      314 

in  kidney  lesions  causing 

hEematiuia       . .  . .     306 

lardaceous  . .  . .       10 

mitral  regurgitation    due 

to  Bright's  disease     . .     240 

nephritis"  . .  . .       466,  646 

chronic 303 

of  old  people  . .       14 

parenchymatous      . .     454 

with  pleitritic  eflfnsion  . .     122 

in    polyuria    with    albu- 
minuria . .  . .     584 

pyelitis  and  pyelonephritis  628 

uraemia      . .  . .        329,  464 

in  urine  from  inferior  vena 

cava  tlirombosis  . .     825 

simuJated  by  mucus  . .     444 

varieties  of  (Plate  I)      . .         7 

-  in  sputum    . .  . .  . .     704 

-  vaginal  .  .  . .  211, 220 
Catalepsy         140 

-  dementia  with         . .  . .     651 

-  melancholia  nith    . .  . .     651 

-  pupils  in       . .  . .  . .     594 

-  retraction  of  the  head  in    . .     641 

-  risus  sardonicus  in. .  . .     651 

-  trismus  in    . .  . .  . .     801 

Cataract,  anterior  polar  from 

corneal  ulceration  . .     806 
from   ophthalmia   neo- 
natorum      . .          . .     836 

-  blindness  never  total   from     839 

-  congenital,  nystagmus  in. .     453 


Cataract,  contd. 

-  extraction,  blue  vision  from     840 
erythropsia  from . .  . .     840 

-  monocular  diplopia  in       . .     198 
Catarrti  of  bile-ducts  (see  Bile- 

ductiij 

-  buccal      and      pharyngeal, 

cheilitis  glandularis  from     403 

-  duodenal,  jaundice  from  . .     361 
pancreatitis  secondary  to     116 

-  gastric  (see  Gastritis) 

-  nasal,  epistaxis  in  . .  . .     251 
epiphora  in          . .  . .     250 

-  of  pancreas  (see  Pancreatitis) 

-  small   bowel,   chronic   diar- 

rhoea from  . .  . .     197 

-  swelling   of   eyes   and   face 

caused  by  . .  . .     459 

Catarrhal  jaundice  (see  Jaim^- 
dice.  Catarrhal) 

-  laryngitis      . .  . .  . .     465 

Catastrophe,  abdominal,  causes   472 
Catching  cold,  UabiUty  to  in 

rickets       .  ^         . .  . .     171 

Catheter  broken  ofE  in  urethra     210 

-  coude,  in  prostatic  enlarge- 

ment        .  .  .  .         440,  441 

-  in  diagnosing  cause  of  pyuria  624 

distended  bladder      '    . .  730 

neuroses  of  bladder        . .  443 

urethral  stricture  . .  439 

-  retained        . .  . .  . .  206 

Catheterization,    acute    epidi- 

dymo- orchitis  after      517,  518 

-  anuria  from  . .  . .       49 

-  in  distention,  care  needed  in     440 

-  rieors  after  . .  . .  . .     647 

Cattle,  anthrax  from  .  .  .  .     603 

Cauda  equina,   affections  of, 

diagnosis  from  sciatica . .  487 

incontinence  of  fieces  from  348 

taUpes  in  . .          . .          . .  131 

tumour  on,  mode  of  onset 

of  symptoms    . .          . .  563 

muscular  atrophy  in   . .  74 

paraplegia  from           . .  561 

Caustic  soda   test  for   elastic 

iibres         701 

Cauterization  in  hypopyon  ulcer  807 

Cautley's  anosteoplasia           .  .  213 

Cavernitis,  gouty       . .        . .  516 

-  due  to  hsematoma  . .          . .  516 

-  pain  in  the  penis  in . .          . .  5]  6 

-  syphilitic       . .          . .          . .  516 

Cavernous  sinus,  carotid  aneur- 
ysm communicating  with  764 

thrombosis    (see    Throm- 
bosis of  Cavernous  Sinus) 
Cayenne  pepper  deposit  in  the 

urine         . .          . .          . .  816 

'Cellist's  cramp           . .          . .  177 

Cellulitis,     acutely      inflamed 

lymphatics  in     . .          . .  455 

-  asymmetrical  oedema  from  455 

-  bacteriology  in  diagnosis . .  459 

-  of  calf  muscles,  tahpes  from  132 

-  diagnosis  from  carbuncle . .  603 

-  gout  simulating      . .          . .  455 

-  local  infection  causing       . .  455 

-  lymphatic  obstruction  from  456 

-  of  neck  from  actinomycosis  748 

-  oedema   of  face,  neck,   and 

arms  from  . .        459,  461 

-  orbital,      cavernous      sinus 

thrombosis  due  to       253,  254 

-  of  pelvis  (see  Pelvis  Cellulitis  of) 
Central  necrosis  of  bone  (see 

Bones,  !N"ecrosis  of) 

-  retinal  artery,  emboUsm  of, 

ophthalmoscopic   appear- 
ance of  (Plate  VHP)       . .     463 
vein,  thrombosis  of,  oph- 
thalmoscopic     appear- 
ance of  (Plate  VIII)  462,  839 


Cephalalgia  (see  Headache) 
Cerebellar   artery  thrombosis, 

ataxy  in    . .  . .  . .        68 

-  articulation  . .  . .        69 

-  ataxia  of  children,  acute . .  68,  69 
intention  tremor  in         . .     800 

-  hfemorrhage,  vomiting  with     847 

-  lesions,  ataxy  in     . .  . .       68 

deviation  of  eyes  in        . .       69 

nystagmus  with  . .  . .       69 

occipital  headache  in     . .     326 

reeling  gait  in       . .         69,  277 

tremor  in  . .  . .     795 

vertigo  with        . .  69,  827 

-  peduncle,  superior,  intention 

tremor  from  lesion  of     . .     800 
Cerebellum,    abscess    of    (see 
Abscess,  Cerebellar) 

-  tumour  of,  ataxy  from        68,  643 

Babinski's  sign  in  . .       82 

bladder  and  rectal  troubles  565 

exaggeration    of    tendon 

reflexes  from  . .  . .     643 

gait  in      . .  . .        565,  643 

headache  with     . .         565,  651 

head  retraction  from    641,  643 

hypothermia  in  . .  . .     346 

knee-jerks  increased  in. .     565 

nystagmus  with  453,  643 

optic  atrophy  and  neuritis 

from      . .  . .  . .     643 

paraplegia  from  . .  . .     562 

pseudo-nystagmus  in     . .     452 

rectal  trouble  in. .  . .      565 

vertigo  due  to     . .  . .     828 

vomiting  with     . .         565,  651 

Cerebral  abscess  (see  Abscess, 
Cerebral) 

-  anaemia,  arteriosclerosis  pre- 

venting    . .  .  .  .  .     359 

-  aneurysm    (see    Aneurysm, 

Cerebral) 

-  congestion,  epistaxis  in     . .     251 

-  cysts,  headache  in. .  . .     327 
-diplegia         ..          ..154,535,686 

-  diseases,  hyperpyrexia  in. .     622 
vomiting  in         . .  328 

-  embolism    (see    Embolism, 

Cerebral) 

-  gumma,  headache  in         . .     327 

-  haemorrhage    (see    Hsemor- 

rhage,  Cerebral) 

-  hemisphere,       left,       with 

speech    centres,    diagram 

of  (Fig.  185)       . .  . .     683 

-  inflammation,    spastic   par- 

alysis of  upper  extremity 
from  . .  . .  . .     547 

-  injuries,   ataxy  in..  ..       68 
grave      significance       of 

hyperpyrexia    in         . .     622 

glycosuria  after   .  .  .  .     292 

hemiplegia  from..        337,  338 

hiccough  in         . .  . .     343 

-  monoplegia,  talipes  in       . .     131 

-  softening,  laryugeai  paralysis 

with  . .  . .  . .     539 

bilateral,    apoplexy   with 

hemiplegia  from         . .     563 

sensory  disorders  in  . .     563 

or     haemorrhage,     para- 
plegia from     . .  . .     562 

hyperpyrexia  in. .  . .     34^1 

increase  of  deep  reflexes 

with .796 

paralvsis    agitans    simu- 
lated by  . .  . .     796 

prosressive  mental  failure 

with 796 

sphincter  trouble  with  . .     796 

-  syphilis  (see  Syphilis,  Cerebral) 

-  thrombosis  (see  Thrombosis, 

Cerebral) 

-  vomiting  (see  Vomiting,  Cerebral) 


CEREBRITIS—CHEIROPOMPHOL  YX 


879 


CerebritLs,  convulsions  in 

172 

Cerebrum,  tumour  of,  conld. 

Chancre,  conld 

Cerebrospinal  fluid 

338 

increased     intracranial 

-  characters  of           . .        675, 

676 

in  acute  meningitis      563 

643 

pressure  in 

686 

-  common  site 

675 

albumin  in,  in  intracranial 

insomnia  in          . .       356, 

358 

-  development  from  soft  sore 

inflammatory  conditions 

339 

loss  of  knee-jtrk  in 

398 

676, 

738 

in    intrn^ipinal    inflam- 

 taste  due  to     . . 

774 

-  diagnosis  from  anthrax 

603 

matory  conditions  . . 

339 

lymphocytosis  in  cerebro- 

- digital           . .          . .        266, 

422 

bacteriological    examina- 

spinal fluid  in . . 

339 

-  enlargement  of  neighbouring 

tion  of..          ..        339 

340 

nerve-deafness  from 

190 

glands  417, 419, 675,676,678,747 

in  cerebrospinal  fever 

598 

occasional  latency  of    . . 

341 

-  of  eyelid 

419 

not  coloured  in  jaundice 

361 

optic  neuritis  in     98,  292, 

341, 

-  on  face,  less  indurated  than 

cytological  examination 

350,  477,  547,  565,   686, 

782 

on  penis  . . 

746 

of          

330 

paralyses  in 

markedsurrounding  oedema  747 

from  ear  . . 

468 

340,  341,  350,  547, 

782 

-incubation   period..         675, 

676 

in  encephalitis,  and  supe- 

 pyre.xia  in 

341 

-  of  lip  (Fiff.  10)            86,  403, 

746 

rior  longitudinal  throm- 

 signs  of     . .          . .        173, 

547 

-  obscured  by  phimosis,  dia- 

bosis of  meningitis     . . 

55S 

simulated  by  arterioscler- 

gnosis of  . .          . .        675, 

676 

general  j)aralysis  of  insane 

osis 

328 

-  oedema    of    labium    minus 

139, 

269 

simulating  hysteria 

798 

from 

770 

lymphocytosis  in 

339 

slow  pulse  in 

782 

-  penile  sore  due  to  . . 

674 

globulin,     albumin,     and 

small  pupil  with  retention 

-  on  perineum 

678 

nucleo-proteid  in 

643 

of  reflexes  in  . . 

594 

-  scrotum        . .          . .        681, 

765 

-  -  hypertension  of,  in  menin- 

 subjective  smell  sensations 

-  simulated     by     moUuscum 

gitis           ..       338,  339, 

643 

from 

669 

contaglosum 

805 

lymphocytes  in  (see  Lym- 

 temporary  glycosuria  from 

292 

epithelioma  of  vulva     . . 

769 

phocytes; 

tender  scalp  in    .  .         781, 

782 

penis      . .          .  .         676, 

677 

meningococci  in. .        340, 

643 

tinnitus  from 

794 

gumma     . . 

677 

-  -  normal     and     abnormal 

tremor  in 

795 

herpes  genitalis   . . 

830 

characters  of  . .        338, 

643 

trigeminal  neuralgia  in  . . 

496 

soft  sore              . .        675, 

676 

from  nose            . .        138, 

203 

of  uncinate  gyrus,  anos- 

- spirochaeta  pallida  in  {Plate 

palsy  of  leg  from  syphilitij 

mia  from 

669 

XII,  Fig.  J,  p.  696) 

meningitis 

544 

unilateral  convulsions  in 

170 

675,  678,  747 

769 

polymorphonuclear    cells 

exophthalmos    due    to 

-  of  tongue,  discussion  of    . . 

813 

in  acute  meningitis    . . 

643 

tubercles                254, 

255 

-  tonsil 

672 

pyrocatechin  in  . . 

203 

vertigo  from        . .        341, 

828 

-  urethra 

209 

reducing  substances  in  203 

643 

vomiting  in,  292,  336,  341, 

477, 

-  vulval  swelling  from 

768 

sugar,     urea,     proteids. 

686,  782,  844 

847 

-  waiting  for  secondaries    in 

choline  in 

339 

unilateral  headache  in  . . 

326 

doubtful  cases  of 

675 

trace  of  globulin  in  normal 

643 

Cerumen          

467 

-  AVassermann's    reaction    in 

trypanosomes       in,       in 

-  creaking  noises  in  ear  from 

793 

diagnosis  of  422,675,678 

747 

sleeping  sickness 

34 

-  deafness  from          . .        188, 

190 

Chancroids  (see  Soft  Sores;  . . 

675 

tubercle  bacilli  in 

643 

-  earache  from 

230 

-  simulated  by  herpes  genitalis 

8.30 

turbid  in  meningitis 

338 

Cervical    adenitis    (see    Lym- 

Chapping of  lips 

403 

yellow  in  meningitis 

338 

phatic  Glands,  Cervical) 

Charcoal,  coloration  of  stools  by 

89 

-  meningitis  (see   ileningitis, 

-  caries  (see  Caries  of   Spine, 

-  test  in  constipation 

140 

Cerebrospinal) 

Cervical) 

Charcot,  dissociative  anaesthesia 

Cerebrum,     abscess    of     (see 

-  glands,  enlarged  (see  Lym- 

of            

285 

Abscess,  Cerebral) 

phatic  Glands,  Cervical) 

-  re  hepatic  intermittent  fever 

6-50 

-  contracture  from  lesions  of 

-  plexus,  interference  with  by 

—  re  spasmogenic  zones 

777 

cortex 

162 

thyroid  gland  tumour  . . 

792 

Charcot's  amyotrophic  lateral 

-  paraplegia  from  congenital 

-  rib  (see  Rib,  Cervical) 

sclerosis,    fibrillary    con- 

defect of  cortex  . . 

558 

-  sympatlietic,       interference 

tractions  In         . .         158, 

159 

-  tumour  of,  anosmia  from  . . 

669 

^\ith    by    aneurysm 

222 

-  joiQt  (Fig.  110)       . . 

387 

aphasia  in             .  .         G85 

686 

paralysis  (see  Paralysis  of 

in  locomotor  ataxy 

562 

aura  in 

80 

Cervical  Sympathetic) 

syringomyelia                 285, 

563 

bradycardia  from 

98 

Cervico-brachial    plexus    and 

painless  character  of 

388 

Cheyne-Stokes  respiration 

its  branches  (Fig.  145) . . 

553 

CHARCOT-LEYDEN      CRYS- 

from 

125 

Cervix  uteri,  carcinoma  of  (see 

TALS  (Fig.  26)             117, 

118 

coma  in   . .          . .        136, 

137 

Carcinoma  of  Uterus) 

In  asthma 

179 

convulsions  in      ..        1G9, 

172 

closure  of,  sterility  due  to 

706 

Charwomen,  acroparaesthesia  in 

493 

not  common  in 

173 

congenital  elongation  of 

586 

Cheeks,  actinomycosis  of 

87 

diabetes  insipidus  from. . 

585- 

erosion    of,   metrorrhagia 

-  affection  of  by  acne  ^Tilgaris 

531 

iliagnosis  from  abscess  . . 

623 

from     . .          . .        433, 

435 

-  coloured  sweat  of  . . 

714 

satiumine     encephalo- 

 metrostaxis  from 

436 

-  dilated  venules  in  alcoholism 

368 

pathy 

139 

sacralgia  from. . 

.509 

in  cirrhosis  of  liver    . . 

410 

-  -  "  ebb  and  flow  "  of  knee- 

gonococci  in        . .        211, 

769 

-  epithelioma  of 

419 

jerk  in  . . 

399 

herpes  of . . 

830 

-  flapping  of,  in  facial  paralysis 

533 

epileptic  aura  from 

80 

inflammation  of . . 

210 

-  myoma  cutis  of 

805 

frontal,      alteration     in 

long  conical,  causing  dys- 

—  new  growths  of 

204 

character  due  to 

798 

menorrhosa 

219 

-  paralysis  of  one,  with  coma 

137 

inattention  due  to 

798 

normal  secretion  of 

210 

-  swelling  of,  due  to  mercury 

86 

incoherence  due  to 

798 

polypus     of,     simulating 

-  syphilitic  ulcer  of  Inside  of 

813 

loss  of  memory  due  to 

798 

prolapse  of  uterus 

587 

Cheilitis  exfoliativa    . . 

403 

unilateral  tremor  due  to 

798 

simulating'  prolapse  while 

-  glandularli  .  . 

403 

haemianopsia  from          81, 

335 

fundus  is  in  normal  posi- 

Cheiropompholyx 

266 

hsemorrhage  into 

341 

tion 

587 

-  brlttleness  of  nails  In 

445 

headache    in    292,     327, 

350, 

rigidity  of,  dystocia  from 

227 

-  buUse  In       ..  110,  111,  654, 

832 

477,  686, 

847 

Ceylon,  oidium  troplcale  in  . . 

705 

-  crusts  in       . .          . .        654, 

832 

hemiplegia  from    138,  340 

341 

Champagne,  explosive  eructa- 

- distinction  from  eczema  . . 

832 

hippus  in 

595 

tion  of  gas  from. . 

639 

pemphigus 

832 

hyperpyrexia  in.. 

344 

-  priapism  caused  by 

586 

-  pruritus  in  . . 

588 

hypertension  of  cerebro- 

Chancre,  appearance  of  secon- 

- relations  to  summer  season 

832 

"  spinal  fluid  in 

338 

daries  4  to  6  weeks  after 

676 

-  tender  hands  and  feet  from 

654 

hypothermia  in  . . 

346 

-  balanitis  with 

676 

-  vesicles  In     . .          . .       654, 

832 

88o 


CHEMICAL    WORKERS,    BULLM    IN— CHLOROSIS 


Chemical  workers,  bullae  in . . 

110 

Chilblains        

253 

CHILLS            

64G 

Chest,  acne  affecting           531 

604 

-  affecting  fingers 

266 

-  acute  general  pains  in  the 

-  asymmetrical,     from    lung 

-  association  with  menorrhagia 

Umbs  in    . . 

503 

affection    .  . 

331 

at  puberty 

430 

-  athetosis  after 

154 

morement  of  in  fibroid  lung  324 

-  from  cold 

810 

-  in  baciUuria 

616 

followed  by  scoliosis 

180 

-  lupus  erythematosus  simulat- 

— influenza 

699 

vertebral  column  in 

192 

ing 

656 

-  malaria 

615 

CHEST.  BLOODY  EFFUSION  IN  118 

-  pruritus  in  . . 

588 

-  myalgia  due  to 

507 

from  new  growtL  in  . . 

322 

Child,  dystocia  due  to  large  . . 

227 

-  pains  in  the  limbs  in 

505 

-  bulging  of,  by  aneurysm  . . 

235 

Child-bearing,     influence     of 

-  in  relapsing  fever    . . 

698 

from  big  heart    . . 

232 

age  on 

707 

-  tremor  from 

798 

causes        . .          . .         193 

,194 

Child-birth,  constipation  after 

148 

-  in  typhus  fever 

698 

hydatid  cyst  of  lirer 

415 

-  infarction  of  lung  after 

322 

Chimney-sweep's  cancer 

679 

precordial,    in     adherent 

-  infective  peritonitis  after.. 

644 

Chin,  acne  vulgaris  of 

531 

pericardium     . . 

242 

-  thrombosis  after 

456 

-  circinate  syphiloderm  of    . . 

532 

in  aortic  disease 

233 

Children     (and    see    Infancy), 

-  in  cretinism  . . 

258 

heart    disease   of    chil- 

absence of  redness  of  joint 

-  effects  of  blow  on  ear  on    . . 

467 

dren     . .          . .     102 

232 

in  pneumococcal  arthritis  in  375 

-  heavy  acromegalic . . 

263 

mitral  regurgitation  . . 

238 

-  adherent  pericardium  in    . . 

62 

-  rece(Ung  in  microcephaly  . . 

214 

by  cystic  renal  tumour.  . 

393 

-  appendicitis  causing  vague 

-  reflex  hiccough  from 

342 

-  cubical,  in  emphysema    186, 

246 

abdominal  pains  in 

350 

-  sycosis  vulgaris  of  . . 

602 

-  deficient   morement   of,  in 

-  athetosis  in  . . 

154 

Chiii-drop  in  myasthenia  (Fig. 

bronchiectasis 

703 

-  Babin.ski"s  sign  in  . . 

82 

83)             ..          ..          .. 

260 

in  pneumothorax          480, 

577 

-  bacteriuria  in         . .            81 

,  84 

China,  distoma  pulmonale  in 

325 

-  deformities    of,    depression 

-  causes  of  frequent  micturi- 

- fUariasis  in  .  . 

33 

of  hver  in . . 

405 

tion  in 

438 

-  paragonimus  "Westermani  in 

705 

shortness  of  breath    in . . 

101 

insomnia  in 

357 

Chloasma,  macular     .. 

423 

-  enlargement  of  affected  .side 

paraplegia  in        . .         556, 

557 

-  pigmentation  of  the  skin  in 

424 

in  pneumothorax 

480 

-  Cheyne-Stokes'     respiration 

-  uterinum      . .          . .        114, 

574 

-  general  changes  in  the  form  of  191 

normal  in . . 

124 

-  varieties  and  causes  of 

574 

-  injuries,  haemoptysis  ia    317, 

320 

-  chorea   as  rheumatic  mani- 

Chloral hydrate,  coma  due  to 

-  myoma  cutis  of 

805 

festation  in 

504 

137 

346 

-  Tiain  in  (see  Pain  in  Chest) 

-  cirrhosis  of  liver  in. . 

369 

purpura  from 

596 

-  pityriasis  rosea  of  . . 

658 

-  colicky  pains  of 

134 

-  pigmentation  of  skin  from 

423 

-  pruriso  ferox  of 

531 

-  coma  at  onset  of  fevers  in. . 

646 

-  Cheyne-Stokes'  respiration 

chest: PUS  IN 

119 

-  convulsions  of,  due  to  drugs 

169 

from 

125 

-  syphilitic  roseola  on 

675 

with  congenital  heart  diseasel69 

-  hypothermia  from  . . 

346 

-  seborrhrpri 

650 

from  laryngismus  stridulus 

466 

-  reducing  body  in  urine  from 

290 

CHEST.   SEROUS  EFFUSION 

otitis  media 

229 

Chlorate  of  potash,  methaemo- 

IN             

120 

rickets      . .           169,  170, 

466 

globinasmia  from 

187 

-  smaU  whitish  scars  on,  after 

—  cycUcal  vomiting  of 

843 

ptyalism  due  to  . . 

690 

herpes  zoster 

479 

-  delirium  from  otitis  media  in 

229 

Chlorides    in    acute    Bright's 

-  tenderness  in  (see  Tenderness 

-  diacetic  acid  and  acetone  in 

disease 

12 

in  Chest; 

urine  of    . . 

843 

-  diminished  in  urine  in  pneu- 

- unilateral    enlargement    of, 

-  enure-iis  in  . . 

247 

monia           . .        186,  321 

,372 

from  empyema    . . 

192 

-  epistaxis  in              .  .         251, 

252 

-  in  phosphorus  poisoning   . . 

373 

shrinldng  ^^ith  fibroid  lung 

-  excessive   fatness    of,    from 

Chloroform,  coma  due  to    . . 

137 

193,  282, 

246 

hypernephroma  . . 

454 

-  headache  from 

328 

after  pleuritic  effusion 

193 

-  extensor  plantar  reflex  in  . . 

557 

-  poisoning,  delayed 

4 

from  pneumothorax   . . 

193 

-  hyperpyrexia  in 

344 

tetany  in 

178 

-  Taricose   veins    (see    Veins, 

-  incidence  of  heart  failure  in 

62 

-  reducing  body  in  urine  due  to 

290 

Taricose,  Thoracic) 

-  intussusception     in,     acute 

Chloroform-benzene      method 

-  wail,  abscess  of  (see  Abscess 

diarrhoea  from     . . 

196 

of   measuring   sp.  gr.    of 

of  Chest  WaU) 

-  jaundice  of  . . 

362 

blood 

580 

retraction  of  from  various 

-  knee  -  jerks     decreased     in 

Chloroma        ..        ..          36 

,599 

causes  . . 

194 

general  illness  in . . 

398 

-  anaemia  in    . . 

44 

tumour  of 

193 

-  leucocytes  in 

399 

-  enlarged      lachrymal      and 

wounds  of,  pneumothorax 

-  loss   of  speech  in  (see  also 

saUvary  glands  in 

599 

after      . .          . .         577, 

578 

Speech,  AbnormaUties  of) 

682 

-  green  colour  of  new-formed 

CHEYNE-STOKES'    RESPIR- 

- lymphocytes  in 

29 

tissue  in  . . 

599 

ATION  (Fig.  28)    124,  125 

128 

-  night  terrors  in 

447 

-  lymphatic    gland     enlarge- 

 in  fatty  heart     . . 

241 

-  otitis  media  in 

229 

ment  in    . . 

599 

tuberculous  meningitis  . . 

174 

-  paraplegia  from  Friedreich's 

-  lymphocytosis    in    cerebro- 

Chicken-pox, affecting  chest 

833 

ataxy  in    . . 

559 

spinal  fluid  in 

339 

pharynx    . . 

670 

due  to  idiocy       . .         556 

557 

-  negative  blood  changes  in . . 

599 

-  date  of  rash  in 

S33 

from  muscular  dvstrophies 

-  occurrence  in  early  life 

599 

-  diagnosis  from  smaU-pox  . . 

834 

560, 

561 

—  purpura  in  .  .          . .         596, 

599 

-  distribution  of  rash  in 

S34 

-  perforation   of    acetabulum 

-  relation  to  sarcoma 

599 

-  eosinophilia  after   . . 

248 

in  hip  disease  in . . 

739 

-  slowly  fatal  covnse  of 

599 

-  gangrene  in. . 

282 

-  peripheral  neuritis  in,  from 

-  spontaneous  fracture  from 

269 

-  occurrence   of    eruption   on 

diphtheria 

559 

-  swellings  on  bones  in 

599 

mucous  membranes 

673 

-  pneumococcal  arthritis  in . . 

375 

Chlorosis         

36 

-  papules  in   . . 

833 

-  position  of  heart  impulse  in 

330 

-  amenorrhcBa  in       . .   23,  41, 

303 

-  parts  affected  by    . . 

833 

-  prolonged  pyrexia  from  toxic 

-  blood  changes  in     . .           41 

303 

-  simulating  molluscum  conta- 

absorrition  (alimentary)  in 

618 

-  bruit  de  diable  in  neck  in  . . 

333 

giosum 

805 

in,  often  unexplainable 

609 

-  cachexia  in  . . 

115 

pustular  syphilide 

833 

-  pulmonary  systoUc  bruit  in 

-  cardiac  bruits  in  41,  105,  303 

333 

strophulus 

833 

normal 

105 

-  colour  index  in 

26 

-  sore  throat  in          . .        670, 

673 

-  rarity  of  mitral  stenosis  in 

62 

-  constipation  in       . .          41, 

143 

-  systemic  disturbance  slight  in 

833 

-  .scurvy  in      . . 

85 

-  displaced  cardiac  impulse . . 

333 

-  vesicles  and  pustules  in     . . 

833 

-  tabes  in 

489 

-  dyspncea  in 

303 

-  vesicular  fluid  within  ilal- 

-  tuberculous  joints  in 

385 

-  epistaxis  in  . . 

251 

pighian  cells  in   .  . 

829 

-  "Werdnig-Hoffmann  muscu- 

- flusliing  in    . . 

268 

Chicory,  oxaluria  from 

471 

lar  atrophy  in 

158 

-  greenish  hue  of  sMn  in 

303 

CHLOROSIS— CIRRHOSIS    OF    LIVER 


CIdorosis,  contd. 

-  hsematemesis  in      . .        294,  303 

-  cedeina  of  feet  and  legs  in 

41,  303,  459,  461 

-  palpitation  in         . .        303,  525 

-  predisposition     to     gastric 

ulcer  in 303 

-  rest  treatment  in    . .  . .       41 

-  symptoms  and  etiology  of. .  41 
Chocolate,  oxaluria  from  ..  471 
Cholaemia  in  cirrliosis  of  liver       368 

-  delirium,  convulsions,  coma 

in 361 

-  headache  in  . .  . .     328 

-  stupor  in      .  .  .  .  .  .      361 

Cholangitis,  albumosuria  in  . .       20 

-  from  carcinoma       . .         369,  725 

-  enlarged  gall-bladder  from  651 
liver  ill 369 

-  from  gall-stones      . .         280,  369 

-  jaundice  from    3G2,  369,  650,  651 

-  leucooytosis  in        . .  . .     400 

-  multiple   abscesses  of    liver 

from  369 

-  pain  in  tlie  liver  region  from  650 
the  back  from      . .  .  .      789 

-  pleuritic  effusion  from       . .     123 

-  pvrexia  \\'ith  .  .  . .     650 

-  rigors  with    .  .  362,  369,  650 

-  septicaemia  from     . .  . .     C98 

-  tenderness  of  liver  in  . .  369 
in  the  back  from.  . .     789 

-  urobUinuria  in  . .  . .  116 
Cholecystitis     catch    in      the 

breath  during  deep  inspir- 
ation in  pressure  over  gall- 
bladder in  . .  . .     499 

-  clironic,  hunger  pain  in  500 

-  diagnosis  of  indigestion  from    350 

-  gall-bladder  enlarged  in  280,  723 

-  from  gall-stones      . .  . .     280 

-  jaundice  nith  . .  . .     650 

-  from  new  growtlis  . .  . .     280 

-  pain  in  the  liver  region  from     650 

-  -  right   hypochondrium   in    499 

-  pyrexia  with  . .        499,  650 

-  rigors  with  .  .  . .         648,  650 

-  simulated       by       phantom 

tumours   . .  . .  . .     721 

-  tendeme&s  over  gall-bladder  499 
Cholelithiasis     (see    Calculus, 

Biliary) 
Choleperitoneum,  rarity  of     . .     718 
Cholera,  acute  gastro-intestinal 

symptoms  in        . .  . .     301 

-  albuminuria  in         .  .  .  .        17 

-  anuria  in      . .  . .  . .       49 

-  Cheyne-Stokes  respiration  in    125 

-  coma  in        . .  . .  . .     136 

-  cramps  after  . .  . .     179 

-  cyanosis  in  . .  . .         184, 187 

-  diagnosis  from  tricliinosis . .     504 

-  gangrene  in  . .  . .     282 

-  hsematemesis  in      . .        294,  301 

-  hyperpyrexia  in      .  .  . .      344 

-  indicanuria  in  . .  . .     349 

-  inspissation  of  the  blood  in     187 

-  leucocytosis  in         . .  . .     400 

-  maligna         . .  . .  . .     184 

-  menorrhagia  in        . .  . .     428 

-  polycythsemia  in    . .        579,  580 

-  purpura  in    .  .  .  .  . .     596 

-  pas  in  the  stools  in         . .     601 

-  rice-water  stools  in  . .     301 

-  rigors  in        . .  .  .  . .     647 

-  severe  diarrhcea  in. .  . .     579 

-  swelling  of  thyroid  gland  in     792 

-  uridrosis  in  . .  . .  . .     715 

-  vibrio  in  motions  in  . .     301 

-  wasting  with  . .  . .       69 
Cholesterin  crystals  in  hydro- 
cele of  epididymis  (Fig.  94^  765 

in  gall-bladder     . .  . .     281 

Choletelin         360 


Choline  in  cerebrospinal  fluid  339 
Choluria,  general  account  of. .  819 
Chondroma,  commonly  multiple 

737,  755 

-  deformity  due  to     . . 

-  pain  due  to  . . 

-  of  pelvis 

fixity  of   . . 

a;-rays  in  diagnosing 

-  plialanges  and  metacarpals 

affected  by  (Fig.  195)   . . 

-  ulceration  of  skin  over 
Chorda  tympani,  paralysis  of 

loss  of  taste  due  to    774 

CHORDEE 


755 
755 
761 
737 
737 

755 
755 
536 

775 
..      125 

-  in  acute  urethritis      '       516,  675 
Chorea,  aortic  disease  after  233,  237 

-  arsenical  neuritis  in  . .       77 

-  chronic  degenerative         156, 157 

-  contractions  of       . .  . .     159 

-  electrica,     causing    convul- 

.sions  169 

Henoch's  . .  . .     157 

clonic  convulsions  of. .     161 

-  endocarditis  with      103,  236,  239 

-  habit  spasm  simulating     . .     156 

-  hand-grip  in  ..  ..548 

-  hemiplegia  in  . .  . .     341   | 

-  history  of,  in  cerebral  em- 

bolism        338 

in  mitral  stenosis  . .     320 

-  hysterical     . .  . .  . .     157 

-  insaniens,    hyperpyrexia   in     344 

-  interference  with  speech  in     156 

-  jerky  respiration  in  . .     156 

-  knee-jerkin..  ..  ..     399 

-  major,  epidemic  manifesta- 

tions of     . .  . .         . .     157 

-  mitral  disease  after  . .     240 
stenosis  witli        . .  . .     773 

-  night  terrors  in  cliildren  with  448 

-  in  pregnancy  . .  . .     156 

-  relationsliip  of  acute  rheuma- 

tism to      .  .    121,  156,  504,  671 

-  simulating  cerebral  lesion . .     341 

-  spastica        . .  . .  . .     800 

paralysis  of  arm  in         . .     548 

-  tongue  movements  in        . .     548 

-  tremor  in     . .  . .        795,  798 

-  valvular  disease  of  heart  from 

233,  237,  240,  320,  526,  773 
Choreiform  contractions      . .      155 

in  Friedreich's  ataxy      . .     560 

infantile  paralysis         155,  156 

Little's  disease    . .  . .     154 

post   and    pre-hemiplegic     157 

Chorion-epithelioma  of  uterus, 

metrorrhagia  from    433,  434 

histology  in  diagnosing  434,  436 

from  hydatidiform  mole       434 

metrostaxis  from  . .     436 

pelvic  swelling  due  to    . .     757 

relation  to  pregnancy    . .     434 

Chorionic  vUli  in  uterine  casts     220 
Choroid,  coloboma  of,  ophthal- 
moscopic   appearance    of 
(Flnlr  VIT)  ..  ..     461 

-  tubercles    of    (Plate    VIII, 

Fig.  Tr,p.463)  341,463,563,699 
with   Cheyne-Stokes'  res- 
piration . .  . .     125 
Choroiditis,  syphUitic,  ophthal- 
moscopic   appearance   of 
(Plate  VII)           ..  . .     462 

-  amblyopia  with  nystagmus 

from  836 

-  macular,  age  incidence  of . .     462 

preceded  by  haemorrhages    462 

Choroido-retinitis,  constriction 

of  field  of  vision  in  . .     838 

-  nyctalopia  from      . .  . .     841 

-  ophthalmoscopic       appear- 

ances (Plate  VII,  Fig.  G)     838 

-  optic  atrophy  in      . .  . .     838 


Chromidrosis  due  to  the  action 

of  cocci    . .         . .         . .  714 

bacillus  pyocyaneus       . .  714 

-  blue,  red,  green,  yellow,  violet 

or  black  sweat  with        . .  714 

-  due  to  copper         . .          . .  714 

-  diagnosis  of  chloasma  from  575 

-  due  to  iron  . .          . .          . .  714 

-  nerve  factor  in        . .          . .  714 
Chrysarobin,  bullae  from        . .  110 

-  poisoning,  diazo-reaction  in  198 
Chrysophanic  acid,  abnormal 

coloured  urine  from      819,  820 


819 
819 

820 
178 

126 
58 
33 


in  rhubarb 

serma    . . 

urine,  test  for  . . 

Chvostek's  sign  in  tetany 
Chylous  ascites  (see  Ascites) 
CHYLURIA 

-  with  ascites 

-  from  filariasls 
Cider,  explosive  eructation  of 

gas  from  . .  . .  . .     639 

Cigarette-roller's  cramp  . .  177 
Cigarette-rolling     movements 

in  paralysis  agitans  . .  796 
Ciliary  body,  inflammation  of 

(see    Cyclitis) 

-  muscle  paresis  after  diphtlieria 

224,  G40 
Cinnamon  oU,  leucocytosis  from  400 
Circumcision,  death  from      . .     423 

-  by  Jewish  method,  tubercu- 

lous infection  in .  . 

-  priapism  after 
Circumflex      nerve,      muscles 

supplied  by 

paralysis  of 

skin  distribution  of 

spinal  roots  derived  from 

Cirrhosis  of  liver 

abdominal  distention  in 

absence   of   clay-coloured 

motions  in 

of    dilatation    of    gall- 
bladder in    . . 

umbilication  of  irregu- 
larities in      . . 

absorption  of  fat  in 

acne  rosacea  in 

age  incidence  of. . 

albuminuria  in   . . 

albumosuria  in    . . 

alcoholism  causing 

300,  368,  599,  809 

amenorrhoea  in  . .  . .       23 

anaemia  in  . .  40,  696 

ascites  in,  40,   51,  55,   59,   60, 

301,  368,  410,  696,  82G 

diagnosis  from  tubercu- 
lous peritonitis        . .     618 

in  Banti's  disease         694,  696 

bottle-nose  in      . . 

in  bronzed  diabetes 

caput  medusae  in 

cause  of  pyrexia  in 

cholferaia  in 

clubbed  fingers  in 

coma  in   . . 

congenital  syphilis  and 

contraction      of      fibrous 

tissue  in  . .  . .     409 

cramps  in  legs  at  nieht  In 

59,  300,  368 

delirium  in  359,  368,  410 

diagnosis  from  carcinoma 

409,  410,  413 

of  stomach. .  . .     301 

from      enlarged      liver 

due  to  obstruction  of 
common  duct         . .     410 

splenic  anemia 

42,  64,  411,  694,  696 

syphilis  of  liver        410,  411 


677 
586 

5-50 
552 
659 
550 
409 
134 

409 

409 


409 
..  409 
59,  368 
..  410 
16 
..   20 


300 


411, 

575 

51, 

826 

618 

368 

129, 

369 

368 

410 

1  .. 

365 

852 


CIRRHOSIS    OF    LIVER— COAL    MINERS'    EPITHELIOMA 


'irrkosis  of  liver,  contd. 

-  diazo-reaction  iii  . .     198 

-  diarrhoea  in         . .  . .     197 

-  dilated  venules  on  cheeks 

in  . .  . .        300,  410 

-  diminished  appetite  in  . .       4.9 

-  distended  abdominal  veins 

in        59,  300,  409,  410,  826 

-  drowsiness  in       . .  . .     368 

-  dry,   harsh  skin  in        . .     410 

-  dyspepsia  in        . .  . .     410 

-  enlai'gement  of  liver  from 

301,  369,  409 
spleen  in  301,  369,  409 

-  enteritis  in  . .  . .     409 

-  epistaxisin  251,  295,300,368,696 

-  firm  irregular  edge  in   368,  409 

-  frequent  total  absence  of 

symptoms  in  . .  . .     410 

-  furred      and      tremulous 

tongue  in  ..59,  368,  410 

-  gastritis  in  . .        352,  409 

-  general  account  of         . .     300 

-  pains  in  the  limbs  in      . .     503 

-  i;enerallv  painless  . .     409 

-  Hanot's 410 

absence  of  symptoms  in    411 

age  incidence  of  . .     410 

ascites  rare  and  of  evil 

omen  in 

chronic  course  of 

clubbing  of  fingers  in. . 

diagnosis  from  spleno- 

megalic  cirrhosis 

enlargement  of  liver  in 

familial  character  of. . 

firm,  smooth  liver  in . . 

-  -  hsemorrhages  in 

-  -  Jaundice  in 
liver  firm  and  smooth  in   410 

-  -  long-standing  jaundice  in  410 
periods  of  illness   with 

pyrexia  in   . . 
prominence  of  abdomen 


411 
410 
411 

369 
410 
369 
410 
411 
369 


411 


-  sex  incidence  of  . .     410 

-  smoothness  of  liver  in      410 

-  splenic  enlargement  in      410 

-  stunting   of  growth  in 

children  with  . .     410 

iiEematemesis    due    to,   40,   60, 

294,  296,  300,   302,  410,  696 
ha^maturia  in       . .  . .     368 

liEemorrhages  in  ..368,  694 
heemorrhoids  iu  . .  . .     368 

hobnail  irregularities  m  409 
hypertrophic  biliary  (see 

Cirrhosis  o£  Liver,  Hanot's) 
icteric  conjunctiva  in     . .       59 
impairment  of  strength  in     410 
infantilism  from  . .     215 

insomnia  in  . .  . .     359 

jaundice  in,  40,   60,   301,   362, 
363,  368,  410,  696 
liver  changes  in  . .  . .       59 

loss  of  appetite  in         59,  300 

-  weight  from  . .  . .  848 
in  malaria  . .  371,  410 
melsena  in  300,  368,  409,  696 
menorrhagia  in  . .  . .  428 
meteorism  in  . .  . .  432 
morning  sickness  in  300,368,410 
muscular  atrophy  in  . .  76 
nervous  symptoms  in  . .  410 
oedema  of  ankles  in  . .  410 
oesophageal  varix  in  . .  296 
pain  from  perihepatitis  in  409 
pancreatitis  from  . .  116 
passive      hyperaemia      of 

uterus  from      . .  . .     430 

perihepatitis  in  .  .  . .     409 

peripheral  neuritis  in  . .  76 
phthisis  complicating  . .  295 
pigmentation  in..  40,  59 


Cirrhosis  of  liver,  contd. 

polyuria  in 

prolonged  pyrexia  due  to 

purpura  in  596,  599, 

pjrrexia  due  to,  40 

362,  368,  410,   609, 
rapid    death    after    onset 

of  ascites  in 

rare  in  melancholies 

red  nose  in 

roughness    and    hardness 

of  liver  iu  301,  368, 

sallow  complexion  in 

sex  incidence  of  . . 

simulating     malignant 

disease 
simulation  by  tuberculous 

peritonitis 
slow  diminishing  of  liver 

dullness  in  late  stages 

smoothness  in  early  stages 

splenic     enlargement      in 

59,  60,  302,   692,  695, 

-  splenomegaiic 

age  incidence  of 

auEEmia  in        369,   693, 

ascites  in 

clubbed  fingers  in      369, 

diagnosis  from  Hanot's 

cirrhosis 

early  age  incidence  of 

enlargement  of  liver  in 

familial  character  of  . . 

ha;matemesis  in         369, 

hremorrhagca  in 

jaundice  in      . .        369, 

lack  of  development  in 

long  course  of . . 

relation  to  Banti's  disease 

splenic  ausemia      411, 

spleen  enlarged  692,  093, 

stunted  growth  in 

telangiectases  in . . 

in  terminal  stage  of  splenic 

aneemia 

tremulous  tongue  in    368, 

tympanites  in 

urinary  changes  in 

urobiUnuria  in     . . 

lu^oerytlirin    in    urine    in 

varicose  abdominal  veins 

vomiting  in     300,368,  410, 

wasting  in  ..69,  410, 

weight  of  liver  in 

-  of  lung,  clubbed  fingers  in. . 
fibroid  lung  and  bronchi- 
ectasis fron^     .  . 

haemoptysis  in    . .        317, 

occupations  tending  to . . 

tubercle  bacilli  in  sputum 

-  of     pancreas,     Cammidge's 

reaction  in 

fat  globules  in  faeces  in  . . 

Cirsoid  aneurysm  (Plate  XI V) 
Citrates,  transient  polyuria . . 
Clark,  Andrew,  re  haemoptysis 

in  arthritic  subjects 
Claudication,       intermittent, 

age  incidence  of  . . 
arterial  pulsation  in  legs 

absent  in 

cerebral  atheroma 

diagnosis    from    orythro- 

melslgia  and  Raynaud's 

disease  .'. 

excessive  smoking  in 

gangrene  in 

hemiplegia  from. . 

local  temporary  insufficient 

blood  supply  in 

-  -  nayokymia  in 

pain  in  legs  after  walking 

relief  by  rest 

pallor  of  foot  iu  . . 


582 
609 
696 
68, 
623 

413 
409 
410 

409 
410 
410 


404 
409 

696 
369 
693 
694 
693 
694 

369 
369 
369 
693 
694 
694 
693 
693 
694 
694 
694 
696 
369 
59 

411 
410 
410 
410 
818 
819 
826 
843 
848 
409 
129 

324 
319 
319 
319 

116 
117 
764 
581 


Clavicle,  affection  in  yaws     . .     449 

-  myeloid  sarcoma  of  . .      756 

-  prominence  of  one  in  phthisis  319 

-  rudimentary  . .  . .     213 

-  swelling  on,  syphilitic  .  .  752 
Clavus  hystericus  166,  329,  506,  798 
CLAW-FOOT  (i^j>.  29)         126-127 

-  paralysis  of  internal  popliteal 

nerve  causing      . .  .  .     543 

CLAW-HAND  (Fig.  30)        ..     127 

-  from  cervical  rib      .  .  .  .      493 

-  chronic   poliomyelitis        .  .     165 

-  neuropathic  muscular 

atrophy     .  .  . .  .  .      159 

-  progressive  muscular  atrophy 

73,  127,  165 

-  syringomyelia  . .         285,  554 

-  in  transverse  myelitis  . .  74 
Cleft  palate,  dysphagia  due  to     225 

harelip  associated  with..     640 

regurgitation       of      food 

through  the  nose  in  202,  640 
Cleido-cranial  dysostosis,  dwarf- 
ism with 213 

Clergymen,     chronic    pharyn- 
gitis in      ..  ..        670,  673 
Climacteric,  flushing  at  the  . .     268 
Climbing-up-himself     posture 
of    pseudo-hypertrophic 
paralysis               . .  . .     560 
Clitoris,  elongation  of  in  pseudo- 
hermaphroditism           . .     706 

-  epithelioma  of,  enlargement 

of  inguinal  glands  in      . .     423 

-  hypertrophied  in  hyperneph- 

roma        . .  . .  . .     455 

-  leukoplakia  of         . .  . .     770 

-  priapism  of..  ..  ..     585 

Clonic  contractions  in  Bright's 

disease      . .  . .  . .     160 

myoclonus  and  paramyo- 
clonus multiplex         . .     161 

pregnancy  . .  . .     160 

torticollis  . .  . .     161 

-  convulsions    in    Jacksonian 

epilepsy    . .  . .  . .     161 

-  spasms,    mild,    in   cases    of 

major  epilepsy     .  .  .  .     160 

Clonus,  account  of     . .  . .     160 

-  ankle  (see  Ankle-clonus) 

-  influence     of     parathyroid 

glands  on  . .  . .     161 

-  patellar  (see  Patellar  Clonus) 
Clots  in  urine  . .  .  .  . .     305 

CLUBBED  FINGERS  (Fig.  31) 

18,  128,  129 

accompanying     cyanosis      184 

in  bronchiectasis    99,  324,  703 

cirrhosis    . .  . .  . .     369 

congenital    heart   disease 

129,  579,  790 
empyema  . .  . .       99 

-  -  flbroid  lung  193,  246,  324 

Hanot's  cirrhosis  . .     411 

hypertrophic  osteoartliro- 

pathy 390 

with   patent    interventri- 
cular septum    . .         . .     129 

pulmonary  stenosis       104,  129 

seldom  present  in  persis- 
tent ductus  arteriosus      579 

splenomegaiic      ciri-hosis 

369,  691 

and  toes  in  congenital  heart 

disease  . .  . .        244,  247 

CLUB-FOOT  (see  Talipes) 
Coaclimen,   Dupuytren's  con- 
tracture in  . .  .  .     167 
Coagulation    time    of    blood, 

effect  of  calcium  salts  on     430 

-  of  urine,  spontaneous  . .  126 
Coal  gas  poisoning,  coma  in  . .     138 

-  miners,  antlu-acosis  in  . .  319 
epithehoma  of  scrotum  in     679 


COCA  INE—COLI TIS,    M  UCO-MEMBRA  NO  US 


Cocaine,  palpitation  from  525, 

527 

CoH-bacillnria,  contd. 

Colic,  conld. 

-  in  diagnosis  o£  asthma     . . 

582 

rigidity  of  the  abdomen  in 

646 

-  laparotomy  may  be  required 

-  spray  in  laryngoscopy 

22(; 

trace  of  albumin  with  576 

848 

in  diagnosis  of    . . 

645 

-  tremor  from            . .        795, 

797 

COLIC              

133 

-  pancreatic 

365 

Cocainism,  palpitations  worse 

-  abdominal  pain  over  colon  in 

136 

signs      and      associated 

when   Jrug  is  not  being 

referred  to  as  . . 

133 

symptoms  of  . . 

135 

taken         

527 

rigidity  with 

645 

-  in  plumbism                        38 

77, 

-  mnlti|ile  prick  marks  on  body 

527 

-  -  wall  in      . .           133,  134, 

645 

144,  473,  500,  507, 

798 

Cocci  in  pustules 

601 

-  absence  of  leucocytosis  in. . 

645 

-  pulse  in        . .          . .        472, 

645 

Cocoa,  oxaUiria  fi-om 

471 

-  in  alcoholism 

136 

-  pyrexia  in   . . 

645 

-  polj'uria  from 

581 

-  appendicular 

135 

-  renal 

47 

Coccydynia,     movements     of 

-  in  arsenical  poisoning 

75 

causes      and       associateiJ 

coccyx  painful  in 

638 

-  atonic  constipation 

143 

symptoms  of    . . 

135 

Coccyx,  bedsore  over 

285 

-  biliary         . .        . .       135, 

509 

ciiaracteristic  tendency  to 

-  fracture  of,  felt  per  rectum 

G38 

absence  of  jaundice  with 

846 

pass  down  into  groin .  . 

500 

-  rectal  examination  of 

635 

in  acute  pancreatitis 

153 

constipation  in    . . 

153 

Cod-liver  oil,  taste  in  mouth 

areas  of  tenderness  in  . . 

779 

diagnosis     from     appen- 

from 

774 

constipation  in    . . 

153 

dicitis    . . 

500 

Celiac  axis,  aneurysm  of  Csee 

with  gall-bladder  tumours 

392 

lead  colic 

500 

Aneurysm  of  Oceliac  Axis^ 

from  gall-stones    152,  278 

363 

distribution  of  pain  in  .  . 

308 

Coffee-drinking,  pseudo-angina 

jaundice  with     . .         153, 

846 

due   to   passage  of  blood 

from 

482 

pain  in  the  chest  with    . . 

846 

clots  down  ureter     305, 

395 

-  gastritis  from 

297 

in  the  right  hypochon- 

-  -  gravel  in  urine  in 

500 

-  insonniia  from         .  .         35G, 

358 

drium  in 

500 

liasmaturia   with 

-  oxaluria  from 

471 

upper  part  of  abdomen 

153,  306,  395 

500 

-  palpitation  from               525, 

527 

with  . . 

846 

-  -  hypernephroma  . . 

395 

-  transient  polyuria  from 

581 

patient  rolling  about  in 

644 

in  kidney  tumours 

307 

Coffee-ground  vomit  in  gastric 

radiation  of  pain  to  back 

malignant  kidney  tumour 

395 

carcinoma 

299 

and  right  shoulder  in 

500 

micturition  frequency    of 

ulcer 

298 

shivering  in 

135 

in       ..          ..            438 

516 

(and  see  Hsematemesis) 

293 

simulation  by  renal  colic 

500 

mode    of    production    in 

Coffin-lid    crystals    of    triple 

urates  after 

500 

renal  calculus. . 

627 

phosphate  (Fig.  155) 

573 

vomiting  with     . . 

846 

from  movable  kidney    .  . 

310 

Cohnheim,  re  end-arteries     .  . 

286 

-  from  carcinoma  of  bowel    91 

147 

pain  in  the  groin  from  . . 

846 

Coin,  oesophagus  obstructed  by 

222 

-  in  colitis 

501 

loin  from 

846 

-  sound     on    percussion   over 

-  collapse  from 

645 

penis  in 

516 

subphrenic  abscess 

501 

-  diagnosis  of  cause  of 

136 

right  hypochondrium  in 

500 

in    pneumothorax 

577 

organic  disease  from 

133 

testicle  from    . . 

846 

Coitus,  causes  of  iisemorrhage  in 

434 

from  peritonitis  . . 

644 

patient  rolling  about  in.  . 

644 

-  excessive,  menorrhagia  from 

428 

-  in  dysentery 

501 

pyrexia  in 

500 

-  fracture  of  penis  during     . . 

125 

-  facies  of 

133 

in  renal  calculus           308 

627 

-  painful  (see  Dyspareunia) .  . 

221 

-  intense  abdominal  pain  in 

645 

tuberculosis                 309 

626 

Colcott    Pox,    re    vacciniform 

-  intestinal 

472 

simulating  biliary  colic.  . 

500 

ecthyma  of  infants 

446 

abdominal  distention  in . . 

473 

simulation  by  abdominal 

Cold  bath,  amenorrhcea  due  to 

23 

in  children,    drawing   up 

neuralgia 

473 

menorrhagia  from 

428 

of  legs  in 

473 

biliary  colic     .  . 

500 

-  chilblains  from 

810 

cold  sweating  in . . 

472 

twisting  of    pedicle  of 

-  common   (and  see   Coryza ; 

contraction  in 

1.34 

ovarian  cyst 

392 

and  J3ischarge,  Nasal) 

all  degrees  of  pain  in 

472 

spasmodic  pelvic  pain  in 

509 

-  -  acute  nasal  catarrh  in  . . 

668 

diagnosis  from  pain  due  to 

-  -  vomiting  with       500,  844 

846 

anosmia  in 

668 

retained  testis 

740 

-  in  spastic  constipation 

144 

inflammation  of  soft  palate, 

from  fnecal  accumulations 

393 

-  sudden  onset  of 

645 

uvula,  and  fauces  in  .  . 

672 

due  to  flatulence 

267 

-  use  of  term  by  patients    .  . 

133 

loss  of  taste  due  to 

774 

in  Henoch's  purpura     90, 

600 

Colic-like  pains  in  dysmenor- 

 micrococcus     catarrhalis 

-  -  infantile    .  . 

357 

rhoea 

219 

causing . . 

203 

in  clironic  intussusception 

148 

Colitis,  abdominal  tenderness  in 

134 

cedema  about  face,  neck, 

due  to  indigestible  food  136 

,473 

-  acute,  diarrhoea  in . . 

196 

and  arms  from         459, 

461 

nausea,    eructations   and 

symptoms  of 

196 

simulated  by  measles    .  . 

203 

borborygmi  in 

473 

tenesmus  in 

196 

-  excessive,  coma  from       137, 

139 

in     organic    stricture    of 

-  blood  and  mucus   in   stools 

-  exposure  to,  haemoglobinuria 

intestine 

146 

from         . .          . .         197 

501 

arisi  ng  from 

315 

palpable  contracted  bowel 

-  catarrhal,    constipation    as- 

 still  neck  from   . . 

708 

witii 

134 

sociated  with 

144 

-  extreme,  gangrene  from    . . 

282 

persistence  of  borborygmi 

-  characteristics  of  faeces  in . . 

134 

-  febrile,  spoken  of  as  influ- 

with 

645 

-  clnronic,  anaemia  in 

39 

enzal 

203 

-  -  due  to  purgatives 

144 

-  colicky  pains  in  abdomen  in 

501 

rigors  in  . . 

647 

intestinal  obstruction   473, 

571 

-  diarrhcEa  in.  .           ..        134 

501 

-  and  heat,  effect  on  mictu- 

 pain       spreading       from 

-  indicanuria  in 

349 

rition  of   . . 

581 

umbilicus  in     . . 

473 

-  loss  of  weight  due  to 

848 

-  influence  on  myom.a  cutis. . 

805 

paroxysmal  recurrent  pain 

-  membranous,  indicanuria  in 

349 

-  muscular  twitchings  from. . 

157 

in 

472 

mucus  casts  in  (Fit/.  123) 

444 

-  nephritis  from 

13 

patient  rolling  about  in 

644 

-  muco-membranous,     blood 

-  sense  of,  in  syringomyelia  . . 

664 

pulse  in    . . 

472 

per  rectum  in     . . 

727 

-  sheets   at   bedtime   causing 

relief  of  pain  by  pressure 

473 

castsofbowelin(Fi(7. 123) 

444 

cough 

175 

restlessness  in     . . 

473 

constipation  in  (Fig.  37) 

-  stage  of  malaria 

35 

rigidity  of  abdomen  in  . . 

473 

145, 

727 

-  tremor  from            . .        794 

795 

shrieking  from    . . 

472 

enterospasm  in  . . 

486 

-  ulceration  of  the  leg  from . . 

810 

simulating  cramps 

177 

mucous  colic  and 

133 

Coli-bacilluria 

16 

dysmenorrhoea 

220 

mucus  in  the  stools  from 

727 

etiology  and  symptoms    8 

2,  83 

perforative  peritonitis 

045 

sex  incidence  of .  . 

727 

little  obvious  pus  with  . . 

576 

spasmodic  pelvic  pain  in 

509 

simulated  by  plumbism 

486 

loss  of  weight  in 

848 

temperature  in    . . 

472 

simulating  tape-worm   . . 

567 

pus  corpuscles  in  the  urine 

visible  peristalsis  m 

473 

tenderness  in  right  lum- 

from 

848 

vomiting  in 

645 

bar  region  from 

727 

884                        COLITIS, 

MUCOUS— COMPRESSION   OF   LUNG 

Colitis,  contd. 

Colon,  continued. 

COMA 

136 

-  mucous,    characteristics    of 

-  carcinoma  of  (see  Carcinoma 

-  absent  in  Jacksonian  epilepsy 

161 

faeces  in 

134 

of  Colon) 

-  in  acute  diabetes     . . 

292 

intestinal  sand  in 

652 

-  congenital   idiopathic    dila- 

 encephalitis 

643 

-  mucus  in  stools  witli 

144 

tation     of    (see     Hirsch- 

 yellow  atrophy  of  liver . . 

370 

-  pain  in  left  iliac  fossa  in     . . 

501 

sprung's  Disease) 

-  from  alcohol  poisoning 

346 

right  iliac  fossa  in           134 

,135 

-  dilated,    gastrectasis    simu- 

 diBSculties  in  diagnosing 

138 

and     tenderness    in     the 

lated  by  . . 

714 

-  anaesthetics              . .          T. 

346 

back  from 

789 

in  acute  obstruction  of  . . 

152 

-  anuria           . .          . .            4r 

,  48 

-  pus  in  the  stools  in 

601 

-  diverticula  of  (see  Diverti- 

- with  apoplexy 

173 

-  sigmoidoscope  in    91,  92, 19G 

501 

cula  of  Colon) 

-  Eabinski's  sign  in  . . 

82 

-  simple,  of  infants,  blood  per 

-  faecal  accumulations  in  (see 

-  from  carbolic  acid  .  . 

346 

anum    and    other    symp- 

F»cal A-CCumulation) 

-  carcinoma  of  liver . . 

413 

toms  in    . . 

92 

-  greedy,  as  cause  of  consti- 

- in  cerebral  conditions,  diag- 

- tenesmus  in 

501 

pation 

143 

nosis  from  diabetic  coma 

292 

-  tetany  in     . . 

3 

-  inflammatory     attacks     of. 

haemorrhage         . .        337, 

140 

-  ulcerative,   abdominal    pain 

constipation  due  to 

727 

-  from  chloral  poisoning 

346 

and  tenderness  in 

92 

local  pain  and  tender- 

- in  cholaemia 

361 

albumosuria  in    . . 

20 

ness  due  to  . . 

727 

-  cirrhosis  of  liver    . .        368, 

410 

blood  per  anum  in    91,  92 

727 

vomiting  due  to 

727 

-  diabetic        . .      _   . .            4, 

293 

death  from 

727 

-  kink  of,  causing  constipation 

147 

preceded  by  vo'miting    . . 

843 

enlarged  mesenteric  glands 

-  malignant    disease    of   (see 

-  from  embolism        . .        237, 

699 

in 

422 

Carcinoma  of  Colon) 

-  encephalitis 

558 

indicanuria  in     . . 

349 

-  normal,  situation  of 

722 

-  in  epilepsy  . .          . .        160, 

646 

leucopeiiia  in 

401 

-  obstruction,     character     of 

-  excess    of   urea  in  cerebro- 

 mucus  in  the  stools  from 

727 

visible  peristalsis  in 

571 

spinal  fluid  in  uraemio    . . 

339 

painful  diarrhcea  with  .  . 

727 

-  pemphigus,  etc.,   of 

114 

-  in  fatty  heart 

241 

palpable  sigmoid  flexure  in 

735 

-  post-dysenteric    ataxy    and 

-  from  fractured  spine 

286 

pneumothorax  from 

578 

paresis  of,  diagram  of    .  . 

144 

-  in  general  paralysis  of  the 

pyrexia  with       . .          92, 

727 

-  pressure  on,  causing  dyschezia 

150 

insane 

340 

subphrenic  abscess  from 

578 

-  resonance     in     tumour     of 

-  hysterical  trance     . .        137, 

140 

tenderness    in    the    right 

kidney 

367 

-  incontinence  of  fseces  in     . . 

347 

lumbar  region  from  . . 

727 

-  scybala'in  transverse 

724 

-  in  malaria    . . 

35 

tenesmus  in 

91 

-  sigmoid,      cachexia      from 

-  ilenifere's  disease    . . 

828 

ulceration  of  rectum  in  . . 

635 

tuberculosis  of     . . 

731 

-  meningitis    . . 

642 

vomiting  in 

727 

-  -  carcinoma  of   (see    Carci 

-  at  onset  of  acute  fevers  . . 

646 

wasting  from       . .           69, 

727 

noma  of  Colon) 

-  in  opium  poisoning          345, 

346 

Collapse       from       abdominal 

in  congenital  dilatation  of 

-  from  oxalic  acid 

346 

injury 

645 

colon.. 

735 

-  in  phosphorus  poisoning    . . 

373 

-  acute  intestinal  obstruction 

153 

dilatation   of,    succussion 

-  from    pontine  haemorrhage 

pancreatitis          . .        292, 

724 

sounds  in 

711 

344 

,345 

-  angina  pectoris 

481 

ffecal  accumulations  in . . 

393 

-  post-epileptic 

171 

-  anuria  with . .         . .             45 

,  49 

normal  situation  of 

722 

-  stertor  in 

707 

-  in  arsenical  poisoning 

92 

pain    in    left    Uiac    fossa 

-  in  Stokes- Adams'  disease    97 

627 

-  colic              . .           133,  135, 

645 

from  kinking  of 

501 

-  superior   longitudinal   sinus 

-  corrosive  poisoning 

297 

palpable   in  left  inguinal 

thrombosis 

643 

-  gall-stone  colic 

363 

region    . . 

731 

-  in  tuberculous  meningitis . . 

174 

-  gangrenous    appendicitis   . . 

484 

normally 

731 

-  urcemic         . .    48,  172,  339, 

464 

-  hypothermia  in 

346 

sigmoid  flexure  in  con- 

- after  urinary  operations    . . 

49 

-  in  intestinal  obstruction  . . 

346 

genital  dilatation   of 

735 

Combined  degeneration  of  the 

-  intussusception 

92 

in  iflcerative  colitis    . . 

735 

cord,  subacute    . . 

493 

-  from  loss   of   fluid. . 

580 

-  spasm  of,  constipation  due  to 

145 

-  sclerosis  of  the  cord,  anfes- 

-  in  pancreatic  haemorrhage 

292 

-  spasmodic     contraction     of 

thesia  from 

667 

-  from    perforated    duodenal 

transverse    (see    Entero- 

ataxia  from 

667 

ulcer 

484 

spasm) 

effects  of 

164 

gastric  ulcer                  484, 

721 

-  stricture  of,  due  to  cicatriza- 

 hyperaesthesia  from   . . 

667 

-  in  peritonitis 

346 

tion           

146 

causing  paraplegia     . . 

561 

-  phosphorus  poisoning 

373 

-  transverse,  normal  situation  of  724 

(and  see  Paraplegia,  Ataxic) 

-  from     rupture     of     aortic 

rarity  of  tumours  in 

724 

spastic  paraplegia  from 

667 

aneurysm. . 

482 

-  tuberculosis    of,    cause    of 

Comedones  in  acne     530,  604, 

609 

extra-uterine  gestation  436 

,760 

swelling  ia  right  lumbar 

Competitions,     physical     and 

-  after  severe  diarrhcEa 

.346 

region 

727 

mental,    transient    poly- 

- -  hsemorrhage 

346 

stricture  from     . . 

146 

uria  caused  by  prepara- 

 vomiting  . . 

346 

tumour  from       .  .         723, 

724 

tion  for     . . 

581 

-  and  shock  in  acute  intestinal 

-  tumour   of   (see  Carcinoma 

Complexion,   florid  and  mot- 

obstruction 

153 

of  Colon) 

tled,  in  Mongolian  idiocy 

-  sudden,  in  myocarditis     . . 

241 

-  ulceration    of    (see    Colitis, 

263, 

264 

Colliers,  verruca  necrogenica  in 

266 

"Ulcerative; 

-  sallow  in  cirrhosis  of  liver. . 

410 

Colloid     carcinoma     of     peri- 

Colourblindness 

840 

congenital  syphilis 

259 

toneum     . . 

57 

due  to  alcohol 

837 

general  congestion  of  liver 

407 

-  -  of  colon    . . 

735 

congenital 

840 

myxcedema 

259 

-  milium,  account  of 

805 

nystagmus  in 

453 

tabes         

262 

Coloboma     of     the     choroid. 

from  optic  atrophy 

840 

tropical  abscess  of  liver . . 

369 

ophthalmoscopic  appear- 

 tobacco                  S36,  837, 

840 

Compositor's  cramp  . . 

177 

ance  of  (Plate  VII) 

461 

-  index  of  blood,  varieties  of 

26 

Compressed-air  illness  (see  Cais- 

- iris     . . 

462 

ankylostomiasis  . . 

570 

son  Disease) 

-  lens   . . 

462 

aplastic  anaemia..            42,  64 

Compression    of  brain,  coma 

-  macular,  nystagmus  with 

836 

in  carcinoma  of  stomach 

352 

due  to 

137 

-  of  the  optic  disc 

462 

chlorosis 

41 

-  of  cord,  causes  of    . . 

561 

Colon,    affection    by     bullous 

congenital  heart  disease 

579 

partial,  simulating  prim- 

eruptions.. 

88 

leukaemia 

32 

ary  lateral  sclerosis    . . 

565 

-  ascending,  palpable 

726 

pernicious  anjemia  64,  302 

616 

transverse  myelitis  from 

564 

-  atony  of 

149 

polycythaemia     . . 

580 

-  of  lung  (see  Lung,  Compres- 

- bacillus  (ses  Bacillus  Ooli) 

-  vision,  normal  ciaracters  of 

835 

sion  of) 

CONCEPTION— CONTORTIONISTS 


885 


Conception,     prevention     of, 

Congenital,  contd. 

Constipation,  contd. 

effect  on  menstruation  . . 

431 

-  ptosis            

590 

-  in  anorexia  nervosa 

50 

menorrhagia  from 

428 

-  spastic  paraplegia,  talipes  in 

131 

-  appendicitis             . .        729, 

736 

Concussion  of  the  brain,  B;i- 

paralyses  of  infants 

156 

-  atonic            . .          .  .         143 

149 

binski's  sign  in  . . 

82 

-  syphilis  Csee  Syphilis,  Con- 

- in  carcinoma  of  colon 

coma  due  to 

137 

genital) 

91,  367,  690 

729 

headache  in 

327 

-  syphilitic  arthritis,  simulated 

of  rectum 

636 

jaundice  from         . .     362 

374 

by  tuberculous  joints     . . 

386 

-  catarrhal  jaundice  . . 

365 

pain  in  the  head  from    . . 

782 

-  talipes 

130 

-  chlorosis 

41 

-  -  tenderness  of  scalp  in   781 

782 

-  tremor 

795 

-  chronic,     with     vesico-colic 

vomiting  from     .  . 

844 

Congestion  of  face  and  lips  in 

fistula 

146 

Condyloma,  characters  of 

769 

mitral  regurgitation 

238 

-  with  colic     . . 

134 

-  in  congenital  syphilis      427, 

446 

-  liver,  active  (see  Liver,  Ac- 

- due  to  colon  inflammation 

727 

-  developing     from     papular 

tive  Congestion) 

-  congenital,     from     narrow- 

syphilide . . 

532 

venous  ("see   Liver,    Con- 

ness of  anal  canal 

150 

-  distinction  from  pemphigus 

gestion  of  Venous) 

obliteration  of  bile-ducts 

365 

vegetans  . . 

654 

-  lungs,    passive,    in    mitral 

-  in  congestion  of  liver         371 

407 

wart 

532 

stenosis     . . 

245 

-  due     to      deficient     motor 

-  distribution  of 

769 

-  of  uterus  (see  Uterus,  Con- 

activity of  intestines 

143 

-  of  external  auditory  meatus 

469 

gestion  of) 

-  definition  of 

140 

-  mercury  in  diagnosis  of    . . 

769 

Congestive  attacks  in  general 

-  in  diseases  of  female  genital 

-  pain  in  perineum  from 

516 

paralysis  of  the  insane    . . 

682 

organs 

144 

-  perineal  sores  from 

678 

-  dysmenorrhoea  described  . . 

219 

-  enteric  fever 

648 

-  on  scrotum  . . 

(;81 

Congo  red  paper  in  detecting 

-  enterospasm 

486 

-  secondary  syphiUtie 

769 

free  HCl 

355 

-  enuresis  with 

248 

-  and   soft  sores,   occurrence 

Conjunctiva,  appearance  of,  in 

-  due  to   excessive  force  re- 

together   . . 

769 

differentiating  conjuncti- 

quired 

145 

-  of  vulva 

768 

vitis,  iritis,  and  elaucoma 

257 

-  foul  breath  with 

99 

Cone-hand 

3 

-  blackening  of,  from  ochro- 

- fragmentary 

142 

Cones,  poisoning  by  tobacco. . 

841 

nosis 

822 

-  in  gastrits    . . 

297 

-  and    rods,    distribution    in 

-  discoloured  by  drugs 

575 

-  gradually  increasing 

350 

retina 

835 

-  foamy    white    patches    on, 

-  habitual,   diagram  showing 

Congenital    abnormality,  with 

from  keratomalacia 

807 

bismuth  test  in    . . 

141 

cervical  ribs 

492 

-  gUstening  in  Graves'  disease 

261 

-  headache  in             . .     -   326 

,328 

-  absence  of  spinous  process 

785 

-  herpes  zoster  of 

831 

-  in  Henoch's  purpura 

90 

of  vasinn  . . 

705 

-  icteric,  in  cirrhosis  . . 

59 

-  with  Hirschsprung's  disease 

-  alkaptonuria 

822 

-  icteroid    tinge    in    tropical 

433,  713 

718 

-  anophthalmos 

839 

abscess  of  liver    . . 

369 

-  in  hypertrophic  stenosis  of 

-  cerebral  diplegia,  tremor  in 

-  CBdema  of,  in  glaucoma 

257 

the  pylorus 

845 

154, 

795 

-  white,  in  pernicious  anaemia 

361 

-  indicanuria  in 

349 

-  colour  blindness 

840 

-  xerosis  of      . . 

807 

-  insomnia  in 

356 

-  constipation 

143 

—  yellow  in  jamidice 

360 

-  intestinal,   bismuth  test  in 

-  crescents,    ophthalmoscopic 

Conjunctivitis  associated  with 

141, 

142 

appearances  of  (Plate  I'll) 

461 

corneal  ulceration 

806 

delayed  passage  of  faeces  in 

141 

-  cystic  hygroma  of  axilla    . . 

732 

-  (and  see  Eye,  Acute  Inflam- 

 diagnosis  of  cause  of 

142 

-  diaphraamatic  hernia        711, 

712 

mation  of) 

from  dyschezia 

141 

-  dilatation  of  the  colon      718 

735 

-  blinking  tic  following 

159 

-  with  intestinal  fermentation 

267 

-  diplegia  (see  Diplegia,  Con- 

- in  cutaneous  diphtheria 

602 

-  due  to  intestinal  hypoplasia 

143 

genital) 

-  differentiation  of  congenital 

obstruction           26v,  431, 

571, 

-  exophthalmos 

247 

duct  obstruction  .from    . . 

250 

644,  645,  733 

846 

-  extroversion  of  bladder     . . 

587 

from  iritis  and  glaucoma 

257 

-  jaundice 

361 

-  eye  defects,  various 

836 

-  with  electric  blindness 

840 

-  lead  poisoning 

-  heart    disease    (see    Heart 

-  epidemic  bilateral  .  . 

256 

38,  77,  136,  507 

798 

Disease,  Congenital) 

-  epiphora  in  . . 

2.50 

-  Malta  fever  . . 

506 

-  h3rpertrophy   of  the  cervix 

-  follictdar 

256 

-  mesenteric  embolism   or 

uteri 

586 

-  haemorrhages  in 

255 

tlirombosis 

90 

-  hypertrophic  stenosis  of  the 

-  haloes  and  rainbow  appear- 

- with       muco-membranous 

pylorus 

426 

ances  in    . . 

257 

colitis 

727 

-  hvpopln.sia  of  intestine 

143 

-  inflammations  causing 

256 

-  mucus  in  stools  in  . . 

443 

-  idiopathic      dilatation      of 

-  lachrymation  from. . 

255 

-  in  organic  nervous  diseases 

149 

fcolon  see  Hirschsprung's 

-  of  new-born 

255 

-  pain  and  tenderness  in  the 

Disease) 

-  from  nuclear  facial  paralysis 

536 

back  from 

789 

-  intestinal  obstruction 

151 

-  pain  in  the  eye  from 

255 

-  in  pancreatic  apoplexy 

90 

-  lachrymal  obstruction 

2-50 

face  from . . 

495 

-  passive  hypersemia  of  uterus 

-  lesions  of  genital  organs,  list  of 

705 

-  photophobia  in       . .        255, 

574 

from          ..          ..         428. 

430 

-  lymphangioma  circumscrip- 

- ptosis  of  lids  in 

590 

-  with  peritonitis         644,  718, 

719 

tum 

833 

-  rainbow  vision  from          257 

840 

-  due  to  purgatives    . . 

848 

-  malformations  of  heart  fsee 

-  with  snow  blindness 

840 

-  pyloric   01    oesophageal   ob- 

Heart Disease,  Congenital) 

Connective  tissue  in  fa?.ces  in 

struction  . . 

144 

causing  intestinal  obstruc- 

defective gastric  digestion 

117 

-  pyrexia  from 

618 

tion 

151 

pancreatic  disease 

117 

-  in  rickets 

171 

of  genital  organs,  dysme- 

Consciousness,  loss  of  (see  Coma) 

-  spastic 

144 

norrhcea  from 

219 

CONSTIPATION 

140 

-  tenderness  in  the  right  iliac 

hemiplegia  in      ..        337, 

338 

-  abdominal   distention  from 

fossa  from 

7S0 

paraplegia  from  . . 

557 

713,  715, 

718 

-  in  tuberculous  peritonitis .  . 

719 

of     rectum,     etc.     (Figs. 

-  absolute     in     strangulated 

-  undue  abdominal  aortic  pul- 

170-173J 

637 

hernia 

741 

sation 

592- 

-  narrowness  of  anal  canal 

150 

-  acute 

151 

-  visible  peristalsis  with 

724 

-  nystagmus   . . 

453 

S3Tnptomatic 

153 

-  and  vomiting  from  intussus- 

- obliteration  of  bile-duct  . . 

361 

-  in  acute  pancreatitis  646,  724 

846 

ception     . . 

736 

-  oedema 

455 

yeUow  atrophy    .  . 

370 

-  a;-ray  Ulustration  of         141, 

142 

-  onychoeryphosis     . . 

445 

-  alternating    with    diarrhoea 

-  in  yellow  fever 

372 

-  persistence   of   pupillary 

in  carcinoma  of  colon     .  . 

690 

Consumption  of  the  bowels  . . 

56 

membrane 

593 

-  anaemia  in    . . 

36 

Contortionists,  lordosis  in 

183 

886 


CONTRA  CTED    PEL  VIS— CO  UGH 


Contracted  pelvis,  paraplegia 

Convulsions,  contd. 

Coronary  arteries,  angina  pec- 

of infant  dae  to . . 

558 

-  pyrexia  due  to       ..169,34^1 

622 

toris  due  to    . . 

778 

CONTRACTIONS,  ATHETOTIC, 

-  in  rickety  children. . 

466 

atheroma       of,       violent 

etc.  (and  see  Athetosis^. . 

153 

—  simulated  by  malingerers.. 

652 

thumpings  of  heart  ^\ith 

527 

-  in  brachial  monoplegia 

546 

-  in  sinus  thrombosis            139 

558 

mistaken  for  rheumatism 

-  carpo-pedal,  in  tetany 

802 

-  Stokes- Adams'  disease 

97 

of  the  shoulder 

778 

-  choreiform  (see  Choreiform 

-  strychnine  poisoning 

802 

pain  and  tenderness  in 

Contractions) 

-  subnormal  temperature  after 

621 

the  back  from 

789 

-  clonic  spasmodic     . .        IGO, 

161 

-  tetanus 

802 

Stokes- Adams' syndrome 

-  definition  of 

153 

-  unilateral,  discussion  of 

173 

from  . . 

97 

-  distinguished    from   contrac- 

- uraemic            14,  45,  48,  464 

647 

Corpora  quadrigemina,  inten- 

tures 

1G3 

opisthotonos  in  . . 

464 

tion  tremor  from  lesion  of 

800 

-  fibrillar  (see  Fibrillar  Con- 

- after  iui.nary  operations    . . 

49 

tumour  of,  loss  of  converg- 

tractions) 

-  in  yellow  atrophy  . . 

370 

ent        accommodation 

-  hysterical,  simulating  tetanus  464 

Convulsive  tic,  chorea  simulating  156 

with  retention  of  light 

-  involuntary  .  . 

153 

-  twit€hing  in  syncope  of  fatty 

reflex  in 

594 

-  spasmodic     ..          ..         159 

162 

heart 

241 

Corpus    cavemosum,    inflam- 

 in  epilepsy 

160 

Copaiba,  effect  on  urine 

6 

mation  of 

125 

a  minor  sign  in  various 

—  eruption 

609 

-  luteum,  haemorrhage  from, 

nervous  disorders 

159 

diagnosis  from  smaU-pox 

609 

pelvic  haematocele  from 

757 

of  sphincter  vesicns 

443 

-  purpura  from 

596 

hEemorrhagic     cyst     of. 

in  tetanus 

162 

-  resin,  polyuria  after 

582 

pelvic  pain  from 

508 

-  tetanic 

161 

Copper,   foul  taste  in  mouth 

-  striatum,  hyperpyrexia  from 

interrupted 

160 

from 

774 

lesions  of . . 

340 

resemble  cramp  .  . 

163 

-  green  sweat  due  to . . 

714 

Corpuscles,    red,    increase    of 

CONTRACTURES 

162 

-  salts,  ptyalism  due  to 

590 

(see  Polvcvthaemia) 

-  in   acute   poliomyelitis 

555 

Coppery  areola  of  syphiUdes. . 

604 

nucleated  (P/a?e//,  Fig.  F) 

28 

-  chronic  arthritis 

390 

Cor  bovinum  .  . 

233 

variation  in   shapes   and 

-  differentiation    of    contrac- 

Coraco-brachialis muscle,  spi- 

sizes of  (Plate  IF) 

28 

tions  from 

153 

nal  nerve  root  supplying 

556 

-  white  (see  Leucocytes) 

-  facial  (Figs.  136-0)          534, 

537 

-  nerve  supply  of 

550 

Corrigan's  pulse 

106 

-  of  hand 

3 

Cord,    combined    sclerosis    of 

Corrosive  poisoning,  oesopha- 

- with  hysterical  chorea 

157 

(see  Combined  Sclerosis  of 

geal  stenosis  from 

222 

-  in  monoplegia 

547 

Cord) 

h»matemesis  in            294, 

297 

-  peripheral  neiuritis 

390 

-  compression   of   (see    Com- 

 loss  of  taste  from 

774 

-  talipes  from.  .          ..          132 

133 

pression  of  Cord) 

sore  tlu-oat  from            671, 

674 

-  Volkmann's 

132 

-  lesions    at    various    levels. 

symptoms  of       ..        297, 

845 

from  injury  to  forearm  .  . 

552 

effects  of  

540 

vomiting  from    . . 

813 

Convalescence,  anaemia  in     . . 

36 

-  spermatic     (see    Spermatic 

-  sublimate   test   for   bile   in 

-  brisk  knee-jerks  in.  . 

397 

Cord) 

stools        

197 

-  hypothermia  in 

346 

-  transverse   lesions    of   con- 

Coryza,   acute,   pains  in    the 

-  irritable  cough  of    . . 

175 

tractures  in         . .        162, 

164 

limbs  in  (and  see  Discharge, 

-  oedema  of  legs  in  .  .         459, 

461 

-  umbilical     (see     Umbilical 

Tsasai ;  and  Cold,  Common) 

-  polyuria  during       . .         582 

583 

Cord) 

503, 

505 

-  priapism  in 

586 

Corea,    paragonimus    'Wester- 

-  in  arsenical  poisoning 

75 

-  shortn&ss  of  breath  in 

101 

mani  in    . . 

705 

-  congenital  sypMlis  .  . 

446 

-  tachycardia  during 

773 

Corn,  perforatiag  ulcer  origin- 

- e  feno,  or  hay  fever,  loss  of 

-  tremor  in     .  . 

795 

ating  from 

809 

smell  in    . .          . .         668, 

774 

CONVULSIONS 

168 

-  suppurating,     distinction 

-  impairment  of  tast«  from. . 

775 

-  in  acute  encephalitis         139 

547 

from  perforating  ulcer  . . 

809 

-  in  influenza 

505 

-  children    corresponding    to 

pain  in  the  foot  from 

809 

-  from  iodides 

87 

rigors  in  adults    . . 

646 

Cornea,  appearance  of,  in  dif- 

- in  measles    . . 

426 

-  cholaemia 

361 

ferentiation  of  conjuncti- 

- various  causes  of   . . 

203 

-  chronic  nephritis     . . 

14 

vitis,  iritis,  and  glaucoma 

257 

Costermongers,  chronic  pharvn;? 

- 

-  clonic,  in  focal  epilepsy     . . 

161 

-  herpes  of 

807 

itis  in       . .          . .         670 

673 

-  definition  of             .  .         168 

267 

-  insensitiveness  of,  from  para- 

Cotton, relation  to  actinomyces 

-  effect  of  oxygen  in 

172 

lysis  of  fifth  nerve 

807 

8/, 

70.^ 

-  epileptic       

160 

-  opacities    of,    in  congenital 

-  sporotrichosis  from 

322 

with  coma  from  haemor- 

syphilis.  . 

259 

-  wool  in  ears,  otorrhoea  from 

469 

rhage     . . 

140 

from  interstitial  keratitis 

806 

eczema  from 

469 

in  eclampsia 

647 

in  keratomalacia 

807 

Coude  catheter           . .         440 

441 

in    general    paralysis    of 

from   ophthalmia   neona- 

COUGH              

174 

the  insane 

340 

torum       . .          . .     836 

839 

-  in  asthma  not  the  essential 

in  lead  neuritis  . .  38,  77, 

139 

paralysis  of  fifth  nerve  . . 

807 

symptom 

582 

not  often  unilateral 

174 

from  ulceration  . . 

806 

-  Charcot-Leyden  crystals  in 

118 

saturnine  encephalopathy 

-  perforation  of,  in  diphtheria 

-  due  to  chronic  pleurisy     . . 

480 

38, 

139 

infection  .  . 

807 

-  drv,  due  to  growths 

175 

in     the     Stokes  -  Adams 

gonococcal  infection 

807 

-  early  in  phthisis      . .         101 

620 

syndrome         . .           97, 

527 

from   ophthalmia  neona- 

— epistaxis  from 

250 

in  ura>mia 

464 

torum   .  . 

8.S6 

-  in  fibroid  lung 

240 

-  in  general  paralysis  of  the 

by  ulceration 

806 

-  haemoptysis  from  violent  . . 

317 

insane        . .          .  .         139 

269 

-  rodent  ulcer  of  (see  Jlooren's 

-  incessant,  in  phthisis 

194 

-  from  hydrophobia  . . 

80.' 

Ulcer) 

-  in  influenza . . 

505 

-  in    hys'teria    (see    Hysteria, 

-  steamy  in  glaucoma 

840 

-  interference  with,  by  laryn- 

Con\Talsions in) 

inserLsitive  in  glaucoma. . 

838 

geal  paralysis      . .         538 

539 

-  infantile,  hyperpyrexia  in . . 

344 

-  tuberculous  ulceration  of  . . 

808 

-  in  mediastinal  growth 

483 

-  .Tacksonian  epilepsy 

161 

-  ulceration  of  (see  Ulceration 

-  micrococcus  catarrhalis   in, 

-  local  (see  Contractions)     . . 

168 

of  Cornea) 

in  influenza 

505 

-  in  meningitis     139,  341,  612 

642 

Corneal  affections,  photopho- 

- mitral  regurgitation 

238 

-  non-obstructive  anuria     . . 

46 

bia  in 

574 

-  morning,  in  bronchLil  catarrh 

176 

-  organic  cerebral  disease     . . 

328 

-  reflex  in  facial  paralysis    .  . 

535 

-  oedema   of   face,    neck   and 

-  otitis  media  in  children 

229 

Cornet  player's  cramp 

177 

arms  from            .  .         459 

4C1 

-  phosphorus  poisoning 

373 

Cornwall,  ankylostomiasis  in 

570 

-  onset     of     pneumothorax 

-  poliomyelitis            . .        128 

555 

Corona  veneris 

532 

during 

480 

COUGH— CYSTIC    DISEASE 


887 


C'oni/li,  i-ontd. 

-  pain  in  the  chest  due  to    . . 

-  painful,  in  phrenic  neuralgia 

-  paroxysmal,    in    whooping 

cough 

-  in  phthisis 

101,  17U,  185,  194,  319,577, 

-  pneumonia   ..  ..175,170, 

-  relation  to  gastric  branches 

of  vagus  . . 

-  severe  epigastric  pain  from 

-  tenderness    in    the    epigas- 

trium from 

-  vomiting  from        . .         4(!7, 
Coughing  in   diagnosis  of   in- 
guinal swellings  . . 

Cousins,  marriage  of,  retinitis 

pigmentosa  from 
Cracked  nipples,  mastitis  from 
Cracked-pot  sound  in  fibroid 

lung 
CRACKLING,  EGG-SHELL  .. 

-  over  myeloid  sarcoma 
CRAMPS  

-  abdominal  (see  Colic) 

-  in  alcoholism  59,  7«,  238,  300, 

-  differentiation    of    contrac- 

tions from 

from  contractures 

peripheral  neuritis  78, 

-  dull,     aching     pain     after 

cessation  of  spasm  in     . . 

-  painful  spasm  in     . . 

-  professional,      ill-health      a 

cause  of    . . 

-  -  from  local  injury 

-  in  syringomyelia     . . 

-  tjrpist's     (see      Occupation 

Neuroses) 

-  writer's,     (see     Occupation 

Neuroses) 

Cranial  nerve  paralyses,  mus- 
cular atrophy  in .  . 

ptosis  in 

sypuihiic,  multiple  asym- 
metrical 

Craniotabes     in     congenital 
syphilis     . . 

-  crepitus  with 

-  egg-shell  crackling  in 
Cranium  (see  Skull) 
Creatinine       

-  darkening  with  picric  acid 

-  oxalates  derived  from 

-  in  urine,  reduction  by 
Cremaster  muscle,  spinal  nerve 

root  supplying    . . 
Crenated  red  corpuscles  (Plate 

II,  Fig.  m 
Creosote,  foul  taste  from 
Crepitations  in  pneumonia 

186,  701, 

-  mediastinal,  in  acute  medi- 

astinitis    .  . 
CREPITUS        

-  in  endosteal  sarcoma 

-  fractured  rib 

-  subcutaneous  (see   Emphy- 

sema, Surgical) 

Crescents,  congenital  myopic 
pigmented,  oplithalmos- 
copio  appearances  of 
(Plalc  VII)  . .        461, 

Cretinism,  amenorrhoca  in     . . 

-  delayed  walking  from 

-  facies  of 

-  fatty  pads  on  shoulders  in 

-  hair  and  skin  in 

-  hypothermia  in      . .        259, 

-  illustrated  (Fir/.   07) 

-  lack     of    mental     develop- 

ment in    . . 

-  paraplegia  due  to     . .        556, 

-  pendulous  belly  in 


462 

23 

557 

258 
259 
259 
345 
210 

259 
557 
259 


no. 


134, 


654, 
829, 
270, 


448, 


Cretinimn,    could. 

-  relative  largeness  of  head  in 

-  slow  pulse  in 

-  stunted  growth  in  . . 

-  thyroid   extract  in 
Crick  in  the  neck 
Crises,  gastric  . . 
jjeriodicity  of 

in  tabes  dorsalis  134,  350 

489,  502,  664,  665,  844, 
diagnosis  from  indigestion 

-  intestinal 

-  laryngeal 

-  in  lobar  pneumonia 

-  pyrexial    in   meningococcal 

meningitis 

-  in  typhus  fever 
Crossed  hemiplegia    . . 

-  paralysis  (and  see  Hemiplegia) 

-  pyramidal  tracts,  Babinski's 

sign  in  lesions  of 
Cross-legged  gait 

in  Little's  disease 

Croton  oil  causing  bullae 

used  by  malingerers 

Crural  lesions  causing  ataxy . . 

-  monoplegia    (see    Paralysis 

of  one  extremity  (lower)  ) 

-  nerve     (anterior),     isolated 

paralysis  of  (see  Anterior 

Crural  Nerve) 
Crus  penis  (see  Penis) 
Crusts  (and  see  Scabs) 

-  in  atrophic  rhinitis . . 

-  cheiropompholyx 

-  eczema         . .  602, 

-  favus 

-  herpes 

-  impetigo       . .  113, 

-  keratosis  foUicularis 

-  lupus    vulgaris 

-  mycosis  fungoides   . . 

-  Paget's  disease       . .        «02, 

-  pemphigus  vulgaris 

-  pustular  eczema 

-  from  pustules 

-  in  scrofulodermia   . . 

-  syphilides     . . 

-  from  vesicles 

-  in  xerodermia  pigmentosum 
Crutch,  musculospiral  paralysis 

from 
Crying,  oedema  of  face,  neck, 

and  arms  from.     . .        459, 
Cryoscopy     of     cerebrospinal 

fluid  

Cryptomenorrhoea 
Cryptorchism  in  infantilism. . 
CRYSTALS,     Charcot-Leyden, 

illustrated 
in  asthma 

-  in     acid     urine     in     renal 

calciilu=    . . 

-  cholesterin,   in  gall-bladder 

(J''i{/.  94) 

in  spermatocele  . . 

-  choline  platino-chloride     . . 

-  cystin,  illustrated  . . 

-  dumbbell,  in  oxaluria 
of  uric  acid 

-  of  fats  and  fatty  acids  in 

stools 

-  fatty   acid  in   pancreatitis 

-  "  hedgehog,"  of  urates     . . 

-  leucin  . .  . .        302, 

-  osazone         . .  . .        115, 

-  oxalic  acid  (Fig.  130) 

-  rosettes,  of  uric  acid 

-  "  thorn-apple,"'  of  urates  .  . 

-  triple  phosphate  (Fig.  155) 

-  tyrosin  . .  . .        302, 

-  of  uric  acid  (Fig.  212  ;  and 

see  Uric  Acid  Crystals). . 
Cud-chewing  (see  llerycism) 


258 
259 
258 
557 
477 
847 
847 
473, 
847 
350 
134 
460 
186 

642 
371 
336 
536 

82 
164 
154 
110 
112 


Cup,  glaucomatous  (Flale  VIII 
p.  463)      . .  . .        257 

-  physiological,      ophthalmo- 

scopic     appearance      of 

(I'late    VII) 
Curettage    in    diagnosis     of 

cause  of  dysraenorrhcEa 

metrorrhagia     . . 

metrostaxis 

-  in  endometritis 

-  relief  of  dysmenorrhoea     . . 

-  sterility 
CURSCHMANN'S     SPIRALS, 

significance  oi  (Fig.  46)  .  . 

iu  spasmodic  asthma     .  . 

CURVATURE,  SPINAL  (sec 
also  Ky|ihi)sLs;  Lordosis; 
Scoliosis ;  and  Spinal  Cur- 
vature) 

Cutaneous  reaction  (von  Pir- 
quet's)  for  tuberculosis.  . 

-  sensibility,  loss  of,  mistaken 

for  paralysis 
Cut  throat,  hoemoptysis  from 

stenosis  of  trachea  after 

stridor  in . . 

CYANOSIS,  EXTREME 

-  blodd  ;ilrr-i-;itions  causing 
cIuI.IhmI  lingers  in 

-  borborygmi  with    . . 

-  in  chronic  mediastinitis   . . 

-  congenital    . . 

-  in  congenital  heart  disease 

129,  244,  579 

-  during   convulsions 

-  of  face  and  neck  with  aortic 

aneurysm  (Fig.  72) 

-  hands     in    some    cases    of 

cervical  ribs 

-  in  laryngismus  stridulus  . . 

-  local,    symmetrical,    of   the 

extremities,  in  Raynaud's 
disease 

-  from  malignant  ulceration  of 

larynx 

-  mediastinal  growth.. 

-  in  mitral  stenosis    . . 

-  myxoedema 

-  passive  congestion   of  liver 

-  periodic,     from     bronchitis 

and  emphysema 

from    fibroid    lung     and 

bronchiectasis 

in  mitral  stenosis 

from  renal  disease 

-  pneumonia  . . 

-  from  pneumothorax  480,  577,  712 

-  polycythsemia  with  187,  579 

-  from  pulmonary  embolism        320 

-  -  stenosis     . .  . .        104,  247 

-  during  rigors  . .  . .     647 

-  in     splenomegalic     polycy- 

themia     ..  187,581,693 

-  in  Stokes- Adams'  disease..       97 

-  from    sudden    irruption    of 

caseous    bronchial  glands 
into  bronchus 
in  sulphhfemoglobinaemia  . . 


401 


401 

220 
433 
436 
429 
220 
706 

179 
118 


180 


612 

.^.45 

318 

710 

710 

184 

184 

128,  184 

97 

..     484 

..     184 


790 
109 


234 


493 
406 


490 

185 
296 
764 
259 
370 

579 

579 
579 
579 

645 


466 

187 


-  syphilitic  ulceration  of  larynx  185 
Cyclical  albuminuria  . .  . .       19 

-  vomiting  of  children         426,  843 
Cyclitis,  causes  of       . .  . .     256 

-  conjunctivitis  distinguished 

from  . .  . .  . .     256 

-  severe  pain  in  the  eye  from     250 
Cyrtometric  tracings  of  various 

forms  of  chest,  illustrated     192 
Oystalgia,    frequent    micturi- 
tion in 443 

Cystic   degeneration  of  fibro- 

myomata  . .  . .     434 

-  disease  of  breast  (see  Breast, 

Cystic  Disease  of) 
epididymis  (see  Epididymis) 


CYSTIC    DISEASE— CYSTS,   VULVAL 


Cystic  disease,  contd. 

Cystilis,  contd. 

Cystoscopy,  appearances,  contd. 

-'-  of  kidneys                       S 

396 

-  simulating  passage  of  fseces 

in    ureteral    tuberculosis 

age  incidence  of 

310 

per  urethram 

264 

(Plate  r.  Fig.  D,  p.  308) 

625 

albuminuria  in 

15 

-  suprapubic  pain  in 

vesical  tumoure  (Plate  VI, 

anuria  in         . .            45,  48 

306,  312,  512,  627 

631 

Figs.  F,   G,  p.  310;    .  . 

311 

bilateral  tumours  in  . . 

310 

-  in  tabes 

628 

in  pneumaturia  .  . 

576 

bulging  of  lower  thoracic 

-  transverse  myelitis 

628 

-  bladder  infected  from  tuber- 

wall by 

393 

-  triple  phosphate  crystals  in 

culous  bowel 

313 

Cheyne-Stokes  respira- 

urine in    . . 

574 

-  in  calculous  anuria 

47 

tion  in 

124 

-  tuberculous,  general  account 

-  carcinoma  of  bladder  (Plate 

continued   polyuria    in 

583 

of  . .          . .            513,  628 

629 

VI,  Figs.  F.  G,  p.  310) 

diagnosis   from    bydro- 

age  incidence  of  . . 

513 

442,  512,  514, 

630 

nephrosis      . .     "    310 

396 

associated     with     tuber- 

- detecting  vesical  fistula      . . 

442 

haematuria  in             304, 

310 

culosis      of      vesicute 

cause  of  bearing-down  pain 

474 

iliocostal  space  length- 

seminales           312,  513 

629 

pyuria  (Plate  V,  p.  308) 

624 

ened  in 

393 

ureteral  tuberculosis  . . 

513 

cystitis      . .            442,  624, 

628 

occupation     of     whole 

cystoscopic     appearances 

papilloma  of  bladder 

abdomen  by 

393 

in    (Plate    F,    Fiq.    E, 

441,  514, 

630 

pain  in 

310 

p.  308)      312.   513,  626, 

629 

pelvic  tumour     . . 

758 

palpability  on  vaginal 

diagnosis     from     renal 

pveUtis  (Plate  V,  Fig.  C. 

examination 

393 

tuberculosis        312,  513 

629 

p.   308)..          ..        625, 

628 

renal  enlargement  from 

310 

ureteral    calculus    im- 

 single     simple     ulcer     of 

similarity  to  ovarian  cyst 

393 

pacted  near  bladder 

627 

bladder 

630 

symptoms  of  . . 

48 

vesical  calculus 

628 

vesical  calculus  (Plates  V, 

-  duct  stenosis,  distention   of 

-  -  examination  for  tubercu- 

VI, pp.  308.  310)     312, 

439, 

gall-bladder  without  jaun- 

lous focus  elsewhere  m 

513 

442,  512,  513, 

629 

dice  in       . .          . .    "     . . 

365 

frequency   of   micturition 

villous  tumour  of  bladder 

calculus  in,  colic  without 

in           . .     306,  312,  513 

581 

512, 

514 

jaundice  from 

846 

uninfluenced  by  rest 

-  in  differential   diagnosis   of 

-  ovary,  congestive  dysmenor- 

in   . . 

513 

ulceration  of  bladder 

630 

rhoea  from 

220 

haematuria  from 

-  haematuria    (Plates    V,    VI. 

Cysticerci,  eosinophUia  with 

452 

304,  312,  441,  628 

629 

pp.  308,  310)                      9 

307 

Cystin  crystals  (Fig.  51) 

187 

lesions  In  testes,  prostate. 

-  silver  nitrate  as  an  aid  to . . 

630 

-  formula  of   . . 

187 

or  vesicles  with 

629 

-  in     suspected     growth     of 

CYSTINURIA 

187 

other  genito-urinary  tuber- 

kidney 

395 

Cystitis,  abscesses  in  mucosa  in 

617 

culosis  in          . .'       312 

513 

renal  tuberculosis  (Plate  V, 

-  albuminuria     in    ascending 

pain  after  micturition  in 

441 

p.  308)..          ..         626, 

629 

nephritis  from     . . 

16 

permeum  in     . . 

516 

-  vesical    tuberculosis     (Plate 

-  bacteriuria  in 

83 

in  penis            .  .         441, 

513 

V,  Fig.  E,  p.  308) 

-  from  calculus            312,  513, 

629 

persistent  slight  pyuria  in 

312 

312.  513.  626. 

629 

-  congestion     of     bladder     a 

primary,    diagnosis   from 

Cysts,  abdominal  swelling  from 

715 

predisposing  cause  of     . . 

627 

primary  renal  tubercu- 

- of  Bartholin's  gland 

770 

-  cystoscope  in  diagnosing  442 

628 

losis       

629 

-  breast,     blood-stained     dis- 

- diagnosis      from     posterior 

prostatic         tuberculosis 

charge  from  nipple  in . . 

745 

urethritis  .  . 

628 

with      ..          ..         513, 

678 

with  chronic  mastitis    202, 

743 

prostatitis 

627 

pyuria  due  to  441,  513,  623 

628 

diagnosis  from  carcinoma 

744 

pyelitis       or       pyelo- 

 rarely  a  primary  affection 

513 

fibro-adenoma 

744 

nephritis 

628 

slight  hsematuria  at  end 

mastitis            . .         202 

744 

urethritis                 207,  628, 

631 

of  micturition  in 

513 

with  fibro-adenoma 

744 

-  due  to  dysenteric  or  tubercu- 

 tubercle  bacUli  in  mrine  in 

fluctuation  rarel.v  felt  in 

743 

lous  intestinal  ulceration 

633 

312, 

513 

, milk  retention  in   lacta- 

- dyspareunia  from  . . 

221 

tuberculous  testis  with  513 

518 

tion  (see  Galactocele). . 

744 

-  frequent  micturition  in    221, 

438, 

vesiculse  semmales  with 

513 

possibly  precancerous    . . 

744 

512,  627,  628, 

817 

ulceration  of  bladder  with 

simple  serous 

744 

-  haematuria  in          304,  312, 

441, 

627,  629, 

630 

-  causing  albuminuria 

17 

512,  627,  628,   629, 

631 

-  from  urethral  strictiu-e 

627 

-  of  corpus  luteum     . . 

508 

-  due  to  instrumentation    . . 

627 

-  urethritis      . .          . .        62  7, 

63] 

-  dentigerous  . . 

757 

-  from   malignant   ulceration 

-  urinary  changes  in . . 

628 

-  derived  from  Wolffian  body 

725 

of  the  bladder     . . 

627 

incontinence  with 

628 

-  dermoid  (see  Dermoid  Cyst) 

obstruction  with 

628 

-  diagnosis  of  ascites  from  . . 

52 

-  mucus   in  urine  from 

221 

-  urine  acid  in             . .       512, 

627 

-  of  epididymis  (see  Epididy- 

- from  non-gonococcal  ureth- 

 alkaline  in 

628 

mis,  C.vstic  Disease  of) 

ritis 

206 

-  vesical  tenesmus  in 

312 

-  hydatid  (see  Hydatid  Cysts) 

-  pain  after  micturition  in  441 

627 

Cystocele  simulating  prolapse 

-  of  kidney,  serous     . . 

396 

in  bladder  irom  . . 

629 

of  uterus  . . 

587 

-  lesser  peritoneal  sac 

725 

penis  from           . .       441, 

511, 

-  dystocia  due  to 

227 

-  liver  simulating  ascites 

717 

512,  513, 

514 

-  pain  in  perineum  in 

516 

-  mesentery,  simulating  ascites 

717 

perineum  in         . .        516, 

627 

-  vulval  swelling  due  to 

768 

-  in  mucous  uterine  polypi  . . 

435 

vulva  on  micturition  in .  . 

442 

Cystoscopy,    adrenalin   as    an 

-  omental 

724 

-  from  papilloma  of  bladder 

630 

aid  to 

630 

-  ovarian  (see  Ovary.  Cysts  ofj 

-  prostatic  obstruction 

627 

-  appearances  in  adhesion  of 

-  of  pancreas  (see   Pancreas, 

-  much  pus  in  alkaline  urine 

appendix    to   bladder   in 

Cysts  of) 

in 

623 

appendicitis 

632 

-  pneumaturia  cattsed  by     . . 

576 

-  pyelitis  from 

625 

in    bilharzia    hfematobia 

-  retroperitoneal,   laparotomy 

crystals  in  urine  in 

629 

irifection      (Plate     VI, 

in  diagnosis  of     . . 

725 

-  pvonephrosis  from  . . 

626 

Fig.  K,  p.  310)  313,  514 

630 

palpable    in    left    hypo- 

-  pyrexia  in  312,  512,  620,  627 

628 

in     descendins    ureteritis 

chondrum 

726 

-  pyuria  due  to           ..       221, 

312, 

(Plate    y,   Figs.    C,   I), 

pyloric  obstruction  from 

713 

512,  623, 

627 

p.  308) 

515 

-  in  sarcoma  . . 

757 

-  recurring  rigors  in  .  . 

648 

dilatation  of  ureter 

625 

-  sebaceous  of  scrotum       681, 

765 

-  with  retention  of  urine      627 

628 

impacted  ureteral  calculus 

-  of  testis  (see  Testis,  Cyst  of) 

-  in    retroversion    of    gravid 

514, 

627 

-  thyroid  gland 

791 

uterus 

628 

in    thickening    of    ureter 

-  lurachal  (see  Urachal  Cvst) 

-  septic  artliritis  from 

375 

(Plate  V,  Fig.  D,  p.  308) 

625 

-  vulval           . .          . .     "    768, 

770 

CYTOLOGY    OF    ASCITIC    FLUIDS— DHOBIE'S    ITCH 


889 


Cytology  of  ascitic  fluids       . .  57 

-  cerebrospinal  fluid..          ..  339 

-  in  general  paralysis  of  the 

insane       . .          . .          . .  209 

-  spinal  meningitis    . .          . .  464 

-  urine  in  acute  nephritis     . .  12 

DACHSHUND  type  of  dwarf  212 
Uactylitis,  tuberculous  (Fig.ldZ)  751 
Diacetic  acid  in  cyclical  vomit- 
ing of  children  . .  . .  843 
Dalrymple's  sign  in  exoph- 
thalmic goitre  . .  . .  792 
Damiana,  priapism  caused  by  586 
Damp,  nephritis  from  . .  13 
Dancers,  cramp  in  . .  . .  177 
Dancing,  hsematuria  after,  due 

to  movable  kidney         . .  310 

-  menorrhagia  from  . .          . .  428 
Darier,  re  priurigo  ferox          . .  531 

-  re  vesicles    . .          . .          . .  829 

Day-blindness  or  hemeralopia  841 
Dead  fingers,  association  with 

jncnoiThagia  at  puberty  430 

in  li'-ripheral  neuritis      .  .  505 

DEAFNESS    (and   see   Word- 
deafness;  . .          . .          . .  187 

-  apoplectic    . .          . .          . .  190 

-  in  congenital  syphilis         . .  260 

-  from  fracture  of  base  of  skull 

468,  794 

-  with   livsterical   hemianses- 

thesia        666 

-  in  Meniere's  disease            . .  828 

-  otitis  media             . .         469,  470 

-  otosclerosis  . .          . .          . .  829 

-  and  tinnitus  associated      . .  79.') 

-  due  to  wax  in  ears  ..          ..  467 
Death  from  inadequate  causes 

in  lymphatism     .  .          . .  423 

-  sudden,     from     pulmonary 

embolism          . .         185,  321 

-  -  from  ruptured  aneurysm 

140,  482 
Debility    in    acute    polymyo- 
sitis           . .          .  .'     '  .  .  564 

-  cirrhosis  of  liver     . .          . .  410 

-  cough  due  to                       . .  175 

-  exaggeration   of   knee-jerks 

in  any  condition  of  serious  397 

-  general,  in  acute  polymyositis  504 
flushing  in            . .          . .  268 

-  in  Malta  fever          .  .          .  .  507 

-  muscular,  in  late  stages  of 

acromegaly          . .          . .  749 

-  neurasthenia  from  . .          . .  506 

-  pain  in  the  back  in              . .  476 

-  in  pcurvy               85,  115,  302,  753 

-  septicaemia              . .           . .  650 
Decerebrate  rigidity  of   Sher- 

ruigton     . .          . .          . .  163 

Decidual  casts,distinction  from 

m?mbranous  dysmenorrhoea  220 
Decubitus  acutus  (see  Bedsore, 

Acute) 
Defaecation,   disorders    of,    in 

cancer  of  sigmoid  flexure  501 

-  disregard  of,  a  cause  of  con- 

stipation . .          . .          . .  149 

-  frequency   of,    in    colitis  of 

infants  .  .          . .           . .  92 

dysentery    .  .          . .         . .  90 

-  frequent    desire    for,     from 

polyin      .  .          .  .          . .  93 

-  hfemorrhage  on,  from  uterine 

srrowths    . .          . .          . .  434 

-  induced  by  finger    . .          . .  149 
soap      ' 149 

-  inerticient  (and  see  Constipa- 

tion :  and  Dyschezia)     . .  148 

-  insufliciency  of        . .          ...  140 

-  mechanism  of          . .          . .  148 

-  obstacles  to  eflicient           . .  150 

-  painful,  in  fissure  of  anus  . .  636 


..     848 
..     432 

503,  500 
worse  on  movement  la  . .     506 

-  pus  in  the  stools  in        . .     601 

-  rapid  pulse  in  . .  . .     506 

-  relapse  after  two  or  three 
days'  improvement  in    . .     506 

-  roseolar  rash,  beginning  on 
hands  and  wrists,  in  the 
relapse  of  . .  . .     506 

-  slow  convalescence  in         . .     500 

-  sore  throat  in  . .  . .     506 

-  sudden  on.set  of       . .  . .     506 
Dental  caries  Csee  Caries,  Dental) 
Dentiserous  cysts       . .  . .     757 
Dentition     causing     infantile 

convulsions 
Depression  due  to  arsenic 

-  with  fatty  heart 

-  in  gastritis  . . 

-  general  congestion  of  liver 

-  influenza 

-  irritability  in 
Dercum's  disease  (see  Adiposis 

Dolorosa) 
Dermatitis  exfoliativa,  affect- 

tion  of  general  health   in 
distinction      from     pity- 
riasis rubra  pilaris 

-  gestationis,  pruritus  in      . .     588 

-  herpetiformis  affecting  fingers  266 
bleeding  gums  in  86,  88 

-  -  buUffi  in  110,  113,  781,  829,  831 


iJefacalicm,  contd.  Dengue,  conld. 

-  peremptory    desire    for,   as  -  loss  of  weight  in 

epileptic  aura       . .          . .  80     -  met€orism  in 

-  precipitate                . .          . .  348     -  pains  in 

-  reflex,  primary  weakness  of  149 

-  time  after  meals  of . .          . .  140 

-  unfavourable  posture  in,  a 

cause  of  constipation     . .  149 

-  weakness  of  voluntary  mus- 

cles of ,148 

Deformities  in  acute  polio- 
myelitis    . .          . .          . .  555 

-  dwarfism  due  to      . .          . .  212 

-  with    paraplegia    in    Fried- 

reich's ataxy        .  .          . .  559 

-  in  svringomvelia  .  .  .  .  563 
DEFORIVIITYOFTHE  CHEST 

(see  also  Chest,  Deformities  of)  191 
Degeneration  of  muscles,  fibril- 
lar contractions  in          . .  157 

-  reaction  of  (see  Eeaction  of 

Degeneration) 
Deglutition  difficult,  in  bulbar 

paralysis  . .          . .          . .  159 

-  effects    on    muscles    of,    in 

hydrophobia  . .  . .  162 
Dejerine,  re  olivo-ponto-cere- 

bellar  atrophy  .  .  . .  799 
DELIRIUM       ..   "                  ..194 

-  abnormal  sense   of   size  in  840 

-  in  acute  yellow  atrophy    302,  370 

-  cholEEmia      . .          . .          . .  361 

-  cordis,  due  to  digitalis       . .  773 

-  from  fractured  spine           . .  286 

-  in  fungating  endocarditis  . .  103 

-  hysteria        . .          . .          . .  345 

-  muttering,  in  cirrhosis  of  liver  368 

-  nocturnal,  in  cirrhosis  of  liver  359 

-  in  non-obstructive  anuria. .  46 

-  otitis  media  in  children      . .  229 

-  phosphorus  poisoning         . .  373 

-  prognostic  significance  of..  194 

-  in  scarlatina             .  .          . .  301 

-  typhoid  fever           . .          . .  90 

-  tremens       195 

with  cirrhosis  of  liver    . .  410 

hyperpyrexia  in . .          . .  344 

insomnia  in          . .          . .  356 

spasmodic  contractions  in  159 

Delivery,  dilEcult  (see  Dystocia) 
Deltoid  muscle,   spinal  nerve 

root  supplying     . .          . .  556 

-  nerve  supply  of       . .          . .  550 

-  pseudo-hypertrophy  of      . .  560 

-  wasting  in  phthisis  . .  72 
Delusions  in  anorexia  nervosa  50 

-  concerning   genital    organs, 

subjective  smell  sensa- 
tions associated  with     . .  669 

Demarcation-line  in  dry  gan- 
grene        ..        (Plate  IV}  283 

Dementia,  amnesia  in            . .  25 

-  catalepsy  associated  with  . .  651 

-  in  cerebral  syphilis. .          ..  173 

-  epileptic,  irritabiUty  in      . .  360 

-  impotence  in            . .          . .  347 

-  mutism  in    . .          . .          . .  C82 

-  precox,  decrease  of  reducing 

body  in  cerebrospinal  fluid  339 

-  ptyalism  in..          ..          ..  591 

-  in  saturnine  encephalopathy  139 
Dendritic  synovitis,  crepitus  in  179 
Dengue,  acute  general  paias  in 

the  limbs  in         . .          . .  503 

-  diagnosis    from    measles   . .  506 

rheumatic  fever              . .  506 

scarlet  fever         . .          . .  506 

yellow  fever         . .          . .  373 

-  erythematous  rash  at  onset  of  506 

-  fever  in        . .          . .          . .  506 

-  hajmatemesis  in      . .          . .  294 

-  headache  at  onset  of          . .  506  | 

-  long  persistence  of  pains  in  j 

limbs  in 506  I 


170 
297 
241 

297 
407 
505 
3C0 


530 
530 


distinction  from  eczema        831 

herpes  zoster  . .  . .     830 

eosinophilia  in    . .  . .     249 

erythema  in         . .  . .     831 

long  course  of      . .  . .     781 

pityriasis  rubra  after      . .     658 

pruritus  in 

pustules  in 

relation  to  herpes  gesta- 
tionis   . . 

scabs  in    . .  . . 

simulated     by     urticaria 

bullosa 
tenderness  of  scalp  in  78C 

-  -  vesicles  in  .  .781,  829,  831 
wheals  in. .  . .  . .     831 

-  of  pregnancy,  bullre  in 
Dermatographia 
Dermatomyositis    (see     Poly- 
myositis, Acute) 

Dermoid  cysts,  diagnosis  of 
meningocele  and  encepha- 
locele  from 

displacement  of  eyeball  by   254 

mediastinal,  varicose  tho- 
racic veins  from 

ovarian     . . 

simulating  fibroma 

xanthoma  multiplex. . 

of  vulva    . . 

Desquamation  in  cheiropom- 
pholyx 

-  in  erythema  scarlatiniforme 

-  scarlatinal    . .  13,  671,  674 
Destructiveness  in  idiocy      . .     682 
Detachment    of    retina,    oph- 
thalmoscopic appearance 
of  (Plate  VIH)    .. 

Determination  of  blood  to  the 

head,  eplstaxis  in 
Deutero-albumose 
Dhobie's  itch  in  bathing- dra^v- 
ers  area  . . 

and    eczema  marginatum 

epidermophyton  inguinale 

pemeti  in 

rubrum  in 

microsporon  furfur  in    . .     275 

-  mlnutissimum  in         . .     275 


8.31 


111 
831 


850 
781 


111 
771 


254 


826 
760 

804 
805 


111 
253 


463 


251 
20 


447 
275 


275 
275 


890 


DIA  BETES— DIPHTHERIA 


Diabetes  

-  azotic,  polyuria  in  583, 

-  bronzed        

absence  of  jaundice  in  . . 

liver  cirrhosis  with        411, 

pigmentation  of  . .        411, 

sugar  in  urine  in. . 

-  insipidus,    acromegaly     and 

myxoedema  simulating 

colourless  urine  in 

extreme  thirst  with 

in     lesions      of     central 

nervous  system         584, 

polyuria  in 

579,  581,  582,  583,  584, 

specific  gravity  of  blood  in 

urine  in 

total  solids  in  urine  in  . . 

various  causes  of 

-  mellitus,     abdominal     pain 

heralding  onset  of  coma 


292 
584 
411 
411 
575 
575 
411 

585 
818 


585 

789 
584 
584 
584 
585 


acetonuria  in       . .     4,  292, 

acute 

appetite  excessive  in  49, 

coma  in  .  .  13(5, 137, 

deep-red  colour  of  tongue 

flushed  face  in 

influence  of  diet  in 

muscular  weakness  in 

oxybutyric  acid  in  urine 

phthisis  in 

pneumonia  in  . . 

prognosis  in    . . 

-  short  course  of 

age  incidence  of 

albuminuria  in   . . 

amenorrhoea  in  . . 

apparent  enlargement  of 

liver  in  . . 
arteriosclerosis   associated 

with 

atheroma  in 

brachial  neuralgia  in    . . 

constipation  in   . . 

delirium  in 

diacetic  acid  in  urine  in  292. 

distinguished     from     ali- 
mentary glycosuria    .  . 

dry  stools  in 

eczema  starting  in  penis 

or  vulva  in 

gangrene  in 

of  finger  in 

leg  in    . .  . .         286, 

lung  in . . 

penis  in 

glycosuria  in       . .         291. 

greenish  urine  in 

lieadache  in 

hypothermia  in  . .  . .  '• 

impotence  in 

increased     frequency     of 

micturition  in 
increase   of  the  reducing 

body   in    cerebrospinal 

fluid  in. . 

iritis  and  cyclitis  in 

irritability  in 

loss  of  knee-jerks  in  75, 292 

weight  in      69,  292,  507 

meteorism  in 

neuritis  due  to 

69,75,  165,  282,492 

of     external     popliteal 

nerve  in 

obesity  preceding 

optic  neuritis  in. . 

pain  and  tenderness  in  the 

scalp  from 

-  -  pancreatitis  a  cause  of    . . 
perforating  ulcer   of   foot 

from 

-  -  polycytliEcmia  in 


432 
583 
292 
292 
292 
292 
292 
292 
292 
292 
292 
292 
292 
292 
292 
16 
23 

405 

282 
811 
492 
145 
195 


584 
141 

447 
282 
266 
811 
703 
266 
507 
818 
328 
345 
347 

437 


339 
256 
360 
399 
849 
432 

507 

543 
453 
292 

784 
117 


Diabetes  mellitus,  contd. 

polyuria  with. .     292,  437,  507, 

579,  583,  584,789 

pruritus  in  . .  . .     588 

shedding  of  nails  in       . .     445 

shortness  of  breath  in. .     100 

skin  troubles  in  . .  . .     507 

specific  gravity  of  urine  in     584 

thirst  excessive  with 

292,  507,  789 

true  292 

ulceration  of  leg  in        . .     811 

urine  per  diem  in  . .     581 

vomiting  in  .  .  .  .      843 

xanthoma  in        . .  . .     805 

-  phospliatic    . .  .  .         572,  584 
absence    of  glycosuria  in 

polyuria  of       . .  . .     572 

achuig  in  loins  and  back  in  572 

continued  polyuria  in  583,  584 

polyuria  without  sugar  in     572 

tliirst  and  emaciation  m      572 

Diacetic  acid,  tests  for        . .    196 

in  urine    . .  .  .  . .         4 

in  acute  cyclical  vomit- 
ing of  infants  .  .     426 

diabetes  meUitus       292,  583 

DIACETURIA  ..196 

Diaphragm,  abscess  of,   caus- 
ing pneumothorax         577,  578 

-  afEected  by  abscess  of  liver      409 

-  immobilization  by  empyema     721 

by  pleuritic  effusion      . .     721 

subphrenic  abscess         . .     721 

-  nerve  supply  of      . .        779,  842 

-  pushed  up  in  abscess  of  liver     409 
by  subphrenic  abscess  . .     721 

-  spinal  nerve  root  supplying     556 

-  tenderness  in  the  chest  from 

affections    of        . .       776,  779. 

-  unilateral  paralysis  of       . .     341 
Diaphragmatic  neuralgia  (see 

Neuralgia,  .Phrenic) 

-  pleurisy  (see  .Pleurisy) 
DIARRHOEA 196 

-  aiC£.tonar.iaL^froni     . .         . .         4 

-  in  acute  gastritis   . .  . .     845 

-  acute,  from  new  growths  in 

bowel        196 

-  alternating      with      consti- 

pation   in   carcinoma    of 
colon         690 

-  due   to  arsenic    75,  87,  297,  579 

-  from  carcinoma  of  colon 

146,  393,  690 
of  rectum  . .  . .     636 

-  carpopedal  spasm  in         . .        '3 

-  in  cholera     . .  . .        301,  579 

-  chronic,  due  to  catarrli   of 

small  bowel         . .  . .     197 

-  in  chronic  intestinal  obstruc- 

tion   267 

-  -  colitis         .  .  .  .        134,  727 

-  collapse  after  severe  . .     346 

-  from  distoma  hepaticum   . .     364 

-  explosive      . .  . .        348,  636 

-  extreme  thirst  from  . .      789 

-  fatty,  in  pancreas  affections     486 

-  fermenta.tive,  starch  in  stools  197 

-  in  gastritis  of  children      . .     297 

-  gastrogenic  . .  . .         196,  197 
muscle  fibres  in  stools  in     197 

-  general  peritonitis  . .     644 

-  hardening  of  fspces  after  . .     150 

-  in  Henoch's  purpura        . .     380 

-  hypothermia  after  .  .         346,  621 

-  indicanuria  in         . .  . .     349 

-  of  infants,  blood  with      . .      92 
bacillus      enteritidis      of 

Gaertner  in        . .  . .     426 

depression  of  fontanelle  in     426 

diminished  knee- jerks  in 

398,  557 
fatty  stools  in     . .  . .     265 


Diarrhoea  of  infants,  contd. 

marasmus  from  . .     426 

Morgan's  bacillus  I.,  in. .     426 

rapid  loss  of  weight  in  . .     426 

sunken  eyes  in   . .  . .     426 

in  summer  .  .  .  .      579 

tetany  from         . .  . .     178 

-  in  influenza. .  . .  . .     505 

-  with  intestinal  fermentation     267 

-  from  lardaceous  disease 

10,  39,  414,  696 

-  loss    of    fluid    from   tissues 

due  to  . .  . .  . .     579 

-  polycythsemia  in  579,  580 

-  in  ptomaine  poisoning       . .     579 

-  pyaemia         . .  . .  . .     649 

-  pyonephrosis  . .  . .     396 

-  rickets  . .  . .  . .     171 

-  in  suppurative  pylephlebitis     649 

-  from  tuberculous  peritonitis     719 

-  typhoid  fever  . .  90,  610 

-  urate  deposit  after. .  . .     815 

-  wasting  with  .  .  69,  420 
Diastolic  bruits           . .          . .     106 

-  collapse  of  veins  of  neck  in 

adherent  pericardium   . .     104 

-  shock,  in  adherent  pericar- 

dium ..  ..  104,  242 
DIAZO-REACTiON  ..  ..197 
Diet,  in  causation  of  beri-beri  460 
rickets       . .          . .          . .     171 

-  -  scurvy       . .  .  .         302,  599 
scurvy-rickets      . .  . .     753 

-  in  diagnosing  gastric  ulcer         40 

nature  of  constipation   142, 143 

scurvy       . .  . .  . .       44 

-  effect  in  gout  . .  . .     381 

-  errors  in,  causing  congestion 

of  liver  . .  . .  . .     407 

in     children,     prolonged 

pyrexia  from       . .  . .     618 

causing  diarrhoea  . .     196 

dyspepsia. .  . .  . .     354 

insomnia  . .  . .  . .     357 

nightmares  357,  447,  448 

severe  vomiting  in  infants     426 

tetany       . .         . .  . .     178 

-  glaucoma  affected  by        . .     257 
Dietl's    crises    with    movable 

kidney      ..  310,  729,  844 

vomiting  with     . .  . .     844 

Differential    leucocyte    count 

(see  Leucocyte  Count) 
Digestion,  time  "occupied  by. .     140 
Digital  chancre  (see  Chancre, 

Digital) 
Digitaiis,  bradycardia  from  . .       98 

-  delirium  cordis  from         . .     773 

-  in  diagnosis  of  mitral  stenosis     61 

-  increased  muscle  tone  due  to 

161,  163 

-  palpitation  from     .  .         525,  527 

-  polyuria  after         . .  . .     582 

-  relief  of  headache  by        .  .     329 

-  tachycardia  from   . .         772,  773 
Dilatation    of    aorta,    systolic 

bruits   in 105 

-  of  aortic  rins,  diastolic  bruit    106 

-  of    cervix    in    diagnosis    of 

pregnancy  haemorrhage        437 

effect    on    neurotic    dys- 

pareunia  . .  . .     222 

-  of  heart  (see  Heart,  Dilata- 

tion of) 

-  of    pulmonary    arteries    in 

mitral  stenosis    . .  . .     245 

-  of   stomach    (see    Stomach, 

Dilated) 
Dilatator  tubfe,  clicking  noises 

in  the  ear  from  spasm  of  793 
Dimpling  of  skin  an  early  sign 

of  breast  cancer  . .     745 

Diphtheria,     acute     dilatation 

of  lieart  from      . .  . .     243 


DIPHTHERIA— DISSEMIN A  TED    SCLEROSIS 


JUplillieria,   cunld. 

-  acute  tonsillitis  from         . .     C70 

-  albuminuria  in       . .  13,  17 

-  alteration  of  voice  after    . .       77 

-  arthritis  in  . .  . .        37G,  708 

-  ataxy  from..  ..  ..       OG 

-  bacilli  (see  Bacillus  Diphtheriae) 

-  bronchial  casts  in  . .  . .     704 

-  Cheyne-Stokes'  respiration  in  12.') 

-  chronic  tonsillitis  from      . .     G72 

-  cornea  ulceration  from     . .     807 

-  cough  from..  ..  ..      176 

-  cutaneous,     conjunctivitis 

with  G02 

frequent  absence  of  diph- 
theritic membrane  in       602 

impetiginous  eruption  with  602 

otorrhcea  and  rhinitis  with    602 

simulating  eczema         . .     602 

-  cyanosis  from  . .  . .     185 

-  diazo-reaction  in     . .  .  .     198 

-  distinction   from    Vincent's 

angina       . .  . .  . .     672 

-  dysphagia  from       .  .  . .     224 

-  of  ear,  otorrhcea  from       . .     469 

-  enlargement  of  submaxillary 

lymphatic  glands  in       . .     419 

-  in  follicular  toiasillitis        .  .     671 

-  foul  breath  in         . .  . .       99 

-  gangrene  in . .  . .  . .     282 

-  laryngeal    226,  465,  642,  670,  673 

examinationof  swabbingsin  466 

extreme  dyspnoea  from  642,  709 

frequent  absence  of  mem- 
brane on  fauces  in     . .     466 

Klebs-Loffler     bacilli     in 

tlu-oat-swabbings  in  . .     466 

membrane  on  fauces  in. .     466 

mistaken  for  meningitis       642 

one     negative      throat- 
swabbing  not  final  in. .     466 

orthopncBa  in      . .  . .     465 

retraction  of  the  head  in 

G41,  642 

-  knee-jerks  lost  after  . .     399 

-  and  measles,  associated     . .     226 

-  menorrhagia  in        . .  . .     428 

-  muscular  atrophy  in         . .       76 

-  nasal,  epistaxis  in  . .  . .     251 
voice  after            . .          . .     181 

-  panophthalmitis  from       . .     807 

-  paralysis    possible    3    or    4 

weeks  after  . .  . .     640 

of  limbs  after     . .  77,  640 

palate  after 

77,  181,  559,  640,  687,  842 

-  paresis  of  ciliai-y  muscles  in  77,  640 

-  -  of  ocular  muscles  in       . .      640 

-  peripheral  neuritis  from      13,  66, 

76,  77,  165,  180,  181,   50G, 
559,  591,  640,  G87,  773,  842 

-  pharyngitis  from   . .  . .     670 

-  phrenic  paralysis  after      . .       77 

-  pt>  alism  from  . .         590,  591 

-  pupil  reflex  lost  in  . .  . .     594 

-  purpura  in  . .  . .        596,  597 

-  in  purulent  rhinitis  . .     203 

-  pyrexia  in    .  .  .  .  .  .      G22 

gravity  of  . .  . .     597 

-  regurgitation  of  food  through 

nose  after    77, 181,  559,  640, 842 

-  rigors  in       . .  . .  . .     647 

-  scoliosis  from  . .        180,  181 

-  simulated   by   membranous 

rhinitis      . .  . .  . .     204 

-  sore  throat  from     . .        670,  671 

-  spinal  arthritis  in   .  .  . .      708 

-  splenic  enlargement  in    698,  692 

-  stiff  neck  in  . .  . .     708 

-  stomatitis  in  .  .  . .      590 

-  stridor  in     .  .  .  .  .  .      709 

-  tachycardia  after        77,  772,  773 

-  talipes  due  to         . .  . .     131 

-  ulcer  of  leg  from     . .  . .     811 


318 
211 

773 

400 
164 
686 
535 
799 


556 
154 

800 
800 
154 
800 
800 
800 
154 
800 
800 
198 


lliplitheria,  cimkl. 

-  ulceration  of  larynx  after . . 

-  vaginal 

-  vagus  neuritis  after 

-  variable     moderate     leueo- 

cy tosis  in . . 
Diplegia,  causing  contractm-es 

-  cerebral  dysarthria  in 
facial  paralysis  in 

-  choreiform  tremor  in 

-  congenital  154, 7U5,  800 

-  -  athetosis  in         . .  . .     154 

causes  of  . . 

choreiform  movements  in 

deep  reflexes  increased  in 

gait  in     . .  . .        154, 

hereditary  causes  of 

optic  atrophy  in  154, 

pupils  unequal  in 

scissor  gait  in 

speech  defective  in 

sphincters  affected  in   . . 

tremor  in  154,  795, 

DIPLOPIA       

-  crossed,  illustrated  199,  200 

-  homonymous,  illustrated  199,  200 

-  monocular,     from      double 

aperture  of  pupil  198,  199 

-  from  ocular  paralyses      277,  709 

-  vertigo  due  to         . .  . .     828 
Diplococci  intracellulares  men- 
ingitidis    Weichselbaumii 
(see    Meningococci) 

Dipping  in  diagnosis  of  ascites 
51 

-  -  of  pyloric  obstruction  . . 
Dirt-eating  disease  . .  50 
DISC,      OPHTHALMOSCOPIC 

APPEARANCES  OF  (Flaics 

VII,  nil ;    see  also  Optic 

Disc)  461,  462 

Discharge  from  Ear  (and  see 

Otorrhcea) 

muco-purulent,    in    aural 

diphtheria 
DISCHARGE,  NASAL  (and  see 
.   Cold,  Common;  and  Coryza)    20: 

on     bending      head     in 

antral  suppuration     . . 

in  glanders 

gonococcal 

leprosy  bacilli  in 

-  -  due     to     periodical     dis- 

charge    of    pus     from 
antrum.. 

recurrent  fibroma  of  basi- 

sphenoid 

sarcoma  of  antrum 

DISCHARGE,  FROM  NIPPLE 
DISCHARGE,  URETHRAL  .. 
bacteriological    examina- 
tion in  all  cases  of 

with  chordee 

fsecal,  commoner  causes 

simulated  by  cystitis. . 

gonococci  in        . .  79,  37G 

in  female  .  .         211,  769 

from,  gout  . .  . .     206 

inguinal  glands   enlarged 

from 

method    of    examination 

of  patient  in    . . 
prostatic  abscess  in  associ- 
ation with 
purulent,    in    acute    ure- 
thritis   . . 

pus  cells  no  bar  to  marriage  209 

DISCHARGE,  VAGINAL       ..     210 

absence  of  gonococci  in, 

in  gonorrhcea  . .  . .     769 

blood-stained    watery,  in 

endometritis    . .  . .     435 

cachexia  with      . .  . .     114 

from  carcinoma  . .  . .     435 


410 
134 
115 


463 


467 


469 


502 
603 
203 
425 


502 

204 
749 
201 
20G 

631 
125 
265 
264 


422 
207 


678 


511 


iJischan/e,  vaginal,   coiitU. 

-  -  endometritis 
epididymo-orchitis  by  in 

fection  from    . . 

from  herpes 

membranous  flakes  in   . . 

perineal  sores  from 

from  pyometra 

with  pyosalpinx 

pyuria  due  to     . . 

-  -  sanious    or    offensive    in 

puerperal  fever 

septic  arthritis  from 

simulating  pyuria 

ureteritis  from    . . 

urinous,  in   carcinoma  of 

vagina  and  uterus 

from  uterine  congestion 

Discoloration  of  skin  (and  see 
Pigmentation ;  and  Jaun- 
dice) 
Discomyces  in  mycetoma 
Dislocation  (congenital)  of  hip 
(see  Hip) 

-  of  jaw,  ptyalism  from  diffi- 

culty in  swallowing  in  . . 

-  lens,  monocular  diplopia  in 

-  spinal,  priapism  from 
Dislocation-fracture  of  cervical 

spine,  ansesthesia  from  . . 
Disorientation 
■Disparateness 
DISPLACEMENT  OF  CARDIAC 


22a 

518 
.  .  83f> 
. .  211 
..  677 
. .  436. 
632,  737 
624,  631 
in 

..  649 
..  375 
..  631 
..     206 


313 
42  & 


574 

sog' 


591 
19S 
585 


199 
330 


586 
888 

38» 

388 
388 

388 
388 
388 


MPULSE  (and  see  Heart) 

-  pelvic,   causing  prolapse  of 

uterus 

-  Of  semilunar  cartilage 
diagnosis     from     loose 

body  in  joint 
nipping      of      synovial 

fringes 

tenderness  in  joint  in 

"  slip  "  or  "  catch  "  in 

joint  in 

sudden  pain  in  joint  in 

synovitis  in 

-  of  uterus  (see  Uterus,   Dis- 

placement of) 

-  of  viscera  in  Glenard's  disease 

(Figs.  39  and  41,  pp.  147 

and  149) 721 

Disseminated  sclerosis,  absence 

of  abdominal  reflex  in    . .     547 

constitutional  symptoms  547 

accommodation  paresis  in     838 

allocheiria  in       .  .  . .        22 

-  -  amblyopia  in 
ankle-clonus  in    . . 

-  -  apoplectiform  attacks  in 
astereognosis  in  . . 

-  -  ataxy  in  . .      67,  341,  565,  SOO 

Babinski's  sign  in  82,  800 

central  scotoma  in  . .     837 

changes      near      internal 

capsule  in         . .  . .     666 

coma  in    .  .  .  .  . .      136 

erytliromelalgia  in  . .     490 

exaggerated  deep  reflexes     80O 

knee-jerks  in  . .        539,  565 

extensor  plantar  reflex  in 

342,  539,  547 

fatuously  placid  expression 

258 

gait  in 

girdle  sensation  in 

headache  in 

and  vomiting  in 

hemianfesthesia  in 

hemiplegia  in        340, 

hippus  in . . 

impotence  in 

inco-ordination  in 

intention  tremor  in 

341,  794,  795,  80O 


800 
342 
174 
665 


277,  800 
289,  665 
327,  328 
547 
..  66» 
342 
595 
347 
277 


141, 


346, 


892 


DISSEMINATED    SCLEROSIS— DUODENUM,     ULCER    OF 


Lisseminated  sclerosis,   contd. 

Diving,  epistaxis  from 

251 

Diihring's  disease,  bullae  in  . . 

114 

knee-jerk  increased  in  . . 

342 

-  fracture  of  spine  from 

269 

eosinophilia  in     . . 

249 

monoplegia  in      539,  540, 

547 

Dizziness  (see  Vertigo) 

827 

-  re  tuberculides 

603 

muscular  rigidity  in 

800 

Doderlein's  theory  of   acidity 

Dullness   behind    sternum    in 

neuralgic  pains  in 

665 

of  vaginal  secretions 

210 

thymus  gland  enlargement 

465 

numbness  in 

665 

Dog-bite,    hydrophobia    from 

-  cardiac  (see  Heart  Dullness) 

nystagmus   in              453, 

547, 

162,  225 

801 

-  in    the    chest    from    lobar 

800, 

838 

Dogs,   taenia   echinococcus   in 

719 

pneumonia            .  .          645 

701 

optic  atrophy  in    547,  565 

838 

Domestic    servants,    acropar- 

-  deficient  hepatic  (see  Liver 

neuritis   uncommon   in 

565 

aesthesia  in 

493 

Dullness,  Deficient) 

paUor  of  optic  discs  in  800 

,838 

Dorsalis  penis  of  pudic,  skin 

-  dome-shaped  at  base  of  right 

parsesthesia  in     . . 

565 

distribution  of     . . 

650 

lung 

324 

paralysis  of  one  leg  in    . . 

539 

Double  consciousness 

26 

-  over  effusion 

192 

paraplegia  from            561, 

565 

Doublejointedness  in  Mongol- 

- with  fibroid  lung    . . 

193 

paroxysmal  occipital  head- 

ism 

216 

-  in   flanks    in   general   peri- 

ache in 

328 

Double  vision  (see  Diplopia) 

tonitis 

644 

precipitate  defaecation    in 

348 

Douclies,  sterility  due  to 

706 

-  of  intellect  in  myxcedema . . 

585 

protean  character  of 

800 

Doughy  feel   to  abdomen    in 

-  in   the   second   right  space 

pseudo-nystagmus  in     . . 

452 

chronic  peritonitis 

472 

due  to  aneurvsm 

790 

scotoma  in           . .         565 

837 

Douglas'  pouch,  swellings   in, 

Dumb-beU  crystals  (FUj.  130) 

sensory  changes  in       665, 

800 

recognition     on     rectal 

470 

816 

signs  of     . . 

174 

examination 

638 

Dum-dum  fever  (see  Kala-azar) 

simulating  functional  para 

Draught,  stiff  neck  due  to     . . 

477 

Duodeno-pancreatic  fistula  294 

300 

plegia    . . 

567 

Drawing  up  of  legs  in  intestinal 

Duodenum,  carcinoma  of  (see 

hysteria              565,  665, 

798 

colic  in  children. . 

473 

Carcinoma  of  Duodenum) 

mercurial  tremor 

797 

Dreams,  terrifying 

447 

-  catarrh  of,  jaundice  from.  . 

361 

primary  lateral  sclerosis 

565 

Dribbling  of  saliva  (see  Ptyalism) 

pancreatitis  secondary  to 

116 

professional  cramp     . . 

177 

Drinking,  polyuria  from       581 

,583 

-  congenital  malformation  . . 

151 

spasticity  in        . .         341 

800 

-  excessive,  oedema  from     458, 

460 

-  normal  situation  of 

722 

sphiricter  trouble  in 

simulation      of     acute 

-  obstruction,       absence      of 

547,  565. 

806 

nephritis 

458 

distention  in 

152 

"  staccato  "  or  "  scanning' 

-  secret,  difllculty  of  diagnosing 

599 

visible   gastric  peristalsis 

speech  in            342,  686 

800 

Drooping  of  eyelid  (see  Ptosis) 

in           ..          ..        570, 

571 

suprabulbar  dysarthria  in 

686 

Dropped  foot  in  paralysis  of 

-  reflex  constipation  in  diseases 

unilateral  convulsions  in 

170 

ext.  popliteal  nerve 

543 

of 

144 

variation     of     symptoms 

(see      Paraplegia       and 

-  surgical  emphysema  from. . 

231 

suggesting  neurosis    . . 

565 

Paralysis) 

-  swellings  of,  in  epigastrium 

725 

vomiting  in 

328 

-  wrist  in  lead  poisoning 

551 

-  ulcer  of,  acute  pallor  in     . . 

300 

Distention    of   abdomen    (see 

Dropsy  (see  CBdema  and  Ascites) 

-  -  albumosuria  in   . . 

20 

Abdomen,  Distention  of) 

Drowsiness  in.  cirrhosis  of  liver 

368 

anajmia  in           . .             37 

,  40 

-  bladder   (see   Bladder,  Dis- 

- organic  cerebral  disease     . . 

328 

blood  per  anum  in 

89 

tention  of) 

-  phosphorus  poisoning 

373 

coma  from  bleeding     137, 

140 

-  gall-bladder  (see  Gall-bladder 

-  uraemia         . .          . .          45, 

329 

communicating  with  sub- 

Distended) 

Drugs,  anaemia  due  to 

37 

phrenic  abscess 

712 

Distoma    hepaticum,    ascites 

-  antipyretic,  rigors  from 

648 

diagnosis  from  gastric  ulcer 

300 

from 

364 

-  aphrodisiac 

586 

-  -  epigastric  pain  from 

295 

enlargement  of  liver  from 

364 

-  black  urine  after     . . 

820 

erosion  of  vessels  in 

300 

flukes  and  ova  in  vomit 

364 

-  brown  urine  after  . . 

820 

ex-treme  thirst  due  to     . . 

789 

jaundice  from      . .        361, 

364 

-  coloiu-ation  of  skin  due  to  424 

,575 

haematemesisin89,294,  300 

,780 

pain  in  right  hypochon- 

—  of  urine  due  to 

"  hunger  pain  "  of       300, 

500 

drium  from 

364 

818,819,820 

823 

hyperacidity     of     gastric 

in  sheep    . . 

364 

-  convulsions  due  to. .         169 

170 

juice  in 

89 

vomiting,  fever,  and  diar- 

- deafness  from 

191 

indigestion  with  . . 

780 

rhoea  in 

364 

-  delirium  due  to 

195 

kinking  of  bowel  from  . . 

147 

-  pulmonale      Westermanni, 

-  diazo-reaction  from 

198 

loss  of  weight  due  to 

848 

geographical  distribution 

325 

-  dryness  of  mouth  from 

789 

melEena  in 

haemoptysis  from      318, 

325 

-  eosinophilia  after    . . 

248 

37,117,300,428,  500 

780 

and  ova  in  sputum 

325 

-  foul  breath  caused  by 

98 

cedema  of  legs  after 

459 

Disuse  atrophy    in  hysterical 

taste  in  mouth  from 

774 

pain  in      . . 

89 

joint 

390 

-  green  urine  after     . . 

823 

the     right     hypochon- 

-  of  muscles  a  cause  of  con- 

- ieucocytosis  due  to. . 

400 

drium  in 

500 

tracture    . .          . .        163, 

165 

-  loss  of  smell  from   . . 

668 

perforated,  peritonitis  from 

Diuretics,  polyuria  from      581, 

582 

-  cedema   of   legs   caused   by 

459 

55,  431,  644, 

780 

Diuretin  in  abdominal  angina 

-  pityriasis  rubra  after 

658 

pneumoperitoneum  due 

351, 

486 

-  ptyalism  from 

590 

to 

711 

Divarication     of     the    recti. 

-  purpura  due  to  various 

596 

severe  shock  and  collapse 

484 

evident    on    raising    the 

-  raslies  simulating  syphilides 

426 

sudden  severe  epigastric 

head  from  the  bed 

524 

itching  and  burning  in  . . 

426 

pain  in 

484 

pain  in  umbilical  region 

-  skin  eruptions  from 

tenderness  in  the  hypo- 

in           . .          . .          . . 

524 

424,  426,  603,  655,  658 

834 

gastriimi  from 

780 

test  f or     . . 

148 

-  that  slow  the  heart 

98 

in     the    right     iliac 

unnoticed   in  the  recum- 

- tachycardia  due  to 

772 

fossa  from 

780 

bent  position  . . 

524 

-  tinnitus  from 

794 

pleurisy  from 

123 

visible  peristalsis  with   . . 

570 

-  tremor  due  to        . .         795, 

797 

pneumothorax     from 

Diverticula   of   colon   causing 

Drug-taker,  shifty  eyes  of     . . 

258 

abscess  due  to 

578 

acute  intestinal  obstruction 

151 

Drummer's  cramp 

177 

ptyalism  in 

591 

in  old  people 

146 

Dryness    of    the    mouth   (see 

severe  hfemorrhage  from 

789 

-   -  simulating  carcinoma     .  . 

152 

:Mouth,  Dryness  of  ;     and 

sex  incidence  of  . .           89 

500 

Diverticulitis,  acute,  age   inci- 

Tongue) 

subphrenic  abscess  from 

dence  of    .  . 

152 

-  of  skin  in  myxcedema 

585 

501,  578,  720, 

721 

resembling  appendicitis . . 

731 

Duchenne's   palsy,    injury    at; 

surgical  emphysema  from 

231 

-  simulating  carcinoma        146 

152 

birth  causing 

552 

thickening     round,     dia- 

- swelling  in  iliac  fossa  from 

731 

Ductus  arteriosus  (see  Patent 

gnosis  from  enlarged 

-  vcsico-colic  fistula  from     . . 

146 

Ductus  Arteriosus) 

gall-bladder  . . 

406 

DUODENUM,     ULCER    OF— DYSTROPHIES,    MUSCULAR 


893 


J)iiodcrmm,  ulcer  of,  contd, 

uroljilinuria  with 

vomiting  in         . .   89,  300, ' 

-  visible  gastric  peristalsis  in 

stenosis  of 
Dupuytren's  contracture   (see 

also  Contractures} 
illustrated 

-  fracture  causing  talipes 
Duskiness  of  face  and  extremi- 
ties in  spleuomegalic  poly- 
cytlutmia 

Dust,  cough  due  to     . . 

-  inllammation  of  soft  palate, 

uvula  and  fauces  from  .  . 

DWARFISM 

Dj'ers,  nail-staining  in 

Dynamometer  .  . 

Dysarthria  from  bilateral  bulbar 

palsy  

cerebral  diplegia 

facial  palsy 

peripheral  palsy  of  palate 

-  definition  of 

-  in  disseminated  sclerosis  . . 

-  electrical  reactions  in  tongue 

in  . . 

-  functional     . . 

-  from  gummatous  meningitis 

at  base  of  brain  . . 

-  hasmorrhage  into  bulb 

-  in  hemiplegia  . .         336, 

-  myasthenia  gravis  . . 

-  palate  reflex  of 

-  in  pseudo-bulbar  palsy 

-  from  softening  in  bulb 

-  suprabulbar  . . 
in  general  paralysis  of  the 

insane   . . 

-  tongue  atrophy  in  . . 

-  tumour  of  bulb 
Dyschezia,  bismuth  test  in  . . 

-  constipation  from  . . 

-  diagnosis   of  causes  of     148,  ' 

-  from    fibrous     stricture    of 

rectum 

-  invagination  of  rectum     . . 

-  pressure  of  gravid  uterus. . 
on  rectum  and  colon 

-  .r-ray  illustration  of 
Dysentery,  albuminuria  in    . . 

-  albumosuria  in 

-  amceba  in     91, 196,  408,  651, ' 

-  arthritis  in  . . 

-  atony  of  bowel  after 

-  bacterial       . .  .  .  91, 

-  blood  per  rectum  in    90,  501, 

-  colic  in 

-  coma  in 

-  cyanosis  in  . . 

-  cystitis  from  . .         31S 

-  diarrhcea  in  . .         196, 

-  enlarged  mesenteric  glands 

in  . . 

-  hajmaturia  in 

-  hyperpyrexia  in 

-  indicanuria  in 

-  inspfesation  of  the  blood  in 

-  involvement  of  bladder  in 

-  liver  abscess  after 

279,  323,  408,  651, 

-  loss  of  weight  in      . .  69 

-  meteorism  in 

-  mucus  in  the  stools  from    . . 

-  pain  in  the  left  iliac  fossa  in 

-  peritonitis  from 

-  purpura  in   . . 

-  pus  in  the  stools      . .         501, 

-  rigors  in 

-  serum  reaction  in  . . 

-  sex  incidence  of 

-  Shiga's  bacillus  in  . . 

-  sigmoidoscopy  in    . . 

-  stricture  of  colon  after 


Dysentery,  could. 

lie 

-  tenderness  in  the  right  lum- 

780 

bar  region  from  . . 

727 

-  tenesmus  in                91,  196, 

501 

571 

-  ulceration  of  rectum  in 

635 

Dysidrosis  affecting  lingers  . . 

266 

385 

-  bulla)  in 

111 

167 

-  relation  to  miliaria  and 

132 

hidrocystoma 
-  (see    Sweating,    Abnormal- 
ities of) 

831 

581 

DYSMENGRRHCEA    .. 

219 

175 

-  due  to  appendicitis 

-  conditions   it  may  be  mis- 

737 

072 

taken  for 

220 

212 

-  membranous,  described,  219, 

220 

444 

-  primary,  described 

219 

337 

-  with  pyosalpinx     . . 

632 

-  secondary,  described 

219 

686 

-  spasmodic    . .          . .        219, 

509 

686 

Dysostosis,  cleido-cranial 

213 

687 

DYSPAREUNIA 

22J 

687 

-  from  lu-;uin),sis 

770 

680 

-  sterility  due  to 

700 

686 

Dyspepsia  (and  see  Indigestion) 

349 

-  acute,   emotional   causes   in 

374 

687 

ptyalism  in 

591 

688 

-  asthenic,  in    atonic    dilata- 

tion of  stomach  .  . 

354 

687 

-  bleeding  gums  m    . .            85 

,  87 

687 

-  in  catarrhal  jaundice 

304 

687 

-  children,  tea-drinking  caus- 

687 

ing             

357 

686 

-  chronic  with  pancreatic  cyst 

724 

686 

-  in  cirrhosis  of  liver 

410 

687 

-  cough  due  to 

175 

686 

-  diagnosis  from  aortic  aneur- 

ysm            

476 

686 

fatty  heart 

526 

687 

-  diminution  of  appetite  in. . 

49 

687 

-  flatulent,  pain  in  chest  and 

142 

palpitation  in 

484 

141 

-  foul  breath  in 

99 

149 

-  functional  achylia  and  hyper- 

chlorhydria  in 

354 

150 

-  headache  in 

328 

150 

-  hyperstlienic 

354 

150 

-  insomnia  in              . . 

356 

150 

-  lack  of  muscular  tone  in    . . 

520 

142 

-  loss  of  weight  due  to 

848 

17 

-  nervous,  and  oxaluria 

471 

20 

-  in  neurasthenia 

506 

704 

-  organic,  differential  diagnosis 

376 

of               

351 

144 

-  oxaluria  with  . .          . .     311 

471 

051 

-  pain  in  back  in 

476 

727 

chest  from            . .       481 

779 

501 

-  palpitation  in 

526 

136 

difficult  to  diagnose  from 

187 

myocardial  disease     . . 

526 

,  633 

-  from  pyorrhoea  alveolaris. . 

87 

,501 

-  simulated  by  dysmenorrhoea 

220 

gastric  carcinoma         299 

848 

422 

leaking  gastric  ulcer 

721 

305 

-  simulating  heart  disease  526 

,779 

344 

-  spasmodic  pelvic  pain  in  . . 

509 

349 

-  tenderness  in  the  chest  from 

779 

187 

-  tinnitus  with 

794 

313 

-  ulceration  of  tongue  in    812 

,  814 

-  in  venous  congestion  of  livei 

407 

,704 

DYSPHAGIA 

222 

,848 

-  from  acute  cervical  adenitis 

674 

432 

-  aortic  aneurysm     . .        482 

841 

727 

-  bilateral  facial  paralysis   . . 

591 

501 

-  bulbar  palsy     591,  641,  687 

,  842 

55 

-  carcinoma  of  oesophagus 

596 

295,  484 

,  841 

,601 

-  cicatricial  sti-icture  of  cbso- 

647 

phagus      . .            222,  484 

,  841 

196 

-  diphtheritic  paralysis 

591 

727 

-  fixation  of  jaw 

591 

196 

-  fracture    or    dislocation    of 

501 

jaw 

591 

146 

-  m  "functional  aphonia 

538 

591 


Dysphagia,  contd. 

-  hydrophobia 

-  from     hypoglossal 

paralysis 

-  idiopathic     dilatation 

oesophagus 

-  loss  of  weight  from 

-  lusoria  described     . . 

-  mumps 

-  myasthenia  gravis 

-  nervous  causes 

-  oesophageal  pouches 

-  oesophagismus 

-  osteo-arthritis 

-  paralysis  agitans     . . 

-  pemphigus  of  mouth 

-  pseudo-bulbar  paralysis 

-  ptyalism  from,  in  jaw  lesions    591 
in  oesophageal  affections       591 

-  quinsy  . .  . .  . . 

-  sore  throat  . . 

-  spasm  of  oesophagus 

-  stenosis  of  oesophagus 
of  pharynx  from  syphilis 

-  stomatitis     . . 


ve 

591 

of 

841 

847 

223 

591 

674 

591, 

842 

224 

84 

484 

591 

591 

591 


591 
073 

841 
222 


86,  88 


792 
591 
226 
233 


582 

46ft 
303 
484 


-  thyroid  gland  tumour 

-  tonsillitis 
DYSPNEA 

-  in  aortic  disease 

-  from      bilateral      laryngeal 

paralysis  . .         537, 539 

-  broncho-pneumonia  . .     642 

-  capillary  bronchitis  . .     642 

-  cardiac   and  renal,   asthma 

mistaken  for 

-  caseous  bronchial  gland  ir- 

rupting into  bronchus    . . 

-  in  chlorosis 

-  chronic  mediastinitis 

-  congenital  heart  disease,  244,  790 

-  embolism  of  the  lung         185,  320 

-  enlarged   heart   froni   over- 

exertion   . . 
thyroid  gland 

-  the    essential    symptom    of 

asthma 

-  in  fatty  heart 

-  fibroid  heart 
lung 

-  foreign    body  in   larynx  . . 

-  hepatoptosis 

-  hydropneumothorax 

-  insomnia  from 
in  laryngeal  diphtheria 


244 
793 

582, 
241 
241 
246 
642 
407 
712 
359 
642 
-  paralysis   . .  .  .  . .     53S) 

laryngismus   stridulus       . .     406 

-  from  mediastinal  growth  . .     483 

-  mitral  regurgitation  . .     238 

-  in  myocardial  degeneration      333 

-  myocarditis  . .  . .     241 

-  non-obstructive  anuria      . .       46 

-  osteitis   deformans. .  . .     763 

-  paroxysmal,  Charcot-Leyden 

crystals  in  . .  . .     118 
in  mediastinal  growth  . .     483 

-  pneumothorax         . .         185, 480 

-  polycythnemia       frequently 

associated  with  . .  . .     580 

-  due  to  pulmonary  stenosis      247 

-  retraction  of  the  head  in    . .     642 

-  retropharyngeal    abscess  225,  042 

-  ruptured  heart  valve  . .     238 

-  spasmodic  from  asthma    . .     467 

urfemic      .  .  . .  45,  329 

DYSTOCIA       227 

-  caused  by  delay  in  delivery 

of  placenta  . .  . .     229 

-  in  etiology  of  talipes         . .     131 

-  symptoms  of  exhaustion  in     229 
Dystrophies,  muscular,  diagnosis 

of  peripheral  neuritis  from    561 

electrical  reactions  in     . .     561 

family  history  in  . .     560 

infantile  and  juvenile  types  500 


894 


DYSTROPHIES,    MUSCULAR— ELECTRICAL    REACTIONS 


l)jstrophies,  muscular,   contd. 

lordosis  in            . .          . .  183 

paralysis  of  arm  in         . .  555 

paraplegia  from  . .          . .  557 

plantar  reflex  in.  .          .  .  82 

pseudo-liypertropliic       . .  560 

sensations  normal  in      .  .  561 

talipes  from         . .          . .  132 

—  primary  muscular  (see  Myo- 

pathy) 

EAE,  acute  pain  and  sweiHns 

in  fiTTunculosis  of  . .     409 

—  aXEections,  tenderness  of  the 

scalp  in      .  .          .  .  .  .  781 

infantile  convulsions  from  1 70 

neuralgia  from    .  .  .  .  781 

—  -  nystagmus  from  .  .  . .  453 

referred  pain  from  . .  498 

Tertigo  due  to     . .  . .  828 

—  atrophy    of,   in    lupus  ery- 

thematosus . .  . .     G58 

—  bleeding  from  (see  Bleedinsj 

from  Ear) 

—  bluish-black  colour  of,  from 

ochronosis  . .  . .     822 

—  cerebrospinal  fluid  from,  in 

fractured  skuU    . .          . .  138 

—  coarseness  in  cretinism     . .  258 

—  description  of  the  . .          . .  187 

—  diphtheria  of           .  .          .  .  469 

—  discharge  from  (see  Otorrhcea) 

—  eczema  of,  a  cause  of  cough  174 
due  to  wax  in     . .          . .  468 

—  enlargement    in    Mongolian 

idiocy        . .  . .  . .     263 

—  epithelioma  of  (and  see  Car- 

cinoma)   . .  ...         419,  468 

—  examination  of,  in  bleeding 

from  the  ear       . .  . .  468 

in  cases  of  otorrhcEa     . .  470 

obscure  pyrexia  . .  018 

—  foreign  body  in  (see  Foreign 

Bodies) 

—  gangrene  of,  in  Eaynaud's 

disease      . .  . .  . .  284 

—  glands  of      . .  . .  .  .  467 

—  granulations  in        . .  . .  469 

—  herpetic    eruption    on,  in 

peripheral  facial  paralysis     536 

—  hyperostosis  of,  in  leontiasis 

ossea         . .  . .  . .     749 

—  injury  of,  from  blow  on  chin    467 

—  ivory  exostosis  of  .  .  . .      754 

—  nerve  supply  of       . .  . .     481 

—  noises  in  (see  Tinnitus) 

—  pain  in,  from  glaucoma     . .     257 

—  I'olypi  of,  discbarge  from  . .     468 
from  caries  . .  . .     469 

—  sodium  urate  in,  in  gout  381,  507 

—  swollen  and  iaflamed  in  otitis 

media        . .  . .  . .  469 

—  syringing  of,  vertigo  due  to  828 

—  tenderness  of,  in  otitis  media  230 

—  thickening  in  myxoedema .  .  259 

—  tophi  in,  in  gout     . .  . .  507 
simulation  by  projection 

of  cartilage      . .  . .     381 

—  use    of  in    detecting   slight 

XJulsation  . .  . .  235 

—  wax  in,  a  cause  of  cough  . .  174 

EARACHE        229 

Earth  eating  . .  . .  . .  11 5 

—  tetanus  from  infection  from  652 
Eating,    excessive,    effect    on 

uric  acid  . .  . .  . .     817 

Ebumation  of  bone  in  osteo- 
arthritis   . .  . .  . .     384 

Ecchondroses,     ankylosis     of 

joints  from  . .  . .     167 

Ecchymosis  (see  Purpura) 
Echinococcus  disease,  alveolar     416 

—  booklets  in  ascitic  fluid  (Fi(i. 

6j  (and  see  Hydatid;       57,  58 


Eclampsia       

-  albuminuria  in 

-  epileptiform  convulsions  in 

-  in  pregnancy 

-  simulating  a  rigor  . . 
Ecthyma,  definition  of 

-  in  impetigo  contagiosa 

-  relation  to  impetigo         601, 

-  scabs  in 

-  vacciniform,  of  infants 
Ectopic  gestation   (see  Gesta- 
tion, Ectopic) 

-  testis  (see  Testis,  Ectopic) 
Ectothrix  in  ringworm 
Ectromelus 

Ectropion,  epiphora  from 
Eczema,  acuminate  pustules  in 

-  affecting  fingers 
naUs  .  .  .  .  275, 

-  anidrosis  with 

-  baldness  from 

-  burning  sensation  in 

-  catarrhal  character  of 

-  character  of  papule  of     528, 

-  crusts  in      . .  . .        829, 


172 
647 
647 
160 
647 
602 
654 
602 
653 
446 


-  diabetic,  pain  in  perineum 

from 
starting  in  penis  or  vulva 

-  diagnosis   from   cheiropom- 

pliolyx  .  . 

dermatitis  herpetiformis 

eczema  marginatum 

erythema  intertrigo 

erythrasma 

favus 

follicular  impetigo 

granulosis  rubra  nasi 

herpes 

impetigo  contagiosa 

lichen  planus       . . 

ruber  planus    . . 

scrofulosorum  . . 

miliaria  rubra 

mycosis  fungoides 

Paget's  disease    . . 

papular  syphiloderms    . . 

jiityriasis  rubra  . . 

prurigo  ferox      . .         531 

psoriasis    . . 

ringworm  of  body 

scalp 

scabies 

small  flat  pustular  syjili- 

ilide 

smallpox  . . 

sycosis  vulgaris  .  . 

tinea  versicolor   . . 

-  of  the  ear,  cough  from     174, 

earache  from 

otorrhcea  from     .  . 

-  eosinophilia  in 

-  erythema  in 

-  fissure  of  the  lips  from 

-  f  olliculorum  . . 

-  gouty  . .  . .  . . 

-  impetiginous,  simulated  by 

cutaneous  diphtheria     . . 

-  impetigo  in. . 

-  intertrigo,  distribution  of. . 
at  umbUicus  in  fat  dirty 

people   . . 

-  itching  in    . .  529,  533,  588, 

657,  781, 

-  of  lips  .  .  .  .  403, 

-  marginatum     in      bathing- 

drawers  area 

and  dhobie's  itch 

diagnosis  from  eczema  . . 

eczema  seborrhoeicum 

erythrasma 

epidermophyton  inguinale 

in  '. .  . .         273, 

general  account  of 

non-involvement  of  hair  in 


273 
214 
250 
601 
266 
,445 
714 
84 
602 
533 
533 
831 

516 
447 

832 
831 
275 
253 
276 
272 
602 
714 
831 
831 
832 
529 
529 
831 
804 
803 
533 
658 
,532 
657 
275 
274 
831 

604 
608 
602 
276 
175 
230 
468 
249 
831 
653 
528 
516 

602 
781 
447 

524 
602, 
831 
653 

447 
275 
275 
275 
276 

275 
275 
275 


Eczema  marginatum,  contd. 

parasitology  of   .  .  .  .      275 

-  oedema  and   infiltration    of 

skin  in 608 

-  papular,  intense  itching  in . .     529 

-  papules  in   ..  ..275,529,831 

-  pityriasis  rubra  after         . .      658 

-  pustular,  general  account  of     602 

-  pustules  in  . .  602,  831 

-  scabs  in        . .  .  .  .  .      653 

-  scales  in    275,  655,  656,  657,  831 

-  sebOrrhCBicum  of  infants   275,276 
napkin-region  incidence  of    446 

-  tenderness  of  the  scalp  from 
780,  781 


529,  714,829,831 
253,  653,  714,  831 
(see    Liver, 

118 


387 


387 
388 


121 

361 
177 
763 
445 
313 
649 
197 

518 


-  vesicles  in   . . 

-  weeping  in  . . 
Edge    of    liver 

Edge  of) 
Effusion,  bloody,  in  chest     .  . 

-  in     joint     in     intermittent 

hydrarthrosis 

periodic,  in    intermittent 

hydrarthrosis  . . 
in  tabetic  arthritis 

-  into  pericardium  (see  Peri- 

cardium) 

-  perinephric  (see  Perinephric 

Effusion) 

-  pleuritic      (see       Pleuritic 

Effusion) 

-  serous,  in  cliest  (see  Chest, 

Serous  Effusion  in) 

-  tuberculous  pleuritic,  inocu- 

lation of  guinea-pig  in    . . 

-  yellow,  pleural,  pericardial, 

peritoneal,  in  jaundice  . . 
EGG-SHELL  CRACKLING  .. 
in  osteosarcoma 

-  nail  with  hyperidrosis 
Egypt,  bilharzia  in   . .  93 

-  relapsing  fever  in  . . 
Ehrlich's  diazo-reaction 
Ejaculatory    ducts,    infection 

in  gonorrhoea 
Elastic     fibres,     method     of 

demonstrating     . .  . .       99 

in  sputum      185,  288,  316,  317, 

319,  321,  651,  701,  703 
Elbows,  osteo-arthritis  of      . .     384 

-  predilection  of  psoriasis  for 

530,  656,  657 

-  rheumatic  nodules  of         . .     804 

-  seborrhceic  dermatitis  of  . .     447 

-  tuberculous  disease  of       . .     385 
Elbow-joint      disease,      arm 

atrophy  in 
Elder,  dwarf,  polyuria  after . . 
Electric  blindness 

-  currents,  gangrene  from    . . 
Electrical   reactions  (and  see 

Keaction  of  Degeneration) 

in  acute  poliomyelitis 

70,  555, 

amyotrophic  lateral  sclerosis  554 

atrophic  palsy  of  arm    . .     549 

bulbar  paralysis  .  .  . .     687 

facial  paralysis    . .         535,  536 

Friedreich's  ataxy  . .       71 

hysterical  paralysis         .  .      541 

of    muscles    and    nerves, 

normal.  . 

in  muscular  atrophy 

myasthenic 

myopathies 

neuropathic    muscular 

atrophy 

paralysis  from  cervical  rib    554 

peculiarities,    apart  from 

H.   D 634 

peripheral  neuritis  66,  75 

progressive     muscular 

atrophy  . .  . .       73 
spastic  monoplegia         . .     540 


582 
840 


559 


633 

69 

225 

70 

633 


ELECTRICAL    REACTIONS—EMPYEMA 


895 


lilectrical  reactions,  contd. 

Embolism  of  the  lung,   contd. 

Emph;/sema,  contd. 

supranuclear  facial  paralys 

s 

mitral  stenosis 

320 

-  enlarged  right  ventricle   in 

534, 

536 

multiple  abscesses  from 

649 

245, 

246 

syringomyelia     . . 

551 

otitis  media 

578 

-  epistaxis  in. . 

251 

tetany 

634 

sources  of 

186 

-  eversion  of  lower  ribs  in    . . 

404 

-  -  Tliomsen's  disease 

634 

sudden  death  in . . 

321 

-  flatulence  in 

267 

I'Uectricity  in  functional  par- 

- mesenteric  . .        .  •       432, 

646 

-  general  pains  in  the  limbs  in 

503 

alysis  of  vocal  cords 

538 

anal  haunorrhage  from     . . 

90 

-  hasmoptysis  in        . .        317, 

320 

-  in  dia'»nosiasc  pains  referred 

constipation  with 

153 

-  heart  failure  from 

from  viscera 

475 

intestinal  obstruction  from 

432 

61,  186,  464, 

525 

I'lloctrotlierapy     in     insomnia 

melaena  and  hiematemesis 

153 

-  inelasticity  of  skin  with    . . 

186 

with  high,  blood-pressure 

359 

mcteorism  with  . . 

432 

-  insomnia  in . .          . .         356, 

359 

Elephantiasis  ..        -.         33, 

456 

-  T  simulating    peritonitis  . . 

646 

-  liver  dullness  lost  from     . . 

406 

-  cliylous  ascites  in  .  . 

58 

-  monoplegia  from    . . 

546 

-  local  bulging  of  chest-wall 

-  chyluria  with 

126 

-  multiple,  in  fungating  endo- 

from 

193 

-  from  filaria  sanguinis  hominis 

carditis     . .          .  .      9,  10, 

699 

-  orthopncna  in          . .        186, 

464 

765, 

810 

-  numbness  of  limb  from     . . 

286 

-  pain  in  the  chest  in 

480 

scrotal  enlargement  in  . . 

765 

-  pain  from     . . 

286 

epigastrium  from 

485 

-  scroti,     occurrence     in    the 

-  paraplegia  from 

563 

-  palpitation  in         . .         525, 

526 

tropics 

765 

-  predisposing  causes  of 

286 

-  periodic  cyanosis  from 

579 

-  testicular  atrophy  in 

78 

-  progressive  ana?mia  with  . . 

138 

-  physical  signs  of     101,  186, 

192 

Eleventh    nerve    (see    Spinal 

-  pyrexia  with 

X38 

-  pneumothorax  from         577, 

578 

Accessory) 

-  of  radial  artery,  inequality 

-  polycytha;mia  in    . .         579, 

580 

Emaciation  (and  see  Marasmus, 

of  pulses  in 

593 

-  shortness  of  breath  in 

and  Weight,  Loss  of) 

-  renal,    albuminuria    in    8,  9, 

237 

101,  526, 

579 

-  in  alcoholic  neuritis 

78 

htematuria  from . . 

237 

-  subcutaneous  (see  Emphy- 

- anorexia  nervosa 

50 

-  rheumatic  history  in 

138 

sema,  Surgical) 

-  cachexia  alkalina 

115 

-  of  spinal  cord 

565 

EMPHYSEMA,  SURGICAL  .. 

231 

-  cancerous  peritonitis 

57 

-  splenic  enlargement  with 

abdominal  distention  from 

716 

-  carcinoma  of  rectum 

636 

138,  699 

692 

swelling  from  .  . 

715 

-  in  malignant  growth  of  ovary 

759 

-  suddenness  of  symptoms  in 

286 

crepitus  with       . .        179, 

716 

-  iihosphatio  diabetes 

572 

-  after  thrombosis  of  Uiac  vein 

egg-shell  crackling  in     . . 

177 

-  i)hthisis 

194 

186 

456 

due     to     gas-producing 

-  progeria 

218 

-  uncinate  gyrus,  anosmia  from 

669 

microbes           . .         231 

716 

-  pyfemia 

372 

Embryoma  of  kidney,  histology 

395 

from  injury  to  chest     . . 

578 

-  Still's  disease 

40 

haematuria  in        304,  307, 

395 

wounds  produeincr 

716 

-  stricture  of  oesophagus     . . 

484 

occurrence  in  children  . . 

395 

-  tenderness  in  the  chest  from 

778 

-  tropical  abscess  of  liver     . . 

369 

symptoms  of 

307 

-  thoracic  telangiectases  in 

826 

Embolism,   absence  of   pulsa- 

- of  fiver 

413 

-  uterine,  hyperaemia  from  . . 

430 

tion  in  limb  after 

286 

-  testis  (see  Testis,  Embryoma  of) 

menorrhagia  in   . . 

428 

-  albuminuria  due  to. . 

237 

Emetics,  vomiting  from 

843 

-  wheezing  in  . . 

526 

-  aneurysm  from       . .         367 

699 

Emissions,     nocturnal,     with 

Emprosthotonus  in  tetanus  . . 

162 

-  of    central    retinal    artery, 

impotence 

347 

Empyema,  without  abnormal 

sudden  blindness  from   . . 

839 

Emotion,  acute  yeUow  atrophy 

physical  signs         99,  323, 

703 

ophthalmoscopic  ap- 

of liver  preceded  by     . . 

370 

-  in  abnormal  situations 

703 

pearance  of  (Plate  YIll, 

-  angina  pectoris  from        482, 

778 

-  albuminuria  in 

17 

Fig.  S) 

463 

-  convulsions  from    . . 

170 

-  album.osuria  in 

20 

-  cerebral  ..  82,128,137,138, 

155, 

-  diarrhoea  from 

197 

-  anaemia  in   .  . 

39 

173,  237,  285,  327,  328, 

337, 

-  disproportionate  exuberance 

-  with  bronchopneumonia   . . 

186 

338,  516,  685,  699 

in  paralysis  agitans 

262 

-  bulging  of  chest-wall  with  192 

,193 

acquired      paralysis      of 

in  double  hemiplegia 

258 

-  clubbed  fingers  in..           99, 

128 

childliood  due  to 

155 

dyspepsia  from       . .        355, 

374 

-  compression  of  lung  from . . 

324 

apliasia  from 

685 

-  expression  of,  diminished  in 

-  diagnosed  by  needling  chest 

186 

athetosis  after     . . 

155 

tabes 

262 

from  gangrene  of  lung 

Cheyne  -  Stokes      respira- 

- in  hysteria  . .          . .        173, 

798 

288,   321, 

703 

tion  from 

125 

-  jaundice  from         . .         362, 

374 

-  diapliragm  immobilized  by 

721 

coma  from          ..137,138 

237 

-  loss  of  control  of  expression 

-  difficulties  in  locating 

119 

headache  in        . .         327, 

328 

of,  in  pseudo-bulbar  palsy 

686 

-  displaced  cardiac  impulse  in 

330 

-  -  hemaniopsia  from 

335 

-  menorrhagia  from  . . 

428 

-  fibroid  lung  and  bronchiec- 

 hemiplegia  from  . . 

338 

-  motor  tics  increased  by    . . 

160 

tasis  from 

324 

loss  of  consciousness  in. . 

338 

-  movements  of,  uncontrolled 

-  foetid  sputum  in     . .        321, 

703 

rheumatic  history  in 

338 

in  facial  paralysis 

536 

-  foul  breath  in 

99 

sudden     transient     coma 

-  myoclonus  increased  by   . . 

160 

-  hsemoptysis  in        . .        317, 

323 

and  hemiplegia  from.. 

099 

-  palpitation  from     . .        525, 

527 

-  indicanuria  due  to..        349, 

821 

-  in  f  ungating  endocarditis  (see 

-  ptyalorrhoea  caused  by     . . 

592 

-  lardaceous  disease  from     10, 

696 

Fungating  Endocarditis) 

-  tremor  from 

795 

-  latent            .  .          .  .         119, 

650 

-  gangrene  from         .  .          282 

286 

Emphysema,   albuminuria  in 

18 

-  leucocytosis  in         . .        400, 

401 

-  liLvmaturia  due  to   . . 

237 

-  ascites  in      . . 

61 

-  after  measles 

050 

-  haemorrhages  with . . 

138 

-  asthma   developing   into 

scarlet  fever 

650 

-  from  heart  lesions  .  .         138 

155 

180,   186, 

582 

-  mistaken     for     abscess     of 

-  heminlegia  from 

-  barrel-shaped  chest  in     191, 

404 

chest-wall 

193 

82,138,237,285 

337 

-  and     bronchitis    (and     see 

-  osteo-arthropathy  in 

390 

-  of  hepatic  artery     . .           59, 

367 

Bronchitis) 

246 

-  pain  in  the  chest  in        478, 

480 

-  of  the  lung,  acute  cyanosis 

-  cardiac  dullness  in . . 

331 

-  periostitis  in 

776 

from 

185 

-  clubbed  fingers  in  . . 

128 

-  physical  signs  of      . .         119, 

192 

from  appendi"itis 

123 

-  compensatory,     in     fibroid 

-  after  pleurisy 

6.50 

caasing  pleuritic  effusion 

123 

lung           

246 

-  pneumococcal 

122 

dyspnoea  in 

185 

-  constipation  in 

149 

-  after  pneumonia     . .        323, 

650 

gangrene  of  lung  from   . . 

287 

-  cyanosis  in   .  .          . .        186, 

479 

slight  value  of  leucocyte 

hsemoptysLs  in    . .        186, 

317 

-  dilatation  of  heart  in  246, 485 

526 

count  in  diagnosis  of. . 

401 

intrathoracic  pain  in     . . 

185 

-  diminished  liver  dullness  in 

404 

-  pointing  on  chest- wall  in  193 

478 

from  lateral  sinus  throm- 

- displaced  cardiac  impulse  in 

-  post-critical        intermittent 

bosis 

578 

232,  330, 

331 

fever  in  pneumonia  due  to 

622 

lividity  in 

185 

-  dyspeptic  symptoms  in     . . 

526 

-  retraction  of  chest-wall  after 

194 

BMP  YEMA  —EOS  IN 


Empyema,  contd. 

-  rigors  with  . .  . .        Ci8,  650 

-  rupture  into  bronchus       . .     578 
causing  pneumothorax. .     577 

-  -  into  lung..  ..99,  323,  703 

diagnosis  of     . .  . .     703 

previous     history     of 

pneumonia  in  . .     703 

no  elastic  fibres  in  sputum  in  703 

foul  taste  from   . .  . .     774 

sputum  in        ..99,  321,  703 

-  scoliosis  from  . .  . .     180 

-  secondary  to  abscess  of  liver     409 
to  otitis  media    . .  . .     123 

-  septicaemia  from     . .        614,  698 
prolonged  pyrexia  in      . .     609 

-  shrinkage  of  chest  after     . .     193 

-  simulating  hepatic  abscess       779 

-  simulation  by  tropical  liver 

abscess      . .  . .  . .     369 

-  suggested    by     ansemia.    in 

bronchopneumonia  of  chil- 
dren   39 

-  subdiaphragmatic      inflam- 

mation causing  . .  .  .      122 

-  from  subplirenic  abscess   . .     720 

-  tenderness  of  the  spine  in. .     785 

-  undiscovered,    difficulty    of 

exploration  with  needle  in     703 

-  varieties  of  cause  and  posi- 

tion of 119 

-  2;-rays  in  diagnosis  of        . .     721 

-  of     antrum    of     Highmore 

(see  An  brum  of  Highmore) 

-  of  frontal  sinus  (see  Frontal 

Sinus) 

-  of    gall-bladder    (see    Gall- 

bladder, Empyema  of) 
Encephalitis,  acquired  paraly- 
sis of  childhood  due  to  . .     155 

-  acute   constitutional  symp- 

toms in     . .  . .  . .     547 

hemiplegia  from. .        337,  338 

optic  nem-itis  in  . .     139 

pupils   in  . .  . .  . .     594 

retraction  of  the  head  in      641 

simulating  meningitis  558,  643 

symptoms  of       . .  . .     139 

vomiting  in         . .  . .     139 

-  ataxy  from  . .  .  .  .  .        69 

-  athetosis  after         .  .  .  .      155 

-  coma  due  to  136,  55S,  643 

-  convulsions  in  139,  547,  558 

-  diagnosis    of    sup.    longitu- 

dinal sinus  tlirombosis  from  558 

-  general  head  symptoms  in      558 

-  headache  in  . .        139,  547 

-  infantile  diplegia  due  to    . .     556 

-  monoplegia  from     . .  . .     547 

-  paraplegia  due  to  . .  . .     556 

-  pyrexia  in    . .  . .         547,  558 

-  vomitmg  in..  ..        547,  558 
Encephalocele,  diagnosis  from 

dermoid  cyst       . .  . .     254 

-  unilateral  exophthalmos  from  254 
Encephalopathy,  saturnine  (see 

Saturnine  Encephalopathy) 

■  ■  744 


Enchondroma  of  breast 

-  simulating     sarcoma     (Fig. 

195)  

Encysted  hydrocele  (see  113^- 

drocele) 
Endarteritis,  gangrene  from.  . 

-  preceding    paraplegia,    his- 

tory of  sjrphilis    in 

-  syphilitic         . .        327,  337,  563 

cerebral,  headache  in     . .     372 

cutaneous  ulcers  in       . .     338 

hemiplegia  from  337,  338 

premonitory  symptoms     337 

without    loss    of    con- 
sciousness m  . .     338 

AVassermann's  serum  re- 
action in  . .  . .     338 


754 


282 
563 


Endocarditis,    acute,    changes 

followmg  . .  . .  . .     240 

-  in  acute  rheumatism 

103,  121,  504,  671 

-  aortic  disease  due  to  106,  236.  237 

-  bruits  in     102,  103,  105,  llOi  671 

-  cerebral  embolism  from    . .     173 

-  changes    in    heart    sounds 

with  239 

-  in  chorea      . .  . .        103,  156 

-  common  causes  of  . .  . .     236 

-  diastolic  bruits  in  . .  . .     106 

-  embolism  from       . .        173,  286 

-  in  erysipelas  . .  . .     103 

-  fungating    (see     Fungating 

Endocarditis) 

-  hfem.aturia  from      . .  . .     305 

-  impulse  displaced  with      . .     239 

-  not  indicated  by  tempera- 

ture chart  103,  239,  622 

-  infarct  of  lung  from  .  .     322 

-  infected    or    infective    (see 

Fungating  Endocarditis) 

-  malignant    (see    Fungating 

Endocarditis) 

-  mid-diastolio  bruit  of         . .     110 
mitral  murmur  in  .  .      639 

-  mitral  regurgitation  from..     239 
stenosis  from       . .  . .     240 

-  monoplegia  due  to . .  . .     547 

-  palpitation  from      . .  . .    .239 

-  in  pneumonia  . .  . .     103 

-  precordial  pain  from  . .     239 

-  in  puerperal  fever  .  .  . .     103 

-  pulmonary  regurgitation  from  107 

-  pulse-rate  in  .  .  . .      239 

-  pvrexia  absent  with         103,  622 
"  due  to 622 

-  in  septicEemia  .  .  . .     103 

-  systolic  aortic  bruit  in       . .     105 
bruit  over  mitral  area  in 

acute  ..         102,  103 

-  ulcerative    (see     Fungating 

Endocarditis) 
Endolymph,   rise   in   pressure 

of,  causing  deafness       . .     190 
Endometritis,  acute,  in  zymotic 

diseases     . .  . .  . .     429 

-  blood-stained    watery    dis- 

charge from         . .  . .     435 

-  cachexia   in..  ..  ..     114 

-  chronic,  ansemia  in  . .       39 
backache  from    . .          . .     220 

-  diagnosis  from  uterhie  scrap- 

ings ..  ..  ..     429 

-  dysmenorrhoea  from         219,  220 

-  enlargement  of  uterus  from     220 

-  infective  peritonitis  from..     644 

-  leucorrhoea  from     .  .  . .      220 

-  menorrhagia  from     210,  220,  428 

-  metrorrhagia  from  433,  435 

-  pelvic  pain  from     . .  . .     508 

-  Pozzi's  syndrome  in  . .     429 

-  sacralgia   in .  .  .  .  .  .      509 

-  senile,  metrostaxis  from    .  .     436 
foul     vaginal     discharge 

from 211 

-  sterility  due  to        . .  . .     706 

-  vaginal  discharge  due  to    . .     210 

-  in  virgins      . .  . .  . .     429 

Endometrium    abnormal      m 

dysmenorrhcEa    . .          . .     219 
Endoscope 208 

-  in  diagnosing  impacted  cal- 

culus m  uretlira  . .  . .     511 
urethral  stricture   439,  440,  511 

-  examination     in     cases     of 

stricture    . .  . .  . .     678 

in  cases  of  urethral  fistula     678 

-  herpes  of  uretlu-a  seen  with    209 

-  and  soft  sores  in  urethra  . .     209 

-  and  urethral  affections      . .     208 

calculus    . .  . .  . .     210 

papillomata         . .  . .     209 


205 
395 
287 
204 
640 
766 
768 
273 


736 


Endothelioma  of  antrum  of 
Highmore,  purulent  rhin- 
itis from  . . 

-  kidney 

-  lung  . . 

-  nose 

-  palate 

-  testis 

-  vulva 

Endothrix  in  ringworm 
Endotriches,       Sahouraud's 

classification  of  . . 
Enemata  in  diagnosis  of  car- 
cinoma of  sigmoid  colon 

of    cause   of    swelling    in 

right  iliac  fossa 

fffical  tumours  393,499,501,691 

intestinal  obstruction     . .     151 

nature  of  constipation  . .     142 

-  relief  of  pain  by,  in  faecal 

accumulations     . .  . .     499 

-  vomiting  caused  by         844,  846 
Enlargement  of  a  bone  (see  Bones) 

-  of     gall-bladder    (see    Gall- 

bladder  Enlarged) 

-  heart  (see  Heart,  Enlarged) 

-  joints  (see  Arthritis) 

-  kidney    (see    Kidney,    En- 

larged) 

-  lacrymal   gland  (see  Eacry- 

mal  Gland,  Enlarged) 

-  liver  (see  Liver,  Enlarged) 

-  lymphatic  glands  (see  Lym- 

phatic Glands) 

-  prostate  (see  Prostate  En- 

larged) 

-  salivary  glands  (see  Salivary 

Glands,   Enlarged) 

-  spleen  (see  Spleen,  Enlarged) 

-  testis  (see  Testis,  Enlarged) 

-  thjToid  (see  Thyroid  Gland, 

Enlarged) 

-  tonsils  (see  Tonsils,  Enlarged) 

-  uterus  (see  Uterus,  Enlarged) 
ENOPHTHALMOS      .. 

-  in     paralysis     of     cervical 

sympathetic        . .         590 
Entassement    ui    sphial    cord 

lesions   causmg   paralysis 
Enteric  fever  (see  Typhoid  Fever  J 
Enteritis,  in  cirrhosis  of  liver       409 

-  indicanuria  in  . .  . .     349 

-  mucus  and  blood  in  stools  in     444 

-  simulating  ascites  . .  . .      717 
Entero-colitis  of  infants,  blood 

per  anum  in  .  .  .  .        92 

Enterogenous  cyanosis  . .     187 

Enterolith  in  the  rectum       . .     635 
Enteroptosis,  abdominal  swell- 
ing from  . . 

-  illustrated    . . 

-  jaundice  in  . . 

-  undue     abdominal     aortic 

pulsation  associated  with 
Enterospasm     in     abdominal 
neuralgias 

-  constipation  from  .  . 

-  distinction  from  tumour  or 

intussusception   . . 

-  induced  by  takmg  food 

-  mucus    and    membrane 

motions  in 

-  obstinate  constipation  in  . . 

-  pain  in  the  epigastrium  in 
relieved    by    passage    of 

flatus     . . 

pressure 

ENURESIS 

-  in  children,  nocturnal 
Envelope  crystals  in  urine  (see 

Oxaluria) 
Eosin,  fluorescence  due  to 

-  pink  urine  from     . .         819 

-  staining  of  mucus  by 


247 


594 
543 


inl 


715 
721 
367 

592 

473 
144 

134 
486 

486 
486 
486 

486 
486 
247 
471 


820 
820 
444 


EOSINOPHILIA—EPISTERNAL     FULLNESS 


897 


EOSINOPHILIA     (J'laia     11, 

Jil>  id  ill  III  II  il  IK ,  iij  nid. 

Einlejjuy,  conld. 

Fici.  L,  p.  28j     .  . 

248 

-  tuberculous,  yeneral  account  of  767 

-  palpitation  in         . .        525, 

527 

-  in  Addison's  disease 

38 

scrotal  sifius  from 

767 

-  partial 

171 

-  ankylostomiasis 

570 

suiipuration  in  most  cases  of 

766 

-  pavor  noctumus  in  connec- 

- associated  witli  parasites    33, 

249 

(see  also  Testis,  Tubercu- 

tion with. . 

357 

-  in  astlima    ..  118,  179,  180, 

582 

lous  disease  of) 

-  peculiar  sense  of  size  in  . . 

840 

-  bloody  effusion  due  to  new 

-  varieties  of  . . 

766 

-  perverted  taste  in  . . 

774 

KTowths  of  pleura 

118 

-  vertical  elongation  of  scrotal 

-  polyuria  in  . .          ..        581, 

583 

bullous  dermatoses 

114 

swellings  due  to. . 

766 

-  priapism  in  . . 

586 

-  exceptional   in  round-worm 

Epididymo  -  orchitis,      acute. 

-  pupils  dilated  with  retention 

infection  . . 

569 

acute    hydrocele     accom- 

of reflexes  in 

594 

-  in  fjlaria-sis  . . 

126 

panying     .  . 

522 

-  relaxation  of  sphincters  in 

160 

-  with  hydatid  cyst  of  liver 

causes  of     . .          . .     517, 

518 

-  simulated  by  heart  block   . . 

97 

58,  279,  413,  415,  719, 

720 

general  account  of 

517 

rigors 

646 

of  luns  . . 

323 

-  gouty            

818 

-  smell  aura  preceding 

669 

-  with  multiple  subcutaneous 

Epigastric  angle,  widening  of 

-  spasm  of  the  glottis  as  an 

cysticerci  .  . 

452 

by  ascites 

50 

aura  in      . . 

828 

-  in  post-febrile  states 

248 

by  emphysema 

246 

-  subconjunctival  hemorrhage 

-  tape-worm  infection 

568 

-  herniae  (see  Hernia,  Epiga.stric) 

in 

256 

-  trichinosis    . .          . .        504, 

801 

-  reflex  in  spastic  paralysis  of 

-  tetanic  contractions  in 

161 

Eosinophile    cells    in    normal 

one  leg     . . 

540 

-  treatment  by  indigo  blue . . 

82.? 

blood         ..          ..          28, 

248 

-  sensation  in  epileptic  aura  . . 

80 

-  trismus  simulated  by 

801 

-  myelocytes  (Plate  11) 

29 

Epigastrium,  bulging  of,  from 

-  unilateral  convulsions  in  . . 

170 

Epicanthus     in     Mongolian 

subphrenic  abscess 

720 

uncommon   in . . 

174 

idiocy       ..          ..        263, 

264 

tropical  abscess  of  liver. . 

369 

-  vertigo  in     . . 

828 

Epidemic  gangrene     . .        282, 

287 

-  definition  of 

722 

-  vomiting  in 

844 

-  jaundice  (see  Jaundice,  Epi- 

- injury  to,  vomiting  from  . . 

844 

-  warning  spasms  of  . . 

160 

demic) 

-  organs  normally  contained  in 

722 

Epileptiform  convulsions  (see 

-  relapsing  fever 

649 

-  pain  in   (see    Pain   in   Epi- 

Convulsions, Epileptic) 

-  trichinosis 

801 

gastrium) 

-  neuralgia    (see     Trigeminal 

Epidermolvsis       bullosa, 

-  pulsation  in,  in  acute  dilata- 

Neuralgia, Major) 

495 

]]0,  113,  2G6, 

445 

tion  of  heart 

243 

EPIPHORA 

250 

Epidermophyton  inguinale  273 

275 

congenital    heart    disease 

244 

-  in  acute  conjunctivitis 

2.55 

-  Perneti 

275 

with  enlarged  right  ven- 

- from  cicatrization  in  lachry- 

- riibrum 

275 

tricle      . .           232,  245, 

246 

mal  duct  . . 

250 

Epididymis,  cystic  disease  of, 

in  fibroid  lung 

246 

-  Graves'  disease 

261 

age  incidence  of  . . 

767 

in  mitral  regurgitation . . 

238 

-  in  inflammation  of  eye     . . 

2.50 

painless    and    harmless 

stenosis 

245 

-  injury  of  lachrymal  duct  . . 

2-50 

nature   of     . . 

767 

-  tenderness   in  (see   Tender- 

- in  nuclear  facial  paralysis 

536 

solitary 

767 

ness  in  Epigastrium) 

Epiphyses,  enlargement  of,   in 

translucency  of  cysts  in 

767 

-  tuberculous  masses  in 

724 

rickets 

695 

-  encysted  liydrocele    of     521, 

765 

-  tumour  in,  in  carcinoma  of 

-  injury   or   inflammation   of 

-  enlargement  of,  causes  of.. 

766 

stomach  . . 

351 

tibial,  causing  talipes   . . 

1.32 

-  fibrous  scar  in,  from  former 

due  to  scybala    . . 

724 

-  separation  of,  in  congenital 

epididymo-orcliitis 

518 

-  various  tumours  felt  in 

syphilis     . . 

752 

-  gonococcal  infection  of     207 

767 

723,  724 

725 

popliteal  swelling  due  to 

-  inflammatory  lesions  of  (and 

-  visible  gastric  peristalsis  in 

723 

761 

763 

see  Epididymo-orchitis) 

517 

Epiglottis,   tuberculosis   of   . . 

325 

in  syphilitic  pseudo-paraly 

-  new  growth  of 

767 

Epiguanin    bases,    uric    acid 

sis 

386 

-  nodules  in,  gonorrhceal     307 

767 

derived  from 

817 

Epiphysitis  in  congenital  sy- 

 in  secondary  syphilis     . . 

519 

Epilepsy,  aphasia  after 

686 

philis 

752 

tuberculous                   307, 

518, 

-  amnesia  in  . . 

25 

Episarkin    bases,     uric    acid 

630,  680, 

767 

-  athetosis  in 

154 

derived  from 

817 

with  tuberculous  testis . . 

680 

-  aura   in  (see  Aura) 

Episcleritis,  causes  of 

256 

-  pain  in,  from  fibrous  scar. 

-  automatism  in 

25 

-  distinction  from  conjuncti- 

diagnosis   from    tubercu- 

- Babinski's  sign  in  . . 

82 

vitis 

256 

losis 

518 

-  biting  of  tongue  in. . 

646 

Epispadias,  changes  in  stream 

-  thickened    and    painful    in 

-  cardiac  thumpings  at  night  in 

527 

of  urine  in 

438 

epididymo-orchitis 

517 

-  in  children  . . 

170 

EPISTAXIS 

250 

-  tuberculosis  of  the         307, 

519, 

—  clonic  spasms  in 

160 

-  in  acute  yellow  atrophy   of 

680, 

767 

-  coma  in       . .     82,  136,  160 

646 

liver          . .          . .         302 

370 

association  with  prostate 

767 

-  convulsions  in 

160 

-  alcoholism    . . 

368 

tuberculosis  of  spermatic 

-  deafness  from 

191 

-  anaemia  after 

36 

cord 

523 

-  dementia  from 

360 

-  in  Bright's  disease 

90 

new  growth  simulating. . 

767 

-  ef4uivalents  of 

686 

-  and  cerebral  embolism 

138 

with  tuberculous  bladder 

441 

-  the  fit  described 

169 

-  chronic  nephritis    . . 

295 

tuberculosis    of    vesiculse 

-  fiushing  as  an  aura  in 

268 

-  cirrhosis  of  liver        295,  300 

696 

seminales  secondary  to 

-  headache  in 

329 

-  hsematemesis     from     swal- 

G29, 

767 

-  imitated  in  hysteria 

160 

lowed  blood  in    . . 

294 

Epididymitis,  atrophy  of  testis 

-  immobile  pupil  in  . . 

160 

—  hiEmophilia 

.302 

from 

454 

-  in  infantile  paralysis 

155 

-  Henoch's  purpura  . . 

90 

-  gonorrhceal,  bacteriology  in 

-  an     infrequent     cause     of 

-  Hodgkin's  disease  . . 

302 

diagnosis  of           . .        454 

766 

mfantile  convulsions 

171 

-  leukamia     . .          . .           31 

302 

-  involving  spermatic  cord   . . 

523 

-  involuntary   micturition   in 

640 

-  multiple  hereditary  telangi- 

- from    non-gonococcal    ure- 

- irritability  in 

360 

ectasis       . .      --0\ 

251 

thritis        ..          ..        206 

766 

-  Jacksonian  (see  Jacksonian 

-  purpura  haBm.orrhagic*'     . . 

600 

diagnosis  of 

766 

Epilepsy) 

-  recurrent 

2.51 

from  tuberculous  epi- 

- mild     clonic     spasms     as 

-  in  relapsing  fever    . . 

373 

didymitis 

767 

"  warnings  "   in  . . 

160 

-  scarlatina  maligna   . . 

301 

-  relation  of  swelling  to  testis 

766 

-  mimicked  by  malingerers. . 

160 

-  typhoid  fever          . .          90, 

697 

-  side-to-side      flattening     of 

-  minor  (see  Petit  mal) 

-  variola  maligna 

301 

swelling    . . 

766 

-  multiple  bruising  simulating 

-  vicarious  menstruation 

251 

-  in  syphilis    . . 

519 

purpura  due  to  . . 

597 

Epistemal    fullness    in    acute 

-  testicular  atrophy  in 

79 

-  myoclonus  in 

160 

mediastinitis 

484 

57 


EPITHELIAL  RENAL  CASTS— EUROPE 


Epithelial  renal  tube-casts    . .         7 
Epithelioma   adenoides  cysti- 

cum  . .  . .     "    . .     805 

-  (see  Carcinoma") 

-  causing  perineal  sores       . .     GTS 

-  histology    in     diagnosis    of 

(and    see     Histology     in 

Diagnosis)      420,  7G9,  803,  812 
Epithelium   in   hsematuria   of 

acute  nephritis    . .  . .     311 

Epitroehlear    gland    enlarged 

(see  Lymphatic  Gland^ 
Epulis,  bleeding  gums  due  to  86,  88 

-  fibrous  . .  . .  . .     748 

association  with  decayed 

tooth 748 

displacement  of  teeth  by      748 

distortion  of  jaw  by      . .     748 

microscopic    examination 

in  diagnosis  of  . .     748 

origin  of  sarcoma  as      . .     748 

softness  of  swelling  due  to     748 

-  malignant     .  .  .  .  .  .      756 

Equilibrium,    neuro-muscular 

mechanism    of    mainten- 
ance of      . .  . .  . .     827 

Erb's  muscular  dystrophy    . .       70 

fibrillary     contractions 

rare  in  . .  . .     158 

-  palsy,  extent  and  causes  of      552 

-  sign  in  tetany  . .  . .     178 
Erections,  Penile,  absence  of 

(see  Impotence) 

Painful  (see  Chordee) 

in  acute  prostatitis  or 

prostatic  abscess    . .     515 

-  -  -  age  incidence  of  . .     585 

in  cavernitis    .  .  . .     516 

gonorrhoja        ..  ..     207 

persistent  (Priapism). .     585 

Ergotism,  gangrene  from  (see 

Gangrene,  Epidemic) 

-  purpura  from  . .  . .     596 

-  simulating    Raynaud's    dis- 

ease or  erythromelalgia . .     287 

-  tetany  following     . .  .  .     178 
Erosion  of  cartilages  in  hyper- 
trophic osteo-arthropathy    -iGO 

-  -  in   joints   in   hemophilic 

artliritis  ..         380,  388 
lupus  vulgaris     . .         448,  808 

-  -  in  osteo-arthritis  . .     384 

-  cervix  (see  Cervix,  Erosion  of) 
Eructatio  nervosa      . .  . .     267 

-  -  diagnosis    from     indiges- 

tion      . .  . .  . .     351 

Eructations  in  gastritis        . .     297 
relief  of  pain  by  . .     484 

-  in  intestinal  colic"  . .  . .     473 
Eruptions,  bullous,  vesicular, 

etc.  (see  Bullae,  Vesicles, 
etc.) 
Erysipelas,  acute  dilatation  of 

heart  from  .  .  .  .     243 

-  albuminuria  in        . .  . .       17 

-  bacteriology  in  diagnosis  . .     459 

-  baldness  from      . .  . .       84 

-  in  bathing-drawers  area   . .     447 

-  bullas  in       . .  110,  113,  746 

-  diazo-reaction  in     . .  . .     198 

-  differentiation  of  erythema 

simplex  from       ..  ...      252 

-  endocarditis  in        . .  . .     103 

-  gangrene  in  . .  . .     282 

-  hyperpyrexia  in      . .  . .     343 

-  leucocytosis  in        . .  . .     401 

-  oedema   of  face    and    arms 

from         . .  . .  . .     4C1 

or  neck  in     . .  . .     459 

skin  m      . .  . .  . .     746 

-  prolonged  pvrexia  in  (Fig. 

166)  ." 614 

-  pyrexia  in    ..  ..611,698,746 

-  rash  of         . .  . .         698,  746 


Erysipelas,  cmitd. 

-  rigors  in  (Fig.  166) 

614,  647,  648,  698,  746 

-  sharply  defined  border  of. .     252 

-  simulated    by    lupus    ery- 

thematosus . .  . .     781 
urticaria   .  .          .  .          . .     850 

-  sloughhig  in  . .  . .     746 

-  splenic  enlargement  in     692,  698 

-  streptococci  m        . .  . .     113 

-  tendency  to  spread  in       . .     746 

-  tenderness  of  scalp  from   780,  781 
ERYTHEMA 252 

-  in  acute  rheumatism  ..     6(1 

-  bullosum,  bleeding  gums  in  86,  88 
of  the  buccal  cavity,  dys- 
phagia in         . .  . .     225 

-  -  buUa3  in   . .  . .        110,  113 
eosinophilia  in    . .  . .     249 

-  in  cerebrospinal  meningitis      643 

-  congenital  syphilis  . .  . .     446 

-  at  onset  of  dengue . .         . .     506 

-  dermatitis  herpetiformis    . .     831 

-  eczema  . .  . .  . .     831 

-  of  fingers 266 

-  fugax  . .  . .  . .     252 

-  gestationis,  bullfe  in  . .     Ill 

-  with  herpes  zoster     .  .      .  .     830 

-  at  onset  of  impetigo  vulgaris     602 

-  indm-atum       scrofulosorum  . 

(see  Bazin's  Disease) 

-  from  inflammation  . .     478 

-  intertrigo      . .  . .  . .     252 

area  of  distribution  of  . .     447 

-  from  iodides  or  bromides. .     112 

-  iris,  buUse  hi  . .        110,  113 

eosinophilia  in    . .  . .     249 

relation  to  pemphigus  .  .     113 

rings  of  vesicles  in  . .     832 

-  keratodes,  nodules  of        . .     451 
cedema     and    tenderness 

of  palms  and  soles  in. .     451 

-  of  the  legs,  from  excessive 

standing  . .  . .  . .     450 

-  macular        . .  . .  . .     423 

-  multiforme,   diagnosis  from 

small-pox  .  .  .  .      607 

herpes  zoster  . .  . .     830 

distribution  of    . .  . .     531 

mainly  on  limbs         . .     607 

papular  and  other  lesions  of  531 

pitjTiasis  rubra  after     . .     658 

scabs  from  . .  . .     653 

-  simulation  by  prurigo  . .     531 

strophulus        . .  .  .      531 

urticaria  .  .  .  .      531 

-  slightness  of  itching  in  . .     531 

-  vesicles  m  . .  . .     832 

-  in  napkin  region      . .  . .     446 

-  nodosum,  absence  of  ulcers 

ia  . .  . .  .  .     450 

-  in  acute  rheumatism    121,  671 

-  -  afEection  of  legs  and  feet  in  450 

-  bilateral    . .  . .  . .     751 

-  -  colours  of  . .  . .     450 

-  -  diagnosis     from     acute 

osteomyelitis   . .  . .     751 

nodular  leprosy  . .     450 

syphilis  . .  . .     450 

•  -  multiple  red  sweUings  on 

shins  in  . .  . .     751 

■  -  pain  and  sweUing  of  joints    450 

■  -  pyrexia  m  . .  . .     450 

■  -  simulated     by     varicose 

veins     . .  . .  . .     450 

■  papulatum,  staining  of  skin 

after  . .  . .  . .     531 

■  in  peliosis  rheumatica         . .     GOO 

•  pruritus  in   . .  . .  . .     588 

■  rheumatic,  albuminuria  with      18 

■  scabs  in         832 

•  scales  in  .  .  .  .  655,  656 
scarlatiniforme  . .  253 
-  desquamation  after        . .     656 


Enjthema,  scarladnijorme,  contd. 
differentiation  from  Ger- 
man measles   . .  . .     253 

measles  . .  . .     258 

pitja-iasis  rubra  . .     253 

strawberry  tongue  in     . .     253 

-  simplex         . .  . .  . .     252 

diagnosis    from    macular 

stage  of  leprosy  . .     424 

-  solare  .  .  .  .  .  .     252 

-  vesicular,  perleche  with    . .     404 

-  vpsirnlosum,  vesicles  in     . .     832 
Erythemato-papular     lesions, 

description  of      . .  . .      528 

Erythrtemia  (see  Splenomegalic 

Polycythasmia) 
Erythrasma  m   bathing-draw- 
ers area     .  .  .  .  .  .     447 

-  description  of  . .  . .     276 

-  diagnosis     from     eczema 

marginatum         .  .  .  .     276 

eczema  seborrhoeiciun  . .     276 

pityriasis  rosea    .  .  .  .      276 

tinea   vesicolor    . .  . .     276 

-  low  contagiousness  of       . .     276 

-  microsporon  minutissimum 

in  276,  277 

-  reddish-brown  lesions  of   . .     276 
Erythroblasts  . .  . .        28 
Erythrocythaemia  (see  Spleno- 
megalic Polycythsemia) 

Erythromelalgia         . .        . .    490 

-  diagnosis  from  intermittent 

claudication         . .  .  .     490 
Raynaud's  disease         284,  490 

-  in  disseminated  sclerosis  . .     490 

-  an    early    sign    of    organic 

nervous  disease  . .  . .     490 

-  elevation   and   cold   relieve 

pain  in      . .  . .  .  .     490 

-  flushing  of  extremities  in  284,  490 

-  gangrene  in..  ..         282,  284 

-  in  some  healthy  persons  . .     490 

-  heat  and  pulsation  in       284,  490 

-  local  patches    of  rose-pink 

to  purplish  flushing  in  . .     49i  1 

-  cedema  in     . .  . .  . .     490 

-  pain  aggravated  by  depend- 

ent    position     and     by 
warmth     . .  .  .  . .     490 

-  simulated  by  ergotism      . .     287 

-  in  tabes  dorsalis      . .  . .     490 

-  tenderness  of  foot  in         . .     490 
Erythropsia   (and  see   Vision, 

defects   of) 

-  from  cataract  extraction  . .     840 

-  in  electric  blindness  . .     840 

-  with  retinal  hsemorrhage  . .     840 

-  in  snow  blindness  . .  . .     840 
Eschar,  black,  gangrenous,  in 

anthrax    . .  . .  . .     603 

-  from     injury     to     mouth, 

ptyalism  due  to  . .  . .     591 

-  on  lips  or  mouth  in  irritant 

or  corrosive  poisoning  . .     674 
Essential  albuminuria  . .       19 

Esthiomfene,  syphilitic  natm'e  of  769 

-  vulval  swelling  due  to       . .     768 
Ether,  headache  from  . .     328 

-  poisoning,  leucopenia  in   . .     401 
Ethereal    sulphates    in    urine, 

indicanuria  indicating   . .     349 
Ethmoidal  air   cells,  infection 

of,  meningitis  from       . .     642 

-  dilatation,  exophthalmos  in     255 

-  sinusitis,      diagnosis     from 

abscess  of  antrum  . .     502 

headache  in         . .  . .     327 

nasal  discharge  from     204,  206 

Eucalyptus  leaves,  sore  fingers 

from  .  .  .  .  .  .      266 

Eunuchs,  obesity  in  453,  454 

Europe,  Malta  fever  in         . .     506 

-  Southern,  dengue  in  .. .     506 


EUSTACHIAN    TUBE— EYE,    ATROPHY    OF 


899 


Eustachian     tube,      deafness 

Exophthalmic  tjoilrc,  conld. 

Exostosis,  contd. 

from  catarrh  of  the 

190 

glistening  conjunctiva  in 

261 

-  usual    situation    near    epi- 

 infection  of  ears   through 

230 

glycosuria  in 

292 

physeal  line  of  long  bone 

obstruction  from  syphilis 

irritability  in 

360 

(Fig.  194)             .  .          754 

,763 

190, 

828 

loss  of  weight  in    244,  797 

849 

-  a'-rays  in  diagnosis  (Fig.  194) 

754 

Exantliemata,  monorrhagia  in 

429 

marked  pulsation  in  neck 

Expectoration   Csee  Sputa,  and 

Excitability    in    exophthalmic 

in 

764 

Haemoptysis) 

soitre 

244 

menorrhagia  in   . . 

430 

Expiration    sound    prolonged 

-  effect  on  alcoholic  tremor  . . 

797 

mental  changes  in 

797 

at  apex  in  phthisis 

319 

choreic  movements 

156 

Mobius's  sign  in. . 

253 

in  emphysema 

192 

mercurial  tremor 

797 

ocular  symptoms  of 

253 

Exposure,  hypothermia  in   346 

619 

tremor  in  Graves'  disease 

797 

oedema  of  eyelids  in 

261 

-  Pinguecula  due  to  . . 

256 

-  after  epileptic  convulsions 

169 

palpitation  in  525,  527,  792 

,797 

Expression  (see  Facies) 

-  producing  diarrhoea 

197 

pigmentation  of  eyelids  in 

-  lack  of  in  paralysis  agitans 

548 

-  religious,   pandemic   chorea 

244, 

261 

Extensor     brevis     digitorum. 

caused  by 

157 

of  skin  in 

792 

nerve  supply  of  . . 

542 

-  tachycardia  from   .  . 

772 

proptosis  in         . .         253 

,261 

pollicis,  nerve  supply  of 

550 

-  transient  polyuria  due  to  . . 

582 

pulse-rate  in 

772 

-  carpi  radialis  brevior,  nerve 

Exclamation-mark     hairs     in 

pupillary  changes  in 

261 

supply  of . . 

550 

alopecia  areata   . . 

274 

relation   to   parenchyma- 

 longior,  nerve  supply  of 

550 

Exercise,  decreased  passage  of 

tous  goitre 

792 

ulnaris,  nerve  supply  of 

550 

urine  after 

581 

sex  incidence  of             772 

,792 

-  communis  digitorum,  spinal 

-  deficient,     effect     on     uric 

shortness  of  breath  in  . . 

100 

nerve-root  supplying     . . 

543 

acid 

817 

signs  of    . . 

244 

nerve  supply  of 

550 

in  etiology  of  dyspepsia 

354 

simulation    of    Addison's 

-  indicis,  nerve  supply  of     . . 

550 

-  effect  in   increasing  haema- 

disease  by 

792 

-  longus      digitorum,      nerve 

tm-ia  in  vesical  calculus 

629 

skin  changes  in  . .        261 

792 

supply  of . . 

542 

micturition     in     vesical 

spasmodic  contractions  in 

159 

hallucis,  hypertrophy  of 

164 

■    calculus 

438 

staring  eyes  in   . . 

772 

nerve  supply  of 

542 

on  rheumatic  pains 

507 

Stellwag's  sign  in         253, 

792 

spinal         nerve  -  root 

-  hsemoglobinuriafi-om 

315 

sweating  in 

797 

supplying     . . 

543 

-  in  health,  shortness  of  breath 

systolic  bruit  in 

244 

pollicis,  nerve  supply     . . 

550 

in  .  . 

100 

tachycardia  in   244,  253, 

-  minimi  digiti,  nerve  supply 

550 

-  want  of,  causing  obesity  . . 

453 

771,  772,  792,  797 

849 

-  ossis     metacarpi     pollicis. 

Exertion,  effect  on  muscle  pains 

478 

thyroid  eland  enlargement 

m 

escape  in  lead  palsy 

77 

pulse-rate   in    myocardial 

244,  253,' 527,  772,  792,797 

,849 

nerve  supply  of 

550 

affections 

526 

occasionally  absent 

527 

-  plantar   reflex  (see    Babin- 

in  raising  temperature  of 

tremor  in             244,  253, 

ski's  Sign) 

81 

body  in  health 

619 

772,  792,  795,  797 

849 

Extensors     of     wrist,     spinal 

on  sciatic  pain    . . 

487 

ulceration  of  the  cornea  in 

807 

nerve-root  supplying 

556 

symptoms  of  cervical  rib 

554 

undue    abdominal    aortic 

External     auditory      meatus, 

-  in  etiology  of  aneurysm     . . 

538 

pulsation  in     . . 

592 

caries  of    . . 

469 

-  hernia  produced  by 

740 

von  Graefe's  sign  in 

253 

cerebrospinal  fluid  from 

468 

-  increase  of  alcoholic  tremor 

EXOPHTHALMOS      .. 

253 

condylomata  of 

469 

by 

797 

-  some  causes  of 

200 

diphtheria  of   . . 

469 

-  influence  upon  pain  due  to 

-  epiphora  from 

250 

eczema  of 

468 

heart  failure 

485 

-  in  exophthalmic  goitre 

epithelioma  of . . 

469 

in  intermittent  claudi- 

527, 627,  772,  792 

797' 

foreign  body  forgotten  in  469 

cation 

489 

-  intermittent,     in     arterial 

in,  ruptured   tym- 

 on  tremor 

796 

aneurysm 

255 

panum  from     . . 

468 

in  Graves'  disease     792 

,797 

-  in  myopathy 

260 

furunculosis  of 

469 

-  palpitations  due  to 

528 

-  from  thrombosis  of  cavern- 

 herpes  in  facial  paralysis 

536 

-  relation  to  angina  abdomi- 

ous  sinus 

651 

injury  of 

467 

nalis 

486 

-  ulceration  of  the  cornea  in 

807 

otorrhcea  from 

469 

pectoris            .  .481,  482 

778 

-  unilateral      .  .          .  .         254, 

754 

polypi  of 

469 

-  tachycardia  from   . . 

772 

Exostosis,  ankylosis  of  joints 

rodent    ulcer    of    (see 

Exhaustion 

619 

from 

167 

Rodent  ulcer) 

-  on  exertion  in  hepatoptosis 

07 

-  bursa  covering 

754 

suppurating    sebaceous 

-  in  obstructed  labour,  sym- 

- composition  of 

754 

cyst  of 

469 

ptoms  of              .... 

229 

-  heredity  in  . . 

754 

syphilitic  ulceration  of 

469 

-  subnormal  temperature  in  619,621 

-  ivory,  in  the  auditory  meatus 

754 

-  cutaneous  nerve,  skin  distri- 

Exopllilialmic goitre,  age  inci- 

 of  bones  of  the  skull     . . 

754 

bution   of . . 

659 

dence  of    . .          .  .         772 

792 

displacement  of  eye  by. . 

754 

neuralgia  of     .  . 

488 

albuminuiia  in    . . 

16 

-  multiple 

754 

-  iliac  artery  (see    Aneurysm 

-  -  amenorrhoca  in    . . 

23 

-  pedunculated  tumour  m  . . 

754 

of  External  IliacJ 

breathlessness  in 

792 

-  popliteal       

763 

-  plantar  nerve,  muscles  sup- 

 cachexia  in 

115 

age  incidence  of 

763 

plied  by  . . 

542 

chloasma  in 

574 

association  with  exostoses 

spinal     roots     derived 

Dalrymple's  sign  in 

792 

elsewhere 

763 

from . . 

542 

-  -  defective  winking  power  in 

261 

common  situation 

763 

-  popliteal     nerve,      muscles 

diagnosis  of 

772 

diagnosis    from    ossifica- 

supplied by 

542 

distinction  from  paroxys- 

tion   of    a    tendon    or 

skin  distribution  of    . . 

659 

mal   tachycardia 

772 

muscle  . . 

763 

spinal     roots     derived 

enlarged  heart  in          232 

244 

presence  of   exostoses   in 

from . . 

542 

epiphora  in 

250 

other  members  of  family 

763 

-  rectus  muscle  paralysis  with 

excitability  in     . . 

244 

slow  growth  of    . . 

763 

peripheral  facial  paralysis 

536 

exophthalmos  in 

tumour  well-defined  in  761, 

763 

Extra-uterine    gestation    (see 

527,  627,  772,  792, 

797 

without  symptoms 

763 

Gestation,  Ectopic) 

occasionally  absent  in 

527 

-  spurious 

754 

Extravasation    of    urine    (see 

extreme  nervousness  in 

-  tumour  capped  with  cartilage 

754 

Urine,  Extravasation  of) 

253,  772,  792, 

849 

-  ungual    phalanx    of    great 

Extroversion  of  bladder 

587 

eyelids  retracted  in 

792 

toe  a  conmion  site  for     . . 

754 

EYE,     ACUTE     INFLAIVIIVIA- 

facies  of  (Fig.  85) 

261 

-  unilateral     exophthalmos 

TION   OF 

255 

flushing  hi 

261 

due  to      .  .          . .        254, 

255 

-  atrophy  of,  from  iritis 

839 

goo 


EYE,    BURNING— FJECES,    BLACK 


Eye,  contd. 

-  burning,  pricking,  or  water- 

ing    of     from     error     of 
refraction 

-  conjugate   deviation   of,    in 

liemiplegia 
in  cerebellar  lesions 

-  dilatation   of    blood-vessels 

of,  in  arterial  aneurysm 

-  diseases,  headache  from 
epiphora  in 

-  -  neviralgia  from    . . 

photophobia  in  . . 

tenderness  of  scalp 

vertigo  due  to     . . 

-  displacement  of,  cause  of. . 
bj"-  dermoid  cyst  . . 

ivory  exostosis    . . 

-  epiphora  in  inflammation  of 

-  herpes  zoster  of 

-  inability     to     close,     from 

facial  paralysis   . . 
in  hemiplegia 

-  light  flashes  before,  relieved 

by  epistaxis 

-  limited  movement  in  cavern- 

ous sinus  thrombosis 

-  melanotic  sarcoma  of 

-  murmur  from  aneurysm    . . 

-  nmscles  of,  abnormalities  in 

congenital  exophthalmos 

in  mvasthenia  gravis  (Fig. 

83",  p.   261)       .  .  225, 
myopatliy 

-  cedema  of,  in  trichinosis  . . 
EYE.      OPHTHALMOSCOPIC 

APPEARANCES      OF 
(Plales    VIl,    nil) 
EYE,  PAIN  IN 

-  paresis   of    muscles     of,    in 

diphtheria  .  .  . .         77, 

-  protrusion   of   (see    Exoph- 

thalmos) 

-  puffiness     of,     in     Bright's 

disease  and  oedema  simu- 
lating 

-  pulsation  from  aneurysm  . . 

-  retraction  of  (see  Enophthal- 

mos) 

-  sarcoma  of  . .  . .         279, 

-  shifty,  of  drug-takers 

-  signs  of  jaundice  in 

-  staring  (see  Exophthalmos) 

-  sunken    in    zymotic    diar- 

rhoea of  infants   . . 

-  tension  of,  in  conjunctivitis, 

iritis,  and  glaucoma 

in    paralysis    of    cervical 

sympathetic     . . 

-  tremor  of  (see  Nystagmus) 

-  tuberculosis  of 
Eyebrows,  seborrhceic  eczema  of 

-  falling  out  of,  in  myxoedema 

-  sycosis  vulgaris  of  . . 
Eyelashes,  pediculosis  of 

-  sycosis  vulgaris  of  . . 
Eyelids,    affected,    in    nuclear 

facial  paralysis   .  . 

-  chancre  of   .  . 

-  coloured  sweat  of  . . 

-  drooping  of  (see  Ptosis) 

-  epithelioma  of 

-  aversion     of,      in     clironic 

marginal  blepharitis 

-  oedema   of  (see  Q'idema  of 

Eyelids) 

-  pigmentation  in  exophthal- 

mic goitre  . .         2-14, 

-  puffiness  in  myxoedema     .  . 

-  quivering  of  in  hysteria  and 

malingering 

-  red  and  engorged  in  cavern- 

ous sinus  tlirombosis     .  . 

-  retraction  in  Graves'  disease 


254 
419 
255 


260 
504 


461 
494 


640 


160 


Eyelids,  contd. 

-  retraction  in  paralysis  agitans  262 

-  stitching  of,  in  perforation  of 

corneal  ulcer       . .          . .  807 

-  thickening  in  cretinism     . .  258 

-  tuberculosis  of         . .          . .  445 

-  xanthelasma  of,  in  jaundice  360 

-  xanthoma  planum  of        . .  805 
Eyestrain,  headache  in  327,  329,  498 

-  migraine  from         . .          . .  495 

-  pain  behind  eyes  in         495,  498 

-  supra-orbital  pain  from    . .  495 

FACE,  acne  afEecting  531,  604 

-  actinomycosis  of     . .          . .  810 

-  acute  swelling  of,  by  gas  . .  231 

-  alcoholic  tremor  of             . .  797 

-  anesthesia    of,    in   syringo- 

myelia      . .          . .          . .  664 

-  asymmetry  of,  in  myasthenia  261 
with  spastic  paralysis  . .  540 

-  athetotic  contractions  of  . .  154 

-  atrophy  of   . .          . .          . .  75 

-  bloody  sweat  of      . .          . .  715 

-  colloid  milium  of    . .          . .  805 

-  coloured  sweat  of  . .          . .  714 

-  congestion     of,     iii     mitral 

regurgitation        . .          . .  238 

-  dusky    or   livid    in   spleno- 

megalic  polycythoemia  . .  ■  581 

-  enlargement  of  all  the  bones 

of,  in  acromegaly            . .  749 

-  epithelioma  adenoides  cysti- 

cum  of      . .          . .          . .  805 

-  erythema  papulatum  of    . .  531 

-  flushing  in  diabetes            . .  292 

-  healed  gvaama.ot(Figs.  156, 

157)           589 

-  hemiatrophy   of  (Fig.  141, 

p.  537)     ..  ..         167,537 

-  herpes  simplex  of  . .          . .  829 

-  hyperostoses  of  bones  of,  in 

leontiasis  ossea   . .          . .  749 

-  lichen  scrofulosorum  of      . .  529 

-  lupus  erythematosus  of     . .  656 
vulgaris  of           . .          . .  808 

-  meningocele   of  (Fig.  75) . .  254 

-  mercurial  tremor  of            . .  797 

-  motor  tics  afEecting            . .  160 

-  movements  in  chorea         . .  156 

-  multiple  benign   sarcoid   of  451 

-  muscular  twitch  ings   of,   in 

petit  mal. .          . .          . .  160 

-  cedema  of   (see   Qildema   of 

Pace) 
FACE,  PAIN   IN         ..         ..495 
in  antral  empyema         . .  205 

-  papular  syphilides  of          . .  532 

-  pemphigus    neonatorum    of  446 

-  pigmented  in  xerodermia  . .  804 

-  pityriasis  rosea  of  . .          . .  658 

-  preference   of   impetigo  for  604 
small-pox  for       . .          . .  605 

-  pustular  syphilides  of         .  .  604 

-  rarity  of  scabies  on  609,  832 

-  roseolar  rash  on,  in  syphilis  675 

-  scrofulous  ulceration  of     . .  808 

-  sebaceous  cyst  of  . .          . .  804 

-  seborrhoea  of          . .         656,  657 

-  seborrhceic     dermatitis     of 

infancv  affecting             . .  447 

-  segmental    areas    of    (Figs. 

132-13.5)                ..         '..  407 

-  spasm  of,  in  hysteria         . .  537 

major  trigeminal  neuralgia  495 

tetanus   ^ 162 

FACE,    SWELLING    OF    (see 

Swelling  of  Face) 

-  sm-gical  emphysema  of      . .  231 

-  sycosis  vulgaris  of  . .          . .  602 

-  tremor  of      . .  . .         795,  797 
in  general  naralysis  of  the 

insane  .'.        "  . .         172,"  796 

-  twitching  of,   during  rigors  646 


262 


258 
749 
159 
C51 
59 


259,  446 
216,  258 
253,  261 


796 

652 
214 


Face,  contd. 

-  type  carr^e   in   acromegaly     263 

-  ulceration  of  (see  Ulceration) 

-  unusual  breadth  in  cretinism   258 

-  varicella  affecting  . .  . .     833 
Facial   changes   in   7th  nerve 

paralysis  . .  . .     533 

-  neuralgia,  varieties   of   (see 

Neuralgia) 

-  paralysis  (see  Paralysis,  Facial) 

-  tic,  chorea  simulatinsj        . .     156 
FACIES,     ABNORMALITIES 

OF  

-  of  acromegaly  (Fig.  88) 

-  bulbar  paralysis 

-  in  catalepsy 

-  cirrhosis 

-  congenital  syphilis  (Figs. 

79) 

-  cretin  (Fig.  67) 

-  of  exophthalmic  goitre 

-  expressionless    in    paralysis 

agitans      .  .  .  .         259 
from  sclerodermia 

-  ferret-like,  in  microcephaly 

-  Hippocratica  in  peritonitis  133,431 

-  hysterical,  contortion  of   .  .     652 

-  in  lardaceous  disease  . .       39 

-  mitral  stenosis        . .  61,  773 

-  Mongolian  idiocv  (Figs.  89, 

90,  91,p.  263) '216, 217,  263,  264 

-  mvasthenia    gravis      (Figs. 

83,  84)      . .  . .         ". .     260 

-  myopathy  (Figs.  81,  82)  . .     260 

-  myxcEdema   (Figs.    76,    77, 

p.  259)  43,  259,  454,  585 

-  paralysis  agitans  (Fig.  86) 

259,  261,  541,  796 

-  pericarditis  . .  . .  . .     480 

-  pernicious  ansemia  . .  . .       76 

-  rat-like,  in  microcephaly  . .     214 

-  simple  colic 

-  starchy,    in    pseudo-bulbar 

paralysis 

-  in  tabes  (Fig.  87)    . . 

Facio-scapulo-humeral  myo- 
pathy, fibrillary  contrac- 
tions rare  in 

Fsecal  accumulation  in  caecum 
m  malignant  growth  of 
colon 

colicky  pain  in  loin  from 

-  in  colon    . .         . .       393 

age  incidence  of 

characters  of  mass  in . . 

constipation  with       145,  692 

diagnosis     from     renal 

tumour         . .  . .     393 

splenic  tumour        . .     691 

movement    of    tumour 

with  respiration     . .     406 
pain  in  left  hypoehon- 

drium  from  . .  . .     499 
simulating    enlargement 

of  liver         . .  . .     406 

enemata   in   diagnosis   of 

393,499,  501,  691 

flatulence  with    . .  . .     393 

obstruction  due  to        145,  692 

occurrence     in     spite     of 

daily  action  of  bowels 

pain  in  iliac  fossae  from 

tumour  in  loin  from 

-  fistula     of     umbilicus      in 

tuberculous  peritonitis     51,  57 

-  odour  in  vomit  (see  "\^omiting, 

Fseculent) 
Faeces,  acid,  in  pancreatitis  . . 

-  alkaline,     in    gall-stone 

obstruction 

-  ankylostomum  ova  in 

-  ascaris     lumbricoides     and 

ova  in 

-  black 


133 

686 


158 


394 
393 
692 
692 
692 


393 
501 
393 


117 


117 
94 


364 
89 


FMCES,    BLOOD    IN— FEET,    TREMOR    OF 


go  I 


Faeces,  could. 

Pieces,   could. 

Fatigue,  contd. 

-  blood  in  (see  Blood  per  Anum, 

-  test  for  bile  in 

197 

-  pains  in  limbs  due  to 

508 

and  Melaena) 

-  tubercle  bacilli  in    . . 

427 

-  spasmodic  contractions  from 

159 

-  characteristics    in     case    o£ 

-  typhoid  bacilli  in    . . 

610 

-  tremor   from              795,  797, 

798 

"  ^eedy  colon  " 

143 

-  worms  in  (see  Worms,  Intes- 

Fatness,   excessive    (and    see 

colic 

134 

tinal) 

Obesity) 

453 

colitis 

134 

Faeculent  vomiting  (see  Vomit- 

 due  to  hypernephroma 

454 

infantile  colitis   . . 

92 

ing,  faecal) 

-  with  thymic  infantilism    . . 

215 

-  -  pancreatic  cyst   . . 

724 

Painting,  associated  with  flush- 

Fatty acid  crystals  in  faeces  in 

in  pancreatitis              116, 

117, 

ing  (and  see  Corna) 

268 

pancreatitis          . .        117, 

135 

135,  364, 

724 

Faintness   in   angina    pectoris 

481 

formed   during    putrefac- 

- Charcot-Leyden  crystals  in 

-  due  to  arsenic 

297 

tion 

283 

117, 

118 

-  on  change  of  position  due  to 

-  casts,   renal . . 

7 

-  clay -coloured   from  chronic 

aortic  disease 

233 

-  heart  (see  Heart,  Fatty) 

pancreatitis 

724 

-  in  fatty  heart 

241 

-  infiltration,  cardiac             62, 

241 

in  obstruction  of  common 

-  hepatoptosis 

407 

-  liver  (see  Liver,  Fatty) 

bile-duct 

362 

-  paroxysmal  tachycardia   . . 

772 

FATTY  STOOLS 

2G5 

-  coloration  in  jaundice      361, 

365 

-  preceding  hoematemesis     . . 

316 

in  pancreatic  disease     59, 

135, 

-  -  consenital  obliteration  of 

-  from     rupture     of     extra- 

197, 292,  364, 

366 

bile-ducts 

365 

uterine  gestation 

436 

infantilism 

216 

rectal  lismorrhase 

89 

Fallopian  canal ,  effects  of  lesion 

-  superposition  of  heart       62, 

241 

suppurative  pylephlebitis 

649 

of  facial  nerve  in 

537 

Fauces,  carcinoma  of    420,  670 

673 

-  condition  of  fat  in,  in  pan- 

- tubes,   absence    of,  sterility 

-  gumma  of     . .          . .        670, 

673 

creatic  lesions 

116 

due  to 

706 

-  inflammation  of 

673 

-  delayed     passage      of,      in 

affection    of,    simulating 

-  mucous  patcli  on,  in  secon- 

intestinal   constipation.. 

141 

movable  kidney 

727 

dary  syphilis 

675 

-  distoma  eggs  in 

364 

inflammation     of,     sub- 

- reddeniag  of,  in  scarlet  fever 

-  discharge      per      urethram 

phrenic  abscess  from. . 

720 

and  erythema  scarlatini- 

In  rectal  carcinoma   313 

633 

new    growtli    of,    pelvic 

forme 

253 

-  dry  and  liard  in  diabetes  . . 

141 

swelling  due  to 

757 

-  simple  ulceration  of 

670 

-  eggs  of  parasites  in 

tumour    of,     swelling     in 

-  spastic,     in    pseudo-bulbar 

04,  364,  569, 

621 

hypogastrium  from     . . 

730 

palsy 

086 

-  enormous  accumulations  of 

718 

Falls  a  cause  of  deafness 

191 

-  tuberculosis  of        . .        670, 

073 

-  examination      in      tropical 

Familial    cliaracter    of    acute 

FavUS,  alfecting  nails  271,  275 

445 

dysentery 

91 

rheumatism                    121 

671 

-  baldness  froin 

84 

-  fat  "in  (see  Fatty  Stools) 

angioneurotic    cedema   . . 

457 

-  body  and  scalp  {Fig.  93)  . . 

271 

-  gall-stones  in    iSo,  300,  363 

621 

congenital  diplegia 

800 

-  crusts  in      . .          . .        270, 

653 

-  with  gas  passed  per  urethram 

576 

Friedreich's  ataxy         559, 

560 

-  description  of  lesions  of     . . 

270 

-  hard  and  bulky,  dyschezia 

-  -  gout          . .          . .        381, 

383 

-  diagnosis  from  alopecia    . . 

272 

due  to 

150 

iisemophilia 

599 

eczema  and  seborrhoea  . . 

272 

-  heat  loss  in. . 

619 

Hanot's  cirrhosis 

369 

lupus  erythematosus     . . 

272 

-  incontinence  of  (see  Incon- 

 hereditary  optic  atrophy 

838 

psoriasis  of  the  scalp 

271 

tinence) 

-  -  jaundice   . . 

362 

ringworm  of  scalp 

274 

-  insufficiency  of  quantity  of 

140 

Milroy's  disease  . . 

456 

-  distribution  of 

270 

-  microscopical  characters  in 

merycism 

431 

-  loss  of  lustre  of  hair  in 

270 

pancreatitis 

117 

myopathy              555,  559, 

560 

-  "  mousey  "  smell  in  270,  271 

272 

examination  in  detecting 

pavor  nocturnus 

357 

-  mycelium  in 

270 

cause  of  flatulence 

268 

phthisis 

848 

-  scarring  in  . .          . .         270, 

272 

FAECES,  MUCUS  IN 

443 

primary    muscular     dys- 

- spores  in 

270 

-  -  from  anal  fistula 

92 

trophies             555,  559, 

560 

-  sulphur  yellow  discs  in 

270 

-  -  in  arsenical  poisoning    . . 

92 

pseudo-hypertrophic  mus- 

- tenderness  of  scalp  from  780 

781 

biUiarziasis 

93 

cular  paralysis 

560 

_  -  transmission   from   animals 

270 

in  carcinoma  of  bowel 

retinitis  pigmentosa 

838 

'  Febricula  in  children 

621 

1.50,  152,  393,  636,   690, 

736 

splenomegalic   cirrhosis.. 

693 

-  diagnosis  from  influenza   . . 

505 

-  -  from  colitis     134, 144,  197 

727 

Tooth's  peroneal  atrophy 

-  pains  in  the  limbs  in         503, 

505 

dysentery . .         . .           90, 

727 

132,  559, 

560 

-  prostration  with     . . 

505 

in   enterospasm   .  . 

486 

Famine  and  filth  in  causation 

-  real  nature  of 

505 

Henoch's  piurpura 

600 

of  relapsmg  fever         373, 

698 

Febrile  albuminuria   . . 

17 

from   intussusception 

Faradism  in  reaction  of  degen- 

- albumosuria 

20 

14S,  152,  196,  636,  727, 

736 

eration 

633 

Feet,    anaesthesia    of,    vertigo 

invagination  of  rectum.. 

150 

Fascia,  gonococcal  inflammation 

from 

827 

from  pelvic  abscess 

474 

of 

376 

-  in  acromegaly           585,  749 

-753 

oxyuris  vermicularis 

93 

-  palmar,    Dupuytren's    con- 

- athetotic  contractions  of  . . 

154 

in  rickets . . 

171 

tracture  of 

167 

-  bloody  sweat  of 

715 

simple  colitis  of  infants. . 

92 

-  rheumatic  nodules  in 

452 

-  broad  in  myxoedema   454,455 

,585 

spastic  constipation 

145 

Fascicular  muscular  twitchings 

157 

-  bromidrosis  of 

714 

in  stomach,  estimation  of 

Fastigium  during  rigors 

646 

-  buUte     of,      in     congenital 

excess  of 

355 

Fat,  emulsifled,  in  urine  (and 

syphilis     .  . 

111 

ulcerative  colitis             92, 

727 

see  Chyluria) 

126 

-  cheiropompholyx:  of         654, 

832 

-  occult  blood  in,  in  carcinoma 

-  in  fsces  in  pancreatitis 

116 

-  cold  and  blue,  ia  paralytic 

of  colon    . . 

145 

-  jaundice 

361 

talipes       .  .          .  .         130, 

131 

FAECES,  PASSED  PER  URE- 

- necrosis    in    acute    hemor- 

- erytliema  nodosum  affecting 

450 

THRAM,  commoner  causes 

264 

rhagic  pancreatitis 

-  -  keratodes  of 

451 

in  carcinoma  of  rectum 

153,  431,   646, 

846 

papulatum  of 

531 

or  colon        . .         313 

633 

Fatigability    in    neurasthenia 

788 

-  in  erythromelalgia  .  . 

490 

simulation   by    cystitis 

264 

-  in  disseminated  sclerosis  . . 

174 

-  cedema  of  (see  ffidema) 

-  pu^  in  (see  Pus  in  Stools) 

-  myasthenia  gravis  (Fi/;.  83, 

-  pruritus  of   .  . 

588 

-  reactions  of              . .         117 

197 

p.  261)       

687 

-  scabies  affecting 

609 

-  ribbon-like,  in  rectal  cancer 

93 

Fatigue,    cause  of  convulsions 

169 

-  sweating  of,  in  rheumatoid 

-  sand  in 

652 

-  in  etiology  of  dyspepsia     . . 

354 

arthritis    . . 

378 

-  shreds  and  casts  in 

134 

-  alcoholic  tremor  increased  by 

797 

-  swelling  of,  in  angioneurotic 

-  simulating  enlarged  liver  .  . 

406 

-  hsemoglobinuria  in 

315 

cedema 

459 

-  tape- worm  ova  in   . . 

569 

-  in  malingerers 

464 

-  tremor  of  from  alcohol 

797 

-  tarry 

89 

-  muscular    twitchings    from 

157 

-  (and  see  Soles  of  Feet) 

902 


FEH LING'S   SOLUTION— FIBROMYOMA 


Feh ling's  solution   in  estima- 
tion of  sugar        . .          .  .  291 

reduction  in  alkaptonuria  822 

carboluria         . .          . .  823 

by  homogentisic  acid  . .  822 

uric  acid           . .          . .  818 

-  test  for  sugar,  albuminuria 

and            290 

sources  of  error  . .          . .  290 

Femoral  abscess        . .        . .  732 

-  aneurysm    (see    Aneurysm, 

Femoral) 

-  hernia  (see  Hernia,  Femoral) 

-  region,  definition  of           . .  732 

ectopic  testis  in  . .          . .  733 

fibroma  of  .  .        733,  734 

lipoma  of..          ..        733,  734 

sarcoma  of          . .        733.  734 

swelling  of,  due  to  osteo- 

artliritis  of  hip  joint  . .  734 
due  to  parametric   ab- 
scess    734 

(see  Swelling,  Femoral) 

-  vein,    thrombosis     in     (see 

Thrombosis) 
Femur,  endosteal  sarcoma  of, 
diagnosis    from     chronic 

osteitis 763 

periostitis             . .  763 

popliteal  swelling  due  to  763 

-  exotosis  of  (Fig.  194)         . .  763 

-  injuries   of,   causing   sciatic 

nerve  paralysis   !^ .          . .  542 

-  myeloid  sarcoma  of            .  .  756 

-  necrosis    of    lower    end    of, 

popliteal  abscess  due  to  762 

-  osteitis  of,  after  typhoid  fever  376 

-  sarcoma  of,  bruit  over     . .  762 
diagnosis  of         . .          . .  762 

-  separation  of  lower  epiphysis 

of 763 

Fenestra     rotunda,     pressure 

on,  vertigo  due  to         . .  828 

Fermentation,  borborygmi  from  97 

-  gastric,  sarcinn?  and  yeasts  in  267 

-  heartburn  from       . .          . .  333 

-  in  pyloric  obstruction       . .  134 

-  starch  cells  in  faeces  in   197,  268 

-  test  in  glycosuria       290,  291,  818 
for     glucose,     possible 

fallacies    . .          . .          . .  291 

as   quantitative   test   for 

glucose              . .          . .  291 
Ferments   in   pancreatic   cyst 

fluid          53 

-  in  stomach  contents,  test  for  355 
Ferret-like    facies    of    micro- 
cephaly    . .          .  .          .  .  214 

Ferric    chloride    reaction    for 

alkapton  . .          . .          . .  822 

after  carbolic  acid,  etc.  196 

diaceturia         .  .          .  .  196 

melanuria          .  .          . .  821 

no  reaction  with  indican  821 

Festination  in  paralysis  agitans  796 
Fever  (see  Pyrexia  and  Hyper- 
pyrexia) 
Fevers,  acute,  anuria  in          45,  48 

dilatation  of  heart  from. .  243 

endometritis  in    . .          . .  429 

infectious,  bacteriuria  in  83 

epistaxis  in       . .          . .  251 

infantile  convulsions  in  170 

nerve  deafness  after  . .  190 

transverse  myelitis  due  to  565 

-  albuminuria  in        . .          . .  17 

-  amenorrhcea  due  to           . .  23 

-  baldness  after         . .          . .  84 

-  bleeding  gums  in  85,  87 

-  Cheyne-Stokes  respiration  in  125 

-  club-foot  arising  from       . .  133 

-  coma  in        . .          . .          .  .  136 

at  onset  of           . .          . .  646 

-  congestion  of  liver  in         . .  371 


Fevers,  conld. 

-  constipation  in       . .         143, 

-  convulsions  of  children  in . . 

-  cramps  after 

-  delirium  in  . . 

-  diazo-reaction  in     . . 

-  eosinophilia  after   . . 

-  encephalitis  after    . . 

-  enlarged  spleen  in.. 

-  epistaxis  in. . 

-  extreme  thirst  in    . . 

-  fatty  heart  following 

-  hsematuria  in 

-  hsemoptysis  in 

-  hoemorrhagic  erosions  in  . . 

-  headache  in 

-  hyperfESthesia  acustica  in 

-  insomnia   in 

-  inspissation  of  bile  in 

-  loss  of  taste  in 

-  matutinal    hypothermia    in 

-  metastatic  orchitis  in 

-  mitral  regurgitation  in      239 

-  necrosis  of  jaw  in. . 

-  polyuria  in  . . 

-  prolonged  pyrexia  from     . . 

-  purpura  in  various 

-  pyelitis  in   . . 

-  pyrexia    in    children    with- 

out obvious  cause,  due 
to  onset  of 

-  rapid  pulse  in 

-  shortness  of  breath  in 

-  specific,  acute  general  pains 

in  the  limbs  in    . . 
tetany  following  . . 

-  tache  c6r6brale  in  . . 

-  thrombosis  of  spinal  artery 

from 

-  tinnitus  in   . . 

-  Tooth's    peroneal    atrophy 

developing  after 

-  transverse    myelitis  due  to 

564, 

-  urate  deposit  in 

-  uric  acid  in  . . 

-  vomiting  at  onset  of 
Fibrillar  contractions.. 

in     amyotrophic     lateral 

sclerosis 

atrophic  palsy  of  arm.  .  . 

chronic  poliomyelitis 

in     lesions      of     central 

nervous  system 

progressive        muscular 

atrophy 

rare  in  primary  myopathy 

of  tongue  in  bulbar  para- 
lysis 

AVerdnig-Hoffmann  pro- 
gressive muscular 
atrophy  of   infants 

Fibro-adenoma  of  breast  (see 
Breast,  Fibro-adenoma  of) 

Fibroid     heart    (see    Heart, 
Fibroid) 

-  lung  (see  Lung,  Fibrosis  of) 

-  tumours,  cachexia  in 

-  of  uterus  (see  Fibromyoma 

of  Uterus) 

-  of  vaginal  wall 
Fibroma  of  breast 

-  of  femoral  region     . .        733, 

-  larynx  mistaken  for  asthma 

-  mediastinal,  varicose  thora- 

cic veins  from 

-  moUuscum,  distinction  from 

lipoma 

sebaceous  cyst 

von     Recklinghausen's 

disease  (Fig.  201)  . . 

-  nasal  . .       '  . . 
epistaxis  due  to. . 

-  recurrent,  of  basi-sphenoid 


153 
169 
179 
195 
198 
248 
155 
692 
251 
789 
241 
.305 
318 
298 
328 
190 
356 
364 
774 
346 
680 
243 
747 
583 
609 
596 
625 


622 
771 
100 

503 
178 
771 

564 
794 

560 

565 
815 
817 
843 
157 

554 
549 
165 


165 
158 


587 
744 
734 
582 

820 

804 
804 

781 
204 
250 
204 


428 


758 
429 


429 
473 


429 


759 
434 
434 


760 
429 
758 
758 
587 
759 
439 
1.50 
219 
227 
759 


Fibroma,  conld. 

-  simulated  by  dermoid  cyst      804 

-  of  vulva       .  .  .  .         768,  771 
Fibromyoma  of  round  ligament 

(see  Round  Ligament) 

-  of  uterus      

absence  of  hasmorrhage  in 

sub-peritoneal. . 

menorrhagia  in 

asymmetrical  enlargement 

of  uterus  in     . . 

bearing-down  pain  from 

connection     with    uterus 

determined  by  bimanual 

examination     . .        392, 
constant  bleeding  due  to 

sloughing  of     . . 

conversion  into  carcinoma 

sarcoma 

cystic  degeneration  of 

429,  434,  759 
diagnosis     from     ectopic 

gestation 

ovarian  cyst    . . 

tumour 

pregnant  uterus 

of  prolapse  from 

solid  ovarian  tumour 

difficult  micturition  from 

dyschezia  from  . . 

dysmenorrhosa  from     . . 

dystocia  due  to  . . 

extrusion  of        . .        434 

after   labour,  inversion 

of  uterus  mistaken  for  587 

fluctuation  in  softening  of     758 

fluid  thrill  m,  from  cystic 

degeneration    . .  . .     4.29 

frequency  of  micturition  in  438 

hardness  of  tumour  in  . .     429 

histological  diagnosis     . .     434 

infection  of  extruded     . .     759 

irregular  outline  of  tumour  429 

length  of  uterine  cavity 

increased  in     . .  . .     429 

median  position  of        . .     392 

menorrhagia  in     428,  758,  759 

metrorrhagia  from       433,  435 

necrobiosis  in 

nephritis  from     . . 

obstructing  labour 

obvious  pelvic  origin  of . . 

often  multiple     . . 

passage  of  uterine  sound  in  429 

pelvic  swelling  due  to    757,  758 

rapid  growth   of  tumour 

indicative  of  degenera- 
tion of 

relation  to  metrorrhagia 

of  round  ligament       741, 

sarcomatous  degeneration 

of  . .  . .        434, 

—  -  simulated  by  inversion  of 

uterns    . . 

simulating  sciatica 

sarcoma 

sloughing  of 

diagnosis  from  malig- 
nant disease 

foul   vaginal   discharge 

due  to 

softening  from  degener- 
ative changes  . . 

in  pregnancy    . . 

spasmodic     pelvic     pain 

from  expulsion  of 

sterility  due  to  .  . 

strangulation  of.. 

subperitoneal,  absence  of 

elongation  of  uterine 
cavity  in 

—  swelling  in  iliac  fossa  from    737 

—  tumour  and  cervix  move 

tosether  in      . .  . .     429 


759 


392 

434 


759 
434 
768 

759 

587 

74 

4S4 

759 

759 

211 

429 
759 

509 
706 
434 


429 


FIBROMYOMA     OF    VAGINA— FLUTE-PLAYER' S   CRAMP 


903 


Fibromyoma,  could 

FINGERS,  SORE 

26G 

Flatulence,  conld. 

-  of  vagina 

768 

-  test  for  movements   of,   in 

-  atonic  constipation 

143 

ii'ibro-lipomata  of   abdominal 

hysterical     and    cerebral 

-  borborygmi  with     . . 

97 

waU           

716 

paralysis  . . 

548 

-  with  chronic  gastritis 

845 

Fibro-sarcoma,  nasal 

204 

-  tremor  of,  in  Graves'  disease 

-  diagnosis  from  morycism  . . 

431 

-  of  naso-pharynx,  snoring  due 

244,  253,  772, 

849 

-  in  dyspepsia. . 

354 

to 

669 

-  tingling  and  numbness   in. 

-  from  faecal  accumulation  . . 

393 

Fibrosis  of   mediastinum  (see 

in  acroparoestliesia 

493 

-  foul  breath  with 

90 

Mediastinum,  Fibrosis  of) 

-  tuberculous  disease  of  skin  of 

266 

-  in  functional  stomach   dis- 

Fibrous tissue  inflammation,  in 

-  ulnar  flexion  of  (Fig.   108) 

orders 

267 

rheumatism  in  cliildren 

504 

379, 

380 

-  with  gall-stones 

350 

Fidgetiness,  excessive 

156 

Firemen,  enlarged  left  ventricle 

-  in  gastric  atony     . . 

267 

Figs,  oxaluria  from    . . 

471 

in  . . 

232 

dilatation 

267 

Fifth  nerve   affected  in  bulbar 

First  lumbrical,  nerve  supply 

fermentation  in  . .          ._, 

267 

paralysis  . . 

159 

of 

542 

offensive  eructations  in.. 

267 

anaesthesia  of,  from  tumour 

-  sound   abnormal  in   hyper- 

- interscapular  pain  from     . . 

474 

of  mid-brain    . . 

708 

trophy  of  ventricles 

331 

-  intestinal 

267 

herpes  of . . 

781 

Pish,  fried,  colic  due  to 

136 

colicky  pains  in  . . 

267 

lesions,  ptyalorrhoea  from 

-  urticaria  from 

746 

spasmodic  pelvic  pain  in 

509 

591, 

592 

Fishbone  in  oesophagus,  haema- 

-  loss  of  weight  due  to 

848 

motor  paresis  of  . . 

496 

temesis  from 

297 

-  may  simiTlate  dysmenorrhoea 

220 

-  -  pain  in,  from  iritis 

495 

-  in  the  rectum 

635 

-  pain  in  the  chest  from      484 

770 

paralysis,  anosmia  from  . . 

688 

Fissure,  anal  (see  Anus,  Fissure 

epigastrium  in     . . 

485 

causing  impaired  taste 

775 

of) 

left  hypochondrium  from 

499 

undue  dryness  of  nose 

-  palpebral     (see     Palpebral 

Uiac  fossa  from 

501 

from. . 

668 

Fissure) 

precordial,  from 

481 

Fiii,  filariasis  in 

33 

Fistula,  anal,  bleeding  in 

92 

-  palpitation  in 

484 

Filaria      sanguinis     hominis, 

-  causing  pneumaturia 

576 

-  simulating  heart  disease    . . 

779 

cedema  from 

455 

-  gastro-colic,  faecal  vomiting  in  845 

-  tenderness  in  the  chest  from 

779 

elephantiasis  due  to 

-  genital,  sterility  due  to     . . 

706 

-  visible  peristalsis  with 

724 

IL'6,  456,  765, 

810 

-  lumbar,  from  kidney  after 

Flatus,  passage   of,   in    acute 

-  -  -  -  of  vulva  due  to 

770 

operation 

442 

pancreatitis 

153 

embrvo      (Plate     XII, 

micturition  tlirough 

442 

intestinal  obstruction     .-. 

151 

Fig.  F)         . .         696, 

770 

-  recto-uretliral,      illustrated 

per  urethram  in  carcinoma 

lymphatic    oljstruotion 

(Fig.  170) 

637 

of  rectum  or  colon 

633 

from . . 

810 

-  recto  -  vaginal,      illustrated 

Flea-bites,  purpura  from     596 

597 

ulceration  of  the  leg  in 

810 

(Fig.  172) 

637 

Flexor  brevis  digitorum,  nerve 

Filariasis,  blood  changes  in  . . 

33 

-  recto-vesical  from  growth  264 

,633 

supply  of 

542 

-  chylous  ascites  in  . . 

58 

-  reno-colic,   from  carcinoma 

577 

haUucis,  nerve  supply  of 

542 

-  chyluria  in  .  . 

126 

-  scrotal,  general  account  of 

679 

minimi  digiti,  nerve  supply 

-  eosinophilia  in        . .         126, 

249 

from  tuberculosis  testis  518 

679 

of          ..          ..        542, 

550 

Filth  and  famine  in  causation 

-  suprapubic,  after  operation 

442 

pollicis,  nerve  supply  of. . 

550 

of  relapsing  fever 

698 

-  umbilihcal  ftecal,   in  tuber- 

- carpi  radiaiis,  nerve  supply 

550 

Fingers     affected     by     acute 

culous  peritonitis           691 

716 

ulnaris,   nerve  supply   of 

550 

rheumatism 

374 

-  -  with  tuberculous  cervical 

paralysis  of 

128 

-  athetotic  contractions  of  . . 

154 

glands 

420 

spinal  nerve  root  supply- 

- bedsore  on  . . 

266 

-  urethral,  acute 

677 

ing     

556 

-  broad,  in  myxoedema      454, 

585 

chronic 

678 

-  longus      digitorum,     nerve 

-  burning   pain    in,    in    acro- 

endoscopic  examination  in 

678 

supply  of 

542 

parfesthesia 

493 

from  gummata   . . 

209 

hallucis,  nerve  supply  of 

542 

-  burrows  of  scabies  on 

832 

perineal  excoriation  in  . . 

678 

poUicis,   nerve  supply  of 

550 

-  chancre  of   . . 

266 

pain  in. . 

516 

-  profundus  digitorum  (inner 

-  clubbed    fand   see   Clubbed 

sore  from 

677 

half)  nerve  supply  of 

550 

Fmgers)        128,  390,  411, 

703 

due  to  stricture  . . 

677 

-  sublimis    digitorum,    nerve 

-  dissection  wounds  of 

266 

-  urinary,  after  childbirth  . . 

442 

supply  of 

550 

-  eczema  of    . . 

533 

from  peri-urethral  abscess 

442 

-  of  wrist  and  long  flexors  of 

-  enlarged  in  acromegaly     . . 

128 

traumatic 

442 

fingers,  spinal  nerve  root 

-  -  pulmonary    osteo-arthro- 

urethral  stricture 

442 

supplying 

556 

pathy    . . 

128 

-  uro-biliary,  choluria  without 

Flmt's  bruit                  108,  109, 

234 

-  epidermolysis  bullosa  affecting 

266 

jaundice  in 

819 

Fluid  in  abdomen  in  bladder 

-  examination  of,  in  obscure 

-  vesical,  cystoscope  in  detect- 

injury (and  see  Ascites) 

308 

pyrexia     . . 

620 

ing 

442 

-  deficiency  in  tissues,  poly- 

-  flexed  in  brachial  monoplegia 

546 

-  vesico-colic,  due  to  carcinoma 

146 

cythaemia  due  to          579, 

580 

-  fusiform      enlargement      in 

due  to  diverticulitis 

146 

-  with  gas  in  pleural  cavity . . 

577 

tuberculous  dactylitis   . . 

751 

-  vesico-intestinal,fLeces  passed 

-  rapid   loss   of,    as   cause   of 

rheumatoid  arthritis 

378 

per  urethram  in. . 

264 

marasmus 

426 

-  gangrene  of,  duetocarcinoma 

-  vesico- vaginal,  in  carcinoma 

Fluorescence  in  urine  due  to 

of  breast  .  . 

287 

of  uterus  . . 

632 

eosin 

820 

diabetes    . . 

266 

methylene  blue  in  tracing 

442 

Fluorescin,     in    detection    of 

intrathoracic  aneurysm  . . 

287 

Fits  (see  Convulsions) 

corneal    ulceration 

806 

in  Raynaud's  disease     . . 

284 

Flaccidity  in  birth  palsies     . . 

558 

Flush,   malar,   of  myxoedema 

43 

-  -  syringom.yelia 

285 

-  in  hysterical  paralysis 

541 

FLUSHING      

268 

-  sonoooccal  arthritis  of 

376 

Flail-like  joint  in  osteo-arthritis 

384 

-  associated  symptoms 

268 

-  Heberden's  nodes  in        384, 

452 

tabetic  arthritis  . . 

388 

-  chronic 

268 

-  pads    on    dorsal    aspect    of 

Flanks,  shifting  dullness  in  . . 

393 

-  in  erythromelalgia  . .        284, 

490 

first  interphalangeal  joints 

Flat  chest  in  phthisis 

191 

-  extremities  .  . 

284 

(Fig.  114,  lln)\. 

385 

Flat-foot  from  gonorrhoea     . . 

376 

-  Graves'  disease 

261 

-  pityriasis      rubra      pilaris 

-  metatarsal  neuralgia  in 

488 

-  hysteria 

345 

papules  on 

530 

-  in  neuralgia  parcPSthetica  . . 

488 

-  local,  in  brachial  neuralgia 

491 

-  pniritus  of,  due  to  scabies 

588 

-  pain  in  tlie  foot  from 

486 

of     skin,     from     visceral 

-  scabies  affecting       588,  609, 

832 

FLATULENCE 

267 

disease  . . 

475 

-  septic  infection,  epitrochlear 

-  in  abdominal  angina       351, 

486 

-  in  paralysis  agitans 

796 

gland  enlarged  in 

422 

-  angina  pectoris         350,  481, 

779 

-  trigeminal  neuralgia 

495 

-  shape  of,  in  achondroplasia 

212 

-  asthenic  dyspepsia 

354 

Flute-player's  cramp . . 

177 

904 


FOAMING    AT   MOUTH— FRIEDLANDER'S  BACILLUS 


Foaming  at  mouth  during  con- 

Forearm, conld. 

Fracture,  fair,  contd. 

vulsions    . . 

168 

-  ulnar  anaesthesia  in,  due  to 

arch  of  jaw  irregular  in. . 

747 

in  epilepsy 

171 

cervical  rib 

493 

commonly  compound     . . 

747 

malingerers 

17.', 

Forehead,  affection  by  acne  . . 

531 

septic    . . 

747 

Focal  epilepsy. . 

161 

-  bulging    in    achondroplasia 

212 

diagnosis  difficult  in  frac- 

Foetid   bronchitis   (see    Bron- 

- coloured  sweat  of  .  . 

714 

tures  of  ascending  ramus 

747 

chitis,  foetid) 

-  congenital  syphilitic  condy- 

 ptyalism  from     .  . 

591 

-  sputum  ("see  Sputum) 

lomata  of 

446 

:r-rays  in  diagnosis  of     . . 

747 

Foetor  of  breath 

98 

-  downy   appearance   in  Mon- 

- leg,  badly  united,  ulceration 

Foetus,  position  in  utero 

228 

golian  idiocy 

263 

from 

810 

Fog  causing  coryza     .  . 

203 

-  new  growths  of 

204 

compound,  talipes  from. . 

132 

Follicular  conjunctivitis 

256 

-  retreating  in  acromegaly  . . 

263 

-  pelvis,  bladder  and  urethra 

-  impetigo      (see     Impetigo, 

-  slope  of  in  microcephaly    . . 

214 

changes  in 

308 

Follicular) 

-  writtkled,  in  acromegaly    . . 

263 

injury  of  uretlira  from  . . 

511 

-  papular  syphilides  . . 

532 

in  tabes    . . 

262 

sciatic  nerve  paralysis  from 

542 

-  tonsillitis     (see     Tonsillitis, 

Foreign  bodies  in  air-passages. 

-  rib,  empyema  from 

120 

Follicular) 

cough  due  to    . . 

175 

haemoptysis  from           317, 

320 

Folliculitis  decalvans   . . 

84 

dysphagia  from 

222 

pneumothorax  from 

578 

-  eczematous,  diagnosis  from 

fibroid  lung  and  bronchi- 

 surgical  emphysema  from 

231 

ringworm  of  beard 

271 

ectasis  from . . 

324 

tenderness  in  chest  from 

776 

Fontanelle,  delayed  closure  in 

gangrene  of  lung  from 

-  Skull,  base  of.  auditory  nerve 

rickets       . .          .  .         171 , 

695 

287,  578, 

712 

damaged  in 

468 

-  depressed  in  zymotic  diar- 

 haemoptysis  from 

318 

bleeding  from    ears    or 

rhoea  of  infants  . . 

426 

mistaken  for  asthma . . 

582 

nose  in         . .         138 

467 

Food,  absence  of  fresh,  cause  of 

pyopneumothorax  from 

712 

subconjunctival    he- 

scurvy 

85 

stridor  from     . . 

709 

morrhage  from 

256 

-  dyspepsia  from 

354 

symptoms  of    . . 

466 

tympanum  damaged  . . 

467 

-  indigestible,  colic  from 

136 

in  ear,  creaking  noises  from. 

793 

cerebrospinal    fluid   from 

-  irritating,  a  cause  of  infantUe 

deafness  from. . 

190 

ear  in                . .         138 

468 

convulsions 

170 

otorrhcea  from  forgotten 

469 

nose  after     . .         138 

203 

vomiting  from     . . 

843 

pain  from 

230 

coma  in    . . 

137 

-  particles     between      teeth, 

vertigo  due  to 

828 

deafness  from      . .          191 

794 

decomposing,    foul    taste 

in  eye,  conjunctivitis  due  to 

256 

diabetes    insipidus    from 

585 

due  to 

774 

—  impacted  in  gum,  ptyalism 

epistaxis  from     .  . 

250 

-  phosphoric    acid    in    urine 

due  to  . . 

591 

hemianopsia  from 

335 

derived  from 

571 

-  -  in  larynx  .  •         . .        465 

642 

hemiplegia  from. . 

138 

-  poisoning,  tetany  from 

178 

causing  cyanosis 

185 

hyperpyrexia  from 

344 

-  regurgitation    through     the 

cough  from 

176 

sudden  blindness  from. . 

839 

nose,  causes  of    . . 

202 

extreme  dyspnoea  from 

642 

sub-conjunctival  haemor- 

-  relation  of  pain  to,  in  gastric 

laryngeal     obstruction 

hage  from 

256 

and  duodenal  ulcer 

89 

from 

C42 

tinnitus  from 

794 

vomiting  to,  under  various 

retraction  of  the  head 

-  spine,  acute  bedsore  from. . 

286 

conditioas 

844 

from 

642 

anaesthesia  from  (i^i?.  180, 

Foot,  anfesthesia  of  (see  Anaes- 

 simulating     meningitis 

642 

p.   663)..          ..          484 

663 

thesia  of  Foot) 

in  nose,  epistaxis  from  250 

252 

coma  and  delirium  from 

286 

-  deformity  of  (see  Club-foot) 

nasal  discharge  from. . 

204 

from  diving 

269 

-  intrinsic  muscles  of,  spinal 

-  -  in    oesophagus,  detection 

girdle  pains  from 

484 

nerve  roots  supplying    . . 

543 

by  .r-rays 

297 

hyperpyrexia  in 

344 

-  numbness  of  (see  Numbness 

hfematemesis  from 

micturition  difficult  after 

443 

of  Foot) 

294,  297 

299 

priapism  from 

585 

-  pallor  after  walking,  in  inter- 

 opening  into  pericardium 

711 

transverse   myelitis  from 

564 

mittent  claudication 

489 

—  in  urethra 

210 

cervical,  fatal  results  of 

709 

-  pain  m  (see  Pain  in  Foot) 

urethral    discharge    from 

206 

immobility  of  neck  in 

709 

-  perforatmg    ulcer    of   (Fig. 

Forgetfulness  (see  Amnesia) 

stiff  neck  from 

709 

207,  p.  809)         ..285,562 

809 

Formalin    method  of  fixation 

dorsal,  priapism  in 

585 

in  locomotor  ataxy    . . 

562 

for  spirochfctes    . . 

769 

FRACTURE,  SPONTANEOUS 

268 

tabes     . . 

285 

histological  tissues 

434 

due  to  carcinoma 

757 

-  spinal  nerve  roots  supplying 

Formication 

588 

-  -  hydatid  cyst 

757 

intrinsic  muscles  of    '    . . 

543 

Formosa, distoma  pulmonale  in 

325 

in  mollifies  ossium 

269 

-  tenderness  in  erythromelalgia 

490 

Foul  air,  headache  from 

328 

from  new  growth 

757 

-  tuberculous,    simulated    by 

-  breath  (see  Breatli,  Foul) 

in  scurvy-rickets. . 

753 

tabetic  arthritis. . 

388 

Fournier  re  chancre  and  herpes 

830 

syringomyelia 

285 

-  ulcers  of  (see  Ulceration) 

Fracture,  badly-united,  pseudo- 

from    tuberculous    caries 

269 

Football,  cramp  during 

177 

elephantiasis  from 

456 

Fraenum  linguee,   abraded  in 

-  enlarged  heart  from 

244 

-  bullae  with    . . 

110 

emphysema  and  bronchitis  320 

-  spinal  symptoms  due  to     . . 

787 

-  contractures  following 

165 

pertussis           . .         320 

,814 

Foot-drop  in  alcoholism 

131 

-  crepitus  a  sign  of    .  . 

179 

—  penis,    perforation    by    soft 

-  after  diphtheria 

131 

-  green-stick   . . 

269 

sore 

675 

-  in  plumbism 

131 

-  in    infants,    simulation    by 

Fragilitas  ossium,  distinction 

-  (see  Paraplegia ;  and  Paralysis 

syphilitic       pseudo-para- 

from moUities  ossium     . . 

269 

of  one  Lower  E.Ytremity) 

lysis 

886 

dwarfism  from    . . 

213 

-  Tooth's     peroneal     atrophy 

560 

-  muscular  atrophy  after       71 

',  75 

late  onset  of 

269 

Foramen  ovale,  patent 

184 

-  simulated  by  scurvy-rickets 

753 

rickets 

269 

-  rotundum,   trigeminal    neu- 

 syphilitic  pseudo-paralysis 

386 

spontaneous    fracture    in 

269 

ralgia  from  tumours  near 

496 

-  swelling  on  a   bone  due  to 

Framboesia 

449 

Forceps  delivery  in  etiology  of 

callus  about  a      . . 

750 

Freckles  in  rheumatoid  arthritis 

378 

talipes 

131 

-  with  tabetic  arthritis 

388 

-  von  Recklinghausen's  disease 

781 

-  infantile  diplegia  due  to    . . 

556 

-  talipes  after 

132 

-  xerodermia       pigmentosum 

paraplegia  due  to 

556 

-  femur,  oedema  of  leg  after 

459 

simulatins 

804 

Fordyce's  disease  of  lips 

403 

sciatic  nerveparalysis  from 

542 

Frequency  of  micturition  (see 

Forearm,    atrophic    palsy    of 

-  humerus,  musculospiial  para- 

JXicturition, Abnormalities  of) 

from  cervical  rib 

493 

lysis  after. . 

549 

Friction,  bullae  from  . .        110, 

112 

-  injury  of.  isphaamic  paralysis 

-  jaw,   abnormal  mobility   of 

Fried  fish,  colic  due  to 

136 

of  liand  from 

552 

fragments  in 

747 

Friedliinder's  bacillus  (see  Bacillus) 

FRIEDREICH'S    ATAXIA— GAIT 


905 


Friedreich's  ataxia      ..       686, 

affection  o£  speech  in     . . 

Babinski's  si^n  in 

cause  of  death  in 

-  -  choreiform  movements  in 

contracture,  etc.,  in      162, 

diagnosis  of  atrophy  from 

duration  of 

electrical  reactions  in 

familial  character  of 

-  -  gait  in 

hallux  eroctus  in    71,  131, 

inco-ordination  in  67, 

insidious  onset  of 

intention  tremors  in    560, 

-  -  knee-jerk  absent  in  71, 131, 

monotonous  speech  in    . . 

nystagmus    in        71,  131, 

optic  atrophy  in  71, 

paraplegia  in      . .  71,  567, 

pseudo-nvstagmus  in 

-  -  reflexes  in  71,  82, 131, 

scoliosis  in  . .        181, 

sensation  normal  in 

slow,  jerky  articulation  in 

slurring-speech  in 

spastic  rigidity  with 

talipes  from  71,  131, 

tremor  w-ith         . .         795, 

-  sign  in  adherent  pericardium 
Friflht   causing   infantile  con- 
vulsions    .  . 

-  diabetes  insipidus  from 

-  nienorrhagia  from  . . 

-  palpitation  from     . .         525, 

-  in  paroxysmal  tachycardia 
Frog-belly  in  cretinism 
Frontal    bosses    m   congenital 

syphilis  (Fig.  28,  p.  124) 

-  headache  in  disease  of  eyes 

-  lobe.agraphia  from  lesion  of 

-  region,  ivory  exostosis  of  . . 
tumours     of,     unilateral 

tremor  due  to  . . 

-  ridges,     increased     size     in 

acromegaly 

-  sinus  dilatation,  exophthal- 

mos in 

disease,    cerebral   abscess 

due  to  . . 

diagnosis  from  abscess 

of  antrum     . . 
headache  in      . . 

-  -  -  meningitis  from 
spastic  brachial  mono- 
plegia due  to 

-  -  empyema  of,  causes  and 

symptoms 

headache  from 

subjective  smell  sensa- 
tions from    . . 

nasal  discharge  from 

referred  pain  in  fronto- 
nasal and  mid-orbital 
areas  in 

Frostbite,  bulla;  from 

-  fingers  affected  by  . . 

-  gangrene  from 

-  haemoglobinuria  in 

-  vesicles  from 
Fruit,  raw,  colic  due  to 

-  unripe,  diarrhcea  from 
Fucus    vesiculosus,    reduction 

of  weight  by 
Fullness  of  abdomen,  in  colic 

-  in  asthenic  dyspepsia 

-  of  the  head,  epistaxis  reliev- 

ing   

sense    of,    from    arterio- 
sclerosis 

-  and     oppression     in     rieht 

hypochondrium,  sense  of, 
in  congestion  of  liver    .  . 

-  in  rectum,  sense  of,  in  cancer 


800 
709 

82 
560 
560 
164 

70 
560 

71 
559 
277 
559 
131 
559 
800 
559 
560 
560 
560 
559 
452 
559 
559 
559 
686 
131 
163 
559 
799 
104 

170 
585 
428 
527 
772 
259 


669 

204 


FULLNESS,  SENSE  OF         ..     270 

in  dyspepsia         .  .  . .     354 

-  -  gastritis 352 

Functional    albuminuria    (see 

Alliuniinuria) 

-  bruits  102,  104,  105,  106 

-  paralysis  (see  Aphonia  :  and 

Paralysis) 
Fungating'  endocarditis,  absence 

of  bruit  in  ..         013,699 

absence   of   clinical    signs 

for  many  weeks  . .     610 

leucocytosis  in      39,  400,  700 

acute  aneurysm  in         . .     699 

peritonitis  from  . .     432 

simulated  by  embol- 
ism in        . .  . .     646 

rheumatism    causing..     314 

albuminuria  in    . .  9,  237 

-  -  anemia  in  9,10,27,38,76,593, 

598,  613,  616,  700 

aneurysm  of  hepatic  artery 

in  ..  ..  59,  368 

axillary  artery   due  to     732 

aortic  disease  due  to       .  .      237 

bacteria  in  blood  in        237,  613 

-  -  bruits  in     38,  76, 102, 103, 106, 

240,  593,  598,  612,  649 

changing  in    38,  76,  240,  598 

cerebral  abscess  due  to..     547 

hfemorrhage  from        . .     700 

cessation  of  pulsation  in 

the  accessible  arteries  in    613 

Cheyne-Stokes  respiration  in  125 

chronic      .  .  .  .      . .  76,  613 

jaundice  with  cyanosis  in  370 

coma  in    . .  . .  . .     237 

continuous  pyrexia  in    . .     612 

delirium  in  .  .  .  .     103 

diagnosis     from     chronic 

heart  lesion  38,  39,  700 

influenza  . .  . .     610 

meningitis        . .  . .     614 

tuberculosis      . .  . .     613 

typhoid  fever. .         611,  613 

typhus  fever   . .         610,  614 

dyspnoea  in         . .  . .         9 

-  -  embolism  in     10,  39,  59,  76,  90, 

103,  138,  186,  237,  314,  338, 
368,  432,  563,  565,  593,  598, 
613,  646,  649,  692,  699 

cerebral  . .  . .      338 

of  cord  due  to. .  . .     565 

hepatic  artery  in         .  .        59 

mesenteric  vessels  in  432,  646 

of  spleen  in      .  .  692,  699 

superior  mesenteric      90,  646 

gastric  erosions  in  . .     298 

lia^maturia  in      .  .  237,  314 

haemoptysis  in    . .  . .     320 

haemorrhage  in 

9,  10,  38,  76,  593 

anal,  in  . .  . .  90 

hyperpyrexia  in..  ..     343 

infarction  in        . .  . .       76 

of  kidney  in     . .  . .     237 

lung  in  .  .  . .     321 

inspissation  of  bile  in    . .     368 

irregular  pyrexia  in       . .     598 

-  -  jaundice  in  . .         368,  370 

with  pyrexia  in  . .     370 

long  course  of  chronic  . .     613 

meningitis  in       . .  . .     614 

mitral  regurgitation  from 

239,  240 

multiple  emboli  In  . .     699 

muscular  atrophy  in     . .       76 

nephritis  in         . .  9,  10 

neuro-retinitis  in  9,  10 

oedema  in  . .  . .         9 

optic  neuritis  in 

38,  76,  .314,  598,  613 

osteomyelitis  causing     . .     314 

peripheral  neuritis  in     . .       76 


Fungaling  endocaTdilis,  contd 

pneumococcal    . .         314,  614 

prolonged  pyrexia  in      . .  609 

pulmonary  embolism  from  186 

incompetence  with     . .  24  7 

valve 245 

purpura  in 

237,  338,  596,  598,  610,  613 

-  -  pyrexia  in  9,10,38,76,103,138, 

237,  314,  343,  368,  593,  598 

without  pyrexia.  .           . .  345 

retinal  haemorrhages  in,  9,  10, 

237,   338,   598,  613 

-  -  rigors  in  103,  237,  613,  648,  649 

rupture  of  valve  from    . .  106 

in  septicaemia      . .          . .  698 

spsistic     brachial     mono- 
plegia due  to..           ..  547 

spleen  enlarged  in  10,38,76,314, 

338,  598,  613,  692,  693,  699 

subcutaneous  hfemorrhage  in  76 

sudden  pain  in  loin  in    . .  314 

sweating  in          . .         103,  237 

symptoms     pointing     to 

cerebral  embolism  from  138 

transverse  myelitis  due  to  565 

typical  temperature  chart 

in  (Fig.  164)    . .          . .  013 
various    signs    and   sym- 
ptoms of          . .          . .  237 

vesetations  on  valves  in  649 

FUNGOUS    AFFECTIONS   OF 

THE  SKIN                       ..  270 
Furnacemen,  enlarged  heart  in  232 
Furred  tongue  (see  Tongue) 
Furuncle,  diagnosis  from  car- 
buncle      . .          . .          . .  603 

-  earache  from            . .          . .  230 

-  of    face,     cavernous    sinus 

thrombosis  due  to         . .  253 

-  point   of   suppuration  in  . .  603 

-  shape  of  pustule  in            . .  001 
Furunculosis  of  external  audi- 
tory meatus,  otorrhcea  from  469 

-  from  iodides  or  bromides  . .  112 

-  tenderness  of  the  spine  from  784 

-  of  viilva       . .          . .          . .  768 

Fusiform  bacilli  (see  Bacillus, 

Fusiform) 

GAERTNEB'S  linfillus  (see 
Bacillus,  (riicrtii.T's) 

GAIT,   ABNORMALITIES  OF  277 

-  in  ataxy       . .          . .          . .  66 

-  cerebellar     . .          . .          . .  69 

-  in  cerebellar  tumour       565,  643 

-  clumsy,  in  Little's  disease  154 

-  cross-legged  in  Little's  disease  154 
in  cerebral  diplegia       . .  800 

-  in  disseminated  sclerosis  . .  800 

-  hesitant,  in  paralysis  agitans  548 

-  high  steppage          . .          . .  66 

-  in  hysterical  paralysis      . .  541 

-  limping,  in  iliac  abscess    . .  739 

-  in  paralysis  agitans           . .  541 

of  external  popliteal  nerve  543 

sciatic  nerve        . .          . .  542 

-  peripheral  neuritis  . .         . .  66 

-  scissor -legged      in     Little's 

disease      . .          . .          . .  154 

-  shuffling  in  paralysis  agitans  796 

-  in  spastic  paralysis  of  one  leg  540 

-  spinal  caries             .  .          .  .  785 

-  staggering  cerebellar          . .  565 

in  disseminated  sclerosis  565 

tabes  dorsalis      . .          . .  827 

-  stooping  in  spinal  caries    . .  181 

-  tabetic           .  .          .  .          .  .  67 

-  tottering  in  general  paraly- 

sis of  the  insane  . .          . .  796 

-  waddling  in  congenital  dis- 

location of  hip    . .          .  .  183 

of     pseudo-hypertrophic 

paralysis           . .          . .  561 


9o6 


GALACTOCLE— GANGRENE    OF    LUNG 


Galactocele 

744 

Gall-bladder,  conld. 

Gall-bladder,  conld. 

Gall-bladder,  carcinoma  of  (see 

-  suppurating,     absence     of 

-  in  pancreatic  ducts 

135 

Carcinoma  of  Gall-bladder; 

jaundice  in  many  cases  of 

737 

-  peritoneal  adhesions  from. . 

280 

-  cholesterin  crystals  in 

281 

albumosuria  in    . . 

20 

-  preceding  carcinoma 

278 

-  constipation  in  diseases  of 

144 

diagnosis  from  appendix 

-  pyrexia  due  to    280,  363,  486, 

621 

-  dilated,  with  carcinoma  of 

abscess 

737 

-  recurrent  jaundice  with    . . 

363 

pancreas  .  . 

265 

-  tenderness  in  the  right  side  of 

-  Riedel's  lobe  with  . . 

404 

-  disease,  absence  of  jaundice 

chest  from  (and  see  Ten- 

- rigors  with        280,  362,  363, 

486 

not  incompatible   with.. 

500 

derness  over  Gall-bladder) 

-  sex  incidence  of     . . 

151 

pain   in   the   epigastrium 

371, 

779 

-  simulated  by  movable  kidney 

500 

from 

779 

-  tumours     of,     absence      of 

cardiac  dilatation 

485 

right     hypochondrium 

interval     between     liver 

-  sizes  of 

36a 

from.. 

779 

and 

392 

-  stercobilin  changes  in  faaces 

shoulder  from 

779 

colic  associated  with     . . 

392 

with 

116 

referred  pain  in  area  of 

diagnosis  from  renal  tu- 

- tenderness  over  gall-bladder  in  499 

lOtli  dorsal  nerve  in  . . 

509 

mours   . . 

392 

of  liver  from 

300 

sex  incidence  of  . . 

500 

duUness  to  percussion  over 

392 

over  lower  dorsal  spine  in 

474 

tenderness    in    the    epi- 

 jaundice  with 

392 

-  typhoid  fever  before        280, 

281 

gastrium  from 

779 

limited  mobility  of 

392 

-  ulceration  into  duodenum 

300 

the     right     liypochon- 

mobility  with  inspiration 

392 

diagnosis  from  gastric 

drium  from 

779 

obstruction  of  portal  vein 

ulcer 

300 

shoulder  from 

779 

by          

692 

-  urobilinuria  with    . . 

116 

-  empyema  of,  cholangitis  in 

369 

oval  outline  of     . . 

392 

-  vomiting  with 

486 

-  -  clue  to  gall-stones 

280 

pelvic    swelling    due    to 

-  wind   and  spasms  as  sym- 

 leuoocytosis  in    . .         281, 

400 

downward  growth  of . . 

758 

ptoms  of  . . 

350 

pus   in   the   stools    from 

Gall-stones,  absence  of  enlarged 

-  without  symptoms 

363 

rupture  of 

601 

gall-bladder  with 

363 

Gallic  acid,  dark  urine  from 

820 

typhoidal. . 

369 

-  account  of  symptoms  of  . . 

363 

drjrness  of  mouth  from 

789 

Widal's  reaction  in 

281 

-  acute  intestinal  obstruction 

extreme  thirst  due  to    . . 

789 

GALL-BLADDER,  ENLARGE- 

due to      . .            151,  152 

300 

Gallop  rhythm  in  myocardial 

MENT  OF 

278 

-  areas  of  tenderness  from  . . 

779 

degeneration 

333 

in  carcinoma  of  pancreas 

-  ball-valve     obstruction     of 

Galton's  whistle 

189 

59,  368, 

500 

ampulla  of  Vater  with  . . 

650 

Galvanic  current   in   reaction 

causes  of 

280 

-  in  bile-ducts 

135 

of  degeneration  . . 

633 

from  cholangitis . . 

651 

-  catch  in  the  breath  during 

Galvano-cautery  in  hypopyon 

807 

cholecystitis 

723 

deep  inspiration  on  pres- 

GANGRENE     

281 

in  chronic  pancreatitis  . . 

135 

sure  over             . .        486, 

499 

-  albumosuria  in 

20 

from  cicatrized  ducts     . . 

365 

-  Charcot's      hepatic      inter- 

- blebs  in 

283 

diagnosis  from  carcinoma 

mittent  fever  from 

650 

-  bullffi  in       . .          . .        110, 

112 

of  duodenum   . . 

280 

-  cholangitis  from  280,  362, 369 

650 

-  in     diabetes    mellitus    (see 

liver  abscess  . .         279, 

369 

-  cholecystitis  from  . .        280, 

650 

Diabetes   Mellitus) 

pylorus 

280 

-  colic  due  to              135,  152, 

650 

-  dry 

282 

suprarenal    . . 

280 

description 

363 

-  epidemic      . .          . .        282, 

287 

gamma  of  liver 

279 

-  collapse  from 

363 

-  in  erythromelalgia  . . 

284 

hydatid  cyst  of  liver  . . 

279 

-  contraction  of  gall-bladder  in 

280 

-  of  face  (see  Cancrum  Oris) 

hydronephrosis 

279 

-  diagnosis  from  appendicitis 

500 

-  fatty  acids  and  sulphides  in 

283 

movable  kidney        279, 

727 

chronic  pancreatitis     265, 

363 

-  of  fingers  from  aneurysm  .  . 

287 

new  growth  in  liver  . . 

279 

gastric  ulcer 

486 

from  carcinoma  of  breast 

287 

pyloric  enlargement  . . 

406 

-  distribution  of  pain  from. . 

135 

-  hand  from  endothelioma  of 

Riedel's  lobe  . .        278, 

737 

-  empyema  of  gall-bladder  in 

280 

lung 

287 

thickening  round  duo- 

- enlarged  gall-bladder  from 

723 

-  hospital,  emphysema  in    . . 

231 

denal  ulcer 

406 

rare  with 

135 

-  in  intermittent  claudication 

489 

gastric  ulcer 

406 

-  etiology  of  . . 

135 

-  of  leg  from  atheroma 

810 

in  duodenal  carcinoma . . 

725 

-  in  ffeces       . .             64,  135, 

363 

-  no  leucocytosis  with 

400 

exceptional     with     gall- 

- glycosuria  in 

292 

-  local,  in  anthrax     .  . 

603 

stones   . . 

135 

-  haBmatemesis  in      . .        294, 

300 

GANGRENE  OF  LUNG 

287 

from  gall-stones. . 

363 

-  hepatoptosis  with . . 

407 

absence  of  clubbed  fingers 

new  growth 

723 

-  impaction  in  common  duct. 

in 

321 

pelvic  swelling  due  to    . . 

757 

large    liver    and    intense 

expectoration  in 

288 

pliysical  signs     . . 

278 

jaundice  in          . .        362, 

363 

foetor  in 

288 

-  -  simulating  ascites 

717 

in  cystic  duct,  large  gall- 

 abundant  foul  sputum  in 

703 

in  stenosis  of  bile-ducts 

bladder   and   no   jaun- 

 acute  history  in   . . 

703 

365 

410 

dice  in. . 

363 

onset  in    . . 

288 

tumour  of  pancreas 

366 

diagnosis  from  carcinoma 

from  broncho-pneumonia 

typhoid  fever        281,  371 

372 

of  liver 

413 

578,  703 

,  712 

-  infection    causing    pleuritic 

-  incidence  in  stout  persons. . 

151 

causes  of     . .        287,  288 

578 

effusion     . . 

123 

-  jaundice  with           300,  361, 

363 

cough  in  . . 

287 

-  inflamed,    local   rigidity    of 

-  leading  to  pancreatitis 

116 

in  diabetes 

703 

rectus  abdominis  with  . . 

644 

-  liver  abscess  from  . . 

408 

empyema   ruptured    into 

-  mucocele,  absence  of  sym- 

 enlarged  with      . .        300 

363 

lung 

703 

ptoms  in 

281 

-  long  duration  of  attack  of 

diagnosis  from  aspiration 

obstruction  of  cystic  duct  in  281 

pain  in     . . 

486 

pneumonia 

288 

sterility  of  fluid  in 

281 

-  mistaken    for    rheumatism 

bronchiectasis. .         321 

,  703 

-  normal  situation  of 

722 

of  the  shoulder  . . 

778 

emoyema         . .         321 

,  703 

-  pain   and   tenderness   over, 

-  mucocele  after 

281 

phthisis 

321 

from  gall-stones. .         280 

486 

-  obstruction     by,      alkaline 

elastic  fibres  in  sputum  in 

-  palpable    in    cases    of    new 

fasces  in    . . 

117 

288,  321 

703 

growth  of  pancreas 

C90 

-  pains  over  gall-bladder  from 

excessively  foul  stench  in 

703 

-  perforation     of,     infective 

300 

486 

fcetor  of  sputum  in 

peritonitis  from.  . 

644 

in  hypochondrium  in    . . 

499 

176,  287,  288, 

321 

-  spontaneous  rupture 

281 

and  tenderness  from     . . 

280 

from     foreign     body     in 

-  stone  in,  epigastric  pain  in 

48G 

in  the  back  from      474 

789 

bronchus 

578 

relation  of  pain  to  food 

-  painful  breathing  with 

486 

foul  breath  in      .  .99,  321 

,  703 

in  some  cases  of 

486 

-  palpable 

723 

taste  from 

774 

GANGRENE    OF    LUNG— GASTRITIS 


907 


Uatigrene  <ij  lumj,  could. 

Gastric  conlenls,   carilil. 

Gastric  ulcer,  could. 

hemoptysis  in     288,  317 

321 

sarcinae  and  yeasts  in    . . 

267 

pancreatitis  caused  by   . . 

116 

-  -  indicanuria  in     . . 

349 

various  characters  of 

844 

perforated,  abdominal  pain 

from      inhalation     pneu- 

 (see  also  Vomit} 

and  collapse  from     484 

,721 

monia   . . 

703 

-  crises  (see  Crises,  Gastric) 

causing  acute  peritonitis 

intratlioracic  growths     . . 

288 

-  derangements  in  Malta  fever 

507 

55 

780 

irregular  fever  in 

287 

-  digestion,  defective,  muscle 

diagnosis     from    acute 

latent 

288 

fibre  in  ffeces  in  . . 

117 

pancreatitis .  . 

431 

-  -  leucocytosis  in    . . 

401 

-  dilatation  (see  Gastrectasis) 

latent   symptoms   w^ith 

721 

from  new  growth 

578 

-  flatulence  (see  Flatulence}. . 

267 

omental    abscess    from 

724 

obstruction  of  bronchus 

712 

-  juice,  acidity  of,  and  heart- 

pneumoperitoneum  from 

711 

peculiarities  in  children 

288 

*  burn 

333 

resembling     dysmenor- 

from  pneumonia            578 

712 

analysis  in  gastritis 

352 

rhoea 

220 

pneumothorax  in          577 

712 

changes  in  dyspepsia 

354 

shock  and  collapse  in . . 

484 

-  -  from  pulmonary  infarct 

712 

deficient,     and     chronic 

sudden  severe  pain   in 

pyopneumothorax  with 

712 

diarrhoea 

196 

the  epigastrium  in. . 

484 

secondary   to   abscess   of 

in  gastric  ulcer    . . 

713 

tenderness  in  the  hypo- 

liver    "  . . 

409 

hyperacidity     in     gastric 

gastrium  from 

780 

from  septic  embolism  of 

and  duodenal  ulcer     . . 

89 

right  iliac  fossa  from 

780 

lung 

703 

organic  acids  in  . . 

333 

peritonitis  in         55,  431, 

pneumonia 

703 

-  lesions,  surgical  emphysema 

484,  644,  721 

780 

sputum  in  99, 176,  287,288 

,321 

from 

231 

pleuritic  effusion  from    . . 

123 

-  -  terminal    . . 

288 

-  peristalsis,   visible,   descrip- 

 pneumothorax  caused  by 

577 

-  moist,  putrefaction  in 

283 

tion  of 

570 

predisposed  to  by  chlorosis 

.S03 

-  in  iXorvan's  disease 

285 

-  reflexes,   epigastric    tumour 

ptyalism  in 

591 

-  of  mucosa  in  acute  cystitis 

627 

from 

72S 

pyloric  obstruction  from 

712 

-  from  pemphigus  vegetans. . 

654 

ptyalism  from 

591 

stenosis  from   . . 

352 

-  of  penis,  diabetic  . . 

266 

-  sensations  as  an  epileptic  aura    80 

relation  of  pain  to  food  in 

485 

-  in  peripheral  neuritis 

285 

-  ulcer 40,  117 

428 

results  of  profuse  haemor- 

- of  piles 

635 

acetonuria  in 

4 

rhage  in 

298 

-  pleura,     causing     pneumo- 

 age  incidence  of  . . 

40 

sex  incidence  of  . .          .  .40,  90 

thorax 

577 

albumosuria  in   . . 

20 

simulated      by      ansemic 

-  due  to  pressure  of  growths 

287 

anaemia  from      . .          40, 

298 

vomiting 

847 

-  pulmonary  (see  Gangrene  of 

blood  per  anum  in           89 

117 

cardiac  dilatation 

485 

Lung) 

in  vomit  with  . . 

846 

heart  disease  . . 

779 

-  in  Raynaud's  disease 

284 

carcinoma  from  . .         351 

713 

tabes    dorsalis . . 

350 

-  senile  (Plate  I r)    ..       283, 

284 

characteristic  signs  of    . . 

298 

subplirenic  abscess  from 

causes  of . . 

286 

characters  of  vomit  in  . . 

298 

119,  501,  577,  578,  720 

721 

insidious  onset  in 

286 

clean  red  moist  tongue  in 

298 

sudden      collapse      from 

upward  spread  of 

287 

"  cofEee-grounds  "  vomit  in 

298 

hsematemesis  in 

298 

G-aol  fever  (see  Typhus  Fever) 

communicating  with  sub- 

 pallor  in 

298 

Garlic,  foul  breath  from 

98 

phrenic  abscess 

712 

surgical  emphysema  from 

231 

Gas,   bacteria  producing,  sur- 

 diagnosis     from     ansemic 

without  symptoms 

780 

gical  emphysema  from  . . 

231 

vomiting 

40 

tenderness  of  abdomen  in 

134 

-  evidence  of  poisoning  from 

138 

gall-stones 

486 

epigastrium  in    . .       89, 

298 

-  irritant,  laryngitis  from     . . 

185 

gastric  carcinoma 

846 

lower  dorsal  spines  in. . 

474 

-  noxious,  anosmia  from 

669 

dyspepsia    simulated    by 

721 

tetany  in . . 

3 

olfactory  neuritis  from  . . 

669 

empyema  from   . . 

120 

thickening  round,  diagno- 

- in  pleural  cavity  Csee  Pneumo- 

 epigastric  pain  from    295, 

298 

sis  from  enlarged  gall- 

thorax) 

tumour  from  . . 

723 

bladder 

406 

-  poisonous,  headache  from 

328 

erosion     of     pancreatic 

time  of  pain  in    . . 

298 

-  production  by  bacillus  coli 

artery  by 

298 

vomiting  in 

298 

231,  577,  578,  711, 

713 

small  vessels  by 

298 

midue    abdommal    aortic 

-  per  urethram  (see  Pneuma- 

splenic  artery  by 

298 

pulsation  suggesting  . . 

592 

turia) 

excess  of  HCl  in . . 

485 

urobilinuria  with 

116 

Gas-workers,    epithelioma    in 

679 

gastrectasis  in      . . 

712 

vomiting  m    89,  298,  485 

843 

Gasserian     ganglion     disease, 

geographical    distribution 

298 

Gastritis,    analysis    of    gastric 

herpes  zoster  from 

496 

hajmatemesis  in,  89,  294, 

295, 

contents  in 

352 

causing        trigeminal 

298,  352, 

485 

-  from  antimony 

297 

neuralgia 

496 

as  first  sign  of . . 

298 

-  arsenical,  diarrhoea  in 

297 

excision  of,  effects  on  eye 

807 

hyperacidity  in  . . 

89 

epigastric  burning  paia  in 

297 

Gastralgia,  absence  of  vomit- 

 inflammatory  deposits  felt 

faintness  in 

297 

ing  in 

485 

in  epigastrium 

723 

nature  of  vomit  in 

297 

-  age  and  sex  incidence  of  . . 

485 

intermittent       blood     in 

red,  inflamed  mucous  mem- 

- diffuse  deep  tenderness  in 

485 

fseces  in 

117 

brane  in 

297 

-  in  functional  dyspepsia     . . 

354 

kinking  of  bowel  from  . . 

147 

rice-water  stools  in 

297 

-  pain  in  the  epigastrium  in 

leaking 

577 

violent  incessant  sickness 

354, 

485 

local  deep  tenderness  in  352 

,485 

in 

297 

Gastrectasis     (see     Stomach, 

loss  of  weight  due  to 

848 

-  bUe  in  vomit  in  acute 

845 

Dilated) 

metena  in           . .        298, 

428 

-  causes  of      . .          . .         297 

352 

Gastric   atony   (see   Stomach, 

multiple,   in   appendicitis 

304 

-  in  cirrhosis  of  liver . . 

410 

Atony  of) 

normal  HCl  with          713, 

846 

-  diarrhoea  in . .          ..         297 

845 

-  contents  (see  Stomach  Con- 

 cedenia  of  legs  after 

459 

-  diminished  appetite  in 

49 

tents) 

pain  in  the  back  in  298,476 

485 

total  acidity  in    . . 

352 

-  carcinoma  (see  Carcinoma  of 

chest  from 

779 

-  dull  boring  pain  behind  ster- 

Stomach) 

epigastrium  in 

484 

num  and  in  epigastrium  in 

484 

-  catarrh  (see  Gastritis) 

after  food  with            89, 

845 

-  epigastric    discomfort    and 

-  contents,     analysis     of,     in 

relieved  by  vomiting 

tenderness  in 

297 

diagnosis    of    strychnine 

352, 

845 

-  excess  of  mucus  in  stomach 

poisoning..          ..         4G4, 

652 

in  left  hypochondrium 

499 

contents  in 

352 

distoma  in 

364 

interscapular  in 

474 

-  flatulence  with 

845 

-  -  HCl  in 

485 

spasmodic  pelvic  in     . . 

509 

-  furred  tongue  in 

49 

recognized  by  smell 

844 

and  tenderness  in  the 

-  haematemesis  in                 294, 

297 

round  worms  in  .  . 

846 

back  from    . . 

789 

-  haemorrhage  and  erosion  in 

297 

9o8 


GASTRITIS— GLA  UCOMA 


Ga-itritis,  contd. 

General  paralysis  of  insane,  contd. 

Gestation,  ectopic,  contd. 

-  heartburn  in 

484 

convulsions  in 

diagnosis       from       small 

-  loss  of  appetite  in  . . 

352 

169, 172,  269 

340 

ovarian  dermoid 

760 

-  mistaken    for    rheumatism 

cyto-diagnosis  in 

269 

pedunculated  fibroid 

760 

of  the  shoulder    . . 

778 

diagnosis  of 

269 

difficulty  of  identification 

-  nausea,    eructations,    and 

of  saturnine  encephalo 

of  uterus  in     . . 

760 

vomiting  in          . .          297 

,352 

pathy  from 

139 

felt  per  rectum    . . 

638 

-  pain  in  the  chest  and  palpi- 

 dysarthria  in  .  . 

686 

importance  of  early  dia- 

tation in  . . 

484 

dysphagia  in   . . 

225 

gnosis  in 

760 

in  limbs  in 

503 

grinding  of  the  teeth  in 

796 

internal  haemorrhage  from 

780 

directly    related    to    the 

headache  in     . . 

327 

pain  preceding  rupture  or 

taking  of  food 

484 

hemiplegia  in    . .         340 

,682 

abortion  in 

509 

radiating  to  left  breast  anc 

impotence  in    . . 

346 

pelvic  haematocele  due  to 

interscapular  region  in 

484 

insomnia  in 

358 

G38 

757 

and  tenderness  in  the  back 

irritability  in   .  . 

360 

pain  in. .          . .         508 

760 

from 

789 

laryngeal  paralysis  with 

539 

swelling  from               757 

,760 

—  phlegmonous,  severe  consti- 

lumbar     puncture     in 

progressive 

760 

tntional  symptoms  with 

845 

diagnosis  of 

269 

rupture  of,  pain  in  right 

-  from  phosphorus     . . 

297 

mental  changes  in      139 

,269 

side  of  abdomen  in    . . 

500 

-  ptyalism  in 

591 

osseous  atrophy  in 

269 

gestation  sac  in 

760 

-  pyrexia  in    . .          . .         297 

,845 

paraplegia  in  .  .         562 

567 

signs  of  pregnancy  in    . . 

760 

-  relief  of  pain  on  eructation 

484 

perforating  ulcer  from 

809 

simulated  by  threatened 

vomiting 

484 

physical  changes  in     . . 

139 

abortion 

436 

-  results  of  test  meal  in 

54 

pupils  in              195,  394 

595 

swelling   in  tube  felt  on 

-  sense  of  fullness  -with 

352 

simulated  by  plumbism 

797 

bimanual  examination 

589 

-  simulated     by     arsenical 

writer's  cramp 

177 

tenderness    in    the    right 

poisoning 

845 

slow  blurred  speech  in 

796 

iliac  fossa  from 

780 

carcinoma 

299 

spasmodic  contractions  in  159 

unruptured 

760 

phosphorus  poisoning    . . 

845 

spontaneous  fracture  in 

269 

uterine  haemorrhage  in 

-  sjTnptoms  of 

845 

stammerigg  in 

688 

436,  646,  760 

780 

in  children 

297 

symptoms  of  . . 

139 

vaginal    examination    in 

-  toxic,  collapse  in    . . 

297 

syphilis  a  precursor  of 

269 

diagnosis  of 

500 

hajmatemesis  in            294, 

297 

tremor  in           795,  796, 

798 

Giant  ceUs  in  tuberculosis     . . 

450 

intense  pain  in    . . 

297 

temporary    aphasia    in 

682 

Giddiness  (see  Vertigo) 

-  vomiting  from        . .         297 

,843 

tottering  in 

796 

Giemsa's  method   of   staining 

Gastrocnemius  bursa,  popliteal 

unequal  knee-jerks  in 

398 

spirochaeta  pallida 

769 

swelling  due  to    . . 

762 

pupils  in       .  .         195 

595 

Gigantism     and     infantilism 

-  nerve  supply  of 

542 

various  signs  of 

172 

associated 

214 

-  pseudo-h3T5ertrophy  of 

560 

Wassermann's  reaction 

Gigantoblasts  (Plate  II,  Fig. 

-  spinal  nerve  root  supplying 

543 

in       ..           269,  340, 

360 

F)              

28 

Gastrodiaphany 

724 

-  peritonitis   (see   Peritonitis, 

Gin-drinking,  polyuria  from. . 

581 

Gastro-enterostomy,  perform- 

Acute General) 

Gingerbeer,   explosive  eructa- 

ance of.  in  tabes,  from  mis- 

- tuberculosis    of   lungs    (see 

tion  of  gas  from  . . 

639 

taken  diagnosis  . . 

525 

Lungs  ;     Phthisis  ;      and 

Gingivitis,  bleeding  gums  in . . 

87 

Gastro-intestinal     disorders, 

Tuberculosis.  General) 

-  purpura  from 

600 

carpopedal  spasm  in 

3 

Genitalia,  affected  by  scabies 

832 

-  in  syphilis    . . 

86 

headache  in 

328 

-  coli   baciUuria  after  opera- 

- tuberculous . .          . .            8  c 

,  87 

from  hepatic  abscess 

651 

tion  on    . . 

832 

Giraldfes,  organ  of,  cyst  of     . . 

521 

insomnia  in 

356 

-  congenital  syphilis  of 

446 

GIRDLEPAIN 

289 

in  movable  kidney 

310 

—  herpes  simplex  of  . . 

829 

from  aortic  aneurysm    . . 

482 

pain  in  limbs  in  . . 

505 

-  lymphatics   . . 

738 

due  to  bilateral  pressure 

prolonged  pyrexia  in  chil- 

- melanotic    carcinoma    of. . 

802 

on  intercostal  nerves . . 

479 

dren  due  "to     . . 

618 

-  myoma  cutis  of 

805 

in  disseminated  sclerosis 

665 

rigors  in    . . 

647 

-  precocious    development     of 

fracture  of  dorsal  spine 

484 

from  round-worm  infection 

569 

with  hypernephroma  (Figs. 

in  spinal  caries    . . 

667 

tetany  from 

178 

125,  126,  pp.  453-1) 

690 

haemorrhage     . . 

787 

Gastroptosis,  dyspepsia  in     . . 

354 

-  pustular  syphUides  of 

604 

-  -  tabes         . .          . .        484 

664 

-  diagnosis;  from  gastrectasis 

353 

Genito-crural       nerve,       skin 

with  transverse  cord  lesions  164 

-  flatulence  in 

267 

distribution  of     . . 

659 

in  transverse  myelitis    . . 

484 

-  mobility  of  right  kidney  in 

353 

region,  erythrasma  in    . . 

276 

from  compression  564 

786 

-  ar-ravs  in  diagnosis  of  (Fig. 

Geophagy 

115 

from    tumour    of    spinal 

105)           

353 

German  measles,  albuminuria  in 

17 

meninges 

667 

Gastroscope 

297 

conjunctivitis    ("  pink- 

Glanders, arthritis  in 

376 

-  in  diagnosing  gastric  carcin- 

eye ")  in 

256 

-  B.  mallei  in 

603 

oma 

299 

diagnosis  from  erythema 

-  bullae  m       . .           110,  112, 

603 

Gastrostaxis    . .        . .       295, 

298 

scarlattniforme 

253 

-  constitutional  disturbance  in 

603 

-  caasing  anaemia 

40 

measles . . 

418 

-  discharge  from  nostrils  in. . 

603 

-  blood  per  anum  in  . . 

90 

scarlet  fever     . . 

418 

-  mallein  in  diagnosis  of 

603 

-  discussion  of 

303 

small-pox 

607 

—  papules,  vesicules,  and  pus- 

- haematemesis  from           294, 

298 

generalized      lymphatic 

tules  in     . . 

603 

Gell6's  test  for  hearing 

189 

gland    enlargement    in 

-  purulent  rhinitis  in            203 

204 

Gemellus  superior,  nerve  supply 

542 

416,  418, 

607 

-  rigors  in 

647 

General  paralysis  of  the  insane, 

rigors  in  . . 

647 

-  ulceration  of  the  leg  from. . 

811 

anmesia  in 

25 

scaly  eruption  with 

655 

-  widespread  ulceration  in  . . 

603 

anosmia  from 

669 

sore  throat  in 

670 

Glands,  heat  production  from 

aural  haematoma  in    . . 

269 

Gestation,    ectopic    (^and    see 

activity  of 

619 

bedriddenness  from    . . 

69 

Abortion,  Tubal)    . .     500, 

759 

-  lymphatic,    enlargement   of 

bleeding  gums  in 

85 

abortion  of 

760 

(see  Lymphatic  Glands) 

cerebrospinal  fluid  in 

coma  from  rupture  of    137, 

140 

-  salivary  (see  Salivary  Glands) 

338,  339 

340 

no  definite  sign  of  preg- 

- thymus  (see  Thymus  Gland) 

Cheyne-Stoke5   respira- 

nancy in 

760 

-  thyroid  (see  Thyroid  Gland) 

tion  in 

125 

diagnosis    from     chronic 

Glaucoma,  acute  (Plate  VIII, 

coma  in            .  .136,139 

340 

salpingo-oophoritis     . . 

760 

Fig.  V,  p.  463)    . . 

839 

congestive  attacks  in . . 

682 

small  cystic  ovary     . . 

760 

-  age  incidence  of 

257 

GLA  UCOMA—GONORRHOiAL  ARTHRITIS 


909 


Olaucoma,  contd. 

-  anterior  chamber  shallow  in    8-40 

-  atropine     and     mydriatics 

contraiudicated  in  . .     257 

-  circunicorneal  injection  in       838 

-  dilTcrcntiation  from  conjunc- 

tivitis and  iritis  . .  . .     257 

-  effects  of  diet  on     .  .  . .      257 

-  lialos  and  rainbows  in       . .     237 

-  lui'zy  vitreous  in     . .  . .     8118 

-  lieadache  in  257,  S27,  328, 

■iy4,  783,  838 

-  laclu'ymation  in      . .  . .     255 

-  loss  of  vision  in       . .  . .     257 

-  ccdema  of  eyelids  and  con- 

junctiva in  . .  . .     257 

-  optic   disc  in   (Plate    VIII, 

Fig.   V,  p.  463)      257,  463,  838 

-  pain  in  eye  in  255,  494,  498 

ears,  and  teeth  from  . .     257 

maxillary  region  from    . .     498 

temporal  region  from    . .     498 

-  periplieral  ,  constriction    of 

vision  in  . .  . .  . .     838 

-  photophobia  in       . .  . .     255 

-  pupil,  dilated,  in     595,  838,  840 

fixed,  in  . .  . .  . .     838 

vmequal,  in  . .  . .     595 

-  rainbow  vision  from  257,  840 

-  secondary  to  iritis.  .  . .     839 

-  steammess  of  cornea  in  838,  840 

-  sudden  blindness  from     . .     839 

-  tenderness  of  forehead  from     783 

temporal  region  from     . .     783 

vertex  from         . .  . .     783 

-  tension  of  eye  in    . .  . .     257 

-  trigemmal  neuralgia  in      . .     838 

-  vomiting  in. .  . .  494,  858 
Glaziers,  plumbism  in  . .  136 
Gleet,  artliritis  from  . .  . .     376 

-  defined  . .  . .  . .     207 

-  epididymitis  due  to  . .     766 
Glenard's     disease,     displace- 
ment of  viscera  in  (Figs. 

39,  41,  p.  147)      ..         -.721 
Glioma  of  cauda  equina,  mus- 
cular atrophy  in  . .       74 

-  cerebral,  diabetes    insioidus 

in 585 

Gliosis,  spinal  . .         . .  . .     492 

Globus  hystericus        166,  224,  225 
342,  506,  538,  710,  798 

associated  with  functional 

paralysis  of  vocal  cords     538 

-  major,  nodules  in  . .  . .     767 

-  minor,  nodules  in  . .  . .  767 
Glossina  palpalis   in   etiology 

of  trypanosomiasis  . .  34 
Glossitis,  chronic,  relation  to 

carcinoma  . .        812,  813 

smoking  . .  . .     812 

syphilis  .  .        812,  813 

-  dysphagia  from  . .  . .  225 
Glosso  -  pharyngeal      nerve, 

paresis  of..  ..        774,  775 

Glossy  skin 423 

with  syringomyelia        . .     128 

Glottis,     spasm     of,     vertigo 

associated  with  . .  . .     828 

Glove-and-stocking  aneestliesia 

("see  Aneesthesia) 
Glutei,  nerve  supply  of 

-  pseudo-hypertrophy  of 

-  spinal  roots   supplying     . . 

-  treadler's  cramp  of 

-  wasting  in  tuberculous  hip 
iTlycogen 
GLYCOSURIA 

-  acetonuria  with 

-  alimentary,      distinguished 

from  diabetes  mellitus  . . 

-  Bottger's  test  in     . . 

-  in  bronzed  diabetes        411 

-  with  carcinoma  of  pancreas 


542 
560 
553 
177 


289 
4 

584 


575 
59 


Clli/cosuria,  cunld. 

-  chronic,  absence  of  abnormal 

thirst  or  appetite  in 

acetonuria  in  . . 

wasting  in 

-  —  advanciim  ,'ige  in 

g I  clTc.l  111'  <]ict  in      .  . 

goul y  Iruili-iicy  in 

moderate  amount  of  urine 

-  from  chronic  pancreatitis 

15,  135, 

-  in  diabetes  . .  . .        291, 

-  diagnostic  importance  of  . . 

-  errors  in  tests  for  . . 

-  Fehling's  test  in     . . 

-  fermentation  test  in 

of  urine   as   quantitative 

test  in  . . 

-  gouty  

-  laryngeal  paralysis  with    . . 

-  Moore's  test  in 

-  multiple  neuritis  from 

-  need    for    confirmation    by 

fermentation  test 
by  phenylhydrazme  test 

-  neuritis  with 

-  Nylander's  test  in  . . 

-  obesity  preceding  . .        292, 

-  with  pancreatic  cyst 

-  in  pancreatic  disease 

59,  292,  366,  486, 

-  Pavy's  test  for 

-  phenyl-hydrazine  test  for. . 

-  picric  acid  test  for  . . 

-  pneumaturia  with  . . 

-  in  pregnancy 

-  quantitative  tests  in 

Fehling's  solution  in . . 

Pavy's  solution  in 

polarimeter  in. . 

-  safranin  test  for 

-  temporary,  in  chronic  alco- 

holism 

conditions  associated  with 

due  to  cerebral  conditions 

-  tests  for 

-  transitory  as  forerunner  of 

true  diabetes 

-  Trommer's  test  for 

-  in  tumour  of  pancreas       59, 

-  uric  acid  crystals  with 

-  yeast  in  testing  for 
Glycuronic  acid,  osazone  crys- 
tals from. .  . .         115, 

precipitate  with  phenyl- 
hydrazine 

in  uruie,  reduction  by  .  . 

Gmelin's    reaction    in    acute 
yellow  atrophy  of  liver . . 

detecting  bile  in  the  uruie 

Gnats,  lumpy  swellings  from 

-  vesicles  from 

Goats,  Malta  fever  from     507, 
Goitre     (see    Thyroid    Gland 
Enlarged,  and  Exophthal- 
mic Goitre) 
Gonococci  in  arthritic  fluid  .  . 

-  ascitic  fluid 

-  bacteriuria  with 

-  causing  chordee      . . 

-  in  the  circulating  blood  . . 

-  difBcult  to  detect  in  clirouio 

urethritis . . 

-  epididymitis  from  . . 

-  in  gleet 

-  mode  of  examining  films  for 

female  genital  organs 

staining    . . 

-  of  Neisser  described  (Plate 

XII,  Fig.  R,  p.  696)    206, 

-  occurrence  within  leucocytes 

211,  643, 

-  ophthalmia  from    . . 
neonatorum  due  to 


292 
292 
292 
292 
292 
292 
292 

724 
507 
291 
290 
289 
291 

291 
817 
539 
290 
551 

818 
818 
75 
290 
453 
724 

724 
290 
290 
290 
576 
293 
291 
291 
291 
291 
291 

292 
292 
292 
289 


366 
817 
290 

290 

291 
290 

370 
819 
747 
834 
612 


376 

57 

83 

125 

650 

209 
454 
209 
768 
211 
211 


769 

255 
255 


Gonococci,  contd. 

-  orchitis  due  to       . .  ..451 

-  panophthalmitis  from       . .     807 

-  peritonitis,  acute   from     . .       55 

-  prostatitis  due  to  . .  . .       83' 

-  ]nirulent  rhinitis  from       . .     20.^4 

-  not  stained  by  Gram's  method  76{> 

-  and  streptococci  associated      377 

-  ulcenitinn  nf  the  cornea  from    807 

-  in  unllii-iil  ilisrharge  79,  206,  675 

-  uretliiilis  (lur  to    ..  83,  675 

-  in  vaginal   discharges        . .     211 

-  vertebral  arthritis  due  to . .     785 

-  in  vulvitis    . .  . .  . .     768 

Gonorrhoea,      acute,      acute 

gouorrhoeal  arthritis  in..     376 

method  of  investigating 

206, 

-  -  prostatitis  and  prostatic 

abscess  from    . . 
uretliritis  in 

-  albuminuria     in    ascending 

nepliritis  from     . . 

-  balanitis  in  . . 

-  chordee  in   . . 

-  chronic  defined 

filaments  found  in  urine  in 

joint  lesions  from 

-  dyspareunia  frona  . . 

-  enlarged  inguinal  glands  from  422 

-  epididymo-orchitis  518,  766 

-  eosinophilia  in        . .  . .     248 

-  flat-foot  from  . .  . .     376 

-  gangrene  in..  ..  ..     282 

-  infection  of  ejaculatory  ducts  518 
prostatic  urethra  in  third 

week  in 

-  iritis  and  cyclitis  in 

-  mode     of     examining     dis- 

charge for  gonococcus  . . 

-  nature  of  vaginal  discharge 

-  nodules  in  globus  minor  in 

-  orchitis  from 

-  pain    in    tlae    penis    durmg 

micturition  in     . . 
sole  of  foot  from 

-  papilloma  uretlnrae  from     . . 
vulva?  from 

-  perineal  sores  from 

-  persistent  pyuria  in 

-  priapism  from 

-  prostatic  abscess  from 
threads  after 


207 

5ir> 
511 

10 
674 
125 
207 
207 
27S 
221 


518 
250 

768 

211 

767 

79 

511 
370 
209^ 
769 
677 
620 
580 
631 
444 
purulent  uretliral  discharge  in  511 

-  pyrexia  in   . .  . .  . .     620 

-  pyuria  due  to         . .        623,  031 

-  redness  of  Bartholin's  gland 

ducts  in   . .          . .          . .  769 

and  swelling  of  carunculte 

my rti formes     . .          . .  769 

-  residual  prostatic  catarrh  of  444 

-  rigors  from  . .          . .          . .  650 

-  scalding  on  micturition  in  769 

-  simulated  by  gouty  urethritis  818 

-  soft  cliancre  of         . .          . .  769 

-  spondylitis  deformans  after  786 

-  testicular  abscess  from      . .  680 
atrophy  after       .  .          . .  79 

-  thread-worm  infection  mis- 

taken for 569 

-  time    of    onset   of  urethral 

symptoms  . .  . .  511 

-  urethral       518 

epididymo-orchitis  in     . .  517 

gonococcus    in   smear    of 

the  discharge  in  (Plate 
XII,  Fig.  R,  p.  696)  . .     675 

pyuria  due  to      . .        623,  031 

staphylococcus     simulat- 
ing'         031 

-  vesiculitis  in  . .  . .     638 

-  vulvitis  in    . .  . .        768,  769 
GonorrhcEal  artliritis  (see  Ar- 
thritis) 


910 


GONORRHCEAL    BARTHOLINITIS— GUMMA 


Gonorrhceal  Bartholinitis 

221 

Gowers'  varieties  of  hemiplegic 

Guaiacum  test  for  blood 

89 

-  epididymitis   (see   Epididj- 

rigidity     . .          .  .        163, 

164 

iodides  and  the  . . 

112 

mitis.  Gonorrhoea^ 

Graafian  foUicle,  haemorrhage 

Guanin  bases,  uric  acid  from 

817 

-  rheumatism   (see   Arthritis, 

into,     spasmodic     pelvic 

Guinea-pig,  inoculation  of,  in 

Gonorrhceal) 

pain  from 

509 

diagnosing  tuberculosis 

Gooseberries,  oxaluria  from  311 

471 

Gracilis,  nerve  supply  of 

542 

57,  121,  026, 

719 

Goose-stin,  severe                528, 

530 

Grain,  sporotrichosis  from    . . 

322 

Gum-boil         

747 

Gout 

380 

Grandeur,  ideas  of,  in  general 

-  foul  taste  from 

774 

-  acut«  attack  of       . .        382, 

383 

paralysis  of  insane       139, 

269 

-  grinding  of  teeth  due  to    . . 

293 

arthritis  in           ..        3S3 

507 

Grandidier,  re  haemophilia  . . 

302 

-  pain  in  the  face  from 

495 

in  other  joints  than  the  toe 

382 

Grand  mal  (see  Epilepsy) 

-  ptyalism  due  to 

591 

-  age  incidence  of     . . 

381 

Granular  casts,  renal. . 

7 

Gumma  of  bone 

386 

-  albuminuria  in 

16 

-  kidneys    (and   see   Bright's 

diagnosis    from    chronic 

-  bony  out-growths  in 

383 

disease)     . . 

13 

pyogenic  infection 

752 

-  brachial  neuralgia  in 

491 

accentuation      of      heart 

sarcoma 

752 

-  carernitis  from 

516 

sounds  in         . .        1,  2 

639 

tuberculoas  disease    . . 

752 

-  cellulitis  simulating 

455 

albuminuria  in  . .            14,  18 

general  thickening  of  bone 

-  chronic  (Figs.  112,  113)     . . 

383 

and  cerebral  haemorrhage 

138 

in 

752 

-  condition  of  nails  in 

275 

Cheyne-Stokes  respiration 

localized  swelling  due  to 

-  confusion     witli     syphilitic 

with      ..          ..        124, 

125 

386, 

752 

pains 

386 

cyanosis  from     . . 

186 

osteomyelitis  due  to 

752 

179 

enlarged  left  ventricle  in  23f 

,639 

-  of  bundle  of  His     . . 

98 

-  diagnosis     from     infective 

epistaxis  in 

251 

-  Cauda     equina,     simulating 

arthriris    . . 

382 

in  gout     . . 

507 

peripheral  neuritis           74, 

563 

-  distribution  amongst  joints  in  383 

haemoptysis  in    . . 

318 

-  cerebral,  diabetes  insipidus  in 

585 

-  Dupuytren's  contracture  in 

167 

heart  failure  in  . . 

464 

headache,    vomiting   and 

-  dyspepsia  in 

354 

high  blood-pressnre  in 

giddiness  from 

336 

-  eifect  of  diet  in 

381 

18,  64,  96,  186,  251,  464 

639 

-  of  cranium,    tenderness     of 

-  epididymo-orchitis  from  517, 

818 

orthopncsa  in      . . 

464 

scalp  from 

782 

-  epistaxis  in  . . 

251 

pale,  albuminuria  in  con- 

- diagnosis  from  abscess 

449 

-  no  essential  relationship  to 

tracted  . . 

17 

Bazin's  disease   . . 

451 

uric  acid  precipitates  816 

817 

or  red    

63 

epithelioma 

420 

-  granular  kidney  in 

507 

palpitation  in     . . 

525 

lupus 

449 

—  glycosuria  in            . .        292, 

817 

pleuritic  effusion  in 

122 

-  enlarged  liver  from 

615 

-  headache  in 

328 

in  plumbism        . .          38, 

144 

-  of  face,  healed  (Figs.  156-7) 

589 

-  heredity  in  . .          . .        381, 

383 

polycythaemia  in 

579 

—  fauces,  palate,  or  uvnla    . . 

678 

-  high  blood-pressure  from  . . 

251 

polyuria  from      528,  579, 

-  of     joints     (see     Arthritis, 

—  importance  of  history  in  381 

383 

582,  583, 

584 

Tertiary  Syphilitic) 

-  intercostal  neuralgia  in     .  . 

478 

reduplicated  heart  sound 

-  of  liver        . .        . .       411, 

615 

-  iuTolTement      of      tendon 

in 

639 

action    of    mercury    and 

sheaths  in 

382 

signs  of    . . 

122 

iodide  in 

279 

-  in  lead  poisoning    . . 

77 

due  to  ureteral  obstruction 

11 

ascites  with 

60 

-  monarticular    character    of 

382 

Granulosis  rubra  nasi 

714 

causing  pleuritic  effusion 

123 

-  neiiralgia  in 

491 

Grating    in    osteo-arthritis  . . 

384 

new  growi:h 

279 

-  orchitis  from 

79 

Gravel,  uric  acid 

816 

secondary  carcinoma. . 

370 

-  oxaluria  in  . . 

471 

-  in  urine  in  renal  colic 

500 

local  enlargement  of  liver 

-  pain  in  the  big  toe  from. 

Graves'    disease    (see    Exoph- 

in      ... 

370 

381,  382, 

486 

thalmic  Goitre) 

pyrexia  in          . .          370, 

615 

-  peripheral  neuritis  in         75, 

507 

Gravid  utenis  (see  Pregnancy) 

simulated    by    phantom 

-  plumbism  causing  . .          38, 

507 

Great    auricular    nerve,    skin 

tumours     "      . . 

721 

—  priapism  in                        585, 

586 

distribution  of     . . 

659 

simulating  enlarged  gall- 

- piyrexia  in   . .          . .        382, 

455 

-  occipital  nerve,  skin  distri- 

bladder..          ..         278 

279 

-  rarity  of  suppuration  in    . . 

382 

bution  of . . 

659 

situation  of 

722 

-  recurrence  of  attacks  of   381 

382 

Great- toe  joint,  favourite  site 

therapeutic  test  for      279, 

370 

-  rigors  in     . .          . .           647, 

650 

for  gout   . . 

381 

Wassermann's  reaction  in 

-  scleritis  and  episcleritis  in 

256 

Greedy     colon,     constipation 

279, 

371 

-  senile  gangrene  and 

286 

due  to 

143 

-  mediastinal  (see  Mediastinum 

-  sex  incidence  of     . . 

381 

Green  cancer  (see  Ohloroma) 

Gumma  of) 

-  shiny  skin  over  joint  in    . . 

383 

Green-stick  fracture  . . 

750 

-  meninges 

687 

-  simulated  by  tabes 

484 

in  rickets 

769 

-  paralysis  of  vocal  cord  from 

538 

-  simulating  "gonorrhceal   ar- 

Grimacing,   mild    choreiform 

-  pelvic,  simulating  sciatica 

74 

thritis 

383 

movements  causing 

156 

-  of  penis 

677 

pyaemia    . . 

383 

GRINDING  OF  TEETH  DUR- 

- pyrexia  with 

615 

-  sodium    urate    crystals    in 

ING  SLEEP 

293 

-  of  skin 

279 

ioint,     bursa,  or    ear    in 

in  general  paralysis  of  the 

-  spinal   cord,    spastic    para- 

'(Figs. 112,  113)  . . 

380 

insane  . . 

796 

lysis  of  one  leg  from     . . 

540 

in  tophi  in 

380 

Groin,  affected  by  eczema  mar- 

 aUocheiria  from  . . 

22 

-  soles  of  feet  in 

3»2 

ginatum    . . " 

275 

-  spleen,  exceedingly  rare    . . 

692 

—  swelling  of  bones  in 

754 

-  coloured  sweat  of  . . 

714 

-  spontaneous  healing  of     . . 

812 

-  tenderness  in  the  spine  in  784 

785 

-  glands  (see  Lymphatic  Glands 

^ 

-  of  testis  (see  Testis,  Gumma  of) 

-  twticular  atrophy  after     . . 

79 

Inguinal) 

-  therapeutic  test  in  diagnosing 

-  tinnitus  with 

794 

-  hernia  in      . . 

716 

254,  279,  420,  672,  677, 

752 

-  tophi    about    joints    or    in 

-  oedema  of  in  ilihoy's  disease 

460 

-  thyroid  gland 

792 

ears  in      ..          ..        380, 

507 

-  pain  in,  from  renal  calculus 

308 

-  tongue           .  .            270,  420, 

814 

-  -  in  (Figs.  112,  113)       381, 

383 

-  sweUing   in   (see   Swelling, 

simulated  by  tuberculous 

-  urethritis  in     206,  585,  586, 

818 

Inguinal) 

ulcer 

814 

-  vertigo  due  to 

829 

due  to  lipoma  of  spermatic 

-  tonsU  simulating  carcinoma 

672 

-  violent  thumpinss  of  heart 

cord          

741 

sore  throat  Irom. . 

670 

4    in  elderly  people  liable  to 

527 

Growing-pains 

18 

-  ulcerating,  description  of  811 

813 

-  z-rays  in  (Fig.  113) 

383 

-  in  children,  relation  to  acute 

-  unilateral      exophthalmos 

Gow   on   reaction   of   vaginal 

rheumatism          . .         504, 

507 

due  to      

254 

secretion  . . 

210 

Guaiacol,  foul  breath  from    . . 

98 

-  uretliral         .  . 

209 

Gowere'  distal  myopathy,  fibril- 

 taste  from 

774 

-  \\'assennann's  reaction   in 

lary  contractions  rare  in 

15S 

-  poisonhig,  diazo-reaction  in 

198 

420, 

752 

G  UMS— HEMOGLOBIN  URIA 


911 


Gums,  uc-tinomycosis  of         . .       87 

-  Wcciliu!,'      (see       Bleeding 

<luiiis,  and  Gingivitis) 

-  Ijliie  line  on,  in  lead  poison- 

ing 130,  153,  473,  507,  525 

-  epithelioma  of         . .        41  !t,  749 

-  examination  of,  in  obscure 

pyrexia     . .  . .  . .     620 

-  lacerated,  in  fracture  of  jaw    747 

-  retraction  of  (see  Retraction 

of  Gums) 

-  septic,  foul  breath  due  to. .       99 

-  spongy,  in  infantile  scurvy 

295,  599 

and  fcctid,  in  scurvy      44,  303 

from  mercury     . .  . .     295 

in  scurvy-rickets  . .     753 

-  -  (see  Bleeding  Gums) 

-  suppurating  (see  Pyorrhoea 

Alveolar  is) 

-  swelling   of,    in   abscess   of 

antrum  of  Highmore      . .     502 

in  alveolar  abscess         . .     747 

Gun  headache . .  ..  ..     329 

Gunpowder  type  of  actinomyces  736 
Gunshot     wounds,     pneumo- 
thorax after  577,  578 
Gurgling,  abdominal  (see  Bor- 

borygmi) 
Gymnastics,  menorrhagia  from    428 

HABITS,  change  of,    causing 

amenorrha3a         . .          . .  23 

-  dirty  in  idiocy         . .          . .  682 

-  effect  on  constipation  of    . .  143 
Habit-spasm  a  cause  of  con- 
vulsions   . .          . .          . .  169 

-  mild  chorea  simulating      . .  156 

-  inusole  twitching  in            . .  159 

-  tetanus  naistaken  for  . .  162 
Hiipmamajba  malarice  . .  35 
H/EMATEMESIS        ..         ..293 

-  in  abdominal  angina          . .  351 

-  after  abdominal  operations, 

no  obvious  lesion  in        . .  304 

-  acid  reaction  of  blood  in    . .  293 

-  in  acute  yellow  atrophy  . .  370 

-  admixed  food  particles  in  293 

-  ni  alcoholism  . .  . .  243 

-  anaemia  after  . .  30,  459 

-  in  carcinoma  of  stomach 

351,  09],  846 

-  cirrhosis  of  liver         60,  368,  409 

694,  696 

-  coffee-grounds     appearance 

of  blood  in  . .  . .     293 

-  coma  from  . .  . .        137,  140 

-  from  corrosive  poisons     674,  845 

-  diagnosis  from  hasmoptysis 

293,  316 

-  differential       diagnosis      of     295 

-  in  duodenal  carcinoma 

-  duodeno-pancreatic  fistula 

294, 

-  from  epistaxis 

-  gastric  ulcer     40,  352,  485, 
or  duodenal  ulcer 

-  hremoptysis 

-  Henoch's  purpura 

-  irritant  poisoning 

-  leucocytosis  after   . . 

-  list  of  causes  of 

-  from   mediastinal   sarcoma 

-  in  mesenteric  embolism 

-  phosphorus  poisoning 

-  preceded    by    nausea 

faintness  . . 

-  in  relapsing  fever    . . 

-  splenic  anaemia 

-  splenomegalic  cirrhosis 

-  tarry  stools  after     . . 

-  variable     colour    of    blood 


90,  380, 
674, 


and 


369, 


Haematidrosis,  account  of 


725 

300 
294 
846 
89 
317 
846 
845 
400 
294 
296 
153 
373 

316 
373 
411 
694 
310 

29.3- 
715 


95 


522 


140 


523 


770 
473 
20 
473 
700 
760 
140 
757 

757 


HiBmatin,  absorption  bands  of 
Hsematocele,  absence  of  trans- 
lucency  in 

-  clinically     like     hydrocele 

except    for    translucency 

-  coma  from  occurrence  of  . . 

-  diagnosis    from    tumour    of 

testis         . .  . .        521 
scrotal  hernia 

-  cocl\ymosis  of  scrotum  ironx 

-  lluctuation  in  ..         521 

-  gradual  onset  in  some  cases 

-  history  of  injury  in 

-  operation  in  diagnosis  of  . . 

-  pelvic  

albumosuria  in    . . 

bearing-down  pain  in     . . 

bulging  into  rectum 

into  vagina 

coma  from  liaemorrhago  of 

due  to  ectopic  gestation 

haemorrhage  from  corpus 

luteum 

pelvic  swelling  due  to  757,  760 

from  tubal  abortion       . .     760 

-  due  to  tapping  a  hydrocele     522 

-  testicular  atrophy  from     . .       78 
Haematocolpos  ..        ■•     761 

-  witli  amenorrhoea  . .  22,  23 

-  imperforate  hymen  in        . .     761 

-  pelvic  swelling  due  to       757,  701 

-  uterus   like  a  cork   on   the 

upper  extremity  of 
Haematoma,  abdominal,  diag- 
nosis from  splenic  tumour 

-  albumosuria  from  .  . 

-  aural,  in  general  paralysis 

-  leaking  abdominal  aneurysm 

causing 

-  pelvic 
dystocia  due  to 

-  penile,  causes  of 

-  perinepln:itic 

-  of  vulva 

swelling  due  to  . . 

Hjematometra    with    amenor- 

rha3a         ..  ..  22,  23 

-  pelvic  swelling  due  to        . .     757 
HEBttiatomyelia,  anaesthesia  in     604 

-  coniiuon  situation  of  .  .      555 

-  history  of  injury  In  .  .      563 

-  paralysis  of  arm  from        . .     555 

-  paraplegia  due  to    . .  . .     561 

-  sensory  disorders  in  . .     563 

-  thermo-anaesthesia  in         .  .     664 
Haemato-nepiirosis    in    papil 

loma  of  kidney    .  . 
Hsematoporphyrinuria  (see  Urine, 

AliiKirmil  ('(iloriitiouof) 

-  abscnre  of  idliuniiuuria  with    820 

-  black  urine  from     819,  820,  821 

-  brown  urine  from    .  .  . .     820 

-  detection    by    spectroscope     819 

-  high  colour  of  urine  due  to     818 

-  in  hydroa  aestivale  . . 

-  method  of  precipitation     . . 

-  pink  urine  from 

-  red  urine  from 

-  sex  incidence  of 

-  simulating   hajmoglobinuria 

-  sodium  bicarbonate  in 

-  due  to  sulphonal     . . 

-  in  tuberculosis 
Haemato-rachis,    talipes    from 
Haematosalpinx  with  amenor- 

rhcea         . .          . .  . .       22 

H/EMATURIA  ..304 

-  in  acute  cystitis     . .  512,  627 

-  age  of  patient  in      . .  . .     306 

-  anaemia  after           . .  . .       36 

-  in  appendicitis        . .  . .     632 

-  with  bacteriuria      . .  . .       83 

-  bilharzia  infection  313,  630 
439 


761 

092 

20 

209 

092 
757 
227 
510 
308 
770 
768 


308 


20 

. .  820 

.  .   819 

819,  820 

..  820 

819 

820 

820 

820 

132 


313 
-  blood-clot  in  bladder  from 


Hcemaluria,  conld. 

-  Briglit's  disease       . .  . .       12 

-  brown  urine  from  . .         . .     820 

-  colic  in  .  .  . .        306,  395 

-  colour  of  urine  in      305,  819,  820 

-  from  corrosive  poisoning  . .     297 

-  with  cystic  kidneys  15,  396 


-  cystoscopy  in  (Plale  V,  p.  308) 


9, 


.307 
313 


315 

306 

305 
305 
307 
300 


310 
395 

306 
12 
632 
600 
305 
306 
307 
689 


-  diagnosis  of 

-  diagnosis     from     haemoglo- 

binuria 

-  disproportionate     albumin- 

uria in 

-  distril^ution  of  blood  in  the 

urine   during   micturition 

-  examination  of  clots  in 
testis  in  cases  of 

-  frequent  micturition  with . . 

-  in  f ungating  endocarditis     9,  237 

-  Henoch's  purpura     90,  380,  000 

-  from  hypernephroma         . .     395 

-  increased  after  exercise  with 

calculus     .  .  .  .  395,  629 

-  influence   of   movement   on     305 

-  intermittent,  from  movable 

kidney 

-  kidney  enlarged  with 

-  penile  pain  with,  in  vesical 

disease 

-  phosphates  coloured  by     . . 

-  due  to  prostatic  abscess     . . 

-  in  purpura  haemorrhagica . . 

-  quantity  of  blood  in  urine  in 

-  reaction  of  uruie  in 

-  rectal   examination    in 

-  renal  enlargement  with 

-  from  renal  calculus 

16,  46,  135,  308,  627,  818 
carcinoma  . .    9,  395,  820 

-  -  colic  . .  . .         153,  500 

embolism  . .         . .         . .     237 

sarcoma    . .  . .  . .     395 

-  -  tuberculosis     10,  394,  620,  629 

tumour  with         . .  16,  367 

unilateral  ureteric  bleed- 
ing in  (Plate  TX,  Fig.  A, 
p.   052) 

-  in  scarlatina  maligna 

-  simple  ulcer  of  bladder 

-  simulated  by  aniline  dyes. . 
uroerythrin 

-  spectroscope  in  diagnosis  of 

-  in  suppurative  nephritis   . . 

-  with  suprarenal  tumour    . . 

-  thrombosis  of  inferior  vena 

cava  .  .  9,  61,  825 

-  unilateral  lumbar  pain  in. .     306 

-  in  uraemia     . .  . .  . .     329 

-  ureteral  calculus      .  .135,  514,627 

-  urethritis      . .  .  .  . .     631 

-  variola  maligna       . .  . .     301 

-  vesical  calculus        . .  . .     512 

-  -  growth47,395,512,514,628,630 

-  -  tuberculosis     441,  513,  628,  029 
Hasmochromatosis,      argyria 

simulating 

-  in  digestive  diseases 

-  slate-coloiured  skin  in 
Haemocytometer 
Hfemoglobin,    increase    of    in 

congenital  heart  disease 

-  sperfr.il  alisiirption  band  .. 
Hsemd'jluhiiinmi'tpr     .  . 
H/EMOGLOBINURIA 

-  colour  of  urine  in 

304,314,  819,820,821 

-  diagnosis    from    haematuria     315 

-  importance  of  fresh  lu-ine  m 

examination  for..  ..     314 

-  methaemoglobin  in  urine  in 

304,  314 

-  mucus,  casts,  and  d^-bris  in 

urine  in  . .    . .    . .  314 


307 
301 
630 
820 
818 
821 
646 
690 


575 
575 
575 
27 

579 

95 

27 

314 


912 


HEMOGLOBIN  URIA  —HMMORRHA  GE 


HaemogloMnuria,  contd 

Hsemorrhage,  anaemia  after   36 

459 

Hcemorrhage,  contd. 

-  oxyhsemoglobin  in  urine   in 

314 

-  ante-  and  post-partum 

436 

-  into     intestinal     wall     in 

-  paroxysmal  . . 

821 

-  peranum  (see  Blood  per  Anum) 

Henoch's  purpura          600,  846 

-  simulation   by   hsematopor- 

-  arachnoid,     convulsions     in 

172 

-  intra-abdominal,       hEemo- 

phyrinuria 

819 

-  in  Bright's  disease  . . 

598 

globinuria  from  . . 

315 

-  spectroscope  in  diagnosis  of 

821 

-  into  calf  muscles  in  scurvy 

599 

-  in     jaundice,    from     trivial 

Hfflmoperitoneum,    blanching 

-  capillary,  in  jaundice 

361 

causes 

598 

with 

717 

-  cerebral        . .        • .      173, 

685 

-  into  joints  in  hfemophilia  (see 

-  rapid  small  pulse  with 

717 

acquired     paralysis      of 

Hfemophilic  Arthritis) 

-  from  rupture  of  liver 

717 

childhood  due  to 

155 

in  Henoch's  purpura 

90 

spleen 

717 

albuminuria  in   . .  98,  137, 

138 

-  in  labyrinth,  nerve  deafness 

-  sighing  respiration  with     . . 

717 

aphasia  from 

685 

from 

190 

-  simulating  ascites  . . 

717 

the  apoplectic  fit  described 

173 

-  from  lung  (see  Haemoptysis) 

Haemophilia,     acute    hsemor- 

-  -  arteriosclerosis  with 

337 

-  in  lymphatic  leulcromia 

599 

rhagic  otitis  in     . . 

408 

athetosis  after     . . 

155 

-  medulla    oblongata,    laryn 

-  antemia  in    . . 

37 

bilateral    . . 

563 

geal  paralysis  due  to 

539 

-  bleeding  gums  in    . . 

85 

brachial  monoplegia  from 

546 

-  meningeal,  acute  onset  of. 

562 

from  mouth  in    . . 

302 

bradycardia  in    . . 

98 

birth  palsies  due  to 

155 

-  blood  in  joints  in    . .         302 

388 

Cheyne-Stokes    respiration 

coma  in    . . 

137 

-  epistaxis  in             . .        251, 

302 

in 

125 

convulsions  in     . . 

172 

-  familial  character  of            86 

599 

choreiform       movements 

talipes  from 

131 

-  hsematemesis  in      . .        291, 

302 

before    . . 

157 

and  thrombosis,  acquired 

-  hsematuria  m 

305 

coma  in   ..          ..137,138 

292 

paralysis   of   childhood 

-  haemoptysis  in 

318 

convulsions  in     . . 

169 

due  to  . . 

155 

-  menorrhagia  in       . .        428, 

430 

cortical,  birth  palsies  due  to 

155 

-  into  mesentery  in  Henoch's 

-  metrorrhagia  due  to          433 

435 

defective  arteries  in 

138 

purpura    . . 

846 

-  persistent  oozing  from  slight 

diabetes  insipidus  from  . . 

585 

-  middle  lobe  of  cerebellum 

cuts  and  scraiiches  in 

599 

diagnosis  of  general  para- 

priapism from 

586 

-  ptyalism  due  to 

590 

lysis  of  insane  from    . . 

139 

-  from    mucous    membranes 

-  purpura  in  . .          . .        59G, 

599 

enlarged  heart  in           138, 

337 

in  Hodgkin's  disease 

649 

-  sex  incidence  of 

599 

granular  kidney  with     . . 

138 

leukaemia 

649 

-  stomatitis  in 

590 

headache  in          173,  327, 

328 

pernicious  anaemia 

649 

Haemophilic  arthritis.. 

388 

hemiansesthesia  from    336, 

666 

pseudo-leukaemia 

42 

Hsemopneumothorax 

577 

hemianopsia  from 

335 

scurvy 

44 

-  needling  of  chest  in  diagnosis 

hemiplegia  due  to 

scurvy  rickets 

753 

of 

711 

82,  138,  285,  336, 

337 

in  von  Jaksch's  disease      42 

-  sucoussion  sounds  with 

711 

high  blood-pressure  in 

-  nasal  (see  Epistaxis) 

H>EMOPTYSIS 

315 

96,  98,  138, 

337 

-  occult  (and  see  Occult  Blood)    94 

-  after    abdominal    operation 

123 

in  Hodgkin's  disease 

302 

in  pancreatitis     . . 

117 

-  admixture  of  sputum  in    293 

316 

hyperpyrexia  from          98, 

344 

-  oedema  of  legs  due  to        459,  461 

-  alkalinity  of  blood  in       293, 

316 

hypertension   of  cerebro- 

- into  optic  thalamus,  hyper 

-  amount  of  blood  in 

293 

spinal  fluid  in . . 

338 

pyrexia  from 

344 

-  anaemia  after 

36 

hypothermia  in  .  . 

346 

-  pancreatic,  collapse  in 

292 

-  bright  colour  of  blood  in  . . 

293 

Jacksonian  epilepsy  from 

161 

constipation  in   . . 

292 

-  bronchial  casts  after 

704 

optic  neuritis  in 

98 

glycosuria  in 

292 

-  casts  in  sputum  after 

704 

-  -  prodromal    symptoms    of 

173 

severe  abdominal  pain  in     292 

-  causes  of       ..          ..317,318 

319 

ringing     aortic     second 

simulating  acute  intestinal 

-  coma  from  . .          . .         137, 

140 

sound  in 

337 

obstruction 

292 

-  diagnosis  from  hfematemesis 

from  rupture  of  an  acute 

vomiting  in 

293 

293, 

316 

aneurysm 

700 

-  in  phosphorus  poisoning    . 

373 

between  true  and  spurious 

316 

simulated    by    saturnine 

-  pontine        

138 

-  elastic  fibres  in  sputum    316, 

317 

encephalopathy 

139 

absence  of  unilateral  para 

- 

-  in  embolism  of  the  lung     . . 

186 

tumour 

341 

lysis  in . . 

138 

-  caused  by  epistaxis 

251 

a  first  symptom  of  chronic 

bilateral    loss    of    move 

-  fatal  from  aneurysm  of  aorta 

322 

nephritis 

15 

ment  in 

345 

-  in  fibroid  lung 

.246 

temporary    glycosuria    in 

292 

coma  in    . .          . .        344,  345 

-  frequency  of  occurrence  in 

tendon  reflexes  after 

337 

hyperpyrexia  ui  . .       13S 

,  341, 

night 

317 

thick  neck  in  those  pre- 

344, 345 

-  frothiness  of  blood  in        293, 

316 

disposed   to . . 

191 

pin-point  pupils  with    138,  345 

-  in  gangrene  of  lung 

288 

unilateral   convulsions   in 

170 

simulating  opium  poison 

-  due  to  growths 

176 

epilepsy  mistaken  for. . 

174 

ing 

345 

-  haematemesis  from  swallowed 

from  uterine  prolapse     . . 

10 

-  postpartum 

27 

blood  in  . .            294,  295 

317 

vomiting  from    . .         844, 

847 

coma  due  to 

137 

-  in  healthy  subjects 

318 

-  into  cord  from  bullet  wound 

563 

from  hourglass  uterus    . 

229 

-  from  infarction  of  lung     186 

,  240 

-  from  ears  or  nose  in  fractured 

leucocytosis  after 

400 

-  malingering  of 

317 

skull          

138 

secondary 

436 

-  in  mediastmal  growth 

483 

-  functional  bruits  after 

106 

severe  anremia  after 

459 

-  mitral  regurgitation         238, 

240 

-  in  fungating   endocarditis 

-  producing  diplopia 

200 

-  in     parasitic     infection     of 

9,  10,  38, 

593 

-  rectal  (see  Blood  per  Anum 

) 

bronchus  . .          . .         318 

,325 

-  gastric  (see  Haematemesis) 

-  in  retina      . .        . .       59 

8,  613 

-  phthisis 

185 

-  into  Graafian  follicle  resem- 

 in    albuminuric    retiniti 

3     462 

-  from  pneumothorax 

577 

bling  dysmenorrhoea 

220 

chronic  Bright's  disease . 

240 

-  profuse,  due  to  aneurysm.  . 

176 

-  from    gums    (see  ^Bleeding 

erythropsia  with 

840 

new  growth          . .        176 

322 

Gums) 

in  fungating  endocarditi 

phthisis 

176 

-  in  Hanot's  cirrhosis 

411 

38,  76,  237,  338,  59 

8,  013 

-  rapidly  fatal 

293 

-  hard  fteces  after 

150 

macular,  precedmgchoroi 

i- 

-  severe  anemia  after 

459 

-  internal  from  ruptured  tubal 

itis         . .          . .          . 

462 

-  spurious,  causes  of . . 

316 

gestation 

780 

scotoma  from      . .          . 

837 

-  from  stonemason's  lung     . . 

317 

signs  of     . . 

646 

-  round  optic  nerve,  sudder 

I 

-  the  only  symptom  of  throm- 

- intermenstrual  (see  Metror- 

blindness from    . . 

839 

botic  infarct  of  lung 

320 

rhagia) 

-  in  scurvy     . . 

44,  85 

-  tickling  in  throat  in 

316 

-  intestinal    (see    Blood    per 

-  into     semicircular     canals 

-  tubercle   bacilli   in           316 

317 

Anum,  and  Melaena) 

M6nifere's  disease  due  t( 

)     828 

-  a:-rays  in 

318 

coma  from           . .        137, 

140 

-  severe,  collapse  from 

346. 

HAEMORRHAGE,  SEVERE— HEAD'S  AREAS 


913 


licemorrliage,  severe,  conld 

Hair,  contd. 

Hand,  contd. 

coniii  due  to            137,139 

140 

-  brittleness  in  cretinism     . . 

259 

-  professional  cramp  of 

177 

ellects  of  . . 

298 

-  broken  in  ringworm  of  scalp 

274 

-  pruritus  of  . . 

588 

extreme  thirst  from 

78a 

-  changes  in  myxoedema 

43 

-  Kavnaud's  disease  affecting 

fall  of  temperature  from 

780 

-  distribution     of     ringworm 

459, 

490 

hypothermia  after 

346 

spores  on . . 

273 

-  redness  or  pallor  in  acropar- 

leucocytosis  after 

400 

-  falling  out,  in  myxoedema 

454 

aesthesia   . . 

493 

cedema  of  legs  after 

461 

-  follicles,  affection  in  papular 

-  scabies  of     . .          . .        447, 

609 

pallor  from 

780 

syphilis     . . 

532 

-  sensation  of  heat  and  swell- 

 rapid  pulse  from             G46 

780 

pityriasis  rubra  pilaris 

530 

ing  in,  in  acroparasthesia 

193 

-  shortness  of  breath  due  to 

100 

xerodermia 

530 

-  sweating  of,  in  rheumatoid 

-  spinal,  amesthesia  due  to  . . 

787 

-  loosening     of,     in     sycosis 

arthritis    . . 

378 

girdle  pain  due  to 

787 

-iTilgaris    . . 

602 

-  tremor  of     . . 

795 

history  of  injury  in 

563 

-  loss  of  (see  Baldnes.s) 

from  alcohol        136,  238, 

797 

paralysis  of  upper  extre- 

 lustre  due  to  favus 

270 

general  paralysis    of   the 

mity  from 

555 

-  mode   of  affection  in  ring- 

nisane  . . 

796 

paraplegia  due  to          561 

787 

worm 

272 

in  exophthalmic  goitre  792 

797 

priapism  from 

585 

-  "  mousey  "  colour  in  Mongo- 

- wasting  of,  in  amyotrophic 

sensory  disorders  in 

563 

lian  idiocy 

263 

lateral  sclerosis  . .           73, 

554 

-  in  splenic  ansmia  . . 

411 

-  scantiness  in  cretinism     . . 

259 

bulbar  palsy 

087 

-  splenomegalic  cirrhosis 

094 

Mongolian  idiocy 

263 

from  cervical  rib 

493 

-  spontaneous,    in   congenital 

and  receding  in  myxoedema 

259 

in  peroneal  atrophy 

128 

obliteration  of  bile-ducts 

365 

-  shape  in  alopecia  areata 

progressive  muscular  atrophy 

-  subconjunctival,     in    acute 

84,  85, 

274 

73, 

127 

conjunctivitis 

255 

-  stumps  in  rmgworm  of  scalp 

273 

syruigomyelia 

285 

distinguished    from    con- 

- suppuration  round,  in  sycosis 

ulnar  paralysis    . . 

127 

junctivitis 

256 

vulgaris    . . 

602 

Hanot's  cirrhosis  (see  Curhosis 

in  fractured  skull 

138 

-  thinness  at  back  from  head 

of  Liver,  Hanot's) 

-  subcutaneous  (see  Purpura) 

rolling 

171 

Harelip  with  cleft  palate     . . 

640 

in  fungating  endocarditis 

76 

-  trophic    changes    in    major 

Harrison's  sulcus  170,  191,  212 

695 

-  subdural,  convulsions  in    . . 

172 

trigeminal   neuralgia 

495 

Hat-makers,  mercury  poison- 

- subperiosteal  in  scurvy  44,  8a 

,314 

Hair-ball,  palpation  per  rectum 

635 

ing  in       . .          . .             Zi 

,   '■7 

-  into  thyroid  cyst  simulating 

Hair-cutter's  cramp  . . 

494 

neuritis  in 

77 

malignant  disease 

791 

Hair-wash,  lead  poisoning  from 

77 

Hav  fever,  acute  nasal  catarrh 

-  uncinate  gyrus,  anosmia  from 

669 

Haldane-Gowers'       hsemoglo- 

"  m 203, 

668 

-  itrinary  (see  Ha?maturia) 

binometer 

27 

loss  of  smell  in    . . 

668 

-  Uterine    (see    Menorrhagia, 

Haller,  vas  aberrans   of,  cyst 

taste  due  to    . . 

774 

Metrorrhagia,  ^Metrostaxis ; 

arising  from 

521 

-  sporotrichosis  from 

322 

L'terus,  Haemorrhage  from) 

Hallucinations   of  hearing   in 

Head,  choreiform  movements 

intermenstrual  (see  iletror- 

mental  cases 

793 

of,  in  spinocerebellar  ataxy 

799 

rhagia) 

Hallux  erectus  in  Friedreich's 

-  enlarged  in  acromegaly     . . " 

585 

-  vaginal    (see    Menorrhagia, 

ataxy        . .             71,  131, 

559 

cretinism  . . 

258 

Metrorrhagia,  :iIetrostaxis) 

Haloes,  appearance  of  in  glau- 

 hydrocephalus     . . 

557 

in  extrusion  of  uterine  fibroid587 

coma  and  conjunctivitis 

257 

osteitis  deformans 

183 

inversion  of  uterus 

578 

Halting  (see  Gait) 

rickets 

170 

new-born  infants           435, 

436 

Hamstrings,  atrophy  of 

560 

-  fixed  in  cervical  caries     . . 

477 

with  ruptured  tubal  gesta- 

- elongation  in  contortionists 

183 

-  forward  droop  in  acromegaly 

263 

tion       

646 

-  spinal  nerve-roots  supplying 

543 

-  fullness  of,  epistaxis  relieving 

2.52 

-  various,  in  leukcemia 

31 

-  treadler's  cramp  of 

177 

-  injuries,  alopecia  from 

80 

-  into  vitreous,  blindness  from 

840 

HAND,  ACCOUCHEUR'S      .. 

3 

cerebrospinal    fluid    from 

erythropsia  from 

840 

-  affected  by  acute  rhetunat- 

nose  after 

203 

sudden  blindness  from  . . 

839 

ism 

374 

chronic  headache  after  . . 

329 

Hsemorrhagic  erosions 

298 

erythema  papulatum     . . 

531 

coma  due  to 

137 

-  small-pox 

605 

-  angioneurotic  cedema  of  457 

459 

effects  of  . . 

137 

KaemorrhoidSjin  alcoholism  . . 

243 

-  athetosis  of  (Fuj.  42) 

154 

hemiplegia  from 

138 

-  bleeding 

92 

-  atrophic  palsy  of,  in  amyo- 

 Jacksonian  epilepsy  after 

174 

-  bearing-down  pain  from    . . 

473 

trophic  lateral  sclerosis  131 

.159 

-  quadrate,  in  rickets 

695 

-  in  cirrhosis  . . 

368 

-  bloody  sweat  of 

'715 

-  retraction  of  (see  Retraction 

-  diagnosis  from  rectal  polypus 

635 

-  bullse  of  in  congenital  sy- 

of Head) 

-  dyspareunia  from  . . 

221 

philis 

111 

-  tremor  of     . .          . .        795, 

796 

-  excessive  blood  loss  from. . 

100 

in  syringomyelia 

112 

in   disseminated  sclerosis 

800 

-  increased  by  pylephlebitis 

59 

-  cheiropompholyx  of         654 

832 

I'riedreich's  ataxy 

799 

-  inflamed,  pain  in  the  penis 

-  chondromata  of 

755 

paralysis  agitans 

796 

after  micturition  in      513, 

515 

-  deformity  in  spastic  hemi- 

- segmental    areas    of    (Ficfs. 

-  internal,  carcinoma  of  rectum 

plegia        

164 

132-135) 

497 

with 

635 

syringomyeUa 

534 

Head,    H.,  re     alterations    in 

difficulty     of     palpation 

tetany 

178 

sensibility 

660 

unless     inflamed     or 

-  enlarged    in    acromegaly 

-  re  Brown-Sequard  paralysis 

664 

thrombosed 

635 

391,  585,  749, 

753 

-  re  distribution  of  sensation 

-  pam  in  perineum  in 

516 

-  gangrene  of 

287 

changes  from  lesions  in  the 

-  priapism  in  elderly  men  from 

586 

-  gonococcal  artliritis  of 

376 

cord          

662 

-  and  prolapse,  association  . . 

93 

-  lupus  erythematosus  of     . . 

656 

-  re  nerves  of  heart  and  aorta 

481 

-  retention     of     urine     after 

-  mercurial  tremor  of 

797 

-  re  pain  in  the  face  . . 

495 

operation  for 

49 

-  muscular    atrophy   of    (see 

-  re  referred  pain  from  pros- 

- sacralgia  from 

510 

Atrophy,  Muscular,  of  Hand) 

tatitis 

491 

-  spasm  of  sphincter  ani  from 

150 

-  in  myxoedema          454,  455, 

585 

-  re  segmental  areas  of  scalp 

-  thrombosis  or  gangrene  of. . 

635 

-  oedema  of  in  heart  faihn-e 

458 

(Figs.  202,  203) 

783 

Hemosiderin  in  macules 

424 

and     tenderness     of,     in 

-  re  spinal  areas  of  referred 

H/EMOTHORAX 

118 

erythema  keratodes  . . 

451 

pain 

788 

Hair,     analysis     for     arsenic 

-  pain  in,  due  to  chondromata 

755 

-  re  trigeminal  neuralgia 

495 

poisoning. .        38,  78,  87, 

576 

-  paralysis     of,     m     Tooth's 

Head's  areas  of  referred  pain 

-  axiUary    and    pubic,    early 

peroneal  atrophy             71 

128 

in  pelvic  disease 

509 

development  with  hyper- 

- preference  of  impetigo  for 

604 

-  segmental  areas  for  referred 

nephroma 

690 

small-pox  for 

605 

pain 

498 

58 


914 


HE  A  DA  CHE— HE  A  R  T,    EN  LA  RGED 


HEADACHE    

326 

Hearing,  defects  of,  delay  in 

Heart  disease,  conld. 

-  in  acute  encephalitis 

139 

acquiring  speech   due  to 

682 

dry  cough  due  to 

175 

meningitis            . .        139, 

563 

-  impaired  in  otitis  media    . . 

229 

eosinophilia  in  diagnosing 

poliomyelitis 

128 

with  facial  paralysis     . . 

536 

asthma  from  . . 

249 

yellow  atrophy  . . 

370 

-  tests  for 

188 

epistaxis  ui 

251 

-  aortic  disease 

233 

Heart,  abscess  of  (see  Abscess 

flatulence  in 

267 

-  arsenical  poisoning 

76 

of  Heart) 

gastritis  in 

352 

-  from  astigmatism   . .        498, 

783 

-  affection  common  in  Mon- 

 general  pains  in  limbs  in 

503 

-  in  cerebellar  abscess  or  tumour565 

golism 

216 

haematemesis  in..         294, 

299 

-  cerebral  abscess  341,  547,  686 

847 

by  post-diphtheritic  peri- 

 hEematuria  in     . . 

314 

syphilis     . . 

173 

pheral  neuritis . . 

640 

headache  in 

329 

-  -  tumour          173,  292,  336, 

341, 

-  alcoholic,  ascites  with 

62 

heart  failure  from 

461 

350,  477,  547,  686 

847 

-  block             

97 

history  of  chorea  in 

526 

-  from  concussion 

782 

-  bruits  (see  Bruits,  Cardiac) 

scarlet  fever  ui 

526 

-  and  cryptomenorrhcea 

22 

-  cloudy  swelling  of,  palpita- 

 syphilis  in 

526 

-  with  cystic  kidneys 

48 

tion  in      .  .          . .         525, 

526 

hyperaemia  of  uterus  from 

430 

-  digestive 

326 

-  compression  in  aortic  aneur- 

 hypothermia  in  . . 

345 

-  in  encephalitis 

547 

ysm 

482 

increase  of  uroerythrin  in 

-  epidemic  jaundice  . . 

372 

-  dilatation  of,  acute,  epigastric 

urine  in 

819 

-  after  epileptic  convulsions 

169 

in  pulsation 

243 

infantile    paralysis  from 

155 

-  in  errors  of  refraction 

498 

general  account  of     . . 

243 

infantilism 

216 

-  frontal  in  diseases  of  eyes. . 

328 

from  specific  fevers  . . 

243 

insidious    onset    of    fun- 

-  -  at  onset  of  typhoid  fever 

610 

canter  rhythm  in 

639 

gating  endocarditis  in 

314 

-  in    fronto-nasal    and    mid- 

in  chronic  bronchitis  and 

insomnia  in          . .        356, 

358 

orbital   areas,    in   frontal 

emphysema 

246 

menorrhagia  in  .  . 

428 

sinusitis   . . 

498 

fibroid  degeneration 

241 

mesenteric  thrombosis  in 

153 

nasal  inflammation . . 

498 

Flint's  murmvu  in 

108 

(jedema  of  legs  from 

461 

-  in  gastritis  . . 

297 

of  left  auricle  from  mitral 

orthopnoea  in      . . 

359 

-  general  tuberculosis 

699 

stenosis 

245 

pain  in  the  chest  in 

478 

-  glaucoma     . .     257,  494,  783 

838 

mitral  regurgitation  from 

temporal  region  from 

783 

-  hysteria        . .          . .        345, 

784 

239,  240, 

243 

and  tenderness  in  back 

-  due  to  hypermetropia 

783 

in  myocarditis     . . 

241 

from  (Fig.  204)     788, 

789 

-  increased  intracranial  pres- 

 pernicious  anaemia 

639 

palpitation  in     . . 

481 

sure           

686 

right   ventricle,    pain    in 

pancreatitis  from 

116 

-  in  influenza             . .        505, 

601 

epigastrium  in 

485 

polyuria    in    clearing    up 

-  iritis  . . 

783 

sharp  short  first  sound  in 

331 

of  effusion  in  . . 

582 

-  with  lardaceous  disease     . . 

48 

simulation   of  gaU-stones 

precordial  pain  in 

481 

-  in  late  stages  of  acromegaly 

749 

by         

485 

puSiness   and  oedema   of 

-  lesions    of   central   nervous 

gastric  ulcer  by 

485 

f ac«  in 

746 

system 

585 

systolic  bruit  in            102, 

106 

referred  pain  in  arm  in  . . 

494 

-  Malta  fever 

507 

-  disease,  albuminuria  in.. 

18 

rheumatic  history  in    121 

620 

-  meningitis    350,  359,  622,  642 

847 

amenorrhcea  in   . . 

23 

shortness  of  breath  hi  . . 

100 

-  in  mid-orbital  region  in  errors 

anaemia  in 

38 

splenic    enlargement    m. 

of  refraction 

498 

anal    haemorrhage    from 

suggesting       fungating 

-  migraine       ..          ..837,  840 

847 

mesenteric  embolism  in 

90 

endocarditis     . . 

699 

-  mode  of  production  of 

326 

ascites  in . . 

61 

subcutaneous  nodules   in 

452 

-  neurasthenia      494,  506,  702 

788 

blood-pressure  high  from 

251 

tenderness  in  chest  from 

776 

-  occipital,    in    affections    of 

low  in   . . 

329 

epigastrium  from      779, 

783 

tongue 

498 

brachial  monoplegia  in . . 

546 

precordial  region  from 

778 

cerebellar  disease 

326 

cerebral  embolism  in     . . 

138 

temporal  region  from 

783 

cerebral  tumour  . . 

477 

in    children,    splenic    en- 

 uric  acid  in 

817 

-  -  diagnosis  from  cervical  caries47  7 

largement  in   . . 

693 

vomiting  in 

843 

meningitis 

327 

—  congenital,  aortic 

238 

-  duUness     diminished     m 

simulated  by  myalgia    . . 

326 

bruits  m          102,  104, 

emphysema 

246 

-  at  onset  of  dengue . . 

506 

129,  244,  579 

790 

with  hypertrophied  heart 

331 

-  paroxysmal,  due  to  eyestrain 

498 

cardiac  dullness  in 

790 

increased  in  acute  dilata- 

- phosphorus  poisoning 

373 

clubbing  of  fingers  in 

tion  of  heart    . . 

2i3 

-  plumbism     . .          . .  38,  77, 

173 

129,  244,  529,  579 

790 

aortic  disease  . . 

233 

-  in  puetmionia 

622 

colour  index  in 

579 

enlarged  heart          231 

232 

-  preceding  apoplexy 

173 

convulsions  due  to    169, 

170 

congenital  heart  disease 

-  with  XJuerperaJ  eclampsia.. 

172 

cyanosis  in      129,  184, 

244 

579 

-  pyelonephritis 

48 

244,  579, 

790 

fatty  heart 

241 

-  referred  pain  in  severe  ear 

dyspnoea  in     . .         244 

790 

mitral  regurgitation   . . 

238 

disease 

498 

enlarged  left  ventricle  in 

232 

stenosis 

245 

-  relief  by  digitalis    . . 

329 

enlargement  from 

244 

pericarditis 

242 

iron 

329 

epigastric  pulsation  in 

244 

HEART,  ENLARGED 

-  with  renal  tuberculosis 

48 

haemoptysis  in 

320 

1,  13,  102,  231 

232 

-  in  scarlatina 

301 

hability  to  phthisis  in 

320 

—  absence    or    presence    of 

-  segmental  areas  of  . . 

498 

polycythaemia  in  244,  579 

,790 

murmurs  in 

331 

-  with  sinus  thrombosis  139 ,  651 

,847 

precordial  thrill  in     . . 

244 

in   adherent  pericardium 

63 

-  temporal,  from  car  disease 

498 

pulmonary  regurgitation  107 

-  -  alcoholism  in         238,  343 

333 

-  from  tic  doulom/eux 

782 

stenosis,  enlarged  right 

angina  pectoris  due  to  . . 

778 

-  toxic  caiises  of 

328 

ventricle  in 

245 

in  aortic  disease. . 

-  in  tuberculous  meningitis. . 

612 

rumbling     systolic 

103,  105,  107, 

359 

-  typhoid  fever90, 610,  620,697 

,699 

bruit  in .  . " 

579 

apoplexy  . . 

173 

-  unilateral  causes  of 

320 

site  of  apex  beat  in     . . 

790 

apparent  health  . . 

332 

172 

thrill  due  to. . 

790 

arteriosclerosis     . . 

639 

-  in  variola     . . 

301 

without  bruit  . .        129, 

184 

beer  drinkers' 

333 

-  various  character  of 

326 

cyanosis 

129 

-  -  Bright's  disease                63,  90 

-  vertical,  from  ear  disease  . . 

498 

conjunctival  oedema  of. . 

256 

cardiac  impulse  displaced 

in  hysteria 

798 

convulsions  in     . .        169 

172 

down  and  to  left  in     . . 

332 

-  in  yellow  fever 

301 

cyanosis  from 

186 

cerebral  haemorrhage    138 

337 

Head-retraction  (see  Ketrac*^ion) 

diagnosis  of 

526 

chronic  nephritis 

Head-rolling  in  rickets         171 

78?. 

displaced  impulse  330,  331 

332 

48,  122,  126,  172,  303,  331 

,639 

HEART,  ENLARGED— HEMIANESTHESIA 


915 


Jlcaii,  fnliinjed,   mnld. 

cJa'onir     |)iireiicliymatoas 

ncpliritis  . .  .  .     '15-1 

coiuiircysiou  of  liiiig  by  3^4,  GG7 

diai^nosis   from    displace- 
ment of  . .  . .     331 

epistaxis  ia  . .  . .     252 

in  exoplithalmio  goitre. .     244 

heart  sounds  in  . .  . .     331 

high    blood-pressure  con- 
ditions       202,  331,  359,  52G 

incompetence  in  . .  . .     247 

insomnia  in  . .  . .     35'J 

laryngeal    jjariilysis   witli     539 

due     to     long-continued 

over-exertion  . .         243,  244 

medullary  degeneration  wlth343 

in  mitral  regurgitation..     102 

from  mitral  stenosis       .  .     245 

in  morbus  ca>ruleus       . .     579 

ortUopncea  due  to         405,  467 

-  -  with     patent      interven- 

tricular septum  . .     244 
prolonged  first  sound  in       331 

-  right    ventricle,     cardiac 
impulse  placed  to  left  in 

causes  of        .  .        244,  245 

diseases      of      lungs 

causing 
in  pulmonary  incom- 
petence 

-  -  skodaic  resonance  due  to 


332 


40 


swelling  of  chest  wall  from   194 


332 

162 

18 

.  243 

61,  62 

64,  96 

97 

14,  63 

.  110 


485 
362 
525 
457 
461 
55 


without  symptoms 

-  failure,  acute,  in  tetanus  . 

albuminuria  in    . . 

from  alcoholism  . . 

ascites  in  . . 

blood-pressure  high  in 

borborygmi  in 

-  -  from  Bright's  disease 

bullae  in    . . 

causes  of,  classified   54,  61,  464 

Cheyne-Stokes  respiration 

in  125 

congestion  of  liver  in     . .     370 

cyanosis  in  . .        184,  186 

enlarged  liver  from  55,  61 

mfluence   of   exertion   on 

pains  of 

-  -  jaundice  in 

lung    conditions    causinj 

main  groups  of  causes  . 

types  of 

nutmeg  liver  with 

oedema  of  limbs  in  61,  457,  458 

459,  461 

orthopncea  from..         464,  465 

_-  -  pain  in  epigastrium  from     485 

polyuria  in  clearing  up  of 

effusion  in        . .  . .     582 

-  -  pulsation  of  liver  due  to       764 
splenic  enlargement  rare  in 

693,  699 

universal  oedema  from  458,  460 

urate  deposit  in  . .  . .     815 

-  fatty,  abuminuria  in  . .       18 

alcohol  causing  . .        238,  241 

ancemia  in  . .  . .     241 

ascites  in . .  . .  . .       62 

canter  rhythm  in  . .     639 

cardiac  asthma  in  . .     241 

causes  of  . .  . .  62,  241 

causing  mitral  regurgita- 
tion      . .  . .         239,  241 

Cheyne-Stokes    breathing 

in  . .  . .         125,  241 

-  -  degeneration  of  . .  . .     464 

from  phosphorus         . .       87 

diagnosis  from  dyspepsia     526 

dyspncea  in  . .  . .     241 

faintness  and  coma  in    . .     241 

-  -  feeble  cardiac  impulse  in     241 
general  account  of  . .     241 


Heart,  fatly,  contd. 

heart  failure  in    . .  . .     404 

in  obesity  .  .        103,  241 

ortliopneea  in      . .  . .     404 

palpitation  in      . .        025,  520 

in  pernicious  anaiiiiia     . .      639 

shortness  of  breatli  witli     101 

after  specific  fevers        . .     241 

systolic  apical  bruit  witli     102 

wasting   diseases    causing     211 

-  fibroid,  albinuinuria  in      .  .        18 

due  to  alcoliol     .  .  .  .      238 

ascites  in  . .         . .  . .       02 

Cheyne-Stokes'      respira- 
tion in  . .  . .     120 

ilcLTi'iicraf  ion  of   .  .  .  .      464 

-  -   .lyspiuiM    ill  ..  ..      t'4l 

-  -  li(':irt  fiiiliire  in   .  .  .  .     404 

mitral  regurgitation  in  239,  241 

palpitation  in       241,  525,  526 

precordial  pain  in  . .     241 

shortness  of  breath  with      101 

sudden  death  from        . .     242 

after  syphilis  02,  241,  242 

systolic  apical  bruit  with     102 

-  Hypertrophy  of  (see  Heart, 

Enlarged) 
HEART       IMPULSE,       DIS- 
PLACED   330 

in   acute    dilatation    of 

heart  . .  . .     243 

endocarditis. .  . .     239 

adherent  pericardium        242 

alterations     in     reson- 
ance in  . .  . .     331 

aortic  disease  . .         233,  332 

regurgitation  . .     107 

in  ascites  . .  . .       51 

asymmetry  of  chest  in      331 

in  athletes    . .  . .     332 

bronchiectasis  . .     703 

chlorosis  . .         . .     333 

congenital  heart  disease     244 

diagnosis  from  enlarged    331 

enlargement    of     right 

ventricle        231,  232,  332 

exophthalmic  goitre  . .     244 

by  fibroid  lung 

129,  193,  232,  240,  324 

with  Flint's  murmur..     109 

fluid  in  chest  . .  . .     193 

huge    hydatid    cyst   of 

liver  . .         . .     415 

hydrothorax     .  .  .  .     467 

in  hypertrophy  of  heart     332 

meteorism        . .  .  .     716 

mitral  regurgitation  238,  332 

stenosis         . .        245,  580 

valve  disease  . .     102 

orthopncea  from         . .     467 

pericarditis       . .  . .     242 

by  pleural  efliusion    232,  764 

pneumothorax 

193,  232,  480,  577,  721 

subphrenic  abscess     712,  721 

x-vays  m  diagnosis  of  . .     332 

feeble  in  fatty  heart      . .     241 

normal  position  of         231,  330 

-  -  position  in  hypertrophy  of 

heart 332 

-  -  raised  in  pericardial  effu- 

sion        333 

-  -  senile  myocardial  degener- 

ation    . .  . .  . .     333 

-  irregular  in  enlarged  heart 

from  over-exertion         . .     244 

mitral  stenosis    . .  . .       61 

in  organic  cerebral  disease    328 

tobacco  poisoning  . .     527 

-  malformation     (see     Heart, 

Disease  Congenital) 

-  malignant  polypus  of        . .     826 

-  nerves  corresponding  to  the 

481,  778 


Heart,  contd. 

-  new  growtlis  of       . .  . .       98 

-  patent  septum  ventriculorum  579 

-  senile,  palpitation  from     525,  527 

-  slow  action  of  (see  Brady- 

cardia) 

-  sounds,  abnormal  (see  Bruits, 

cardiac,  and  Heart  Sounds, 
Accentuation  of,  and  Re- 
duplifatioii)  ..  ..     101 

HEART  SOUNDS,  ACCENTU- 
ATION OF  1 

in  albuminuria  ..        14 

arteriosclerosis  .  .      039 

cerebral  hajmorrliage  139,  337 

chronic  nephritis 

14,  122,  454,  039 
parenchymatous    ne- 
phritis      . .  . .     454 

emphysema      . .         . .     192 

with    high    blood-pres- 
sure . .  90,  252 

loud  sharp  slapping  1st 

sound     at    apex     in 
mitral  stenosis        . .     520 

in  mitral  stenosis       108,  320 

regurgitation  . .     239 

(see    Reduplication    of 

Heart  Sounds) 
relation  to  reduplication    039 

-  -  -  second  sound  in  hyper- 

trophy   of     the    left 
ventricle       . .          . .     331 
altered  in  cerebral  haemor- 
rhage      138 

enlargement  of  heart     . .     331 

estimation  of  blood-pres- 
sure      . .  . .  . .       90 

reduplicated         . .  .  .         2 

-  strain,   albuminuria  due  to       18 

-  symptoms  of  arteriosclerosis 

and  sclerosis  of  kidney  . .       14 
in  chorea  . .  . .     548 

-  thumpings  of,  with  coronary 

atheroma  .  .  . .     527 
in  elderly  gouty  men     . .     527 

-  -  from  excessive  smoking. .  527 
at  night  in  epilepsy     . .     527 

-  transposition  of       . .  . .     330 

-  weakness  suggested  by  cough 

on  exertion  . .  . .     176 

HEARTBURN  333,484 

-  definition  of  . .  . .     842 

-  diagnosis  from  merycism  . .     431 

-  in  dyspepsia  . .  . .     354 

-  regurgitation  of  acrid  fluid 

into  mouth  in     . .        431,  484 
Heat,  distribution  of,  influence 
of     blood,     lymph,     and 
tissue  juices  on  .  .  . .     619 
of  nerve  centres  on     . .     619 

-  extreme,  gangrene  from.    . .     282 

-  and  flushing  in  the  extremi- 

ties in  erythromelalgia  . .     284 

-  from  inflammation  . .     478 

-  loss,  modes  of         . .  . .     019 

-  production,  modes  of         . .     619 

-  stroke,  coma  from  137,  139 

hyperpyrexia  in  . .  . .     344 

Heberden's  nodes  (Fir/.  109) 

380,  384,  452 
Hebra,  prurigo  ferox  of  . .     531 

Hedgehog  crystals  of  urates. .  815 
Heel,  bedsore  over     . .  .  .     285 

-  conical  . .  . .  . .     130 

-  Jacquet's  erythema  of  . .  446 
Hegar's  sign  in  pregnancy  . .  437 
Heller's  test  for  albumosuria  6,  20 
Hemeralopia,  albinism  causing    841 

-  in  snow-blindness  . .  . .     841 

-  tobacco  poisoning  . .  . .  841 
Hemianaesthesia  from  apoplexy  666 

-  from  cervical  cord  injurj'. .     341 

-  disseminated  sclerosis        . .     665 


9i6 


HEM  I  A  NmSTHESIA  —HERNIA ,  ING  UINA  L 


666 
666 
336 
798 
157 

66G 
595 
333 

335 

749 


335 
81 
336,  666 
..  336 
..  595 
..   836 


595 


HemiancEsthcsia,  contd. 

-  dissociative  from  tlirombosis 

of  left  posterior   inferior 
cerebral  artery  (Fig.  184) 

-  with  hemianopsia  . .        336 

-  hemiplegia    . . 

-  iiysteria      69,  166,  506,  666 

-  witli  hysterical  chorea 

-  loss  of  taste,  smell,  hearing, 

and  sight,  with  .  . 
Ilemianopic  pupillary  reflex. . 
HEMIANOPSIA 

-  bilateral  homonymous,  illus- 

trated (Figs.  103,  104)  . . 

temporal,   in   acromegaly 

(Fig.  102,  p.  334) 

from  tumour  near  optic 

chiasma 

-  in  cerebral  tumour 

-  with  hemianresthesia 

-  hemiplegia    . . 

-  light  reflex  in 

-  migraine 

-  with  normal  light  reflex  in 

optic   fibre   lesions  above 
corpora  quadrigemina    . . 

-  from  occipital  cortex  lesions 

595,   837 

-  optic  tract  lesion    . .  . .     595 

-  perimeter  in  demarcating. .     333 

-  pupil  tests  for  site  of  lesion  in  336 

-  quadrant  variety  in  migraine   837 

-  with  word  blindness  . .     684 
Hemiataxia     . .          . .  68,  69 
Hemiathetosis              . .          . .     338 
Hemiatrophy  of  face  with  torti- 
collis        . .          . .          . .     167 

simulating  facial  paralysis 

(Fig.  141)  . .  . .     537 

-  -  or  trunli:    .  .  . .  .  .        72 

Hemichorea     . .  . .        156,  341 

-  paralysis  of  arm  m  . .  . .     548 

-  simulating  hemiplegia      340,  341 
Hemicrania  from  ej^e-strain . .     495 

-  in  migraine  . . 
Ilemiopia   ("see   Hemianopsia) 
HEMIPLEGIA 

-  abnormal  gait  in    . . 

-  from  abscess 

-  acute  bedsore  in      . . 

-  agraphia  with 

-  altered  reflexes  in  . . 

-  ankle-clonus  in 

-  aphasia  in    . . 

-  articulation  in 

-  ataxy  in 

-  atlietosis  from 

-  Babinski's  sign  in  . . 

-  bedsores  in  . . 

-  from  bilateral  cerebral  soft- 

ening 

-  causas  of 

-  from  cerebral  embolism    285,  699 

syphilis     . .  . .  . .     173 

thrombosis  . .  . .     285 

-  chorea  simulating  . .         340,  341 

-  choreiform  movements  before 

and  after. .  . .  . .     157 

tremor  in..  ..  ..     799 

-  with  coma    . .  . .  .  .     137 

-  without  coma  in  thrombosis     138 

-  condition  of  muscles  in      . .     336 

-  conjugate  deviation  of  eyes  in  137 

-  contractures  witii  . .        162,  163 

-  crossed  . .  .  .  . .     336 

-  double,  dysarthria  in       336,  687 

without  aphasia  in      . .     687 

emotionalism   in..  ..      258 

-  facial  paralysis  with  533,  536 

-  with  fungating  endocarditis     237 

-  gangrene  in  . .  . .     282 

-  hemianfEsthesia  with        336,  666 

-  hemianopsia  with   . .  . .     336 

-  hysterical     . .  . .  . .       69 


838 

336 
278 
138 
285 


..  137 
44 
336,  685 
..  687 
68 
..  155 
..  82 
..   811 


563 
82 


Hemiplegia,  contd. 

-  inequality  of  knee-jerks  in        397 

-  infantUe        .  .  .  .  . .      155 

ataxy  in  . .  . .  . .       68 

athetosis  in  . .  . .        68 

hemi-athetosis  in  . .     338 

talipes  in. .  . .  . .     131 

-  from  porencephalus  . .     164 

-  puffing  out  of  one  cheek  in     137 

-  rigidity  with  . .  . .     164 

-  site  of  lesion  in        . .  . .     336 

-  spastic,  characters  of  hand, 

arm,  and  leg  in  . .  . .     164 

in  general  paralysis  of  the 

insane   . .  . .  . .     682 

-  tremor  in     . .  . .         795,  798 

-  ulceration  of  the  leg  in       . .     811 

-  unequal  pupils  in  . .  . .  137 
Hemitrophy  of  face  on  trunk  72 
Henoch's  chorea  electrica  ..  157 
convulsions  in. .         161, 169 

-  purpura  (i^«>.  111)..        90,  380, 

382,  600 
acute    abdominal    symp- 
toms in  380,  600,  846 

age  incidence  of  (Fig,llV) 

380,  600,  846 

arthritic  symptoms  in     90,  380 

blood  per  anum  in  90,  600 

-  -  colic  in     . .  . .  90,  380,-  600 

constipation  in   . .  . .       90 

diagnosis  of  . .  . .     600 

from  acute  nephritis . .     600 

rheumatism  .  .  . .      380 

rheumatic  purpura. .     380 

diarrhcea  in         . .  . .     380 

epistaxis  in  . .  . .       90 

heematemesis  in  380,  846 

-  -  hifimaturia  in^     90,    380,    600 

lisemoglobinuria  in  . .     315 

lia;niorrhage  from  kidney  in  600 

intestine  in      . .         600,  846 

joint  pains  in        .  .  .  .      600 

melfena  in  . .  . .     380 

mesenteric  haemorrhage  in     846 

purpura  in  . .        596,  600 

pyrexia  in  .  .  .  .      380 

recurrence   of   attacks  of     600 

severe  prostration  in      . .     600 

simulating     intestinal 

obstruction      . .  90,  846 

intussusception    90,  600,  846 

stomach-ache  in..  ..     600 

urine  in     . .  . .  . .     600 

-  -  vomiting  in    90,  380,  600,  844, 

846 
Hepatic  abscess  (see  Abscess, 
Hepatic) 

-  artery,     aneurysm    of    (see 

Aneurysm,  Hepatic) 

-  colic  (see  Colic,  Biliary) 

-  reflex  ptyalism  from  . .     591 

-  tumour  (see  Liver  Enlarged) 
Hepatitis,   pain   in   the  right 

hjrpochondrium  in  . .     499 

Hepatogenous    albumosuria . .       20 
Kepatoptosis,  blood-stagnation 
in   abdominal   vessels    on 
standing  in  . .  . .     407 

-  dragging  pain  in     . .  . .     407 

-  dyspnoea  on  exertion  in     . .     407 

-  faintness  in  . .  . .  . .     407 

-  floating  kidney  with  . .     407 

-  gallstones   with       . .  . .     407 

-  heaviness  of  liver  region  in      407 

-  influence  of  posture  on      . .     406 

-  kiiiliing  of  bile-duct  in        . .     407 

-  occurrence  usually  in  neurotic 

dyspeptic  valetudinarians     407 

-  palpitation  in  . .  . .     407 

-  physical  signs  of        404,  406,  407 

-  rarity  of 406 

-  sudden   attacks   of  pain  in 

riglit  of  abdomen  in       . .     407 


Hepatoptosis,  contd. 

-  from  venous  congestion     . .  407 

-  w'ithout  symptoms. .          . .  407 
Hereditary  ataxia  (see  Fried- 
reich's Ataxy) 

-  chorea           . .          . .          . .  156 

-  optic  atrophy          . .          . .  837 

-  trophoedema    (see    ilibroy's 

disease) 

Heredity  and  anosteoplasia  . .  213 

-  baldness  due  to       . .          . .  84 

-  and  bradycardia      . .          . .  97 

-  cystinuria     . .          . .          . .  187 

-  exostoses      . .          . .          . .  754 

-  Friedreich's  ataxy  . .         . .  164 

-  gout 381 

-  haemophilia  . .         . .          . .  86 

-  Milroy's  disease       . .          . .  460 

-  myopathies . .           . .          . .  70 

-  obesity          . .          . .          . .  453 

-  paroxysmal  hsemoglobiniu-ia  315 
Hernia,   bands  and  adhesions 

from           .  .          .  .          .  .  152 

-  bladder  in    . .          . .          . .  742 

passage    of    more    water 

after  reduction  of  hernia 

in  cases  with    . .          . .  742 

-  cerebri,  movement  with  re- 

spiration  . .          . .          . .  764 

-  congenital,  first  descent  in 

adult  life  . .          . .          . .  742 

-  epigastric,  pain  in  the  epi- 

gastrium in          . .          . .  485 

-  in  the  groin              . .          . .  716 

-  gurgling  on  reduction        . .  741 

-  hydrocele  of  sac  of . .          . .  740 

-  identification  of  contents  of  742 

-  importance  of  examination 

both   in  upright  and   re- 
cumbent position            . .  742 

-  impulse  on  coughing  in    739,  741 

-  internal,  obstruction  due  to  133 

-  labial,  simulating  Bartholin 

cyst  . .  . .         768, 770 

-  of  the  lung  . .  . .         194,  764 

-  palpation    of    appendix    in  742 

-  perineal         . .          . .          . .  768 

-  reducibflity  of         . .          . .  739 

-  resonant  on  percussion  un- 

less omentum  only  in   739,  741 

-  retention     of     urine     after 

operation  for       . .          . .  49 

-  diaphragmatic,    congenital  712 

rarity  of 712 

succussion      sounds       in 

thorax  with      . .          . .  711 

-  femoral,  age  incidence  of  733,  740 

causes  of  irreducibility  of  733 

diagnosis    from    femoral 

gland     ..  ..734,738,740 

from    hydrocele    of    a 

hernial  sac  . .          . .  740 

inguinal  hernia            . .  739 

mal-descended  testis  . .  740 

obturator  hernia         . .  740 

psoas  abscess  . .          . .  739 

saphena  varix. .          .  .  739 

disappearance     on    lying 

down 732 

femoral  swelling  due  to. .  733 

general  account  of          . .  733 

gurgling  on  reduction  of  733 

impulse  on  coughing  in . .  732 

position  and  relationship 

739,  740 

reducible  on  pressure    732,  740 

resonance  of        . .          .  .  733 

sex  incidence  of  . .         733,  740 

simulated  by  lipoma      . .  716 

psoas  abscess  . .          . .  733 

saphena  varix. .          . .  733 

strangulation  of  . .          . .  733 

-  inguinal,    age    incidence    of 

740,  742 


HERNIA 

INGUINAL— HIP.    INJURY    OF 

917 

Hernia,  inguinal,  co7ild. 

Hi.rnin,  siroii'jidalnl,  mnlil. 

Hrrfics,  zoxtrr,  could. 

bowel  and  testicle  in  same 

resonant   . . 

741 

distribution  of     . . 

830 

or  different  sacs 

742 

severe  vomiting  in 

741 

enlarged  lymph  glands  in 

479 

commoner  than  femoral  at 

shock  and  collapse  in     . . 

153 

erythema     and     vesicles 

all  ages  and  in  both  sexes 

740 

-  testis,  characters  of 

681 

with 

830 

descent     almost     always 

diagnosis    from    epitheli- 

 of  eyes,  mouth  and  tongue 

831 

into  a  congenital  sac. . 

742 

oma  of  scrotum 

681 

flaccid  vesicles  in 

829 

-  -  diagnosis      of      adherent 

slougliing  papilloma  .  . 

681 

from  Gasserian  ganglion 

omentum  from  encysted 

due  to  syiDhUis     680,  681, 

766 

disease 

496 

livdrocple          . .        741, 

742 

tuberculous          . .        681, 

766 

herpes  genitalis  and 

675 

between      direct     and 

-  umbilical 

716 

hypersesthesia  from 

667 

indirect 

740 

age  mcidence  of  . . 

524 

of  painful  area  in  post- 

 from  encysted  hydrocele 

diagnosis  from  sebaceous 

herpetic  pain 

494 

of  the  cord  . . 

740 

cyst  of  umbilicus 

524 

influence  of  age  on  pains 

femoral  hernia 

739 

frequently  irreducible    . . 

524 

due  to               . .        479, 

496 

lymphangioma  of  cord 

741 

globular  "shape  of 

524 

intercostal  neuralgia  after 

478 

extension  into  labium    . . 

739 

impulse  on  coughing 

524 

involvement  of  lips  in    . . 

403 

scrotum 

739 

pain  in     . . 

524 

lymphocytosis  in  cerebro- 

 frequent  association  with 

pressure  by  omentum  in 

524 

spinal  fluid  in. . 

339 

undescended  testis     . . 

523 

sex  incidence  of  . . 

524 

macules  in 

424 

gradual  development  of 

742 

Herniae  along  linea  alba 

716 

malaise  and  pyrexia  with 

496 

history  of  hernia  in  infancy 

742 

-  quite   small,    intestinal   ob- 

 neuralgic  pain  with 

830 

hydrocele  of  the  sac  of  an, 

struction  from     . . 

716 

origin  as  vesicular  eruption 

404 

diagnosis     from     new 

-  vulval           

771 

pain  in  arm  in     . . 

494 

growtli  of  retained  testis 

742 

Herpes,  on  the  ear     . . 

536 

back  from        . .        475, 

476 

mode  of  reduction 

740 

-  facial  paralysis  witli 

536 

chest  from        . .        477, 

777 

position  and  relationship 

-  febrilis,  involving  lips 

403 

left  hypochondrium  in 

499 

739 

740 

-  frontalis,  corneal  ulceration 

right  hypochondrium  in 

501 

relation  to  straining       740 

742 

from 

807 

papules  in 

830 

simulated  by  lipoma 

716 

insensitiveness  of  cornea  in 

807 

persistence  of  pain  after 

strangulated,   diagnosis 

itching  in . . 

781 

disappearance  of  erup- 

from inflamed  hydrocele 

741 

opacity  of  cornea  from  . . 

807 

tion 

499 

suppuration  of    . . 

739 

raised  ocular  tension  in . . 

807 

rarely  bilateral   . . 

830 

testicular  atrophy  from 

78 

tenderness  of  the  scalp  in 

781 

not  recurrent 

830 

varicocele  with    . . 

742 

vesicles  in 

807 

scabs  from 

653 

vulval  swelling  due  to    . . 

768 

-  genitalis,  bubo  rare  with  . . 

675 

scars  after           . .        479 

653 

direct,   ease    of   reduction 

diagnosis  of 

675 

simulating  pleurisy 

830 

and     suddenness      of 

soft  sores  from  suppu- 

 tenderness  with  . . 

830 

return  in 

740 

rating  stage  of 

675 

in  chest  from             776 

777 

globular  shape  of 

740 

distmction    from    herpes 

of  scalp  from    . . 

780 

rarity  of 

740 

zoster    . . 

830 

spine  in. .          . .        784 

785 

relation    of     spermatic 

enlarged   inguinal  glands 

trigeminal  neuralgia  in  . . 

496 

cord  to         . .        740, 

742 

from 

830 

ulceration  from  . . 

s.-so 

scrotum  rarely  reached 

irritation  during  micturi- 

 vesicles,   on   an   inflamed 

740, 

742 

tion  in  . . 

209 

base  in..          ..         479 

829 

-  Obturator,     diagnosis     from 

itching  and  burning  in  . . 

830 

most  marked  at   exits 

femoral  hernia     . . 

740 

occurrence  in  herpes  zoster  675 

of  branches  of  inter- 

 neuralgia  from    . . 

488 

parts  affected  by 

830 

costal  nerves 

479 

pain  shooting  along  inner 

penile  sores  in     . .        515 

674 

Herpetic   eruption  on  auricle 

side  of  thigh  in 

740 

of  prepuce 

209 

inperipheral  facial  paralysis  536 

rectal  or  vaginal  examhia- 

recurrent  nature  of 

675 

-  urethritis  described 

209 

tion  in  detecting 

740 

simulation  of  chancre  by 

830 

Herpetiform  eruptions  in  ar- 

- -  strangulation  of . . 

740 

chancroids  by 

830 

senical  poisoning 

76 

swelling  vague  in 

740 

simultaneous     occurrence 

Herter,     views    of    intestinal 

-  omental,  diagnosis  from  hy- 

of syphilis  and 

675 

infantilism 

215 

drocele  of  hernial  sac     . . 

741 

vaginal  discharge  from  . . 

830 

Heteroxanthin      bases,      uric 

lipoma  of  cord  or  round 

vesicles,     pustules,     and 

acid  derived  from 

817 

ligament 

741 

ulcers  in 

675 

HICCOUGH 

342 

new  growth  of  retained 

-  gestationis,  bullaj  in         110 

HI 

Hides,  anthrax  from  . .        603 

746 

testis 

742 

eosinophilia  in     . . 

249 

Hidrocystoma . .          ..        714, 

829 

granular  feel  in  . . 

741 

-  iris,  bulliB  in 

832 

-  relation  to  mUiaria 

831 

strangulated,       diagnosis 

eosinophilia  in    . . 

249 

High  altitudes,  polycythsemia 

from  torsion    of    testis 

742 

relation  to  pemphigus    . . 

113 

caused  by  residence  at  . . 

579 

-  scrotal,    absence   of  limita- 

- labialis  in  lobar  pneumonia 

High-stepping  gait  in  paralysis 

tion  above  in 

522 

186 

372 

of  external  popliteal  nerve 

543 

diagnosis  from  haematocele 

523 

-  simplex,     distinction     from 

HUl,  re  pyrexia  in  health 

619 

hydrocele 

522 

herpes  zoster 

830 

Hip,     congenital     dislocation, 

varicocele 

767 

face   and   genital    organs 

signs  and  symptoms  of .  . 

183 

impulse  on  coughing  in . . 

522 

affected  by 

829 

lordosis  in        . .        183, 

277 

nearly     always     oblique 

vesicles  in 

829 

skiagraphy  for 

183 

inguinal 

742 

-  simulating  unpetigo 

830 

waddling  gait  in 

277 

reducible  with  gurgle    . . 

522 

-  urethral 

209 

-  disease  in  caries  of  spine  . . 

564 

resonance   in 

522 

-  zoster,  affection  of  3rd,  4th, 

chronic    inguinal    abscess 

testis  distinguishable  in 

522 

and  5  til  intercostals  most 

from 

739 

translucency  in  infants . . 

522 

often  in    . . 

479 

insomnia     from      night 

variations    in    size    with 

from  central  nervous  lesion  675 

starting  in 

357 

position  of  patient     .  . 

522 

crusts  in  . . 

829 

lordosis  with 

183 

-  Strangulated,   absolute  con- 

 diagnosis  from  dermatitis 

pelvic  abscess  in 

739 

stipation  in           151,  431, 

741 

herpetiformis  . . 

830 

perforation  of  acetabulum 

diagnosis    from    inflamed 

eczema  . . 

831 

in 

739 

hydrocele  of  the  sac  .  . 

740 

erythema  multiforme 

830 

wasting  of  thigh  with    .  . 

183 

undescended  testis     . . 

523 

herpes     simplex      and 

-  hysterical     . . 

166 

difficulty  of  detecting  . . 

733 

herpes  genitalis 

830 

-  injury    of,    causing    sciatic 

possibly  obturator 

740 

perUche 

404 

nerve  paralysis  . . 

542 

9i8 


HIP—HYDA  TID    DISEA  SE 


Hip,  conld. 

Histology  in  diagnosis,  conld. 

Hydatid  cysts,  conld. 

-  osteo-arthritis  of     .  .        383, 

384 

for  torsi 0  testis  . . 

521 

of  bone     . . 

757 

with  spondylitis  aeformans 

787 

trichinosis 

504 

spontaneous  fracture  in 

757 

-  rarity  of  gout  in 

383 

tubercle  of  uterus 

435 

causing  discharge  at  the 

-  stiff  after  typhoid  ferer    . . 

376 

tuberculosis  255,  435,  744, 

814 

nipple   . . 

202 

-  tuberculous 

564 

ulcer  of  tongue  . . 

814 

diagnosis  of  ascites  from 

53 

femoral  swelling  from  . . 

734 

uric  acid  crystals 

816 

from  ovarian  cyst 

761 

lardaceous  disease  from . . 

10 

xanthoma  multiplex 

805 

eosinophilia  with 

-  -  obturator  neuralgia  and 

488 

Hoarseness  from  pharyngitis 

673 

58,  323,  415,  719, 

720 

pain  refr-rred  to  knee  in 

278 

-  and  dysphagia  in  laryngitis 

226 

felt  per  rectum    . . 

58 

relative  frequency  of    . . 

385 

Hob-nail  liver,  with  ascites  . . 

60 

geographical   distribution 

secondary     afEection     of 

Hock,  polyuria  from. . 

581 

323,  719, 

720 

Uium  in 

737 

Hockey,  cramp  during 

177 

of  kidney. . 

396 

simulated    by    ilio-psoas 

Hodgen's     splint,     extension 

simulating  hydronephrosis 

396 

bursa     . . 

734 

apparatus,  talipes  from. . 

132 

—  of  liver 

58 

swelling  in  right  iliac  fossa 

Hodgkin's   disease  (see  Lym- 

abscess  from    . .         408, 

410 

from 

730 

phadenoma) 

ascites  in 

60 

wasting,  muscular  in      72, 

386 

Hoftmann's  baciUi,  acute  ton- 

 breath  sounds  on  right 

Hippocratic  facies     . .         431,' 

644 

sillitis,      laryngitis,     and 

side  impaired  from. . 

415 

-  succussion    . . 

193 

pharyngitis  from 

670 

bulgingrightside  of  chest  415 

Hippuric  acid  in  urine,  reduc- 

Hofmeister's test  for  albumo- 

 causing  pleural  efEusion 

123 

tion  by     . . 

290 

suria 

20 

compression  of  lung  by 

607 

Hippus,  association  with  cen- 

Hollow-back (see  Lordosis') 

confusion  with  pleuritic 

tral  scotoma 

595 

Holmgren's    test    for    colour 

effusion 

415 

nystagmus 

595 

blindness  . . 

840 

diagnosis  from  abscess 

415 

-  in  cerebral  tumour 

595 

Homogentisic  acid    in  alkap- 

 adenoma  of  liver     . . 

414 

-  chronic  alcoholism  . . 

595 

tonuria 

822 

carcinoma    . .         413, 

415 

-  definition  of 

595 

quantitative  estimation. . 

822 

syphilitic  liver 

415 

-  in  disseminated  sclerosis  . . 

595 

Fehling's  solution  reduced 

dome-shaped      upward 

Hirschsprung's  disease  U7,  432 

718 

by          

"822 

extension     of     liver 

abdominal   distention    in 

Hooklets,  hydatid      45,  57,  58 

415 

dullness  in  . . 

415 

148,  151,  152, 

713 

in  nrine    . . 

396 

eosinophilia  in           279, 

413 

ballooning  of  colon  in    . . 

433 

Hook-worm  (see  also  Ankylo- 

 extension  upwards  of  406 

415 

bismuth  in  diagnosis  of. . 

433 

stomiasis)  (Figs.   14,   16, 

general  account  of     719, 

720 

constipation  147,  151,  _433 

713 

p.  94)        

570 

giving  rise  to  hydatid  of 

diagnosis  of 

433 

Horse-hair,  anthrax  from     . . 

746 

lung  . . 

323 

illustrated  (Fig.  122)    . . 

432 

Horse-riding,     torsio     testis 

great    enlargement    of 

intestinal  obstruction  in 

from          .  .          .  .         521, 

7C6 

liver  in          . .        415, 

416 

151, 

433 

Horses,     actinomycosis     in 

heart  displaced  by     415, 

416 

tympanites  in     .  .        148, 

152 

workers  amongst 

705 

jaundice  in         364,  366 

415 

risible  peristalsis  with  148 

724 

Hospital     gangrene,     surgical 

latency  of 

27!) 

.r-rays  in  diagnosis  of    . . 

433 

emphysema  in    . . 

231 

occasionally  multiple 

415 

His'  bundle,  lesions  of 

07 

-  sore  throats..          ..         419 

073 

pressure  symptoms  in 

415 

Histology  in  diagnosis  of  affec- 

Hot-cross-bun   skull    in    con- 

 previous  hydatid  history 

279 

tions  of  breast     744,  745, 

746 

genital  syphilis    .  .         752, 

782 

rareness  of  fluctuation  in 

415 

larynx  . .          . .        226, 

674 

in  ricksts 

212 

senim  reaction  in 

279 

orbit 

255 

Hot  eye,  Hutchinson's 

256 

simulating     enlarged 

tonsil     . . 

672 

-  stage  of  malaria 

35 

gaU-bladder    278,279 

415 

uterus         434,  435,  706 

759 

-  water-bottles,  bedsores  from 

285 

situation  of     . . 

722 

carcinoma  of  jaw 

749 

-  weather,  urate  deposit  with 

815 

skodaic  resonance  above 

007 

uterus   . . 

435 

Hour-glass      contraction      of 

supptuating     . . 

415 

cause  of  perforate  palate 

640 

uterus,  dystocia  due  to . . 

227 

tenseness  of    . . 

415 

cysticerci 

452 

placenta  retained  in  . . 

229 

thrill  in..         ..        413, 

415 

epithelioma  420,  769,  803 

812 

-  stomach  (see  Stomach  Hour- 

 urticaria  from. . 

415 

of  penis            . .        ()76, 

677 

glass 

—  of  lung 

323 

perineum 

678 

Humerus,    fracture     of     (see 

absence  of  symptoms  in 

323 

epulis 

748 

Fracture) 

liEcmoptysis  in           317 

323 

erosion  of  uterus 

435 

-  myeloid  sarcoma  of 

750 

secondary    to    hydatid 

faeces  in  jiancreatitis 

117 

-  tuberculous  periostitis  of  . . 

752 

of  liver 

323 

gastric     ulcer    and     car- 

Hump-back (see  Kyphosis) 

mediastinal 

826 

cinoma.  . 

713 

Hunger,  infantile  insomnia  from  356 

varicose  thoracic  veins 

growths    . . 

421 

Hunger-pain  in  appendicitis  350 

,500 

from.. 

826 

of  testis 

520 

-  in  elironic  cholecystitis 

500 

pelvic        . .          . .         757 

,761 

hsemoglobinuria 

821 

-  duodenal  ulcer       . .          40 

500 

in  peritoneum     . . 

58 

melanotic    carcinoma    or 

Hunt?r,   re   toxaemic    catarrh 

ribs  affected  by  . . 

776 

sarcoma 

802 

of  bile-ducts 

370 

simulating  movable  kidney 

727 

in  metrorrhagia  . . 

433 

Hunting,     ha?maturia     after. 

phthisis 

323 

molluscum  contagiosum 

805 

due  to  movable  kidney. . 

310 

spherical    a--raT   shadows 

-  -  multiple  benign  sarcoid 

452 

Huntington's  cliorea,  descrip- 

in (Fig.  100)   . . 

323 

nature  of  ovarian  tumour 

759 

tion  of      . . 

156 

of  spleen  .  . 

092 

new  growth  of  epididymis 

767 

Huppert's  test  for  bile  pigment 

819 

subphrenic  abscess  from 

721 

Paget's  disease   . .     "    . . 

803 

Huskiness  (see  Speech,  Abnor- 

 of  thyroid  gland 

792 

polyuria    with    albumin- 

malities of) 

with  tumour  of  liver     . . 

58 

uria 

58^ 

Hutchinson's  liot  eye 

250 

Varicose  thoracic  veins  from 

826 

ptyalism  . . 

591 

-  teeth   described    (Figs.    79, 

-  disease,  death  from  exhaus- 

 rectal  carcinoma 

636 

80)             

259 

tion  in 

410 

sarcoma    . . 

803 

Hyaline  corpuscles     . . 

28 

description  of 

720 

bone      . .          . .         75G 

703 

-  renal  tube-casts 

7 

extreme  rarity  of 

416 

jaw 

748 

Hyaloid      artery      persistent, 

gastro-intestinal      symp- 

 sebaceous  cyst    . . 

681 

amblyopia  witli  nystagmub 

830 

toms  in 

416 

spinal  growtlis    . . 

564 

Hydatid  cysts,   abdominal  tu- 

 of  joints  . . 

388 

stomach  contents 

355 

mours  from 

720 

liable  to  suppurate     . . 

388 

sjphilis  and  cancer  672,  709 

,813 

in     bile-ducts,     jaundice 

kyphosis  from     . . 

182 

for  tapeworm  ova 

569 

from 

301 

lajjarotomy  in  diagnosis  of 

720 

HYDATID    DISEASE— HYPERALGESIA 


919 


415 

,  58 

415 

57 

434 
211 
26 
228 
759 
228 
387 
114 

820 
249 
111 


Hydatid  disease,  conld. 

physical  signs  of  415, 

pyrexia  in 

relation  to  taeniae  chino- 

coccus  . . 

-  -  serum  reaction   in 

58,  279,  415,  719, 

site  of  development  of  . . 

peritoneum,     account    of 

of  vertebras  ..181,785, 

-  fluid,  characters  of  . . 
in  ascitic  fluid  (Fiq.  6)    57 

-  -  hooklets    . .  45,  57,  58, 

illustration  of 

Hydatidiform  mole,   chorion- 
epithelioma  following     . . 

vaginal  discharge  from . . 

Ilydraemia 

Hydramnios,  diagnosis  of 

from  ascites         . .  .1 

-  dystocia  due  to      . .        227, 
Hydrarthrosis,  intermittent. . 
Ilydroa 

-  sestivale,  hjematoporphjTin- 

uria  in 

-  eosinophilia  in 

-  Ljfstationis,  biiUce  in 
Hydrocele,  translucency  in  not 

always  apparent.  .  ..      765 

-  acute,  "accompanymg   acute 

epididymo-orchtis  . .     522 

in  mumps  . .  . .     522 

polyorrhymenitis  . .     522 

rheumatism  . .  . .     522 

from  scrotal  injuries       . .     522 

in  small-pox         . .  . .     522 

-  bleeding  mto  . .  . .     765 

-  bloodstained    fluid     in,     in 

malignant  disease  of  testis    520 

-  of  canal   of  Nuck,  diagnosis 

from  fibromyoma  of  round 
ligament  . .  . .  . .     741 

disappearance  on  lying 

down  . .  . .     771 

simulating  hernia        . .     771 

vulval  swelling  from   .  .      768 

-  cholesterin  crystals  in  fluid 

of  (Fig.  94,  p.  281)     . .     765 

-  chronic,  aching  in  testicle  in     522 
dragging  sensation  in  loin 

m  522 

-  of  the  cord  . .        .  ■        740,  741 
diagnosis    from    inguinal 

hernia  . .  . .         740,  741 

vaginal  hydrocele        . .     765 

extension  upwards  along 

cord       . .  . .  . .     765 

impulse  on  coughing  in. .     741 

not  reducible       . .  . .     740 

size  and  shape     . .  . .     765 

translucency  in   . .  . .     741 

-  development  in  sac  of  hernia    740 

-  diagnosis  from  cyst  of  testis     521 

encvsted  hydrocele  of  cord   765 

^"  testis  .  .  . .     522 

growth  of  testis 

520,  521,  522,  742 

hfematocele  522,  523,  765 

scrotal  hernia      . .  . .     522 

-  of  femoral  hernial  sac      733,  734 

-  flabby  consistency  of         . .     765 

-  fluctuation  in  . .        522,  765 

-  formation     of     hoematocele 

after  tapping       . .  . .     522 

-  frequent    association    with 

hernia        . .  . .  .  .      742 

-  gi-eat  thickening   of  tunica 

vaginalis  in  some  cases  of     521 

-  of  a  hernial  sac        . .  . .     740 
diagnosis    from    femoral 

hernia    . .  . .  . .     740 

-  inflamed,     diagnosis     from 

strangulated  hernia        . .     741 

-  loculated      . .  . .  . .     765 


521, 

522, 


522, 


Hydrocele,  conld. 

-  milky  fluid  in 

-  plivsical  signs  of     . . 

-  relation  of  testis  to 

-  with  syphilitic  orchitis 

-  scrotal  swelling  due  to 

-  size  of 

-  straw-coloured  fluid  in 

-  testicle  enveloped  by 
atrophy  from 

-  translucency  in 

-  vaginal 

-  with  tuberculous  testis 
Hydrocephalus,  anosmia  from 

-  antenatal  recognition  of    . . 

-  Cheyne-Stokes  respiration  in 

-  convulsions  in         . .         170, 

-  crepitus  with 

-  dwarfism  witli 

-  dystocia  due  to 

-  egg-shell  crackling  in 

-  headache  in 

-  infantile  diplegia  due  to    . . 

-  meningitis  with 

-  paraplegia  duo  to  . .       556, 

-  vomiting  from        . .         844, 
Hydrochloric  acid  in   gastric 

juice,    absence  of  37, 

-  -  deficiency    in    carcinoma 

of  stomach        ..353,845, 

in    benign    pyloric 

obstruction 

gastric  contents  . . 

in  chronic  gastritis. . 

gastrectasis  . . 

test  for 

Hydronephrosis,     absence    of 

htematuria  in 
pain  in     . . 

-  bilateral,   from    obstruction 

to  outflow  of  urine  from 

bladder 

in  pelvic  carcinoma 

prostatic  disease 

urethral  stricture  causing 

in  vesical  disease 

-  conversion  into  pyonephrosis 

-  diagnosis  of  ascites  from    . . 
from  cystic  disease  of  the 

kidney   .  . 
enlarged  gall-bladder 

-  direction    of    growth    from 

above     downwards     and 
inwards     ... 

-  fluctuation  in 

-  hsematuria  in  . .        304, 

-  intermittency  in     . . 

-  due  to  movable  kidney 

500,  581,  583, 

papilloma  of  kidney 

renal  calculus      .  .309,  581, 

uterine  carcinoma 

-  pelvic  swelling  due  to 

-  periodic  polyuria  in  500,  581, 

-  renal  enlargement  from 

391,  394,  396,  500, 

-  round  smooth  outlme  of    . . 

-  sense     of     tenseness     and 

elasticity  m 

-  simulation  by  cyst  of  kidney 

-  in  ureteral  obstruction 

135,  395, 

-  variations    in    quantity    of 

urine  passed  in    . . 
in  size  of   . . 

-  from  vesical  growth 
Hydrophobia,  convulsions  in  169. 

-  diagnosis  of  tetanus  from . . 

-  due  to  dog  or  wolf  bite      162, 

-  dysphagia  in  . .         225, 

-  long  latency  of 

-  mental  symptoms  in 

-  priapism  in  . . 

-  ptyalism  in  . . 


765 
522 
765 
519 
765 
765 
521 
765 
78 
765 
765 
765 
669 
228 
125 
172 
179 
214 
227 
177 
327 
556 
557 
557 
847 

845 


Hydrophobia,  conld. 

-  retraction  of  the  head  in    . .  641 

-  rigors  in  "    . .          . .          . .  647 

-  spasms  in     . .          . .          . .  162 

-  trismus  rare  in  . .  162,  801 
Hydropneumopericardium, 

churning  sounds  in         . .  711 

Hydro-pneumothorax            ••  577 

-  acute  cyanosis  from           . .  712 

dyspnoea  from     . .          . .  712 

pain  in  the  chest  from    . .  712 

-  from  injury              . .          . .  712 

-  needling  of  chest  in  diagnosing  711 

-  from  paracentesis    thoracis  712 

-  due  to  phthisis        . .          . .  712 

-  simulated     by     subphrenic 

abscess      . .          . .          . .  712 

-  succussion  sounds  in          . .  710 

-  sudden  onset  of       . .          . .  712 

-  tubercle  bacilli  in  sputum  in  712 
Hydrops   amnii,    diagnosis   of 

ascites  from         . .          . .  52 

physical  signs  of . .          . .  52 

Hydroquinone-acetic    acid    in 

alkaptonuria        . .          . .  822 

Hydrosalpinx,  pelvic  swelluig 

due  to       . .          . .          . .  757 

Hydrothorax  in  mitral  regurgi- 
tation      . .          . .         239,  240 

-  orthopncsa  from  . .  465,  467 
Hygroma,  cystic,  in  axilla  . .  733 
Hymen,    closure    of,    sterUity 

due  to       . .      . .  705,  706 

-  imperforate,    with    amenor- 

rhoja  .  .  .  .  22,  23 
hsematocolpos  from        . .  761 

-  unruptured,  dyspareunia  from  221 
Hyoid  area,  referred  pain  in, 

in  affections  of  lateral  part 

of  tongue              . .          . .  498 

with     hypersesthesia 

in  ear  disease       . .  498 

Hyoscyamus,  delirium  from  195 
Hyperacidity  of  gastric  juice 

with  ulcer            . .          . .  89 

-  of  urine,  frequency  of  micturi- 

tion from  . .  . .  438 
Hyperacusis     from      nuclear 

facial  paralysis  . .  536 
paralysis  of  stapedius    . .  537 

-  in  fevers,  etc.          . .          . .  190 

-  migraine       . .          . .          . .  190 

HypersBsthesia   in  adiposis 

dolorosa    . .          . .          .  .  455 

-  of  arms,  from  visceral  disease  494 

-  band  type  in  tabes  dorsalis  665 

-  in  brachial  neuralgia          . .  491 

-  from  combined  scleroses  of 

the  cord    . .          . .          . .  667 

-  compression  of  cord           . .  786 

-  in  Dercum's  disease           . .  455 

-  herpes  zoster  . .        494,  667 

-  hyoid  region  from  ear  disease  498 

-  hysteria        . .          . .          . .  509 

-  leprosy  nodules       . .          . .  450 

-  from    lesion    of    the    optic 

thalamus 666 

-  in  lipomatosis,  diffuse       . .  455 

-  peripheral  neuritis      505, 506,  666 

-  pernicious  anaemia..          ..  667 

-  predisposing  to  pruritus  . .  588 

-  referred  pains          . .          . .  475 

-  spinal  caries              . .          .  .  667 

-  from  spinal  tumour           . .  667 

-  in  tabes  dorsalis      . .        665,  666 

-  vesicae,  frequent  micturition 

in 443 

Hypenesthesic  spots  in  neur- 
asthenia and  hysteria    . .  667 
Hyperalgesia  during  regenera- 
tion  of  peripheral   nerve  661 

-  of    muscles     in    peripheral 

neuritis     . .  . .        660,  661 

-  thoracic        . .          . .          . .  778 


920 


HYPERCHLORHYDRIA— HYSTERIA 


Hyperchlorhydria,   absence  of 

local  tenderness  in  . .     485 

-  in  fonctional  djapepsia      . .     354 

-  heartburn  with       . .  . .     333 

-  increased  appetite  in  . .       49 

-  pain  in  the  epigastrium  in. .     485 

relieved  by  taking  food    485 

Hyperidrosis    ("see    Sweating, 

Abnormalities  of) 
Hjiperlactation,  anaemia  from         40 
H  ypermetropia,        congenital 

crescents  associated  with    461 

-  convergent  squint  due  to  . .     709 

-  headache  from         . .       327,  783 

-  increasing  in  tumour  of  optic 

nerve         . .  . .  . .     255 

-  small  size  of  pupil  in  . .     594 

-  tenderness  of  forehead  from     783 

temporal  region  from     . .     783 

vertex  from         . .  . .     783 

Hypermetropic     astigmatism, 

ophthalmoscopic    appear- 
ance of  (Plate  YIIl)      . .     463 
Hypemmesia   . .  . .  . .       25 

Hypernephroma,  aching  in  loin    395 

-  causing  premature  develop- 

ment of  external  genitalia 
(Figs.  125-6)        . .        454,  690 

-  demarcation  from  renal  tissue  395 

-  enlargement  of  the  kidney  in   395 

-  haematuria  in  . .  . .     395 

-  microscopically    similar    to 

adrenal  tissue      . .  . .     395 

-  obesity  in    . .  . .  . .     453 

-  origin' from  adrenal  rests  395,  690 
upper  pole  of  kidney      . .     395 

-  premature  puberty  with  . .     690 

-  renal  colic  in  . .  . .     395 

-  secondary  deposits  in  lungs     455 

-  simulating   enlarged   spleen     726 

-  slow  growth  of        . .  . .     395 

-  yellow  colour  of      . .  . .     395 
nyperpiesis        (see        Blood- 

prtesure,  hish) 
HYPERPYREXIA  ..     343 

-  in  acute  rheumatism        194,  622 

-  cerebral  diseases      98,  138, 

345,  346,  622 

haemorrhage 

injtiries 

-  heat-stroke  . . 

-  hysterical 

-  from     lesions      of     corpus 

striatum  . .  . .  . .     346 

of  subthalamic  region    . .     346 

-  pontine  haemorrhage        138,  345 

-  -  lesions       . .  . .  . .     346 

-  septic  conditions     . .  . .     622 

-  typhoid  fever  . .  . .     622 

-  uramia  . .  . .  . .     622 

Hyper-resonance  to  percussion 

in  pnetimothorax  . .     577 

Hypersecretion   in   functional 

dyspepsia  . .  . .     354 

-  stomach-tube  test  for        . .     355 
Hypertrophic  pulmonary  osteo- 
arthropathy   (see     Osteo- 
arthropathy) 

-  pvloric  stenosis,  congenital 

426,  845 

-  rhinitis  (see  Ehinitis,  Hyper- 

trophic) 
Hypertrophy   of  cervix  uteri 
simulating     prolapse     of 
uterus       . .  . .  . .     586 

-  extensor  longus  haUucLs  . .     164 

-  of  heart  (see  Heart,  Enlarged) 

-  oesophagus,  idiopathic       . .     225 

-  prostate  (see  Prostate,  Enlarged) 
Hypnotics,  delirium  due  to  . .     195 
Hypochlorhydria     in     gastric 

carcinoma  . .  37,  351 

-  in  functional  dyspepsia     . .     354 

-  gastritis        . .  . .  . .     352 


98 
622 
139 
618 


Hypochondriasis, constipation  in  144 

-  insomnia  in  . .  . .     358 

-  oesophagismus  type  . .     484 

-  in  oxaluria    . .  . .  . .     471 

-  pruritus  in    . .  . .  . .     588 

-  with  undue  abdominal  aortic 

pulsation  . .  . .     592 

Hypochondrium,  definition  of    723 

-  enlarsed  spleen  felt  in        . .     726 
HYPOCHONDRIUM,      LEFT, 

PAIN    IN    (see    Pain    in 
Hyp  ochondrium) 

bulging   of,    by   enlarged 

Spleen    . .  . .  . .     688 

liver  palpable  in. .    .     . .     726 

retroperitoneal  cyst  in  . .     726 

swelling  in,  due  to  tubercu- 
lous peritonitis  . .     691 

subphrenic  abscess         . .     720 

suprarenal  tumour  . .     393 

tumour  in,  due  to  carci- 
noma of  splenic  flesnre     690 

of  pancreas      . .  . .     726 

pancreatic  cysts  . .     724 

various  tumours  felt  in. .     725 

HYPOCHONDRIUM,  RIGHT, 
PAIN  IN  (see  Pain  in 
Hypochondrium) 

discomfort  in,  in  catarrhal 

jaundice  . .  . .   '  365 

organs  normally  contained 

in  722 

redness   and    swelling:    of 

due  to  hepatic  abscess 

-  tendemes  in  (see   Tender- 

ness in  Hypochondrium) 

various  tumours  felt  in  . . 

Hyp  ocythaemia 

HjTJOgastric  region,  definition 

organs      normally      con- 

tataed  in 
Hypogastrium,  bladder  form- 
ing swellirig  in  (Fig.  191) 

-  Fallopian  tube  tumour  in. . 

-  intussusception  felt  in 

-  ovarian  tumour  in  . . 

-  pain  in  (see  Pain  in  Hypo- 

srastrium) 

-  uterine  tumour  in  . . 

-  various  tumours  felt  in     730,  731 
Hypoglossal     nerve,     bulbar 

paralysis  affecting 

paralysis,  ptyaltm  in  . . 

H5Tiomnesia     . . 

Hypopyon,  cauterization  in. . 

-  galvano-cauteiy  in 

-  from  paralysis  of  fifth  nerve 

-  pnetmiococcus  in    . . 

-  pure  carbolic  acid  in 

-  from,  ulceration  of  the  cornea    800 
Hypospadias,       changes 

stream  of  urine  in 
Hvpothenar  muscles,  atrophv  of    73 
HYPOTHERMIA        .-        345,621 


715 


722 
26 

722 


730 
730 
730 
730 


730 


159 
591 


807 
807 
807 
807 


438 


-  in  alcoholism           , .          . .  344 

-  children,  from  exhaustion . .  621 
in  marasmus       . .          . .  621 

-  cerebral  abscess      . .         547,  623 

-  conditions   associated   with 

much   pain          . .          . .  621 

-  after  convulsions                . .  621 

-  in  cretinism             . .          . .  259 

-  heart  disease           . .          . .  345 

-  from   internal   haemorrhage  780 

-  with  lardaceous  disease   . .  48 

-  in  myxoedema         . .          . .  259 

-  neurasthenia            . .          . .  506 

-  opium  poisoning               138,  34-1 

-  pyelonephritis         . .          . .  48 

-  renal  tuberculosis   . .          . .  48 

-  starvation    . .          . .          . .  621 

-  summer  diarrhcea   . .         . .  621 

-  tuberculous  peritonitis      . .  57 

-  uraemia         . .          . .          . .  45 


156, 
506, 


137, 


field  of 
666,  837, 
163,  165, 

IGO,  1G9, 


Hypothyroidism,   in  ateleiosis 

-  nervous  symptoms  with    . . 

-  obesity  in    . .  . .        453, 

-  tetany  from 

Hypotonia  of  muscles  in  tabes 
Hypoxanthin  bases,  uric  acid 

derived  from 
Hysteria : 

-  abdominal  aortic  pulsation  in 

-  absence  of  fatigue  in 

-  acute  pains  in  limbs  in     . . 

-  age  incidence  of     . . 

-  amblyopia  with     . .         800, 

-  amnesia  from 

-  anaesthesia  in  (see  Anaesthesia 

Hysterical) 

-  anorexia  in  . . 

-  anuria  in     . .  . .  45 

-  aortic    aneurysm   mistaken 

for 

-  aphonia  in  (see  Aphonia) 

-  ataxy  in 

-  Babinski's  sign  absent       82; 

-  bilateral  adductor  paralysis 

in  . . 

-  blindness  in . . 

-  borborygmi  in 

-  brisk  knee-jerk  in 

-  hullfe  in 

-  change   of  signs  and  sym- 

ptoms in 

-  choreic  movements  in 

-  clavus  hystericus  in 

-  clonic  spasms  in    . . 

-  club-foot  in . . 

-  coma  in 

-  constipation  in 

-  constriction     of 

vision  in  . . 

-  contractures  in 

-  convulsions  in 

345,  464, 

impaired  consciousness  in 

polymorphous  character  of 

simulating  tetanus 

sphiacter  unrelaxed  in  . . 

-  cough  due  to 

-  danger  of  diagnosing 

-  deafness  in  . .  . .        191, 

-  delirium  in 

-  diagnosis  from  disseminated 

sclerosis     . .  665,  798, 

by    effect    of    suggestion 

from  malingering 

neurosis    . . 

strychnine  poisoning 

tetanus     . . 

-  distention  in 

-  dysphagia  due  to  . . 

-  emotional  outbursts  in 

-  exaggeration    of    deep 

flexes  in        166,  342, 

-  excessive  appetite  in 
thirst  with 

-  facial  spasm 

-  faecal  vomiting  in  . . 

-  fits  described 

-  flexor  plantar  reflex  in 

-  flushing  in  . . 

-  globus  hystericus  in 

342,  506,  710, 

-  "  alove  "  anaesthesia  in    342 

-  headache  in       329,  345,  784 

-  hemianassthesia  in 

69,  506,  666, 

-  hemiplegia  in  69,  340, 

-  hiccough  in. . 

-  hyperaesthesia  in    . .        509, 

-  hyperpyrexia  in      . .         344, 

-  impaired  consciousness  in. . 

-  increase  of  symptoms  from 

anaemia  in 

-  insomnia  in . . 

-  intention  tremor  in 


162, 


re- 
343, 


342, 


216 
454 
451 
178 
262 

817 

592 
464 
503 
710 
836 
26 


50 
,  49 


69 
800 

798 
666 

97 
509 
111 

506 
157 
798 
652 
132 
140 
150 

838 
166 
173, 
801 
160 
464 
464 
160 
175 
798 
666 
345 

800 
150 
389 
527 
801 
801 
465 
224 


800 
49 
789 
537 
847 
173 
343 
345 

798 
506 
798 

798 
342 
342 
667 
345 
160 

784 
356 

800 


HYSTERIA— INCO-ORDINA  TION 


921 


Hysteria,  conld. 

-  joint  symptoms  in  166,  389 

diagnosis  o£         . .  . .     389 

disappearance  under  anes- 
thesia     389 

disproportionate  pain  iu      389 

muscular  atrophy  in       . .     390 

sleep    unaffected    bj^   the 

pain  and  tenderness  of      389 
stiffness  often  extreme  . .     389 

-  leg-raising  test  of  . .  . .     342 

-  lock-jaw    in.  .  .  .  .  .     464 

-  loss  of  smell  in        . .        666,  669 
taste  in     . .  . .        666,  774 

-  mediastinal     new      growth 

mistaken  for       . .  . .     777 

-  meteorism  in  .  .  .  .     433 

-  mistaken  for  asthma         . .     582 

-  mj^oclonus  in  .  .  . .     160 

-  and  neurasthenia,  difficulty 

of  distinguishing  . .     788 

-  nystagmus  absent  in         . .     800 

-  opistliotonos  in        162,  463,  464 

-  optic  discs  not  affected  in. .     800 

-  pains  in  the  limbs  in        . .     506 

in  ovarian  region  in      . .     509 

and  tenderness  in  back  in     788 

scalp  from       . .  . .     784 

-  palate  reflex  in        . .  . .     509 

-  palpitation  in         . .         525.  527 

-  paralysis  agitans  mistaken  for  54S 

-  paralysis  in..  157,  163,  389, 

506,  798,  800 

absence      of      associated 

movements  in  . .     549 

muscular  wasting  in  . .     541 

antesthesia  in     . .  . .     549 

of  arm  in  . .  .  .  . .     548 

general  atrophy  in     . .     548 

characteristic  attitudes  of     166 

with  chorea         . .  . .     157 

electrical  reactions  in   . .     541 

flaccidity  in         . .  . .     541 

gait  in      . .  . .  . .     541 

with  hysterical  chorea   . .     157 

joint 389 

of  one  leg  due  to . .  . .     541 

typical  attitude       . .     541 

reflexes  in  . .  . .     541 

-  -  rigidity  in  398,  541,  548 

of  arm  in  . .  . .     548 

of  Imibs  in       . .  . .     39S 

simulating  pregnancy    . .     166 

-  paraplegia  in  ..69,  562,  567 

-  perverted  taste  in..  ..      774 

-  phantom  tumours  in       433,  721 

-  phosphorus  excretion  in  . .     572 

-  pneumonia  mistaken  for  . .     777 

-  pleurisy  mistaken  for        . .     777 

-  polyuria  with  581,  582,  789 

-  professions  of  insomnia  in      359 

-  pruritus  in  . .  . .  . .     588 

-  pseudo-neuralgia  in  . .     498 

-  ptyalorrhoea  from  .  .  .  .      590 

-  pupiUary  reaction  in  . .     160 

-  pyrexia  from  .  .  . .      618 

-  quivering  of  eyelids  in      . .     160 

-  retention  of  urine  in  . .     441 

-  retraction  of  the  head  in  . .     641 

-  rigidity  of  limbs  in  . .     398 

-  rigor-like  attacks  in         646,  647 

-  risus  sardonicus  in.  .         651,  652 

-  scoliosis  in  .  .  . .  . .     180 

-  screaming  in  . .  . .     160 

-  "  seizures  "in         . .  . .     506 

-  sex  incidence  of      506,  641,  710 

-  simulating  cerebral  tumour      798 

epilepsy     . .  . .  . .     160 

strychnine  poisoning    464,  652 

tuberculous  hip  or  knee      166 

-  spasm  of  bladder  in  . .     443 

-  spasmodic  contractions  in 

159,  106,  537 

-  sphincters  not  paralyzed  in     800 


Hysleria,  conld. 

-  spinal  caries  mistaken  for        777 

-  spine  symptoms  in  . .     788 

-  "  stocking  "  anaesthesia  in      506 

-  stridor  from  .  .  . .     710 

-  subjective  smell  sensations  in  669 

-  sudden  recovery  from       . .     506 

-  suggestion  treatment  in 

150,  343,  577 

-  some  symptoms  of . .  . .     157 

-  tenderness  in  the  chest  from 

776,  777 
of  the  scalp  from  . .     781 

-  tests  for  motor  types  of  548,  567 

-  tetanic  spasnis  in     162,  464,  802 

-  tetany  simulated  in  . .     178 

-  trance  in      . .  . .         137,  140 

-  tremor  in     . .  . .         795,  798 

-  trismus  in   . .  . .         162,  801 

-  typhoid  spine  simulating  . .     787 

-  variable  paralyses  in         . .     506 

-  vomiting  m..  ..  844,  847 
simulating  indigestion    . .     350 

-  writer's  cramp  simulated  in  178 
Hystero-epilepsy         . .  . .     161 

-  retraction  of  the  head  in  . .     641 

ICELAIND,    hvdatid     disease 

in  . .  .'.  . .         719,  720 

Ichthyosis,  age  incidence  of  . .     530 

-  anidrosis  with         . .  . .     714 

-  diagnosis  from  tinea  imbri- 

cata  .  .  .  .  . .  276 

-  hystrix,  papules  of  . .  530 

-  onychogryphosis  in  . .  445 

-  scales  in       . .  . .  . .  655 

-  sore  fingers  from  . .  . .  266 
Icterus  (see  Jaundice) 

Ideas  of  grandeur  in  general 

paralysis  . .  139,  172,  269 

Idiocy,  absence  of  speech  due  to  682 

-  convulsions  of  children  in. .     169 

-  delayed  walking  from       . .     557 

-  destructiveness  in  .  .  . .     682 

-  dirty  habits  in        . .  . .     682 

-  irritability  in  . .  . .     682 

-  kyphosis  with  . .  . .     182 

-  and  microcephaly  . .  . .     214 

-  Mongolian,  facies  of  . .     263 

-  paraplegia  in  .  .  556,  557 

-  ptyaiism  in  . .  . .  591 
Idioglossia,  description  of  . .  688 
Idiopathic    dilatation    of    the 

colon  (see  Hirschsprung's 
Disease) 
cesophagus  . .  . .     225 

-  muscular  atrophy  and  hyper- 

trophy, fibrillary  con- 
tractions in  . .  . .     158 

Ileum,  congenital  malforma- 
tion . .  . .  . .     151 

Iliac  abscess  (see  Abscess,  IliacJ 

-  crest,  bedsore  over  . .     285 

-  fossa,  swelling  in  (see  Swell- 

ing in  Iliac  Fossa;) 

pain  in  (see  Pain  in  tlie 

Iliac  Fossae) 

-  glands,  enlarged  (see  Lymph- 

atic Glands,  Hiac) 

-  vein,  thrombosis  in  186,  456 
Iliacas,  nerve  supply  of  . .  542 
Ilio-costal  space,  bulged  out  by 

renal  tumour      . .         391,  393 

perinephric  abscess     . .     392 

Ilio-bypogastrio    nerve,    skin 

distribution  of  . .         659 

nio-inguinal  nerve,  skin  distri- 
bution of . .  . .         . .     659 

Ilio-psoas  muscle,  spinal  nerve- 
root  supplying    . .  . .     543 

Ilium,  disease  of,  swelling   in 

iliac  fossa  from  . .         730,  737 

-  osteomyelitis  of       . .  .  .     737 

-  tuberculous  disease  of        . .     737 


Illusions  iu  chronic  alcoholism  172 
Imbecility,  amenorrlicca  in  . .       23 

-  dwarfism  with         . .  . .     214 

-  prominent  in  Mongolism  . .     216 

-  ptyaiism  in. .  . .  . .     591 

Impacted  wisdom   tooth,  dia- 
gnosis of  tetanus  from..     162 

Im.pending  death,  delirium  in      195 
Imperforate    hymen,    vagina, 

or  cervi.x. .  . .  . .       23 

ImpetiflO,  bulte  in 

110,  113,  446,  602,  608 

-  crusts  in       . .  . .         602,  831 

-  cutaneous  diphtheria  with        602 

-  diagnosis   from  mild  modi- 

fied smallpox  (Fir/.  161). .     607 

pustular  syphilide  . .     604 

ringworm  . .  . .  . .     274 

-  distinction   from   eczema..     831 

-  enlarged  occipital  glands  in     419 

-  flat  and  irregular  pustules  in     601 

-  no  leucocytosLs  with  . .     400 

-  lips  rarely  affected  by       . .     830 

-  papules  in   . .  . .  . .     831 

-  perleche  with  . .  . .     404 

-  preference     for     face     and 

hands        ..  ..  604.609 

-  pustules  in    . .  601,  602,  654 

-  pyrexia  slight  in     . .         602,  608 

-  relation     to     pemphigus 

neonatorum     . .  . .     446 

-  scabs  in        . .  . .  653,  654 

-  simulated  by  herpes  facialis     83(i 

-  small  erythematous  spots  in      602 

-  sore  fingers  from     . .  . .     26f; 

-  streptococcal  infection  in  . .     601 

-  tenderness  of  the  scalp  from     781 

-  vesicles  in     . .  . .         608,  831 

-  bullosa,  description  of      113,  602 

-  circinata       6O2 

-  follicular,     diagnosis     from 

pemphigus  . .  . .     602 

pustular  eczema         . .     602 

distribution  of  eruption  in     602 

pustules  pierced  by  hairs     602 

staphylococcal  infection  in    601 

yellow  crusts  in   . .  . .     602 

-  gyfata  6O2 

-  herpetiformis  .  •  ■  •  113 
Implantation  cyst  of  vulva  .  .  768 
IMPOTENCE 346 

-  in  cachexia  .  .  . .  - .     347 

-  distinction  from  sterility  . .     346 

-  senile,  priapism  preceding  585 
Impulse   on  coughing  in  rare 

cases  in  hydrocele 

-  displaced  cardiac  (see  Heart) 
Incompatibility,  sterility  due  to 

706, 
INCONTINENCE  OF  F/ECES 

in  meningitis 

primary  lateral  sclerosis . . 

-  Of  urine  (and  see  Micturition, 

Abnormalities  of) 

chronic  cystitis  from 

from  destruction  of  spinal 

centres . . 

diagnosis  of  distention  from  440 

differentiation  of  enuresis 

from 

distinguished  from  enuresis 

dribbling  per  uretlnram  in 

from  enlarged  prostate 

false 

in  meningitis 

from   retroverted    gravid 

uterus    . . 

vesical  sphincter  lesions 

Inco-ordination  (and  see  Atax-y; 
and  Contractions) 

-  causing  abnormal  gait       . .     277 

-  ataxic  paraplegia    . .  . .     277 

-  cerebellar  disease   . .  . .     277 

-  chronic  alcoholism  . .     172 


522 


707 
347 
642 
567 

437 
628 

443 


247 
257 
440 


440 
642 


438 

440 


922 


IXCO-ORDIXA  TIOX—INFL  UENZA 


Inco-ordination,  could. 

Infancy,  coiUd. 

Inferior  vena  cava,  contd. 

-  combined  sclerosis . . 

277 

-  insomnia  in. . 

356 

obstruction  of,  varicose 

-  disseminated  sclerosis 

277 

-  jaundice  in  . . 

365 

veins  in 

61 

-  distineruished  from  paralysis 

545 

-  metrostaxis  in 

435 

thrombosis  (see  Throm- 

- in  Friedreich's  ataxy        131 

277 

-  mUk  in  breasts  in  . . 

202 

bosis  of  Inferior  Vena 

-  peripheral   neuritis. . 

506 

-  muscular  dystrophy  in     158 

561 

Cava) 

-  Tabes  dorsalis 

277 

—  nystagmus  in 

452 

Inflammation,    cardinal   sym- 

- t«st  for  presence  of 

277 

-  obscure  fever  in,  possibly  due 

ptoms  of  . . 

478 

India,  ankylostomiasis  in 

570 

to  baciUuria         . .     "    . . 

616 

Inflation,    in    diagnosing    car- 

- mTcetoma  in 

809 

-  osteochondritis  in  congenital 

cinoma  of  pancreas 

59 

-  relapsing  fever  in    . .        373, 

649 

Syphilis  in 

386 

hour-glass  stomach 

353 

India-rubber   bottle   stomach 

-  paraplegia    of,    from    spina 

pancreatic  cyst  .  . 

690 

123,  270, 

299 

bifida        

556 

timiour  . . 

366 

-  neuritis  in  workers  in 

77 

-  priapism  in,  causes  of 

585 

size  of  stomach   . .         355 

724 

INDICANURIA 

348 

-  regurgitation  of  mUk  in     . . 

842 

Influenza,  abdominal  pain  in 

505 

-  abnormal  protein  decompo- 

— scurvy  of  (see  Scurvy, Infantile) 

-  acute  general  pains  in  the 

sition  indicated  by          97 

821 

-  seborrhoeic  dermatitis  of   . . 

446 

limbs  in 

503 

-  in  acute  appendicitis 

500 

-  spastic  paralyses  of 

154 

ha?morrhagic  otitis  in    . . 

468 

-  black  urine  from     . .        820, 

821 

-  splenic  ansemia  in  .  . 

42 

-  albuminuria  in 

17 

-  bleaching  powder  test  for  . . 

821 

-  summer  diarrhcEa  of,  poly- 

- ariosn^  ia  in  . . 

069 

-  brown  urine  from . .         820, 

821 

cythemia  in         .  .         579, 

580 

-  arthritis  in  . . 

376 

-  ciu-e  by  calomel 

821 

Infantile  paralysis  (see  Paralysis, 

-  bacillus  (see  Bacillus  Influ- 

- darkening  of  urine  on  es- 

Infantile) 

enzae) 

posure  to  air,  from 

821 

Infantilism       

212 

-  brachial  neuralgia  in 

493 

with  liquor  potassae  due  tc 

290 

-  causes  of      . . 

215 

-  bronchitis  in 

505 

-  general  account  of . . 

821 

-  in  congenital  syphilis 

260 

-  broncho-penumonia  in      321, 

505 

-  intestinal  origin  of . . 

821 

-  cryptogenetic 

210 

-  conditions  mistaken  for     . . 

620 

-  and  lactic  acid  therapy     . . 

349 

-  cryptorchism  in 

218 

-  conjunctivitis  in    . . 

256 

-  nitric  acid  t-est  for  . .    "     3i8 

821 

-  and  dwarfism  distinguished 

214 

-  coryza,  severe,  in    . . 

505 

-  normal  colour  of  urine  with 

821 

-  essential 

"216 

-  cough  in       . .          . .        175, 

.505 

-  in  pancreatitis 

116 

-  and  gigantism  together 

214 

-  danger  of  diagnosing  76,  699 

773 

-  due  to  pus  collections 

821 

-  illustrated  (Fig.  66) 

215 

-  depression  in 

505 

-  from  putrid  empyema 

821 

-  intestinal 

215 

-  diagnosis  of . .          . .        505, 

610 

-  simulating  melanuria        821 

822 

—  ossification  premature  in  . . 

214 

from  febricula     . . 

505 

-  tririal  significance  of 

349 

-  with  premature  senility  in 

fungating    endocarditis.. 

610 

Indies,  ^Vest,  vellow  fever  in 

372 

progeria    . . 

218 

paratyphoid  fever 

611 

INDIGESTION 

349 

-  thyroid  type  described  (Fig. 

tuberculosis 

610 

-  in  children,   insomnia  from 

357 

67)             

216 

typhoid  fever       610,  611, 

699 

-  chronic,  anaemia  in 

36 

Infarction  (and  see  Embolism) 

-  diarrhoea  in. . 

505 

-  flushing  in  . . 

2G8 

-  from  fungating  endocarditis 

-  epididymo-orchitis  from  517 

518 

-  in  general  congestion  of  liver 

407 

39,  76,  138,  237 

321 

-  epistaxis  in  . . 

251 

-  pancreatic  lesions  causing 

117 

-  of  kidney,  albuminuria  in. . 

9 

-  extreme  prostration  in     505, 

699 

-  in  pyloric  obstruction 

144 

diagnosis      from      acute 

-  gastro-en'teritis  in  . . 

610 

—  rosacea  from 

268 

Bright's  disease 

314 

-  headache  in. .          . .        505, 

610 

Indigo-blue,  blue  urine  after 

823 

in  fungating  endocarditis 

237 

-  jaundice  in. . 

505 

-  treatment  of  epilepsy  by  . . 

823 

haematuria  in        . .       305, 

314 

-  lachrymation  in 

505 

Indoor  life,  aniemia  due  to    . . 

36 

renal  abscess  from 

625 

-  leucocytosis  uncommon  in400 

,699 

Indoxyl-glycuronic   acid,  blue 

casts  in  urine  in 

314 

-  menorrhagia  in 

428 

tint  of  urine  due  to 

823 

-  of  lung,  embolic,  sudden  pain 

-  micrococcus    catarrhalis    in 

505 

Induration  of  lungs  in  mitral 

in  chest  in 

321 

-  muscular  atrophy  in 

76 

stenosis     . .    ~     . . 

245 

in  fungating  endocarditis 

321 

-  needfor  bacterial  diagnosis  of 

203 

Inequality  of  the  Pulses  (see 

gangrene  of  lung  from . . 

712 

caution  in  diagnosis  of  . . 

699 

Pulses,  Inequality  of/ 

haemoptysis  from  240,  317 

321 

-  nerve  deafness  after 

190 

-  pupils  (see  Pupil,  Abnormal- 

 in  leukaemia 

321 

-  orchitis  from 

79 

ities  of) 

mitral  regurgitation  . . 

240 

-  pain  at  the  back  of  the  eyes  in 

610 

Inertia,  uterine,  dystocia  from 

227 

stenosis 

320 

in  the  lumbar  region  in 

610 

symptoms  of 

229 

after  operations  . . 

322 

severe  in  . . 

505 

Infancy    (and    see    Children), 

physical  signs  of  . . 

321 

-  pancreatitis  from    . . 

116 

athetosis  in 

154 

pleuritic  effusion  in 

123 

-  peripheral  neuritis  after   165 

506 

-  buLke  in 

111 

puerperal .  . 

322 

-  Pfeilfer's  bacillus  in        505, 

610 

in  impetigo  in     . . 

446 

pyopneumothorax  from 

712 

-  pink-eye  in  . . 

256 

-  choreiform  movements  in  156 

,157 

in  venous  thrombosis    . . 

321 

-  pneumonia  in           505,  610, 

702 

-  colic  in 

136 

-  in  spleen 

699 

-  prolonged,    absence    of   the 

-  colitis  of 

92 

-  thrombotic  . . 

700 

characteristic  svmptoms  in 

610 

-  constipation  in 

149 

Infectious  jaundice  (see  Jaun- 

- pyrexia  m  505,  609,  610,  651 

699 

-  contractures  in 

1G5 

dice,  Epidemic) 

-  "  the     recently     developed 

-  convulsions  in,  causes  of    . . 

169 

Infective  arthritis  (see  Arthritis 

refuge  of  the  diagnostic- 

discassion  of 

170 

Infective) 

ally  destitute  "   . .          . .  _ 

620 

not  often  unilateral 

174 

-  endocarditis  (see  Eungating 

-  pulse-rate  relatively  slow  in  _ 

771 

porencephalus  in           170 

172 

Endocarditis) 

-  respiratory  type 

505 

-  diarrhoea  of  (see  Diarrhoea 

-  synovitis  (see  Synovitis,  In- 

- rigors  m            647,  648,  651, 

099 

of  Infants) 

fective) 

-  significance  of  delirium  in. . 

194 

and  vomiting,  acetonuria  in      4 

Inferior  dental  nerve,  neuralgia 

-  splenic  enlargement  in      692, 

099 

-  epistaxis  in  . . 

251 

of ■: . 

502 

-  spondylitis  deformans  after 

787 

-  eruptions  in  napkin  region  in 

446 

-  gluteal  nerve,  skin  dLstribu- 

-  sputum  in  pneumonic       505, 

702 

-  erythema  of  Jacquet  in,  dia- 

tion  of 

659 

-  sudden  onset  in 

099 

tmosis   of   congenital   sy- 

 spinal  roots  derived  from  542 

-  sweating  in 

699 

philis  from 

446 

-  vena  cava,  obstruction  of 

-  tachycardia  after   . .        772, 

773 

-  fibrillary  contractions  in    . . 

158 

54,  461 

825 

-  talipes  from 

131 

-  hemiplegia  of 

338 

albuminuria  from  .  .17,  61 

-  testicular  atrophy  after     . . 

79 

ataxy  in  . . 

68 

ascites  in 

60 

-  thrombosis  after     . . 

131 

talipes  in 

131 

hfcmaturia  in . . 

61 

-  transverse   myelitis   due   to 

565 

-  hypertrophic     stenosis     of 

cedema  of  back  from 

825 

-  tropical     abscess     of     liver 

pylorus  in,  vomiting  from 

843 

legs  from . .        450 

4G1 

mistaken  for 

408 

INFLUENZA— INTERNAL    POPLITEAL    NERVE 


923 


Influenza,  could. 

-  vagal  neuritis  after  . .     773 

-  Tomiting  in  . .  . .  505 
Infra-orbital  nerve,  distribution  659 
Infraspinatus,    atrophy    from 

supra  -  clavicular      nerve 
paralysis  . .  . .     552 

-  nerve  supply  of       . .  . .     550 

-  pseudo-hypertrophy  of       .  .     560 

-  wasting  in  phthisis  . .  7"2 
Infratrochlear     nerve,     skin 

r^istribution  of     . .  . .     C59 

Infundibuluni,  swellings  at,  in 

sinusitis    . .  . .  . .     255 

Infusion,  oedema  after        458,  400 

-  need  for  indicated  by  specific 

gravity  of  blood..  ..     580 

Inguinal  canal  examuiation  in 

diagnosis  of  ascites         . .     717 

-  glands  (see  Lymphatic  Glands) 

-  liernia  (see  Hernia,  Inguinal) 

-  region,  organs  normally  con- 

tained in  . .  . .     722 

various  tumours  felt  in 

729,  731 
INGUINAL  SWELLING        ■■     737 

due  to  acute  abscess       . .     739 

aneurysm  of  external  iliac 

artery   . .  . .  . .     741 

chronic  abscess  from  hip 

disease  . .         . .     739 

from  sacro-iliao  disease  739 

distended  psoas  bursa    . .     741 

femoral  hernia    . .  . .     739 

hernia        . .         . .  . .     739 

-  -  hydrocele  .  .  . .      740 

iiigumal  hernia   . .  . .     739 

lipoma  of  spermatic  cord      741 

obturator  hernia  . .     739 

pelvic  abscess     . .  . .     760 

psoas  abscess       . .        632,  739 

retained  testis  523,  740 

sarcoma  of  pelvis  . .     741 

tumours  of  the  cord        .  .     741 

round  ligaments         . .     741 

-  -  ureteric  calculus              .  .      135 
IN6UIN0-SCR0TAL  SWELL- 
ING   741 

due  to  gro^-th  in  testis . .     742 

hernia  (see  Hernia) 

torsion  of  retained  testis     742 

Injuries,    abdominal,    causing 

coUapse     . .  . .  . .     645 

chyluria  . .  . .     126 

chylous  ascites  . .       58 

peritonitis        . .  . .     646 

-  causing  amenorrhcea  . .       23 

amnesia    . .  . .  . .       25 

aneurysm  of  axillary  artery  732 

anuria       .  .  .  .  45,  49 

bleeding  from  ear  . .     467 

gums     . .  . .  . .       86 

bony  swelling      . .  . .     750 

extroversion  of  bladder. .     587 

paralysis  of  arm.. .  . .     552 

paraplegia  . .  . .     558 

ulceration  of  larynx       . .     710 

-  cerebral      (see       Cerebral 

Injuries) 

-  to  cervical  cord,  rapidly  fatal   341 
region,  various  effects  of 

552, 

-  chest,  empyema  from 

pneumothorax  from     577, 

surgical  emphysema  from 

231, 

-  chordee  due  to 

-  compression  of  cord  from  . . 

-  corneal  ulceration  from 

-  diaphragmatic  hernia  from 

-  of  ear,  laceration  of  tympanic 

membrane  visible  on  ex- 
amination 

-  ectropion  and  epiphora  from 


Injuries,  could. 

-  epistaxis  from        . .         250, 

-  of  external  auditory  meatus 

from  blow  on  chin 
bleeding  from  ear  in 

-  of  eye 
irregular  pupil  due  to . . 

-  forearm,    ischoemio    paraly- 

sis of  hand  from . . 

Volkmann's     contracture 

from  (Fig.  43,  p.  166) 

-  gangrene  from        . .         281 , 

-  ha?matemesis  from 

-  hoematuria  from 

-  hnffmoperitoneum  from 

-  htemorrhage  into  cord  from 

-  to  head  (see  Head  Injuries) 

-  hemiplegia  from 

-  history  of,  in  pneumococcal 

artluritis    . . 

-  hydropneumothorax     from 

-  hyperpyrexia  after 

-  incontinence  of  urine  from 

-  to  internal  popliteal  nerve, 

claw-foot  from     . . 

-  kidney,       diagnosis       from 

urethral  or  vesical  injury 

hematuria  in      . .         304, 

renal  abscess  from 

enlargement  in 

-  lachrymal    duct    or    canal- 

iculus, epiphora  after   .  . 

-  larynx,  haemoptysis  from  . . 

-  loin,  perinephric  haematoma 

from 

-  loss  of  pupil  reflexes  from 

-  neck,  stiff  neck  from 

-  necrosis  of  nasal  bones  from 

-  nerve  deafness  from 

-  nerves,  contracture  from  163, 

-  neurasthenia  resulting  from 

-  nystagmus  following 

-  onycliia  due  to 

-  of  'optic  nerve,  hippus  from 
sudden  blindness  from. . 

-  orchitis  from 

-  pain  in  the  back  from 

-  paralysis  of  serratus  magnus 

from 

-  penile  hsematoma  from     . . 

-  periostitis  from 

-  professional  cramp  from  . . 

-  to    sacral    cord,    claw-foot 

from 

-  sarcoma  after  . .        756, 

-  slight,  as  cause  of  haemophilic 

arthritis    . . 

-  spinal  symptoms  after 
Brown-Si^quard  paralysis 

from  (Fig.  181) 

difficult  micturition  from 

h^matorrhachis  from     . . 

paraplegia   from. . 

priapism  after 

talipes  after         . .        131, 

-  swelling  of  face  from 

-  tender  scalp  from  780, 
spine  from 

-  testicular  atrophy  due  to    79 

-  tetanus  due  to 

-  of  tibia,  talipes  from 

-  tortion  of  testis  from 

-  transverse   myelitis   due   to 

-  ulceration  of  lar3'nx  from. . 
leg  from  . . 

-  to  uncinate  gyrus,   anosmia 

from 

-  of  vagina  causing  discharge 

-  vomiting  after 
Innominate     aneurysm     (see 

Aneurysm,  Innominate) 
Innominate  veins,  obstruction 

by   mediastinal  growth.  . 
of,  oedema  of  arm  fi-om 


251 

467 
467 
594 
594 

552 

552 
283 
299 
304 
717 
563 

338 

375 

712 
344 
440 

127 

308 
308 
625 
308 

250 
318 

392 
594 
709 
204 
191 
165 
787 
453 
445 
595 
839 
79 
475 

551 
516 
776 
177 

127 
803 

388 

787 

664 
440 
132 
561 
585 
132 
747 
781 
784 
,  80 
709 
132 
766 
564 
226 
810 

669 
210 
844 


465 
826 


Innominate  vein.i,  conld 

stenosis  by  bronchial  glands  422 

thrombosis,  causes  of     . .     826 

varicose  tlioracic  veins 

from 
Insane,  general    paralysis    of 

(see  General  Paralysis  of 

the  Insane) 
Insanity,  amenorrhea  in 

-  athetosis  in  .  . 

-  from  chorea  of  pregnancy . . 

-  chronic  alcoholism.. 

-  constipation  in 

-  gangrene  of  lung  in 

-  and  Huntington's  chorea  . . 

-  insomnia  in . . 

-  and  Little's  disease 

-  perverted  appetite  in 
taste  in     . . 

-  pupils  in 

-  retraction  of  head  in 

-  subjective  smell  sensations 


820 


23 
154 
15C. 
172 
144 
288 
156 
356 
154 

50 
774 
595 
041 


Insect  bites  on  face   . . 

-  -  wheals  from 
INSOMNIA 

-  due  to  aortic  aneurysm 

-  cerebral  syphilis 

-  chronic  alcoholism 

-  insanity  from 

-  methods  of  mitigating 

-  due  to  plumbism    . . 
pruritus 


155 
55S 


206 


156 


669 
747 
850 
356 
848 
173 
797 
358 
358 
38 
588 
Inspissation  of  blood  in  cholera  187 

cyanosis  from     . .  . .     187 

in  dysentery        . .  . .     187 

yellow  fever         . .  . .     187 

Instrumental    delivery,    birth 
palsies  due  to 

paraplegia  due  to 

Instrumentation,        urethritis 

from 
Insular  sclerosis  (see  Dissemi- 
nated Sclerosis) 
Insurance  (see  Life  Assurance) 
Intention  tremors,  diEEerentia- 
tion  of  choreiform  move- 
ments from 

in  disseminated  sclerosisl74,341 

Friedreich's  ataxy  . .     560 

general  account  of         . .     799 

in  Little's  disease  ..     154 

illustrated  (Fig.  205)     ..     799 

Intercostal    nerve    paui    (see 
Pain,  Intercostal) 

relation  of  herpes  zoster  to  830 

skin  distribution  of        . .     659 

-  neuralgia    (see     Neuralgia, 

Intercostal) 

-  spaces,   fullness  in  medias- 

tinitis        483 

sucking  in  of        . .        186,  642 

-  tenderness    (see    Neuralgia,         / 

Intercostal) 
Intercosto-humeral  nerve,  skin 

distribution  of     . .  . .     659 

Intermittent  albuminuria     .  .       19 

-  claudication  (see  Claudication) 

-  closm-e  of  cerebral  vessels, 

hemianopsia  from  . .     33G 

-  hydrarthrosis,  general  account 

of 387 

Internal  capsular  lesion  causing 

hemianfesthesia   . .  . .     666> 

hemianopsia  334,  666 

hemiplegia    . .        330,  666 

-  capsule,     changes    in     dis- 

seminated sclerosis        . .     660 

-  cutaneous   nerve,   skin   dis- 

tribution of 

-  jugular  vein  thrombosis    . . 

-  popliteal     nerve,      muscles 

supplied  by 
roots  derived  from     . . 


659 
651 


542 

542 


924 


INTERNAL   SAPHENOUS    NERVE— IODOFORM 


Internal  saphenous  nerve,  skin 

Intestinal  obstruction,  contd. 

Intoxication,  contd. 

distribution  of     . . 

659 

simulated  by  ascites 

717 

-  clironic,  leucopenia  in 

401 

-  secretions,  efEect  on  menstrua- 

 Henoch's  purpura       90, 

846 

Intracranial  growth  (see  Cere- 

tion 

430 

mesenteric    thrombosis 

brum,  Tumour  of) 

on  arteriosclerosis 

430 

or  embolism 

90 

Intrathoracic  new  growth  (see 

Interossei,  atrophy  of 

73 

pancreatitis  90,  292,  046 

846 

Mediastinum,  New  Growth 

n) 

-  and  lumbricales,  spinal  nerve 

peritonitis 

645 

Intubation  of  larynx,  haemo- 

root supplying     . . 

550 

stiffening  of  intestine  in. . 

152 

ptysis  from 

318 

-  norve  supply  of       . .         542, 

550 

strangulated  hernia  causing 

Intussusception,     abdominal 

Interphalanseal  joints,  hyper- 

716,- 

733 

tumour  with  92,  134,  148, 

152, 

trophic  osteo-artliropathy 

temporary,   due  to  faecal 

196,  723,  727,  730, 

736 

in  . . 

390 

accumulation 

692 

-  asre  incidence  of      . .        636 

736 

Interscapular  pain  (see  Pain, 

thrombosis    or    embolism 

-  blood  and  mucus  per  rectum 

Interscapular) 

of  mesenteric  vessals . . 

432 

in  148,  196,  443,  036,  727, 

736 

Interstitial    keratitis,    photo- 

 tuberculous  peritonitis  . . 

719 

-  colic  due  to 

148 

phobia  in 

574 

colon  causing  . . 

731 

-  constipation  in        . .        148, 

736 

-  nephritis       ("see        Bright's 

visible  peristalsis  in     151, 

152, 

-  diagnosis  from  enterospasm 

134 

Disease,     Chronic ;      and 

267,  350,  431,  571,  723, 

724 

-  diarrhoea  from 

196 

also  Granular  Elidney) 

vomiting  in  133,  153,  350, 

431, 

-  felt  per  rectum       . .        148, 

036 

Intertrigo,  erythema  fi-om    . . 

252 

571,  844,  845 

846 

-  indicanuria  m 

349 

-  pain  in  perineum  from 

516 

and   constipation   witli 

-  intestinal  obstruction  from 

-  of  umbihcus 

716 

431,  045, 

733 

151,  152,  431,  636, 

730 

Inter vpntricular   septum,  pat- 

- parasites  (see  Parasites,  In- 

- rectal  examination  in  148, 196 

,636 

ent             ..          ..        129, 

244 

testinal) 

-  sausage-shaped    tumour    of 

152 

intestinal     colic     (see    Colic, 

-  putrefaction  (see    Putrefac- 

- sigmoidoscope   in    . . 

190 

Intestinal) 

tion) 

-  simulated  by  Henoch's  pur- 

- constipation  (see  Constipa- 

Intestine, acute  diverticulitis  of 

731 

pura          ..          ..90,  600, 

840 

tion) 

-  atony  of,  illustrated 

144 

appendicitis 

135 

-  crises  in  tabes  dorsalis     134, 

665 

-  borborygmi  in  (see   Borbor- 

- spasmodic   abdominal  pain 

ygmi) 

from 

727 

liver  dullness  in  . . 

404 

-  carcinoma  of  (see  Carcinoma 

-  symptoms  and  signs  of 

92 

-  fermentation,   flatulence   in 

267 

of  Colon) 

-  tenesmus  from 

727 

microscope  m  diagnosis  of 

268 

-  diseases  of,  referred  pain  in 

-  tumour  with           . .          92, 

152 

tetany  in  . . 

3 

area  of  10th  dorsal  nerve  in 

509 

in    hypochondrium   from 

723 

-  fistula  causing  pneumaturia 

576 

-  dysenteric  ulceration  of,  cys- 

 hypogastrium 

730 

-  neuralgia 

134 

titis  in 

033 

right  lumbar  region  from 

727 

-  obstruction,  abdommal   dis- 

 extension  to  bladder  024 

633 

-  visible  peristalsis  in 

148 

tention  in              134,  350, 

571 

infective  peritonitis  from 

644 

-  vomiting  from         .  .         727, 

736 

absolute    constipation    in 

431 

tenderness  in 

134 

Inversion  of  uterus   . .        587, 

768 

acetonuria  in 

4 

tuberculous,  cystitis  in 

633 

Iodide  of  potassium,  anosmia 

acute 

151 

-  enlarged  mesenteric    glands 

from 

668 

bile  in  vomit  in. . 

846 

in  tuberculous  enteritis. . 

422 

-  bleeding  gums  from 

85 

borborygmi  in     . .        153, 

431 

-  hypoplasia  of 

143 

-  buite         ..       ..      no. 

112 

from  carcinoma  of  colon 

92, 

-  indicanuria   in    tuberculous 

-  coryza  from             ..87,  203, 

668 

393,  500,  501,  645,  690,  731 

735 

colitis        

349 

-  in  diagnosis  of  gumma 

681 

causes  and  symptoms  of 

-  lardaceous  disease  of 

414 

syphilis           226,  254,  279, 

325, 

151, 

431 

-  large,  diagram  of  normal  . . 

143 

449,520,521,604,640, 

058, 

chronic,  diarrhcsa  in 

267 

-  matting       of,       abdominal 

672,  674,  677,  681,  808 

814 

flatulence  in    . . 

267 

tumour  due  to     . . 

691 

-  eruption,  absence  of  come- 

 or  recurrent     . .  ■      147, 

148 

-  musculature  of,  weak 

143 

dones  in  . . 

603 

colic  in 

473 

-  neuro-muscular  defects  of 

age  incidence  of  . . 

603 

collapse  in 

346 

142,  143, 

144 

bright  red  colour  of 

003 

conditions  of   incomplete 

-  pain  in  spastic  constipation 

144 

diagnosis  from  acne 

603 

constipation   in 

151 

-  paralysis  of,  in  acute  general 

acuminate  syphilide   . . 

604 

constipation  in     145,  350, 

431, 

peritonitis 

472 

small-pox 

609 

571,  644,  645,   733, 

846 

from  spmal   cord   lesions 

432 

distribution  of     . . 

603 

from  cystic  l?:idneys 

15 

-  perforation  of  tuberculous 

711 

pustules  in           . .        112, 

603 

diagnosis  from  colic 

571 

typhoid  ulceration  of     . . 

711 

-  foul  taste  in  mouth  from  . . 

774 

peritonitis 

431 

-  peristalsisof  (see  Borborygmi' 

97 

-  influence  on  syphilitic  pyrexia 

615 

"feeculent  vomiting  in    431 

845 

-  rupture    of    aneurysm    into 

140 

-  laryngeal  symptoms  from 

foul  breath  in 

98 

-  small,  visible  peristalsis  in 

571 

185,  465, 

709 

gall-stones  causing 

300 

-  stricture     of,     constipation 

-  loss  of  taste  due  to 

774 

general    abdominal    pain 

due  to       . .          . .       ... 

146 

-  and  mercury,  aggravation  of 

in           . .          . .        350, 

473 

-  tuberculous,  blood  per  anum 

Bazin's  disease  by 

451 

hiccough  in 

342 

due  to 

731 

in  diagnosis  of  gumma . . 

279 

—  hypothermia  in  . . 

346 

cachexia  due  to  . . 

731 

effect  of,  on  gumma 

677 

indicanuria  in 

349 

infiltration  causing  stricture  140 

-  ptyalism  due  to 

590 

from  intussusception     636 

736 

obstruction  due  to 

731 

-  purpura  from 

596 

laparotomy    in    diagnosis 

tenesmus  due  to . . 

731 

-  relieving  pain  in  secondary 

of 

267 

iilceration  of 

719 

syphilis     . . 

725 

leucocytosis  in    . . 

400 

causing      pneumo-peri- 

-  simulatmg  laryngeal  crises 

460 

meteorism  in 

431 

toncum 

711 

-  swelling  of  eyes  and  face  from  459 

from  minute  herniae 

716 

extension  to  bladder 

-  testicular  atrophy  due  to. . 

79 

nausea  in 

846 

313,  024, 

633 

-  universal  oedema  from      458, 

400 

pain  in     . . 

153 

pus  in  stools  from 

601 

-  vesicles  in    . . 

834 

peritonitis  from  . . 

431 

-  typhoid   ulceration   of,   pus 

Iodine  used  by  malingerers  as 

from  pressure  of  appendix 

in  the  stools  in  . . 

001 

vesicant  ". . 

112 

abscess  on  rectum 

038 

-  ulceration  of  (see  Ulceration) 

-  scaly  eruption  due  to 

655 

recurrent,  in  children,  in 

-  venereal  ulceration  of,  pus 

-  test  for  bile  pigment 

819 

H  irschsprung's    disease 

433 

in  the  stools  in  . . 

601 

Iodized    serum,    psorosperms 

rigidity   of  abdomen  not 

-  worms     in     (see     \Vorms, 

demonstrated  by 

803 

marked  with   . .        431, 

645 

Intestinal) 

Iodoform      capsule      test     of 

severe  abdominal  pain  in 

846 

Intoxication,    Babinski's   sign 

pancreatic  disease 

216 

sigmoidoscope  in            267 

350 

during  alcoholic  . . 

82 

-  purpura  due  to 

596 

IRIDOCYCLITIS— JOINTS,    AFFECTIONS    OF 


925 


Iridocyclitis,  causes  of  . .     25G 

-  from  corneal  ulceration     . .     800 

-  cedema  of  eyelid  from        . .     'JoCi 

-  severe  pain  in  the  eye  from     25G 
Iridodialysis,     irregularity    of 

pnpil  from  . .  . .     501 

Iridopiegia  (see  Pupil,  Abnor- 
malities of) 
Iris,    adhesions    of,    diatrnosis 
between  inflammatory  and 
ronireuital  origin  of         . .      503 

-  appearance      of,     in     con- 

junctivitis,     iritis,      and 
glaucoma  . .  . .     257 

-  coloboma  of  . .  .  .      402 

-  photophobia   in  diseases  of     57-1 

-  prolapse    of,    from    corneal 

ulceration  . .  . .     800 

-  tremulous  in  lens  dislocation    108 
Iritis,  atropine  treatment      ..      257 

-  atrophy  of  eye  from  .  .      830 

-  blindness  total  from  . .     830 

-  blockage  of  pupils  from     .  .     830 

-  causes  of      . .  . .  . .     250 

-  constriction  of  pupil  in      . .     505 

-  diagnosed  from  conjunctivitis 

256,  257 
glaucoma  .  .  .  .        256,  257 

-  glaucoma  from        . .  . .     830 

-  headache  in  327,  328,  783 

-  irregular  pupil  from  . .     503 

-  laclirymation  from  . .     255 

-  from  ophthalmia  neonatorum  250 

-  pain  in  eye  in  255,  256,  404,  408 
temporal    and    maxillary 

segmental  areas  in         . .     498 

photophobia  from         255,  574 

trigeminal  area  in  . .     404 

-  in  syphilis     .  .  .  .  .  .     450 

-  tenderness  of  the  temporal 

region  from  . .  . .     783 

-  -  vertex  from  . .  .  .  783 
Iron,  black  stools  from  .  .     428 

-  blue  sweat  due  to    . .  .  .      714 

-  coloration  of  stools  by        . .       80 

-  in  diagnosis  of  cldorosis     .  .       41 

-  headache  from  taking        . .     328 

-  m  intestinal  sand    . .  . .     052 

-  percliloride  of,  dryness  of  the 

mouth  due  to       . .  . .     780 

-  relief  of  headache  by  . .  320 
Irresponsibility      of      patient 

after  epileptic  convulsions    100 
IRRITABILITY  ..     359 

-  of  the  bladder  . .        443,  817 

-  in  chorea      .  .  . .  . .     150 

-  general   congestion   of  liver     407 

-  in  idiocy       . .  . .  . .     082 

-  leukaemia      . .  . .  . .       31 

-  meningitis    . .  . .  . .     350 

-  neurasthenia  . .  . .     788 

-  pruritus  causing      .  .  .  .     588 

-  in  rickety  children . .  ..  170 
Irritable  breast  of  Astley  Cooper  479 

-  spins,  tyjahoid  spine  called  787 
Irritant,  local,  causing  cliloasraa  574 
coryza   . .  . .  . .     203 

-  poison,   analysis   of    gastric 

contents  for         . .  . .     074 

eschars  on  lips  or  mouth 

from 674 

haematemesis  from         . .     674 

symptoms  produced  by. .     845 

vomiting  from     . .        674,  843 

skin  pigmentation  from         574 

Ischsemia  of  calf,  talipes  from     132 

-  paralysis  of  the  liand  from      552 
Ischio-rectal  abscess  (see  Ab- 
scess,  Ischio-rectal) 

-  fossas,  rectal  examination  of  035 
ITCHING  (and  see  Pruritus)       588 

-  absence  in  syphilides         . .     604 

-  in   dermatitis  herpetiformis     786 

-  drug  rashes  . .       424,  421 


llclmig,  contd. 

-  eczema  533,   057,   781,  831 

-  herpes  genitalis        . .         . .  830 
ophtiiaimicus        ..          ..  781 

-  intense^  in  iK'/.ema    .  .  . .  831 

papular  eczema    ..  ..  520 

prurigo  ferox        . .  . .  531 

-  -  stropliulus  . .  . .  850 

-  -  urticaria    . .  . .  . .  531 

-  from  leukoplakia     . .  . .  770 

-  of  lips  in  Fordyce's  disease  403 

-  pustular  eczema      . .  . .  602 

-  ringworm      . .  . .  . .  275 

-  scabies  . .  .  .  .  .  054 

-  at    site    of    inoculation    in 

antlirax 603 

-  slight  with  psoriasis  . .  057 

-  in  small-pox  . .         . .  055 

-  urticaria  pigmentosa  . .  805 

-  with  vesicular  eruptions    . .  829 
Ivory  exostosis  (see  Exostosis, 

Ivory) 

JABORANDI,  ptyalism  from  500 

Jacl<sonian  epilepsy             lol,  174 

cni-'inu'  I'liuvulsions        .  .  109 

from  chronic  inflammation  161 

clonic  convulsions  in     .  .  161 

diagnostic  importance  of 

aura  in             . .          . .  SO 

motor  cortex  lesion  in  . .  174 

muscular  atrophy  from  101 

from  new  growths         . .  101 

Jacquet's  infantile  erythema  446 

Jafl!('''s  test  for  indican          . .  348 

Jamaica,  ankylostomiasis  in  570 

Japan,  distom.a  pulmonale  in  325 

-  paragon  imus  Westermani  in  705 
JAUNDICE 360 

-  acholuric       . .         . .         372,  819 
m  septicaemia      . .          . .  372 

-  in  acute  yellow  atrophj-  of 

liver  302 

-  alcoholism    . .  . .  . .     243 

-  in     alveolar      echinococcus 

disease      . .  . .  . .     416 

-  from   aneurysm   of   hepatic 

artery  . .  . .  59 

-  with  ascites,  causes  of       . .       54 
in  portal  obstruction      58,  301 

-  with  biliary  colic      135,  153,  846 

-  from  carcinoma  of  bile- ducts    725 
of  duodenum       . .  . .     725 

-  -  liver  ..  ..00,412,413 

-  -  pancreas  280,  500,  690,  724,  725 

-  catarrhal 303 

albumosuria  in   . .  . .       20 

general  account  of        364,  365 

similarity     to     onset     of 

acute  yellow  atrophy  of 
liver      . .  . .         302,  370 

-  causes      associated      with 

disease  of  liver    . .  . .     368 

-  with  cholangitis      . .  650,  651 

-  choluria  in  . .          . .  . .     819 

-  with  cholecystitis  . .  . .     650 

-  in  cirrhosis  of  liver 

60,  .301,  410,  411,  093,  606 

-  from  congenital  obliteration 

of  bile-duct  . .  . .     3G1 

-  danger  of  fatal  post-opera- 

tive oozing  in     . .  . .  598 

-  ease  of  bruising  in  . .  . .  508 

-  epidemic,  general  account  of  372 

-  ejiistaxis  in  . .  .  .  251 

-  experimental,  from  toluylene 

diamine  poisoning  . .     374 

-  due  to  fungating  endocarditis  370 

-  from  gall-stones     .  .278,  300,  410 

-  grave,  of  children   . .         302,  365 

-  haemorrhage     from     trivial 

causes  in. .  . .  . .     508 

-  from  hepatic  abscess         408,  051 

-  in  influenza  . .  . .     505 


Jaundice,  ainld. 

-  irritability  in  .  .  . .     360 

-  frotn    kinking    of    bile-duct 

in  hcpatoptosis   .  .  .  .     407 

-  with  large  gall-bladder      . .     IJO.'V 

-  long-standiiii.',  carcinoma  of 

liver  the  commonest  cause     412 
in  Hanot's  cirrhosis      410,  411 

-  in  malaria    . .  . .  . .     371 

-  nervous         . .  . .  . .     374 

-  olive-green,  in  cancer  of  liver    413 

-  from  pancreatic  cyst  . .     724 

-  with  pancreatitis 

117,  135,  280,  292,  724 

-  ])assivo  congestion  of  liver  370,407 

-  jjiirpura  with  . .         506,  59S 

-  in   |)yh!|ildebitis       .  .  59,  370,  (>49 

-  relapsing  fever         .  .  .  .      373 

-  simple,  of  infants    . .        302,  303 

-  slow  licart-action  in  98,  30.5. 

-  in  splenic  amcmia  . .  . .     411 

-  spleuomegalic  cirrhosis      . .     093 

-  stenosis  of  bile-ducts        305,  410 

-  tuberculous  portal  glands  50 

-  tumours  of  gall-bladder     ..     392 

-  urine  colour  In  300,  820,  821 

-  urolilhiuiria  and       ..  ..      116 

-  xanthoma  planum  with     . .     805 

-  xantliopsia  in  .  .  .  .     840 
Jaw,     actinomycosis    of    (see 

Actinomycosis) 

-  carcinoma  of  (see  Carcinoma 

of  Jaw; 

-  clenched  during  convulsions     109 

-  fibroma  of   . .  ..  ..     "48 

-  fixed,  ptyalism  from  . .     591 

-  fracture  of  (see  Fracture  o£ 

Jaw) 

-  hypertrophy    of,    in    acro- 

megaly (Fir/.  88)     203,  749,  75.3. 

-  lesions  of,  causing  ptyalism     591 

-  motor  tics  affecting  . .     1 OO 

-  muscles,  trichinosis  of        . .     801 

-  myeloid  sarcoma  of  . .     756 

-  necrosis  of,  in  acute  exan- 

themata   . .  . .  . .     747 

periosteal  abscess       . .     747 

from  alveolar  abscess     . .     747 

detection    of   sequestrum 

in  diagnosis  of  . .     748 

following  injury..  ..     747 

from  mercurial  poisoning     747 

phosphorus  poisoning     87,  747 

ptyalism  due  to  . .  . .     590 

stomatitis  due  to  . .     590 

from  syphilis       . .         747,  748 

in  typhoid  fever. .  . .     747 

a'-rays  in  diagnosis  of    . .     748 

-  new  growths  of       . .  . .     204 

-  osteoma  of,  site  and  charac- 

ters . .  . .  . .      74  8 

-  sarcoma  of  (see  Sarcoma  of 

.Jaw) 

-  stifrness  of,  In  tetanus       ..     102 

-  lower,  pain  In  •  •     501 
swelling    of  (see  Swr-lllng 

of  Jaw) 

-  upper,  pain  in         . .        . .     502 
swelling  of   (sec   Swelling 

of  Jaw) 
Jejunum,  obstmction  to,   ab- 
sence of  distention  in    . .     1 52 
Jelly-fish  stings,  pruritus  from     588 
Jenner's  .stain . .  ..  ..       27 

Jerk,  achillis  (see  Ankle-jerk) 

-  knee  (see  Knee-jerk) 
Jewellers,  nail-staining  in     . .     444 
JOINTS,  AFFECTIONS  OF  (and 

see    Artliritis   and    Osteo- 
arthritis)      . .      . .  . .     374 

contractures  from  ..     107 

local  muscular  atrophy  in       72 

mistaken  for  paralysis  ,  .     545 

in  peliosis  rheumatica    . .     599 


926        JOINTS,    AFFECTIONS    OF— KIDNEY, 

TUBERCULOSIS    OF 

Joints,  affections  of,  conld. 

Kidney,  contd. 

Kidney,  contd. 

simulating        occupation 

-  atrophy  of,  due  to  complete 

-  hypernephroma  from  supra- 

neuroses 

178 

ureteral  obstruction 

627 

renal  rests  in 

690 

-  chief  site  of  pain  in  some 

-  bimanual  examination  of 

-  liypertrophy,  compensating 

cases    of    chronic    rheu- 

306, S94, 

689 

for  atrophy  of  the  other 

394 

matism     . . 

507 

-  calculus  in  (see  Calculus) 

-  infarction  of  (see  Infarction 

-  gummata  of  (see  Arthritis, 

-  carcinoma  of  (see  Carcinoma 

of  Kidney) 

Syphilitic) 

of  KidneyJ 

-  inflammations     of,    general 

-  hasmorrhage  into,  in  haemo- 

-  changes  in  old  people 

14 

pains  in  the  limbs  in    503, 

505 

pliilia 

302 

-  colon   carcinoma   communi- 

 subphrenic    abscess   from 

720 

-  malignant  disease  of 

3S8 

cating  with 

577 

-  injury  to  (see  Injuries  to  Kidney) 

-  mechanism    of    recognition 

-  cystic  disease  of  (see  Cystic 

-  lardaceous  (see  Lardaceous 

of  movements  of 

661 

Disease) 

Disease) 

-  obscure  pyrexia  due  of 

620 

-  disease,  brachial  monoplegia  in 

546 

-  lesions      causing      pleuritic 

-  pains  in,  in  acute  rheumatism  121 

compensatory  hypertropliy 

effusion 

123 

dengue 

506 

of  other  kidney 

394 

Cheyne-Stokes  respiration  124 

Henoch's  purpura 

600 

high  blood-pressure  from 

-  movable  (see  Movable  Kidney) 

-  -  (and  see  Pain  in  Joints) 

(and  see  Bright's  Disease 

)  96 

-  new  growths  of  (see  Carci- 

- prominent      in     achondro- 

 insomnia  in 

356 

noma  of  Kidney ;  Sarcoma, 

plasia 

212 

pain  in  the  back  in 

476 

etc.) 

-  pseudo-ankylosis      of,       in 

referred  pam  in  area   of 

-  normal  situation  of 

722 

chronic  rheumatism 

507 

10th  dorsal  nerve  in  . . 

509 

-  of    old    people,    interstitial 

-  rheumatic  nodules  round . . 

d52 

reno-reflex    pain    on    the 

fibrosis  in.  . 

14 

Jordan  Lloyd,  on  renal  pain 

sound  side  in   . . 

394 

-  pain  in  penis  from   disease 

witli  calculus 

306 

-  displacement    in    general 

of 

510 

Judgment   defects   in  general 

visceroptosis        . .         407 

473 

-  papilloma  of  (see  Papilloma 

paralysis  . . 

172 

-  effect  of  fevers   on. . 

17 

of  Kidney) 

Jugular  vein,  obstruction  by 

-  embolism  of . .          . .        8,  9, 

237 

-  polycystic  disease  of  310,  391 

558 

thyroid  gland  tumour   . . 

793 

-  embryoma  of 

395 

-  rhabdomyoma  of    . . 

395 

thrombosis  (see  Thrombosis) 

-  endothelioma  of 

395 

-  right,  normally  palpable  . . 

7-27 

Juvenile  muscular  dystrophy 

561 

KIDNEY,  ENLARGEMENT  OF 

-  Rose- Bradford 

14 

fibrillary  contractions  in 

158 

(and  see  Kidney,  Tumour 

-  sarcoma  of  (see  Sarcoma  of 

of)..          ..            310,391, 

500 

Kidney) 

KAHLER'S   DISEASE 

21 

aching  in  lorn  in. . 

307 

-  serous    cyst   of,    simulating 

Kala-azar           . .          . .         34 

693 

albuminuria  in     . . 

367 

hydronephrosis    .  . 

396 

-  enlarged  spleen  with  anemia 

band  of  colon  resonance  in 

367 

-  stone  in  (see  Calculus,  Renal) 

in    {Plate   XII,    Fig.   H, 

causing  excessive  fatness 

-  tenderness  in  (see  Tenderness 

p.  696)     

34 

in  children 

454 

over  Kidney) 

-  geographical  distribution  of 

693 

confusion    with   movable 

-  tuberculosis  of         309,  394, 

612 

—  Leishman-Donovan     bodies 

kidney 

394 

abscess  in 

394 

in  (Plate  XII,  Fig.  H)  693 

696 

from  cystic  disease  310,  396 

,558 

absence  of  symptoms  in 

-  spleen  enlarged  in  . .         692, 

693 

filling  of  loin  by  . . 

729 

miliary  form    . . 

626 

-  splenic  puncture  in 

693 

hfcmaturia  in      304,    307. 

367 

aching  in  loin  in  . .         309 

626 

Kaposi's  disease         . .         575, 

804 

in  hydronephrosis           500 

583 

age  of  patient  in . . 

309 

Kathode,  meaning  of . . 

633 

from  hypernephroma     . . 

395 

albuminuria  with       8,  16, 

310 

Keith  on  rectal  malformation 

637 

iinjury 

308 

slight  in 

626 

Keratin-coated     capsules     in 

jaundice  from      . .        362, 

367 

anuria  in. .          . .             4c 

,  48 

testing     for      pancreatic 

liver  mistaken  for 

405 

caseous  form,  abscess  in 

394 

disease 

364 

from  new  growth 

origin  as  primary  focus 

of  methylene  blue  in  dia- 

307, 391,  394 

395 

in  one  kidney     394 

626 

gnosing  pyloric  obstruc- 

 obscured  in  various  ways 

394 

causing  pleurisy. . 

123 

tion 

713 

palpable  in  epigastrium.. 

725 

Cheyne-Stokes       respira- 

Keratitis in  congenital  syphilis 

lumbar  region.. 

727 

tion  in. . 

124 

259, 

828 

from  papilloma    . . 

308 

colic  in     . .          . .        135, 

309 

—  conjunctivitis  due  to 

256 

pelvic  swelling  due  to     . . 

757 

cystitis  secondary  to     . . 

629 

-  corneal  opacity  from 

806 

possibly  the  only  function- 

 cystoscopy   in  (Plate    V, 

-  e  lagophthalmo 

807 

ing  one 

394 

Fig.  D,  p.  308)          626, 

629 

-  neiu-oparalytica 

807 

in  pyelitis            . .         500, 

625 

diagnosis  from  growth  . . 

395 

-  photophobia  in 

574 

due  to  pvonephrosis 

renal  calculus  . .        310, 

626 

Keratomalacia,  age  incidence 

807 

266,  583 

624 

typhoid  fever  . . 

612 

—  associated    with    marasmus 

807 

pyramidal  clots  in  urine 

vesical  tuberculosis 

-  corneal  opacity  in  . . 

807 

in 

307 

312,  516, 

629 

-  foamy    white    patches     on 

pyuria  in. . 

367 

frequent  micturition  in 

306, 

conjunctiva  in     . . 

807 

in  renal  calculus . . 

500 

310,  312,  394,  438,  626, 

629 

-  night  blindness  in  . . 

807 

colic  in  . . 

307 

hD?maturia  in      . .  16,  304 

309 

-  prognosis  in 

807 

tuberculosis     .  .312,  315 

629 

394,  626, 

629 

-  xerosis  of  conjunctiva  in  . . 

807 

sickening  sensation  from 

increase    in    severity    of 

Keratosis  follicularis  ■  ■ 

806 

pressure  on 

280 

symptoms   with    infec- 

 simulated     by     keratosis 

simulated     by     enlarged 

tion  of  pelvis  in 

626 

pilaris    . . 

806 

spleen    . .          . .          726 

729 

infection  of  ureter  in    . . 

310 

mollusoum  contagiosum 

806 

tumour  of  right  suprarenal 

inoculation  of  guinea-pigs 

-  pilaris,  papules  of  . . 

580 

capsule  simulating 

367 

in  diagnosing  . . 

626 

relationship  to  ichthyosis 

530 

from  vesical  tumour 

395 

kidney  enlarged  in  394,  515 

629 

scales  in   . . 

655 

worm-like  clots  in  urine  in 

307 

miliary  form  of  .  .         394, 

626 

simulated     by     keratosis 

-  evidence  of  bleeding  from  . . 

305 

muco-pus  in  urine  with 

306 

follicularis 

806 

-  felt  in  left  iliac  fossa 

735 

pain   in  penis  at  end  of 

Kerion,  tender  scalp  from     . . 

781 

-  floating 

407 

micturition  in. . 

629 

Kernig's  sign  in  meningitis  . . 

350 

confusion    with    Riedel's 

plugs  of  muco-pus  in  urine 

306 

Kidney   abscess  (see  Abscess, 

lobe  of  liver     . . 

405 

polyuria  in 

626 

Eenalj 

-  granular      (see       Granular 

primary    . .          . .          . .  - 

309 

-  affection  from  back-pressure 

Kidneys) 

pyelitis  from 

438 

from  distended  bladder. . 

440 

-  hydatid  cyst  of 

396 

pyonephrosis  due  to 

626 

-  alveolar  sarcoma  of 

395 

simulating   hydroneph- 

 pyuria  in 

-  angiosarcoma 

395 

rosis 

396 

16,  310,  394,  623,  626, 

629 

KIDNEY,  TUBERCULOSIS  OF— LABYRINTH 


927 


Kiditfii,  titbfirculosis  of,  contd. 

Kink  of  tho  nolon  causing  con- 

Knee-jerk, exaggeralrd,  conld. 

renal  pain  in        . .        312, 

626 

stipation  . . 

147 

spastic  paralysis  of  upper 

tiimour  in 

391 

Klebs-Lotller      bacillus      (see 

extremity 

547 

skiairraphy  in 

310 

Bacillus  Diphtheria.') 

paraplegia        . .        494, 

558 

tenderness  in 

694 

Klumpke's  paralysis  . .        553, 

555 

syringomyelia 

554 

of  Icidney  in                394, 

.')15 

Knee,   Baker's  cyst  of 

762 

transverse  myelitis 

74 

in  loin  in 

629 

-  bursa  in  neighbourhood  of 

761 

-  method  of  eliciting  iu  children 

thickened  ureter  in      31--', 

394, 

-  commonest    site    of    inter- 

390, 

397 

626, 

629 

mittent  hydrarthrosis     . . 

387 

-  in  paralysis  from  intra-  and 

felt  per  rectum  in  620 

629 

-  congenital  syphilitic         260, 

386 

extra-medullary      lesions 

546 

vatcinam  in 

629 

-  flexion,  impaired  in  paralysis 

-  ready       disappearance       in 

-  -  tubercle  bacilli  in  urine  in 

of  anterior  crural  nerve . . 

541 

children  who  are  ill 

557 

39t, 

026 

lost  in  sciatic  paralj'sis. . 

542 

-  "  reinforcement "      in     the 

tuberculosis    of    prostate 

in  popliteal  abscess 

702 

eliciting  of 

397 

with     ..          ..        394, 

626 

-  gout  in 

382 

-  in  Tooth's  peroneal  atrophy 

500 

testis  in            . .        394, 

518 

-  ha.'mopl)ilic  arthritis  of 

388 

-  unequal  with  coma . . 

137 

vesiculae  seminales  in  394 

626 

-  hysterical 

166 

in  general  paralysis  of  the 

tuberculous  cystitis  due  to 

629 

-  injury-  to,  vomiting  from  . . 

844 

insane   .'.       '  . . 

398 

urinary  changes  in 

626 

-  ETonococcal  arthritis  of 

376 

hemiplegia           . .        337, 

397 

-  -  urine  normal  in  early  sta'-'es 

310 

-  lichen  planus  affecting 

057 

strong  evidence  of  organic 

very  slight  symptoms  in 

-  locking   of,   from   displaced 

nervous  change 

397 

earliest  stages  of 

626 

cartilage   . . 

.388 

Knee-joint,   locking  of,    from 

.c-rays  in  diagnosis  of    . . 

626 

-  osteo-artliritis  of    . . 

384 

displaced  cartilage 

388 

-  tumour  of  (and  see  Kidney, 

semi-membranosus   bursa 

Knife-grinders,     cirrhosis     of 

Enlargement  of). . 

307 

frequently  disteudad  in 

762 

lung  in 

319 

albuminuria  with       9,  16, 

689 

-  pain  in,  in  hip-joint  disease 

278 

-  lung,  hremoptysis  from 

317 

ascites  in. . 

59 

from  sj-novitis     . . 

486 

Knife-rester  crystals  of  triple 

-  -  bimanual  examination  of 

391 

-  i>ityriasis  rubra  pilaris  of. . 

530 

phosphate  (Fig.  155) 

573 

bulging  of  loin  due  to    . . 

689 

-  pneumococcal  artlu-itis  of . . 

375 

Knock-knee  in  Mongolism    . . 

216 

cystic 

15 

-  psoriasis  of  . .          . .        650, 

657 

-  from  rickets 

212 

cystoscopy  before  opera- 

- seborrhccic  dermatitis  of  . . 

447 

Kocher,     re     eervico-brachial 

tion  in 

395 

-  tuberculous,  Baker's  cyst  in 

plexus 

553 

-  -  diagnosis    from     bladder 

connection  with. . 

762 

-  re  lumbo-sacral  plexus 

543 

tumour 

311 

relative  frequency  of 

385 

Koplik's  spots  in  measles    . . 

203 

fsecal  accumulations  . . 

393 

with  spinal  caries 

564 

Korsakow's  psychosis            25, 

505 

hematoma       due      to 

thigh  atrophy  with 

72 

Krallenhand  ("see  Claw-hand) 

leaking  aneurysm  . . 

692 

Knee-elbow  position  in  diagnos- 

Krallen  der  Zehen  Csee  Claw- 

hepatic  tumour         391, 

392 

ins  abdominal  aneurvsm 

763 

foot)          

120 

gall-bladder  tumours.. 

392 

KNEE-JERK.    ABNORMALI- 

Kraurosis vulva,  age  incidence  of770 

growth  of  colon 

393 

TIES    OF 

390 

confusion  with  leukoplakia 

mesentery  tumours    . . 

394 

-  absent  in  Friedreicli's  ataxv 

vulvitis 

770 

omental  tumour 

394 

131, 

559 

dyspareunia  from 

221 

ovarian  cyst    . . 

392 

in   anterior   crural  nerve 

pain  and  tenderness  from 

770 

tumour 

391 

paralysis 

541 

vulval  swellmg  from 

768 

pancreatic  tumour     . . 

394 

some  cases  of  myelitis  . . 

74 

Kyphosis,  causes  of  . . 

181 

pelvic  tumours           392 

393 

-  -  diabetes    . . 

75 

-  combined  with  lordosis 

183 

perinephric  abscess  391, 

392 

Friedreich's  ataxy 

71 

-  dwarfism  due  to 

214 

splenic  tumours  391,392 

689 

peripheral  neuritis        488, 

562 

-  from  hydatid  disease  of  ver- 

suprarenal  tumour     . . 

690 

-  -  tabes         ..134,  285,  350, 

4G6, 

tebrre 

181 

thickening  round  appen- 

473,  562, 

847 

-  infantilism  with 

215 

dix     

393 

dolorosa 

507 

-  in  Little's  disease    . . 

164 

uterine  tumour 

392 

-  in  acute  poliomvelitis 

559 

-  from  osteo-arthritis 

214 

fixation   in   loin   by  pre- 

- comparison  with   other   re- 

- osteomalacia 

214 

ceding  inflammation 

391 

flexes  needed 

397 

-  with  psoas  abscess. . 

733 

hfematuria  in       9,  16,  305 

689 

-  diminution  of 

398 

-  from  rickets 

214 

due  to  hydronephrosis  . . 

391 

in  anterior  crural  neuralgia 

488 

-  and  scoliosis  associated    181, 

183 

increased  hsematuria  after 

-  disappearance    in    broncho- 

- from  spinal  caries    . . 

214 

movement  in  . . 

305 

pneumonia 

557 

-  in  spondylitis  deformans  . . 

183 

laparotomy    in    diagnosis 

in  simpl?  diarrho'a 

557 

from      suprarenal     tu- 

- exaggerated  in  undue  abdo- 

LABIA,   condyloma    of 

709 

mours   . . 

393 

minal  aortic  pulsation  . . 

592 

-  herpes  of 

830 

in  movable  kidney 

500 

amj'otrophic  lateral  sclero- 

- majora,  epithelioma  of     . . 

423 

due    to    new    growth    of 

sis          ....          73 

565 

-  -  leukoplakia  of     . . 

770 

kidney  . . 

391 

birth  palsies 

558 

pain    in,    from  renal  cal- 

 pelvic    swelling    due    to 

causes  of              . .         397, 

398 

culus 

135 

downward  growth  of 

758 

cerebellar      abscess      or 

-  minora,  kraurosis  of 

770 

in  perinephric  abscess  . . 

.500 

tumour 

565 

leukoplalcia  of      . .        221 

770 

physical  signs  of           391 

,689 

compression  paraplegia 

786 

-  myxoma  of .  . 

805 

due  to  pyoneplu-osis 

391 

in   ciisseminated  sclerosis 

-  a?dem.a  of  in  acute  nephritis 

458 

pyuria  in              . .           16 

689 

342,  539 

565 

Labour,  "  after-pains  "of    . . 

509 

due  to  renal  abscess 

391 

functional  paraplegia    . . 

567 

-  ditKcult  (see  Dystocia) 

227 

right,    bile-duct   obstruc- 

 hysteria     . .           44,  342, 

509, 

-  dysmenorrhopa  cured  by  . . 

219 

tion  from 

367 

541,  567 

592 

-  eclampsia  with  and  after  . . 

172 

in  right  lumbar  region. . 

727 

hysterical  paralysis  of  one 

-  inversion  of  uterus  after  . . 

587 

simulation  by  tumour  of 

leg         

541 

-  paralysis   of  anterior  crural 

liver 

392 

due    to    lesion    ot    upper 

nerve  during 

541 

-  -  sudden,  painless,  profuse 

motor  neurone 

397 

-  prolonged,  birth  palsies  due  to 

155 

hsemorrhage  in 

305 

neurasthenia 

787 

-  pysemia  after 

372 

due    to    tuberculosis    of 

neurosis    . . 

44 

-  tenderness  in  the  back  froTn 

789 

kidney 

391 

primary  lateral  sclerosis . . 

567 

-  urinary  fistula  after 

442 

urinary  changes  in 

391 

pyramidal  tract  lesion  .  . 

546 

Labyrinth,    escape    of    liquor 

varicocele  in 

391 

relation  of  ankle-clonus  to 

44 

Cotunnii  from  ear  in  in- 

 sudden  appearance  sug- 

 spastic   paralysis    of    one 

juries  of  . . 

468 

gestive  of     . .          . . 

395 

leg         

539 

-  various  aft'octions  of 

190 

928 


LABYRINTHINE    DEAFNESS— LARYNX 


Labyrinthine    deafnesB,    liow 

Lajjarolomy  in  diagnosing,  conta 

Laryngismus    stridulus,  acute 

indicated 

189 

hydatid  cyst  of  liver     279, 

364 

dyspnoea  in 

466 

liaceration  of  leg;,  talipes  from 

132 

disease " 

720 

carpopedal  spasm  with  . . 

466 

Lachrymal    abscess,    epiphora 

intestinal  obstruction    . . 

267 

convulsions  with .  . 

d66 

from          

250 

-  -  mesenteric  embolism     . . 

432 

cyanosis  in           . .        185, 

466 

-  duct,    epiphora    after  exci- 

 mucocele  . . 

281 

mistaken  for  diphtheria 

466 

sion  of 

250 

retroperitoneal  cysts 

725 

orthopnosa  in        . .       465, 

466 

-  obstruction  causing  epipliora 

250 

Kiedel's  lobe 

279 

paroxysmal  laryngeal  ob- 

 syringing  in  diagnosis  of 

2.^0 

splenic  haemorrhage 

700 

struction  in 

466 

-  t'lnnds,     enlargement     in 

strangulated  spleen 

700 

in  rickety  children        170 

466 

chloroma 

599 

subphrenic  abscess 

501 

Laryngitis,  acute,    association 

in  lymphatic  leukfeniia 

31 

suprarenal  tumour 

690 

with  acute  pharyngitis  . . 

673 

-  nerve,  skin  distribution  of 

659 

tuberculous  crecum 

736 

blood  streaks  in  sputum 

-  secretion,     arrest     of     in 

liver 

414 

of           

176 

paralysis  of  fifth  Berve  . . 

807 

-  distinguishing  kidney,  supra- 

 due  to  diphtheria 

67,^ 

Lachrymation  from  conjuncti- 

renal, and  splenic  enlarge- 

 dysphagia  from  . .         225 

226 

vitis 

255 

ment 

726 

oedematous,  from  staphy- 

- corneal  ulceration  . . 

.S06 

renal  and  suprarenal  tu- 

lococcus 

70!) 

-  date  of  first 

250 

mours   . . 

303 

rapid  oedema  of  larynx  in 

-  in  influenza . . 

505 

-  haimatemesis  after . .         294, 

304 

673 

709 

-  iritis . . 

255 

-  infective  peritonitis  from 

644 

sore  throat  in 

673 

-  major  trigeminal  neuralgia 

495 

-  scar,    peristalsis    visible    in 

suffocative,   bacteriology 

185 

-  running  at  nose  from 

203 

ventral  herniation  of     . . 

570 

rapid  cyanosis  from    . . 

185 

Lacrosse,  cramp  during 

177 

-  urgent,  in  acute  abdominal 

tracheotomy  in    . . 

673 

Lactation,  acute  mastitis  in.. 

743 

conditions             .  .        485, 

846 

-  bacteriological   diagnosis  of 

-  amenorrhcpa  due  to 

23 

-  visible      intestinal      peristalsis 

natureof  185,226,  465,  670 

673 

-  anaimia  due  to  prolonged . . 

40 

an  indication  for 

571 

-  in  congenital  syphilis 

44G 

-  breast  cliar.ges  in    .  . 

713 

Lardaceous  casts,  renal 

10 

-  diagnosis  of  laryngeal  par- 

- discharge     of     milk     from 

-  disease,    absence    of    ascer- 

alysis from 

537 

nipple  during      . .        201, 

743 

tainable  cause  extremely 

-  dry  cough  in 

175 

-  flushing  in  . . 

268 

rare 

414 

-  haemoptysis  in        . .         318, 

325 

-  mastodynia  in 

479 

-  -  affection  of  intestines  in 

696 

-  hoarseness  in           . .         226 

673 

-  prolonged,  followed  by  tetany 

178 

albuminuria  in.           8,  10, 

197, 

-  laryngeal  obstruction  from 

465 

Lactic  acid  in  gastric  contents 

414, 

696 

-  laryngoscopic  inspection  in 

673 

299,  333,  351,  353,  845, 

846 

anfemia  in            . .           39 

696 

-  in  measles    . . 

226 

in  gastrectasis. . 

845 

anuria  in. .          . .             4r 

,  48 

-  pneumococcal          . .         465 

466 

gastric      carcinoma 

blood-count   in   diagnosis 

-  causing  rough  cough 

175 

351,  353, 

846 

from  leukpemia 

696 

-  streptococcal 

465 

-  therapy  in  indicanuria 

349 

in  bronchiectasis 

696 

-  stridor  due  to 

709 

-  in  vaginal  secretions 

210 

causes  of . .     • 

39 

-  syphilitic 

86 

Lactose,  darkening  vrith  picric 

from  congenital  syphilis 

414 

-  -  bilateral    . .          . .         325 

673 

acid 

290 

diarrhoea  in           197,  414, 

696 

diagnosis  of 

325 

-  distinction  from  glucose  . . 

290 

from  empyema    . . 

696 

from  carcinoma 

67."} 

-  osazone  crystals  from 

290 

facies  in  . . 

39 

tuberculous      . .         226 

673 

-  reduction  of  bismuth  by  . . 

290 

liver,  enlarged,  in         414, 

696 

dysphagia  from  . . 

226 

-  in  urine,  tests  for  . . 

290 

firm  in  . . 

414 

effect    of    mercury    and 

Laennec,  metallic  tinkling    of 

193 

from    long-standing  sup- 

iodide in  diagnosis  of. . 

674 

Laevulose  in  m-ine 

291 

puration           . .         414 

696 

extensive  bilateral  tissue 

Lalling,  defmition  of . . 

688 

syphilis 

414 

destruction  in. . 

325 

-  persistence  of,  indicative  of 

low  specific  gravity  urine 

healing  with  deformity  in 

325 

mental  deficiency 

6S8 

in 

197 

hemoptysis  from            318 

325 

Lamina  cribrosa          461,  462, 

463 

patient  weak,   frail-look- 

 oedema  of  larynx  in 

466 

Landouzy  -  Dejerine's     facio- 

ing,  and  bloodless  in  . . 

696 

sore  throat  from 

670 

scapulo  -  humeral      myo-. 

from  phthisis 

696 

subacute  nature  of 

673 

pathy,  characters  of 

561 

polyuria  in            58?.,  584, 

696 

Wassermann's  reaction  in 

fibrillary     contractions 

renal  changes  in 

696 

325, 

674 

rare  in 

158 

sago  spleen  in 

696 

-  tuberculous,     apical     lung 

muscular  atrophy  in   . . 

70 

severe  chlorotic  ancrmia  in 

696 

signs  in    . . 

325 

Landry's  paralysis,  acute  onset 

562 

in  spinal  caries  . . 

696 

association  with  phthisis 

674 

parapelgia  from..         5G2, 

507 

spleen  enlarged  in        1 97, 

414, 

bilateral  occurrence  of  . . 

673 

plantar  reflexes  in 

81 

692 

696 

how  diagnosed    . . 

226 

Language,  written,  unafiected 

symptoms  of 

39 

diagnosis  from  carcinoma 

673 

by  word  deafness 

684 

-  -  in  tertiary  syphilis       411 

696 

syphilitic  laryngitis   . . 

673 

Tjanngo-like  hair 

84 

tube-casts  in 

10 

dysphagia  from  . . 

226 

Laparotomy,  after  abdominal 

now  uncommon  in  tuber- 

 hfemoptysis  from           318 

325 

injury 

646 

culous  joint  disease    . . 

366 

multiple  shallow  ulcers  on 

-  In  diagnosing  acute  abdom- 

 of  liver,  characters  of    . . 

10 

epiglottis  in     . . 

325 

inal    conditions       90,  342 

780 

of  spleen  . .          .  .10,  414, 

696 

cedema  of  larynx  in 

466 

hfemorrhagic  pancreatitis  646 

Large  intestine,  carcinoma  of 

primary  lung  disease  in  32c 

,674 

pancreatitis     . .         724 

846 

(see  Colon,  Carcinoma  of) 

sore  throat  from 

670 

-  -  carciaoma  of  cxcum 

736 

-  white  kidney  (and  see  Bright's 

stridor  from 

710 

colon 

501 

Disease)    . . 

13 

subacute  nature  of 

673 

gall-bladder 

278 

Laryngeal  afl'ections,  ptyalism 

tubercle  bacilli  in  sputum 

sigmoid  colon  . . 

735 

from    difficulty    in    swal- 

in          ..          ..         325 

674 

chronic  pancreatitis 

364 

lowing  in . . 

591 

tuberculolis  of  tonsil  with 

672 

-  -  cicatrized  bile-ducts 

365 

-  branches    of    vagus,    effect 

Iiaryngoscope  in  diagnosis  of 

colic 

645 

on  cough  . . 

174 

cause  of  ha?moptysis 

325 

encysted  ascites 

73  9 

-  crises  of  tabes          465,  466, 

562 

-  essential     in     diagnosing 

-  -  gall-stones            . .        364 

365 

-  diphtheria  (see  Diphtheria, 

laryngeal  ulceration 

226 

gastric  carcinoma  352,  713 

,848 

Laryngeal) 

-  inspection  by  in  laryngitis 

673 

general  peritonitis         645 

713 

-  obstruction     (see    Larynx, 

-  in  laryngeal  paralysis       537 

539 

gumma  of  liver  . . 

279 

Obstruction  of) 

Larynx,  affected  early  in  my- 

 hepatic  abscess  . . 

279 

LARYNGEAL     PARALYSIS 

asthenia  gravis    . . 

225 

growth 

279 

(see  Paralysis,  Laryngeal) 

-  affections  of,  vertigo  due  to 

828 

LARYNX— LEUCOCYTE    COUXT 


929 


Larynx,  conld. 

Lateral  sclerosis,  cotild. 

Let/,  conld. 

-  angioma  of,  haemoptysis  from 

-  -  primary       

565 

-  siiasticity  of  (see  Paraplegia) 

318, 

325 

ankle-clonus  in 

567 

-  tremor  of,  in  disseminated 

-  carcinoma  of  (see  Carcinoma 

bladder      and      rectal 

sclerosis    . . 

800 

of  Larj'nx) 

troubles  iu  . . 

567 

in  Graves'  disease 

797 

-  cyanosis  in  syphilitic  ulcera- 

 conditions  simulating 

565 

-  ulceration  (see  Ulceration  of 

tion  of 

185 

contractures  in          162, 

164 

Leg) 

-  decubital  ulceration  of 

226 

extensor  plantar  reflex  in 

567 

-  AVerdnig-Hoffmann  paralysis 

-  deficiency  of  deep  tenderness 

incontinence  of  fePces  in 

567 

of  . .          

1.58 

in  locomotor  ataxy 

562 

knee-ierks  increased  in 

567 

Le^al's  test  for  acetonuria    . . 

4 

-  epithelioma  of  (see  Carcinoma 

loss  of   abdominal   re- 

Leishman-Donovan bodies  in 

of  Larynx) 

flexes  in   (Fig.    146) 

567 

kala-azar  (Plate  XII,  Fig.  H 

-  fibroma  of,  stridor  from     . . 

710 

paraplegia  from         561, 

565 

p.  696)     .  .          . .           34, 

'693 

-  foreign  body  in  (see  Foreign 

retention  of  urine  in  . . 

567 

Leishman's  stain                 29,  33,  34 

Body  in  Larynx) 

shuffling  gait  ua 

278 

Lemon-yellow  colour  of   skin 

-  gangrene  of  lung  after  opera- 

 spastic  paresis  of 

567 

in  pernicious  anaemia   610, 

849 

tion  on 

288 

sjrphilitic  origin  of 

567 

Lemonade,  artificial,  transient 

-  injury,  h.Tmoptysis  in     318, 

325 

-  sinus,  erosion  from  chronic 

polyuria  caused  by 

581 

cedema  of  larynx  from  . . 

466 

tympanic  suppuration   . . 

468 

Lens,  coloboma  of 

462 

-  irritable,  couc;h  with 

175 

thrombosis  (see  Tlirombosis) 

-  dislocation  of,  irregularity  of 

suggested    by    cough    on 

-  spinal  curvature  (see  Scoliosis) 

pupil   from 

594 

getting  into  bed 

176 

Lateropulsion      in      paralysis 

monocular  diplopia  in  . . 

198 

-  leprosy  ulceration  of 

226 

agitans 

796 

signs  of     . . 

198 

hfpmoptysis  in     . . 

318 

Latissimus   dorsi,   atrophy   of 

560 

Lentigo  (see  Freckles) 

-  lupus  of 

226 

nerve  supply  of  . . 

550 

Leontiasis  ossea          . .         749 

753 

cyanosis  from     . . 

185 

spinal  nerve  roots  supplying 

556 

Lepidophs^ton  in  tinea  imbri- 

haemoptysis  in     ..        318, 

325 

Laughter,  explosive  bursts  of, 

cata 

276 

oedema  of  larynx  in 

466 

in  double  hemiplegia     . . 

258 

Leprosy,  anaesthesia  in   75,  4.50 

575 

-  up-and-down    movement  in 

-  hiccough  from 

342 

diagnostic  importance  of 

424 

diagnosis  of  site  of  respira- 

- in  paralysis  agitans 

262 

due  to  pressure  of  infiltra- 

tory distress 

467 

Lavage  of  stomach,  diagnostic 

tion  on  peripheral  nerves 

424 

in  laryngeal  obstnic- 

352,  353,  354 

355 

-  bullaj  in 

6.54 

tion     185,  186,  465 

642 

indications  for  in  cases  of 

-  cachexia  from 

575 

-  new   growths   of,    mistaken 

coma     . . 

137 

-  diagnosis  of  erythema  nodo- 

for asthma 

582 

Law-suit,    influence   on   neur- 

sum from 

450 

-  obstruction      of,      broncho- 

asthenia   . . 

788 

from  erythema  simplex . . 

424 

pneumonia  associated  with  186 

Lead  miners,  ankylostomiasis 

leucodermia 

575 

causes  of  . .          .  .185,  465 

709 

in  . . 

570 

syphilis     . .          . .           75 

450 

in  children 

185 

-  poisoning  (see  Plumbism) 

syringomyelia      . .           75 

424 

from  crises  of  tabes 

465 

Lecithin,  deriv.-ition  of  urinary 

tinea  versicolor   . . 

276 

cyanosis  from     . . 

184 

phosphorus  from 

571 

-  erythema    on    face,    limbs. 

diagnosLs  of 

465 

Leech-bite,  purpura  from     596 

597 

and  trunk  in 

424 

from  diphtheria..         642, 

709 

Leg,    atrophic   palsy   of    one. 

-  exacerbation   of   symptoms 

extreme  dyspnosa  from . . 

642 

from  acute  poliomyelitis  128,544 

with  each  crop  of  macules 

424 

from  foreign  body        465, 

642 

-  in  Ba/in's  disease    . . 

4.51 

-  gangrene  in              . .         282 

285 

-  -  head  retracted  in          641 

642 

-  analgesia,  in  tabes  dorsahs 

C65 

-  hyperaesthesia  of  nodules  in 

450 

orthopnoea  in 

465 

-  athetosis  of . .          . .         154 

536 

-  of  larynx 

226 

paroxysmal,      in     laryn- 

- causes  of  oedema  of  one     . . 

455 

hsmoptysis  in               318, 

325 

gismus  stridulus 

466 

-  compound       fracture       of. 

-  lepra  bacillus  in  lesions  of. . 

425 

from  pneumococcal  laryn- 

talipes from 

132 

in  nasal  discharge  in . . 

425 

gitis       . .          . .         465 

466 

-  drawing    up     of    right    in 

-  lupus  simulating     . . 

450 

-  -  retropharyngeal  abscess  64l 

,710 

appendicitis 

736 

-  lymph,  glands  enlarged  in . . 

424 

simulating  meningitis    : . 

642 

infants   . .          . .        136, 

357 

-  macular        . .          . .         424, 

450 

from  streptococcal  laryn- 

 in    intussusception     . . 

92 

absence  of  sweating  in  . . 

424 

gitis       

465 

-  erythem.a  of,  from  excessive 

-  mucous  membrane  affected  in 

4-50 

stridor  in               185,  465, 

642 

standing   . . 

450 

-  nerve  trunks  thickened  in_. . 

424 

sucking     in     above     and 

induratum  of 

450 

-  neuritis  in  (Fig.  144,  p.  551) 

belov,"  clavicles  in      465, 

642 

nodosum  affecting 

450 

75 

551 

intercostal  spaces      465 

642 

papulatum.  of 

531 

-  nodules  of  (Fig.  124,  p.  450) 

up-and-down   movements 

-  hysterical  paralysis  of 

541 

75, 

450 

of  larynx  in     .  .         465, 

624 

-  lupus  vulgaris  of     . . 

812 

-  pain  in  joints  in 

450 

-  oedema    of   (see  QEdema  of 

-  method  of  mejisuring  length  of  180 

-  perforating    ulcer     of    foot 

Larynx^ 

-  multiple  benign  sarcoid   of 

451 

from 

809 

-  pain   in,  causing  dysphagia 

225 

-  muscles,     atrophy     of,     in 

-  rosacea  simulating 

450 

-  paresis  of,  due  to  syphilis  . . 

640 

mycetoma 

810 

-  scabs  in 

654 

-  post-diphtheritic  ulceration, 

sciatica  . . 

487 

-  scarring  in  . .          . .        450, 

654 

hfemophysis  in              318, 

325 

innervation  of  (Fig.  143) 

541 

-  skin  pigmentation  in 

575 

-  progressive  weakness  of,  in 

-  niggling  pain  in,  from  tabes 

-  sore  fingers  from     . . 

266 

bulbar  paralysis  . . 

224 

dorsalis     . . 

489 

—  sycosis   simulating. . 

450 

-  sarcoma  of,  hremoptysis  in 

-  cedema  of  (see  Oedema  of  Legs) 

-  telangiectases    simulating. . 

450 

318, 

325 

-  in  osteitis  deformans 

383 

-  three  types  of 

450 

-  stridor  from  obstruction  of 

709 

-  peroneal  atrophy     . . 

128 

-  ulceration  in             . .        450, 

654 

-  syphilitic    (see    Laryngitis, 

-  predilection  of  psori^'.sis  for 

447 

of  larynx  in 

185 

Syiahilitic) 

-  sensation  impaired  in  trans- 

 nose,  epistaxis  in 

250 

potassium    iodide  in  dia- 

verse mvelitis 

564 

Leucin,  absent  from   urine   in 

gnosing              . .        226, 

674 

LEG,    PARALYSIS   OF    ONE 

phosphorus  poisoning     . . 

373 

-  tuberculous  (see  Laryngitis, 

(and  see  Paral.vsis) 

539 

-  and  tvrosin  in  urine  in  acute 

Tuberculous) 

-  intermittent  claudication  in 

489 

yellow  atrophy     302,  370, 

843 

-  tvphoid  ulceration  of      226, 

318, 

-  paresis  of,  in  diabetes 

75 

Leucocyte  count,  differential 

28 

325, 

466 

-  pruritus  of  . . 

588 

in  bullous  dermatoses 

114 

-  ulcers  of  (see  ricersof  Larynx 

; 

-  in  pseudo-hypertrophic  para- 

 malaria              402,  583, 

615 

Lateral  sclerosis,  amyotrophic 

lysis 

560 

splenomedullary  leukae- 

(see Amyotrophic  Lateral 

-  pseudo-oedema  of,  in  myx- 

mia    . . 

693 

Sclerosis,) 

oedema 

585 

typhoid             . .        402, 

615 

59 


930 


LEUCOCYTES— LIGHTNING    PAINS 


Leucocytes,  abnormal  varieties  of  29 

Leukaemia,  contd. 

Levator  ani  muscles,  contd. 

-  in    blood,    variations    with 

-  epistaxis  in             . .        251 

302 

function  in  defaecation 

148 

digestion  and  time  of  day 

399 

-  hasmaturia  in          . .         305 

314 

injuries  of,  causing  pro- 

- excess  of,  in  urine  in  bacteri- 

-  haemoptysis  in 

318 

lapse  of  uterus 

586 

uria           . .          . .            83,  84 

-  hfemorrhage    from    mucous 

painful  spasm  of 

221 

-  normal  varieties  (Plate  IT) 

28 

membranes  in     . . 

649 

-  palpebrce,  congenital  absence 

Leucocythfemia  (see  Leukaemia) 

-  heavy  sweats  in 

649 

or  ill-development  of     . . 

590 

Leucooytic  renal  tube  casts. . 

7 

-  hyperplasia  of  marrow  in 

776 

paralysis  of,  causing  ptosis 

589 

LEUCOCYTOSIS 

399 

-  irritability  in 

31 

spasm  of,  in  exophthalmic 

-  absence  of  in  malaria      371 

583 

-  jaundice  in  . . 

362 

goitre    . . 

253 

-  in  acute  general  peritonitis 

472 

-  infarction  of  lung  in 

321 

Leyden's  myopathy,  fibrillary 

cellulitis    . . 

455 

-  leucocytosis  in          64,  302, 

contractions  rare  in 

158 

r-  after  severe  loss  of  blood  . . 

400 

399,  599,  617,  620, 

693 

Lice,  pruritus  caused  by 

588 

-  definition  of 

399 

-  lymphatic,  albumosuria  in 

20 

Lichen      annularis     affecting 

-  with  empyema  of  gall-bladder 

280 

anaemia  in 

599 

fingers 

266 

-  with  hepatic  abscess  279,  369 

,408 

ascites 

58 

-  planus  affecting  fingers     . '. 

266 

-  in  Hodgkhi's  disease 

617 

blood  changes  in           31, 

366 

flexor  surfaces 

657 

-  in  leukfemia      64,  302,  366, 

examination  in 

739 

character  of  papule  of  528 

533 

599,   620, 

693 

changes  in  liver  in 

414 

diagnosis     of     pityriasis 

-  new  growth  of  stomach     . . 

691 

enlarged    axillary    glands 

421 

rubra  pilaris  from 

530 

-  with  parasitic  worms 

620 

portal  glands  in 

58 

from  eczema  . . 

832 

-  in  pneumonia          . .          39, 

645 

haemorrhagic 

599 

psoriasis 

657 

-  pregnancy    . . 

399 

liigh  colour  index  in 

32 

syphilides 

533 

-  pyaemia 

649 

jaundice  in 

366 

verruca  plana . . 

530 

-  with  ruptured  tubal  gesta- 

 leucocytosis  in     . .        399, 

693 

intense  itching  in 

832 

tion 

646 

lymphatic  gland  enlarge- 

 involvement  of  lips  in  . . 

403 

-  significance   of,    in   pyrexia 

ment  in          58,  59,  76, 

416, 

macules  in 

424 

without  obvious  cause  . . 

620 

419,   421,  599,  617, 

693 

papules  in           . .         657 

832 

-  in  septic  arthritis    . . 

375 

lymphocytosis  in  cerebro- 

 pityriasis  rubra  after 

658 

-  slight    in    fungating    endo- 

spinal fluid  in  . . 

339 

predilection     for     flexor 

carditis     . . 

39 

lymphocytes  in    . .        302 

693 

surfaces 

657 

-  in  subperiosteal  abscess     . . 

750 

myelocytes  in 

32 

pruritus  in 

588 

-  subphrenic  abscess,   501,  720 

721 

pleuritic  efEusion  in 

122 

simulated    by   xanthoma 

-  due  to  suppuration . .        614, 

620 

purpura  in          . .         596, 

599 

diabeticorum  . . 

805 

-  in  suppurative  peritonitis. . 

645 

-  -  relation  of  chloroma  to . . 

44 

umbilication  of  papules  in 

530 

-  trichinosis    . . 

.504 

spleen   scarcely    enlarged 

vesicles  in 

832 

-  typhus  fever 

371 

in  some  cases  . . 

693 

wheals  in  . . 

832 

Leucodermia,      diagnosis     of 

enlarged  in   59,  599,  692 

693 

-  ruber  planus,  character  of 

chloasma  from    . . 

57-'^ 

-  metrorrhagia  due  to          433, 

435 

papules  in     528,  529,  533 

658 

lineae  albicantes  fromi 

402 

-  mixed           . .          . .          32, 

693 

diagnosis    from    papu- 

 from   scbrodermia,    mor- 

-  myelocytes  in          . .            3: 

,  32 

lar  eczema    . . 

529 

phoea,  macular  leprosy, 

-  nerve  deafness  in    . . 

191 

syphilides. . 

533 

syphilides,   and  partial 

-  noises  in  the  ears  from 

794 

staining  of  skin  after 

529 

albinism 

575 

-  oedema  of  legs  from         459, 

461 

-  scrofulosoriim,    absence    of 

-  macular 

423, 

-  pericarditis  in 

122 

itching  in 

529 

-  pigmentation  of  the  skin  in 

424 

-  peripheral  neuritis  in 

76 

character  of  papule  of  528 

,529 

Leuconycliia     .  . 

445 

-  pleuritic  efEusion  in 

122 

distinction   from   miliary 

LEUCOPENIA 

401 

-  priapism  in  . . 

586 

papular  syphilides 

530 

-  in  malaria   . .           303,  369, 

698 

-  punctate  basophilia  in 

30 

papular  eczema 

529 

-  pernicious  anemia  . . 

30 

-  pyrexia  in  32,  609,  617,  620 

649 

xerodermia 

530 

-  splenic  ansemia 

411 

-  rigors  in       . .          . .        648, 

649 

long  duration  of 

529 

-  typhoid  fever             90,  372, 

697 

-  serous  inflammations  in     32, 

122 

pustules  in 

529 

Leucoplakia,  age   incidence  of 

770 

-  shortness  of  breath  in 

100 

relation     to     sebaceous 

-  oiiithelioma     arising     from 

-  skodaic  resonance  due  to  . . 

667 

glands  . . 

529 

(Plate  XV,  p.  814)  770,  813 

814 

-  splenomedullary,  absence  of 

scales  in   . . 

529 

-  syphilis  causing      . .         257, 

813 

glandular  enlargement  in 

64 

tendency  to  recurrence  of 

529 

-  o£  vulva        . .          . .        768, 

770 

albumosuria  in    . .            17 

,  20 

-  urticatus,  pruritus  in 

588 

-  -  a  cause  of  dyspareunia  . . 

221 

ascites  in 

64 

Lichenization,  pruritus  in     . . 

588 

intense  itching  from 

770 

blood  changes  in       31,  76, 

693 

-  of  skin  in  prurigo  . . 

531 

Leucorrhcea    (see    Discharge, 

diagnosis  from  new  growth 

Lientery 

197 

Vaginal) 

of  stomach 

691 

Life    assurance,    accentuation 

Leukaemia,     acute,     without 

differential  leucocyte  count 

693 

of  lieart  sound  and 

3 

enlarged  spleen  or  gland 

617 

eosinophilia  in    .  .         248, 

249 

albuminuria  in  relation  to 

19 

-  albuminuria  in        . .           10 

,  17 

leucocytosis  in                64, 

693 

importance    of   not   mis- 

- albumosuria  m 

21 

-  -  myelocytes  in    29,  64,  302, 

693 

taking     reduction     by 

-  amenorrhoea  in 

23 

pleuritic  effusion  in 

122 

uric  acid  for  glycosuria 

818 

-  aiuemia  severe  in     459,  599, 

649 

purpura  in 

596 

polyuria  caused  by  exam- 

- ascites  in      . .          . .           64, 

122 

spleen  enlarged  in 

ination  for       . .        581, 

582 

-  basophile  corpuscles  in        3'. 

,  32 

64,  617,  692, 

693 

Lifting  weights,  orchitis  from 

79 

-  bleeding  gums  in    . . 

85 

-  tenderness  in  ribs  in 

776 

Ligature  of  arteries,  gangrene 

-  blood  per  anum  in  . . 

90 

of  the  sternum  in 

776 

from          . .          . .        282, 

287 

-  blood-count     in     diagnosis 

-  thrombotic  infarcts  in 

10 

-  oedema  of  limb  caused  by. . 

457 

from    lardaceous    disease 

696 

of  spleen  in 

700 

Lightning,  gangrene  from     . . 

282 

-  cachexia  in  . . 

114 

-  uric  acid  in  . . 

817 

-  pains  in  childhood.. 

489 

-  Charcot-Leyden  crystals   in 

118 

-  von  Jaksch's  disease  simu- 

 in  face  in  tabes  dorsalis . . 

498 

-  compression  of  the  lung  in 

667 

lating 

42 

-  -  in  tabes    . .         350,  489, 

498, 

-  duration  of  . . 

31 

-  wasting  in   .  . 

649 

507,  562, 

664 

-  enlarged  portal  glands  In  .. 

362 

-  .T-rays  in,  effect  of  . . 

31 

all  degrees  of  severity  in 

489 

lachrymal  glands  in 

31 

Levaditi's  method,use  for  spiro- 

bilateral  character  of 

489 

-  -  liver  in      . .          . .          76, 

414 

chaeta  pallida 

769 

fleeting  nature  of 

489 

lymphatic  glands  in       31, 

362 

Levator  anguli  scapulae,  nerve 

frequently     the     first 

.salivary  glands  in 

31 

supply  of  . . 

550 

symptom 

489 

spleen  in    31,  59,  64,  76, 

302, 

-  ani  muscles,  constipation  due 

induced     by     changes 

314,  599,  617,  667,  692, 

693 

to  weakness  of     . . 

149 

in  the  weather 

489 

LIGHTNING    PAINS— LIVER,    CONGESTION    OF 


031 


Lirjldning  pains  in  tabes,  contd. 

irregular  periodicity  in  489 

points    to    be    investi- 
gated in  diagnosis  of  489 
Limbs,  choreiform  movements 

oi  in  spinocerebellar  ataxy  799 

-  inequality  of  lower,  scoliosis 

due  to 180 

-  motor  tics  affecting           . .  160 

-  muscular  twitchings  of,  in. 

petit  mal 160 

-  pain  in  (see  Pain  in  Limbs; 

-  papular  syphilides  of         . .  532 

-  pityriasis  rosea  of  . .          . .  858 

-  post-diphtheritic  paralysis  of  640 

-  prurigo  ferox  of      . .          . .  531 

-  seborrhoea  of           . .          . .  656 

-  tremor  of,  in  paralysis  agitans  796 
Limping  gait  in  iliac  abscess. .  739 

-  (see  Gait,  Abnormalities  of) 
Linea  alba,  hernioe  along     485,  716 
LINE/E  ALBICANTES          ..  402 

on  abdomen         . .          . .  402 

breasts 402 

caused  by  ascites           . .  50 

diagnosis  from  leucodermia  402 

morphoea          . .          . .  402 

on  shoulders        . .          . .  402 

thigh         402 

-  atrophicae     . .          . .          . .  402 

Lingual  nerve   paralysis,   loss 

of  taste  due  to    . .          . .  774 

Lipoma    of     abdominal    wall  716 

-  of  axilla        .  .          .  .          .  .  732 

-  breast            . .          . .          . .  744 

-  distinction     from     fibroma 

moUusoum            . .          . .  804 
sebaceous  cyst    . .          . .  804 

-  of  face          . .          . .          . .  746 

-  in  femoral  region   . .        733,  734 

-  periosteal      . .          . .          . .  755 

-  popliteal        . .          . .          . .  762 

-  retroperitoneal,      diagnosis 

from  ovarian  cysts         . .  761 
occurrence  even  in  emaci- 
ated persons    . .          . .  717 

pelvic  swelling  due  to   757,  761 

simulating  ascites          ..  717 

-  of  round  ligament  . .          . .  741 

-  simulating  axillary  abscess  731 

-  spermatic  cord        . .          . .  741 

-  vulva             .  .          . .          . .  768 

Lipomatosis,    diffuse,    alcohol- 
ism causing          .  .          . .  455 

congenital  syphilis  causing  455 

no  effect  of  thyroid  treat- 
ment in            . .          . .  455 

-  -  hyperaesthesia  in            . .  455 
obesity  of            . .        453,  455 

-  parts  affected  in      .  .          . .  455 
LIPS.    AFFECTIONS   OF    RED 

PART  OF  ..403 

-  in  acromegaly          .  .          . .  263 

-  alcohoUc  tremor  of            . .  797 

-  angioneurotic  cedema  of  . .  457 

-  ataxy  of       .  .          .  .          .  .  69 

-  biting,    cheilitis   exfoliativa 

from  inveterate  . .          . .  403 

-  burning     and     itcliing     in 

Fordyce's  disease           . .  403 

-  capillary  pulsation  in        . .  233 

-  chancre  of  (Fig.  10)           86,  4C3 

-  ■'  chapping  "of      . .          . .  403 

-  circinate  syphiloderms  of  . .  532 

-  congestion     of,     in    mitral 

regurgitation       . .          . .  238 

-  constant  licking  in  perleche  403 

-  in  cretinism. .          . .          . .  258 

-  eczema  of    . .          . .          . .  403 

-  epithelioma  of   204,  403,  419,  420 
origin  as  abrasion,  crack 

or  pimple         . .          . .  403 

-  eschars    on,   in    irritant   or 

corrosive  poisoning        . .  674 


Lips,  conld. 

-  exfoliation  of  vermilion  of     403 

-  fissure  of,  from  eczema      . .     653 
in  ilongolian  idiocy       . .     263 

-  milium-Uko    bodies    on     in 

Fordyce's  disease  . .     403 

-  paresis  of,  in  bulbar  paralysis  641 

-  perleche  of  . .  . .  . .     403 

-  i^rogi-essive  weakness  of  in 

bulbar  paralysis..  ..     224 

-  pouting  in  myopathy  (Fig. 

82)  .  ."  . .  .  .     260 

-  rarely  affected  in  impetigo       830 

-  rhinoscleroma  of     . .  . .     805 

-  scars     radiating     from,     in 

congenital  S3'philis 

-  stiffness  in  Fordyce's  disease 

-  swelling  of,  due  to  mercury 

in  myxoedema     . . 

stomatitis 

-  sypliilitic  ulcer  on.. 

-  tremors  of  in  general  jiaraly- 

sis  of  the  insane  . . 

lead  poisoning     . . 

paralysis  agitans 

-  ulceration  in  yaws . . 

-  unaffected  in  herpes   zoster 

-  skin  diseases  involving 

-  white     and     macerated     in 

perleche    .  . 
Lipuria  (see  Chyluria) 
Liquor  amnii,  deficiency  caus- 
ing dystocia 

-  Cotunnii  from    ear,    escape 

in  labyrinthine  injuries.. 
similarity     to     cerebro- 
spinal fluid 

-  epispasticus  used  by  malin- 

gerers 

-  potassae,  psorosperms  demon- 

strated by 

test  for  pus 

sugar 

urates    . . 

Lithates  (see  Urates) 
Little's  disease 

athetosis  m 

choreiform  movements  in 

clumsy  gait  in    . . 

contracture  in     . . 

defective  speech  in 

diagnosis  of     acquired 

palsies  from    . .        154,  155 

hereditary  causes  of       . .     154 

mental  deficiency  in      . .     154 

optic  atrophy  in. .  .  .     154 

spastic  paralysis  in       . .     154 

tremor  in  . .  . .     154 

Littre's  glands,  infection  of  . .     208 
Liver,  ss  of  the  body  weight 

in  adults 404 

-  jL  to  Jj  of  the  body  weight 

in  children  . .  . .     404 

-  abnormal  lobes  of,  palpable 

in  epigastrium     . .  . .     723 

-  abscess  of  (see  Abscess,  Hepatic) 

-  actinomycosis  of     . .  . .     415 

-  active  congestion  of,  etiology 

and  symptoms  of         371,  407 

-  acute  yellow  atrophy  of     . .     302 
-  absence  of  bile  from 

urine  in  late  stage  of  370 

age  incidence  . .     302 

albumosuria  in        . .       20 

anorexia  in. .  . .     370 

bile  in  urine  in       302,  370 

bleeding  gums  in   . .       85 

coma  in        . .  . .     370 

constipation  in        . .     370 

convulsions  in         . .     370 

delirium  in  . .        302,  370 

diagnosis  from  phos- 
phorus poisoning        373 
yellow  fever       372,  373 


259 
403 

86 
259 

88 
813 

796 
797 
796 
449 
831 
403 

403 


227 

468 

4C8 

111 

803 
623 
290 
815 

800 
154 
154 
154 
164 
154 


Liver,  acute  yellow  atrophy,  contd. 
diminution    of    liver 

dullness  in  302,  370,  404 

urea  and  uric  acid 

in  urine  in 

dry  brown  tongue  in 

302 

epistaxis  in. .         302 

following  fright 

h»matemesis  in 

294,  302^ 

hyperpyrexia  in 

jaundice  in  302,   362,   370 

leucin     and     tyrosin 

m  urme  in  302,  370,  843 

metaena  in  . .         302,  370 

metrorrhagia  in 

nausea  in     . .        302 

nervous  symptoms  in 

onset   like   catarrhal 

jaundice   . .         302,  370 
pain  in  right  hypo- 

ohondrium  in 
pregnancy  associated 

with 

pulse  in 

pyrexia  in    . . 

rapid  course  of 

restlessness  and  head- 
ache in     . . 

sex  incidence  of     302 

toxaemic       biliary 

catarrii  in 

lurinary  changes  in  302,  370 

vomiting  m  302,  370,  843 

-  adenoma  of,   lias  been  con- 

fused with  hydatid 

rarity  of  . . 

undiagnosable  during  life 

-  amoebic  abscess  of  (see  Ab- 

scess, Hepatic) 

-  angioma,  resembling   carci- 

noma 

fifteen  recorded  cases  of 

removal 
relationship  to  abdominal 

wall 
undiagnosable  during  life 

-  carcinoma  of  (see  Carcinoma 

of  Liver) 

-  characters  in  chronic  peri- 

hepatitis  . . 

-  cirrhosis    (see    Cirrhosis    of 

Liver) 

-  confusion,    in   palpation   of 

kidney,   -with  right  lower 
part  of  normal    . . 

-  congestion  of,  general 

lithates  in  urine  in 

sense  of  weight  in  hepatic 

region  in       . .  . .     407 

jaundice  in  . .  . .     362 

with  large  liver  in    363,  407 

pain  in  the  epigastrium  in     486 

-  venous     

in  aortic  disease 

ascites  with     . . 

in  bronchitis    . . 

cardiac  oedema  in 

in   chronic   pulmonary 

disease 

dusky-green  tint  of  skin 

dyspepsia  in    . . 

edge  in  . .        370, 

enlargement  to  level  of 

umbilicus  in 
firm   uniform    enlarge- 
ment in        . .        370, 
hepatic  pain  and  tender- 
ness in 

hepatoptosis  in 

icteric  tinge  of  skin  in 

in  mitral  disease        407, 

myocardial  disease     . . 


370 

370 
370 
370 


544 


370 
370 
370 


370 

302 
370 
370 
370 

370 
370 

370 


414 
414 
414 


414 
414 


404 
414 


412 


405 
371 
407 


407 
407 
407 
407 
407 

407 
370 

407 
407 

407 

407 

407 
407 
370 

764 
407 


93^ 


LIVER,    CONGESTION    OF— LIVER,    SPLENOMEGALIC 


Liver,  cotigeslion  of  venous,  contd. 

pain  in  the  right  hypo- 

chondrium  in          . .  499 

perihepatitis  in           . .  407 

pulsation  of  liver  in  . .  407 

skin    tenderness     over 

liver  in         . .          . .  407 

slight  jaundice  in       . .  407 

smooth  surface  of  liver 

in       . .          . .        370,  407 
in    tricuspid    incompe- 
tence            . .          . .  407 

-  cyst  of,  simulated  by  pan- 

creatic cyst         . .          . .  723 

-  diiEculty  in  estimating  size 

in  conditions  with  much 

ascites       . .          . .          . .  406 

-  diseases,  ascites  in..  53,  59 

causing  jaundice  3G2,  368 

haemoclu-omatosis  in      . .  575 

increase  of  uroarythrin  in 

urine  in            . .          . .  819 

insomnia  in          . .          . .  356 

pain  in  epigastrium  from  779 

right      hypochondrium 

from              . .          . .  779 

side  of  chest  from  . .  779 

shoulder  from          . .  779 

and  tenderness  in  back 

from  (Fig.  204)      788,  789 

pleuritic  effusion  from  . .  123 

ptyalism  in           .  .          .  .  591 

urobilinuria  in      . .          . .  818 

xanthoma  multiplex  with  805 

-  displaced   by  fluid  in  chest 

193,  405 
chest  conditions  simu- 
lating enlargement. .  405 

-  -  downward  by  abscess     . .  720 

in  general  visceroptosis . .  473 

due  to  spinal  curvature.  .  405 

rickety  chest  deformities  405 

right  lobe  of  from  tight 

lacing    . .          . .          . .  405 

right-sided  pneumothorax  405 

upward  by  meteorism  . .  716 

-  deep     furrow     from     tight 

lacing  or  belt      .  .          .  .  405 

-  dropped         . .          . .        148,  473 
LIVER     DULLNESS,     DEFI- 
CIENT         404 

acute  yeUow  atrophy 

302,  "370,  404 

in  emphysema           246,  406 

from  gas   in  peritoneal 

cavity            . .          . .  406 
from  presence  of  intes- 
tine in  front  of  liver  404,  406 

in  hepatoptosis  . .          . .  406 

meteorism         . .          . .  716 

general  peritonitis          . .  644 

diminution  in  tight  lacing  404 

dome-shaped       extension 

upwards      in      tropical 

abscess              . .          . .  409 

hydatid  cyst  . .  415 

extent  of  . .          . .          . .  404 

-  dwarfing  of  one  or  other  lobe 

in  alcoholism       . .          . .  404 
syphilis     .  .          .  .  404 

-  edge  of,  in  chronic  universal 

perihepatitis        . .          . .  412 

cirrhosis    .  .          . .          . .  409 

fatty  degeneration          . .  414 

firm     and     uniform      in 

health 404 

lardaceous  disease           . .  414 

lymphadenoma    . .          . .  414 

rounded  in  fatty  liver  . .  414 

secondary  carcinoma     . .  412 

venous  congestion          . .  407 

-  embryomata   of,   impossibi- 

lity of  diagnosis  durincr  life  413 

-  engorgement  in  pneumonia  372 


300, 
370, 

3V9, 


rectal 


LIVER,   ENLARGED    869,404, 

from  abscess 

active  congestion 

and  ascites,  causes  of      55, 

in  bronzed  diabetes 

from  carcinoma  .  .60,  363, 

in  catarrhal  jaundice 

cirrhosis  60,  301,  363, 

cholangitis 

chronic     bronchitis     and 

emphysema 

heart  failure    . . 

compression  of  lung  by . . 

congenital  syphilis 

congestion  . .        363, 

diagnosis  of  cancer  of  colon 

from 

from  renal  tumour     391, 

in  distoma  hepaticum  in- 
fection . . 

epidemic  jaundice 

extreme  depression  simu- 
lating   . . 

fibroid    lung    and    bron- 
chiectasis from 

free  downward  movement 

with  inspiration  of 

with  gall-stones  . . 

gumma 

hsematemesis  with 

in  Hanot's  cirrhosis 

hepatic  abscess   . . 

Hodgkin's  disease 

in  hydatid  disease 

importance       of 

examination  in 

with  jaundice,  causes  of  363 

lardaceous  disease    10,  39, 

in  leuksemia         . . 

lymphosarcoma  and  lym- 
phadenoma 

in  mitral  regurgitation  238, 

normal  resonance  in  loin 

unimpaired  by 

obstructed  common  bile- 
duct 

obstruction     to     inferior 

vena  cava  by  . . 

of  portal  vein  by 

phosphorus  poisoning  363, 

pseudo-leuksemia 

pylephlebitis 

in  relapsing  fever 

from  secondary  carcinoma 

sharp  edge  in 

simulated     by     omental 

tumour 

tuberculous   peritonitis 

-  -  simulating  renal  tumour 

in  splenomegalic  cirrhosis 

suppurative  pylephlebitis 

swelling  of  chest  wall  from 

from  syphilis        . .  55, 

tricuspid   regm:gitation . . 

tropical  abscess  . . 

tumour    of    right    supra- 
renal capsule  simulating 

varicose  abdominal  veins 

from 

-  fatty  

absence  of  symptoms  due  to 

in  alcoholism 

characters  of 

from  phosphorus   . . 

in  severe  ansemia 

tuberculosis 

uniform    enlargement    of 

in  wasting  diseases 

-  fluke  (see  Distoma) 

-  gas-containing  loculi  in 

-  gumma  of  (see   Gumma  of 

Liver) 

-  hard,  with  definite  beaded 

edge,  in  cirrhosis . . 


407 
363 
371 
366 
411 
368 
365 
368 
369 

246 
61 

324 
370 
370 

367 
392 

364 

372 


324 

391 
363 
615 
295 
410 
651 
303 
415 

367 

,366 

696 

76 

366 

240 

392 
363 


373 
42 
370 
373 
412 
391 

367 
56 
392 
369 
649 
194 
363 
106 
408 

367 

825 
414 
414 
414 
414 
87 
41  "J 
414 
414 
414 

231 


368 


(see 


Liver,  contd. 

-  hard  nodules  on,  in  second- 

ary carcinoma . . 

-  very  hard     . . 

-  hobnail,  with  ascites 

-  hydatid      cysts      of 

Hydatid  Cysts) 

-  injiu'y,  abscess  of  liver  from 

-  lardaceous  (see  Lardaceous 

Disease) 

-  large  and  smooth  in  stenosis 

of  bile-ducts        . .         365, 

-  lateral  mobility  in  hepato- 

ptosis 

-  lobes,  abnormal 

-  lobulation,     when    present, 

due    to   previous  disease, 
not  mal-development 

-  local  enlargement  in  gumma 

of  liver 

-  lower  edge  normally  palpable 

under  right  ribs  on  deep 
inspiration  in  thin  people 

-  lymphadenoma  of,  absence 

of  jaundice  in 

pain  in 

tenderness  in  . . 

diffuse  form  of     . . 

firm  edge  of  liver  in 

nodular  form  of  . . 

undetectable  in  life    . . 

smooth  surface  in 

uniform  enlarged  liver  in 

-  melanotic       sarcoma       of, 

melanuria  due  to 

-  neoplasms  of,  causing  pleu- 

ritic effusion 

-  normal  situation  of 

-  nutmeg  (see  Nutmeg  Liver ; 

and  Liver,  Congestion  of, 
Venous) 

-  pain  in  (see  Pain  in  Liver) 

-  palpation  of  normal 

-  peritonitic  rub  over 

-  primarv  cancer  of  (see  Car- 

cinoma of  Liver,  primary) 
sarcoma  of,  indistinguish- 
able from  carcinoma .  . 

-  pulsatile       61, 1O6,  370,  407, 
diagnosis  from  transmitted 

movement  from   aorta 
hypertrophied  heart 

-  pushed   up    by    abdominal 

tumours    . . 
by  ascites     . . 

-  relatively  larger  in  children 

than  adults 

-  Hiedel's  lobe  of  (see  Riedel's 

Lobe) 

-  rotation    round    horizontal 

axis  in  hepatoptosis 

from    upward    extension 

of  right  renal  tumour . . 

-  rupture  of,  haemoperitoneum 

from 

-  sarcoma  of  (see  Sarcoma  of 

Liver) 

-  secondary    cancer    of 

Carcinoma  of  Liver) 

-  shrunken,  in  cirrhosis 

-  slight    depression     in 

phragmatic  pleurisy 

-  smooth  in  chronic  universal 

perihepatitis 

fatty  degeneration 

Hanot's  cirrhosis 

health 

lardaceous  disease 

and  hard  m  general  con- 
gestion 

-  soft,  in  fatty  degeneration . . 

-  splenomegalic  cirrhosis  (see 

Cirrhosis  of  Liver,  Spleno- 
megalic) 


(see 


dia- 


412 
60 
60 


408 


406 
723 


404 
370 

404 

414 
414 
414 
414 
414 
414 
414 
414 
414 

822 

123 


404 
644 


413 
764 


407 
407 


406 
40G 


406 
393 
717 

60 

405 

412 
414 
410 
404 
414 

407 
414 


LIVER,  STREPTOTRICHOSIS  OF— LUNG 

FIBROSIS  OF 

933 

JAvir,  could. 

Loss  of  consciousness  (see  Coma 

) 

Luii/j,  compression  of,  could. 

-  stroi)totricliosis       of       (see 

-  weight  (see  Weight,  Loss  of) 

by  ascites             . .         324, 

668 

Actinomycosis    o£    Liver) 

Love,  loss  of  weight  due  to  . . 

848 

-  -  big  heart  . .          . .         324, 

667 

-  suppuration,    subphrenic 

Lower  extremity,  pain  in  (see 

carcinoma  of  the  liver    . . 

667 

abscess  from 

720 

Pain   in   the   Lower   Ex- 

 empyema 

324 

-  swelling  of,  rectus  abdominis 

tremity)    

487 

flbroid  lung  and  bronchiec- 

muscle mistaken  for 

723 

-  jaw  (see  Jaw) 

tasis  from 

324 

-  s-.vellings  in  situation  of     . . 

722 

-  limb,  tables  of  innervation 

greatly  enlarged  spleen  324 

667 

-  syphilis  of  (see   Syphilis   of 

of  muscles  of       . .        542, 

543 

gumma  of  liver    . . 

667 

Liver^ 

Ludwig's   angina,    oedema    of 

hepatic  abscess    . . 

667 

-  tender  (see  Tenderness  over 

face  or  neck  in    . . 

459 

hydatid  cyst  of  the  liver 

667 

J.iver) 

lityalism  due  to  . . 

590 

liver  tumour 

324 

-  tenderness  in  the  chest  from 

Lumbago,  always  bilateral   . . 

476 

by  mediastinal  new  growth 

667 

affections  of 

77G 

-  association  with  sciatica  .  . 

487 

pericardial  effusion        324, 

667 

-  tonsue-like     projection     of 

-  diagnosis  from  pelvic  disease 

477 

-  -  pleural  effusion      324,  331 

667 

right  lobe  of 

40-1 

t\imours    . . 

47G 

skodaic  resonance  in 

332 

-  transposition  of 

404 

-  exclusion   of   abdominal  or 

in    splenomeduUary    leu- 

-  tropical   (see   Liver,    Acute 

pelvic    growths    in    dia- 

kasmia  . . 

667 

Congestion  of) 

gnosis  of  . . 

476 

by  subphrenic  abscess  324 

667 

-  tropical     abscess     of     (see 

nervous  disease  in 

47G 

thick  pneumonic  lympli 

324 

Abscess,  Hepatic) 

organic  disease  in 

476 

tubular  breathing  in      . . 

332 

-  tuberculous,    undiaguosable 

-  from  myalgia  of  the  back  . . 

507 

-  destruction  of,  elastic  fibres 

clinicall.y  . . 

414 

-  pain  in  the  back  in . . 

476 

in  sputum  as  evidence  of 

701 

-  tumour  of   (see   Liver,  En- 

- simulated     by     spondylitis 

-  disease,  albuminuria  in     . . 

18 

larged) 

deformans 

787 

ascites  in  . . 

61 

-  turned-up     edge,     in    peri- 

- tenderness  of  the  spine  in 

785 

causing     enlarged     right 

hepatitis  . . 

60 

Lumbar  cushion 

458 

ventricle           . .        245, 

246 

-  umbilicated  nodules  in 

-  plexus,  muscles  innervated 

pancreatitis 

IIG 

60,  270, 

412 

by 542, 

543 

chronic,    cedema    of    legs 

-  various  tumours  of 

360 

-  puncture    in    cerebrospinal 

from 

461 

-  venous  congestion  of  (see  Liver, 

fever         ..          ..         328, 

598 

epileptiform  convulsions  in 

172 

Congestion  of  Venous) 

diagnosis  of  cause  of  pro- 

 haematemesis  in   . . 

294 

-  wandering  (see  Hepatoptosis) 

longed  pyrexia 

609 

heart  failure  from 

461 

Lividity,  extreme  (see  Cyanosis) 

cerebral  conditions. . 

558 

insomnia  in         . .        356, 

359 

Lobar  'pneumonia  (see  I'neu- 

meningitis 

orthopnoea  in 

359 

monia) 

328,  464,  563 

,643 

pain  in  temporal  region 

783 

Lobelia  in  diagnosis  of  asthma 

582 

radicular  pain  in  arm 

494 

tenderness  in  chest  from 

77G 

Locking  of  joint  in  osteo-ar- 

diagnostic    characters    of 

epigastrium  froni 

783 

thritis 

384 

fluid  obtained  from    . . 

338 

-  embolic  infarct,  sudden  pain. 

from  displaced  cartilage 

888 

in    general    paralysis    of 

dyspnoea,    cyanosis,     and 

Lockjaw  in  hysteria  . . 

464 

the  insane 

269 

haemoptysis  in    . . 

320 

-  tetanus         . .           162,  463, 

652 

post-basal  meninaitis     .  . 

328 

-  emphysema  of  (see  Emphy- 

- (see  Trismus) 

-  reQJon.  definition  of 

722 

sema) 

Locomotor    ataxy  (see  Tabes 

left,  organs  normally  con- 

- endothelioma   of,   gangrene 

Dorsalis) 

tained  in 

722 

of  hand  from 

287 

Loin,  aching  in  (see  Aching  in 

spleen  bulging . . 

688 

-  fibrosis  of,  albuminuria   in 

18 

Lom  ;   and  Pain  in  Loin) 

various  tumours  felt  in 

729 

alterations  of  resonance  in 

332 

-  colicky  pains  in,  from  faecal 

right,          intussvisception 

apparent  enlargement  of 

accumulations     . . 

393 

causing  tumour  in 

727 

liver    from    depression 

-  draggmg    sensation    in,    in 

organs    normally    con- 

due to  . . 

405 

hydrocele 

522 

tained  in 

722 

ascites  in . . 

61 

-  filling  out  of,  by  cystic  renal 

various     inflammatory 

breathing  abnormalities  in 

246 

tumour     .  .          . .          393 

G89 

swellings  in.  . 

727 

—  with  bronchiectasis,  abun- 

- -  in  perinephric  abscess    . . 

391 

tumours  felt  in      726, 

727 

dant  expectoration  in 

246 

by    renal    or    suprarenal 

visible  peristalsis  in  . . 

727 

causes  of 

324 

tumour 

729 

-  vertebrae,  carcinoma  of,  pain 

clubbing  of  fingers  in. . 

324 

-  injury,  perinephric  effusion 

in  the  testicle  in . . 

524 

diagnosis  of     . . 

324 

of  blood  after     .  . 

392 

Lumbo-sacral      plexus       and 

fcetid  sputum  in 

246 

-  pain  in  (see  Pain  in  Loin) 

branches,    diagram   illus- 

 physical  signs  of 

324 

-  swelling     in,     in     ureteric 

trating  (Ficj.  143) 

544 

cavernous     or     amphoric 

calculus    . . 

135 

tumours  affecting,  causing 

breatliing  in     . . 

246 

-  tenderness  (see  Tenderness  in 

paraplegia 

561 

clulabing  of  fingore  in 

Loin) 

Lung,  abscess  of  (see  Abscess 

128,129,  193,246 

324 

-  tumour  due  to  ftecal  accu- 

of Lung) 

congestion  of  liver  in     . . 

370 

mulations.  . 

393 

-  actinomycosis  of     . . 

322 

cough  in  . . 

246 

London,  ringworm  parasites  in 

haemoptysis  in    . . 

317 

cracked-pot  sound    in  . . 

246 

272 

273 

-  acute   cedema   of,   in  acute 

crackling  rales  m 

332 

Long  flexors  of  the  toes,  spinal 

Bright's  disease  . . 

466 

-  -  cyanosis  from 

18G 

nerve  roots  supplying   .  . 

543 

-  anchovy-sauce  sputum  from 

diagnosis  of  phthisis  from 

246 

-  thoracic     nerve,     muscles 

abscess  of  liver  bursting 

dyspnoea  in 

246 

supplied  by 

550 

through    . . 

323 

enlarged    right    ventricle 

spinal     roots     derived 

-  aneurysm  of  aorta  ruptur- 

due to  .  .          .  .         245, 

246 

from.. 

550 

ing  into    . . 

318 

epigastric  pulsation  in  . . 

246 

Loose  body  in  joint,  diagnosis 

-  aspergillosis  of 

322 

from  epithelioma  of  bron- 

from    displacement     of 

haemoptysis  in    .  . 

317 

chus 

324 

semilunar  cartilage 

389 

-  carcinoma  of  (see  Carcinoma 

foul  sputum  in    . . 

246 

in  osteo-arthritis 

389 

of  Lung) 

haemoptysis  in    . . 

2i6 

Lordosis          

183 

-  cirrhosis    (see    Cirrhosis    of 

heart  displaced  with 

-  in  achondroplasia  . . 

212 

Lung  ;  and  Lung,  Fibrosis 

129,  193,  232,  246,  330 

332 

-  congenital     dislocation     of 

of) 

317 

failure  from  61,  186,  464 

525 

hip 

277 

-  collapse,  in  aortic  aneurysm 

482 

hypertropliic  osteo-arthro- 

-  and  kyphosis  combined     . . 

183 

from  bronchial  stenosis 

322 

pathy  in 

390 

-  myopathic,  illustrated 

183 

-  compression       of,       absent 

impairment  of  percussion 

-  secondary  in  rickets 

214 

1           breath  and  voice  sounds  in 

331 

note  in . . 

246 

93  f                              LUNG, 

FIBROSIS    OF— LYMPHANGITIS 

Lung,  fibrosis  oj,  contd. 

Lupus  erythemalous,  contd. 

Lymphadenoma,  conld. 

increased    resonance   and 

diagnosis  from  granulosis 

-  bronchial  obstruction  from 

343 

vocal  fremitus  in 

332 

rubra  nasi 

714 

stenosis  in 

324 

inspissated  mucus  in 

324 

lupus  vulgaris. . 

449 

-  cerebral  haemorrhage  in     . . 

302 

from     mediastinal     nev7 

other  forms  of  erythema 

656 

-  of  cervical  glands,  diagnosis 

growth . .          . .  ^     .. 

121 

psoriasis 

657 

from  tuberculosis 

420 

-  -  orthopnoea  in      . .  --'     . . 

4G4 

ringworm 

65G 

-  characteristic     temperature 

palpitation  in      . .     '    . . 

525 

rosacea 

268 

chart  in  (Fit/.  168) 

017 

passive  congestion  of  liver 

erysipelas  simulated  by 

781 

-  no    characteristic    differen- 

from heart  failure  in  . . 

370 

of  hands  and  face 

656 

tial  leucocyte  count  in  . . 

r,[i5 

periodic  cyanosis  from  . . 

579 

involvement  of  lips  in    . . 

403 

-  chloasma  in. . 

574 

physical  signs  of          193, 

232 

nodules  of 

449 

-  commencement    usually    in 

polycythEemia  in           579, 

580 

scabs  and  scales  in 

656 

glands  of  neck    . . 

41 G 

retraction   of   chest   wall 

scales  with            268,  657, 

711 

-  course  of      . .          . .        303, 

695 

from      . .          . .        193, 

194 

scarring  in      268,  272,  656 

658 

-  deposits  in  abdominal  wall  in 

715 

scoliosis  with       . .        180, 

193 

sex  incidence  of  . . 

781 

-  distinction  between  lympho- 

 shortness  of  breath  with 

579 

simulating  chilblains 

656 

sarcoma    and    Hodgkin's 

shoulder  drawn  down  in 

246 

tenderness   of  scalp  from 

780 

disease      . .         . .        417 

695 

spinal  ciurvature  from  . . 

246 

-  vulgaris,  affection  of  cartilage 

-  enlarged     abdominal    lym- 

 tactUe     vocal     fremitus 

by              

808 

phatic  glands  in. . 

725 

increased  in     . . 

246 

fingers  by 

266 

axUlary   glands    in  (Firj. 

tubular  breath  sounds  in 

332 

age  incidence  of  449,  808, 

812 

119,  p.  417)     . . 

421 

vomiting  with     . . 

844 

apple-jelly  nodules  in 

cervical  glands  in 

421 

-  fluke      (see       Paragonunus 

603,  655 

812 

groin  in 

738 

"Westermani) 

bones  never  eroded  by  . . 

808 

femoral  glands  from    734, 

738 

-  gangrene   of  (see  Gangrene 

in  carias  of  spine 

564 

fibroid  lung  and  bronchi- 

of Lung) 

characters  of 

808 

ectasis  from     . . 

324 

-  growth  of,   progressive  loss 

of    cheek,  ectropion    and 

glands  in          64,  76,  303, 

416, 

of  weight  from   . . 

322 

epiphora  from 

250 

599,  617,  695, 

715 

-  hvdatid  cyst  of  (see  Hydatid 

crusts  with 

448 

liver  and  spleen  in  59,  303 

366 

C^st) 

description  of 

448 

portal  glands  in             58, 

362 

-  infarction  of  (see  Infarction 

diagnosis  from  carcinoma 

808 

-  epistaxis  in  . . 

302 

of  Lung) 

epithelioma 

449 

-  fibroid    lung    and   bronchi- 

- injuries      causing      surgical 

leprosy 

450 

ectasis  from 

324 

emphysema 

231 

lupus  erythematosus  . . 

449 

-  general     lymphatic     gland 

-  mottling  of,  in  phthisis 

120 

multiple  benign  sarcoid 

452 

enlargement  in    . .        416, 

617 

-  new    growth,   blood-stained 

rodent  ulcer     . .         449 

809 

-  hajmatemesis  in      . .        294, 

.302 

pleuritic  effusion  in 

322 

scrofulodermia           449, 

603 

-  haemoptysis  in 

318 

sputum  in    . . 

322 

syphilis 

•808 

-  hsemorrhage    from    mucous 

breaking  down  pneumo- 

 yaws 

449 

membranes  in     . . 

649 

thorax  from 

578 

epithelioma  starting  from 

803 

-  heavy  sweats  in     . . 

649 

bronchial  stenosis  in  . . 

322 

involvement  of  lips  in  . . 

403 

-  and  Hodgkin's  disease,  sy- 

 diagnosis  of     . . 

322 

Koch's  tuberculin  test  in 

812 

nonymous      terms     with 

effects  of 

185 

of    larynx    (see    Larynx, 

most  authors 

417 

gangrene  from 

578 

Lupus  of) 

-  increasing  anaemia  with    . . 

738 

haemoptysis  in           317, 

322 

of  leg 

812 

-  intermittent  pyrexia  in     . . 

738 

heart  displaced   in     . . 

330 

leprous    nodules    simula- 

- jaundice  in  . .          . .        362, 

366 

particles  of  growth  in 

ting       

450 

-  ieucocytosis  in 

617 

pleuritic  effusion  in 

322 

nodules  of 

448 

-  leucopenia  in 

401 

in  sputum  in 

322 

of  nose 

448 

-  liver  changes   in    (and   see 

physical  signs  of 

322 

discharge  due  to 

204 

Liver,  Lymphadenoma  of) 

pleuritic  effusion  in  121 

322 

occasional  implication  of 

303, 

414 

pneumothorax  from  .  . 

578 

glands  in 

449 

-  lymphatic     gland     enlarge- 

 profuse  haemorrhage  in 

322 

penis 

677 

ment  in    . .    58,  362,  416, 

red-currant-jelly-like 

scabs  in    . . 

655 

421,  599,  695,  734, 

738 

sputum  in    .  . 

322 

scarring  from 

448 

-  myelocytes  in          .  .29,  303, 

695 

varicosity    of    thoracic 

tuberculous  ulcer  of  palate 

-  cedema  of  legs  from         459, 

461 

veins  in 

322 

with 

640 

-  paralysis  of  vocal  cord  in . . 

538 

-  obstruction  to   root  of,    by 

ulceration  with  . . 

448 

-  pericarditis  in 

122 

aortic  aneurysm 

322 

of  larynx 

226 

-  peripheral  neuritis  in 

76 

-  passive    congestion     of,    in 

von  Pirqust's  skin  test  in 

812 

-  pleuritic  effusion  in 

122 

mitral  stenosis    . . 

245 

Lymphadenoma      (Hodgkin's 

-  possibly   a    chronic    tuber- 

- rupture  of  aortic  aneurysm 

Disease),  general  (fig.W^)  417 

culosis 

420 

into 

322 

-  absence  of  ansemia  in 

695 

-  prognosis  in. . 

303 

-  secondary  deposits  in  hyper- 

 breaking  down  of  glands. . 

420 

-  purpura  in  . .          . .         596, 

599 

nephroma 

455 

definite  blood  changes  in 

-  pyrexia  in  {Fig.  168,  p.  617) 

-  sporotrichosis  of  (see  Sporo- 

64, 

695 

32,  609,  016, 

649 

trichosis) 

fixation  of  glands  in      416 

420 

-  rigors  in 

649 

-  thrombotic  infarction 

320 

of  leucocTtosis       64,  366, 

599. 

-  severe  anaemia  in       459,  649 

695 

-  wounds      and      contusions, 

617, 

695 

-  spleen  enlarged  in          64,  76 

,  86, 

gangrene  of  lung  from  287 

288 

splenic  enlargement  in . . 

695 

303,416,420,617,692,695 

738 

Lumbricals,  nerve  supply  of 

suppuration  in    . . 

416 

-  thrombotic      infarction      of 

542, 

550 

-  acute 

695 

spleen  in. . 

700 

Lupoid,  miliary   benign,   dia- 

- albuminuria  in 

17 

-  varicose  thoracic  veins  from 

343 

gnosis  of  lupas  and  sar- 

- amenorrhoea  in 

23 

-  wasting  in    . . 

649 

coma  from 

451 

-  anaemia  in      303,  366,  459, 

617, 

Lymphangioma     circumscrip- 

Lupus erythematosus  affecting 

6l9,  695,  715, 

738 

tum 

S33 

fingers 

266 

-  ascites  in..             ..    58,  64, 

122 

age  incidence  of  . . 

833 

sebaceous  ducts 

657 

-  basophile  cells  in  . .         303, 

695 

vesicles  in 

833 

age  incidence  of  . .        449, 

781 

-  bleeding  gums  in  . . 

85 

-  of  the  cord,  diagnosis  from 

atrophy  of  ears  in 

658 

from  mouth  in 

302 

irreducible  hernia 

741 

baldness  from            84,  85, 

781 

-  blood   changes  in  (and  see 

Lymphangitis,  causing  blubber 

course  long  of     . . 

781 

Antemia)  .  .          .  .41,  417, 

695 

lips 

746 

—  diagnosis  from  favus     . . 

272 

examination  negative  in 

617 

-  of  penis 

515 

LYMPHATIC    GLANDS,    ABDOMINAL— MEDIASTINAL 


935 


Lymphatic    glands,    abdominal 

(and  see  Lym|ili;itir  uiunds, 
Portal ;  Lyniphatic  i,'laiKls, 
Betroperitoucal ;  etc.) 

calcified  . .  . .     725 

caseous.  .  . .  .  .      7l!5 

cystic    .  .  .  .  .  .      725 

enlarged,    in     oln-onic 

peritonitis     . .  .  .      725 

Hodgkin's  disease  . .     725 

malignant  disease  .  .     725 

tuberculous     perito- 
nitis ..         G91,  725 

—  axillary,    enlarged    (Fi{f. 

119,  p.  117)  421,  732 

ia  carcinoma  o£  breast 

■121,  743,  745 

chronic  mastitis      . .     74.S 

diagnosis        between 

inflammatory   and 
malignant  421,  743 

in  herpes  zoster     479,  714 

Hodgkin's  disease  59,  417, 

421,  617 

inflammatory  421,  731,  743 

in  leukaBmia  59,  421 

malignant     . .        718,  745 

in  prurigo  ferox      . .     531 

simulating     brachial 

neuritis     . .  . .     492 
tuberculous      . .        421,  744 

—  bronchial,  in  sputum    . .    704 
enlarged,  cyanosis  from     4G6 

- diagnosis  Iroin  aortic 

aneurysm. .  . .     422 

chronic  mediastinitis  422 

mediastinal  growth    422 

dyspnoea  from         . .     466 

in  Hodgkin's  disease     617 

inflammatory,     rarity 

of  bronchial  stenosis 
from  . .  . .     422 

laryngeal      paralysis 

from         . .  . .     422 

in  lymphatism         . .     423 

obstruction  from     . .     422 

stenosis  of  innominate 

vein  from. .  . .     422 

vena  cava  by       . .     422 

.T-rays  in  diagnosis . .     617 

tuberculous,  almost  always 

due  to  infected  milk      427 

caseous,  in  sputum. .     704 

cough  due  to  . .     176 

frequency  of  . .     427 

general     tuberculosis 

from  . .  . .     427 

hemoptysis  from    . .     318 

irritative     hiccough 

due  to       . .  . .     313 
irruption  into  bron- 
chus         . .          . .     406 

marasmus  from       . .     427 

meningitis  from      . .     427 

opening  into  tracliea     709 

- periodic    febrile    at- 

tacks from  . .     343 

stenosis  of  bronchus 

from  .  .  . .      324 

- ar-rays  in  diagnosis  of     617 

caseous  (and  see  under  the 

various  groups  of  glands, 
e.g..  Lymphatic  glands. 
Cervical,  Tuberculous, 
etc.),  anosmia  with     . .       36 

lichen       scrofulosorum 

associated  with       . .     529 
mesenteric,  causing  ob- 
struction     . .  . .     151 

—  cervical 421 

acutely  inflamed   after 

scarlatina     . .  . .     674 

diagnosis     from 

mumps. .  . .     674 


Lymphatic  glands,  cervical,  contd. 

acutely  inflamed,    dys- 
phagia from  . .     674 

sore  throat  from. .      674 

with  sore  throat  and 

pyrexia  sometimes 
the  only  symptoms 
of  scarlet  fever. .     674 

sources  of  infection 

in  ..  ..     674 

stiu:-neck  from    . .     674 

—  -  carcinomatous,  diagnosis 

from  tuberculous     . .     421 

sites  of  primary  growth  420 

vocal   cord   paralysis 

from  . .  . .     538 

enlarged     (Fig.      119, 

p.  417)  13,  417,  420 

age  incidence  of       . .     421 

due  to  carcinoma  of 

oesophagus  .  .      296 

epithelioma  of  ear  419,  468 

German  measles     418,  607 

hospital  sore  throat      419 

length   of   history  in 

diagnosis  of         . .     421 
from  local  septic  ab- 
sorption   . .  . .     420 

in  Ivmphadenoma 

59,421,465,617 

_ tracheal  obstruction 

from      . .  . .     465 

lymphosarcoma       . .     421 

from  malignant  thy- 
roid gland  . .     492 

otitis  media. .  . .     420 

pediculosis  capitis  . .     420 

sarcomatous,  rarity  of   421 

after  scarlet  fever  . .     420 

secondary  growth  in    421 

tuberculous  . .  . .     564 

from     ulceration     of 

the  tongue  . .     815 

in  epithelioma  of  face       449 

fixation  to  deeper  parts     417 

leukaemia  . .  . .       59 

lupus  of  face    . .  . .     449 

malignant         . .         465,  812 

stridor  from  . .     710 

tracheal    obstruction 

from  . .  . .     465 

normal  anatomy  of  731,  732 

obstruction    to    trachea 

by  ..        465,  710 

paralysis  of  vocal  cords 

from 538 

stiff-neck  from  inflam- 
mation of     . .  . .     708 

tuberculous,    general 

account  of    . .         420,  421 

paralysis     of     vocal 

cords  due  to        . .     538 

phthisis  not  related  to  420 

scrofulodermia  with 

449,  529 

tuberculous      lesions 

elsewhere  w  ith     . .     420 
enlarged  in  German  measles  418 

—  epitrochlear,  enlarged  in 

digital  chancre  266,  422 

in  infective  synovitis 

of  finger    . .  . .     422 

rheumatoid  arthritis 

39,379 

femoral,  area  of  drainage  of  738 

diagnosis  from  femoral 

hernia  738,  740,  743 

from     hydrocele     of 

hernial  sac  . .     733 

enlarged  .  .         422,  738 

in  groin  in   . .  . .     738 

prurigo  ferox  . .     531 

inflammatory    . .         . .     734 

—  -  -  hi    lymphadenoma      .  .      734 


Lymphalic  (/lands,  /emoral,  coiitd. 

malignant        . .  . .     734 

position  of       . .  . .     738 

gastric,  enlarged  in  lymph- 
adenoma  . .  . .       55 

palpable  in  epigastrium     75!) 

iliac,  area  of  drainage  of      738 

enlarged,  causes  of      . .     422 

in  malignant  growtli 

of  testis    .  .  . .      202 
S3condary  to  inguinal 

or  femoral  glands       738 
swelling  in  right  iliac 

fossa  from  730,  736 

inflamed,  asymmetrical 

oedema  from  . .     455 

malignant         . .  .  .      735 

palpable  in  left  iliac  fossa  735 

in  malignant  disease      422 

per  rectum    . .  .  .     422 

in  peritonitis    . .  . .     736 

position  of       . .  . .     738 

inguinal,  area  of  drainage     738 

carcinomatous  209,  630,  738 

site  of  primary  growth  423 

enlarged  . .        . .    422 

buboes  from  422,  675 

'  -  from    carcinoma    of 

rectum      . .  .  .      036 

urettoa     . .  . .     209 

from  chancre  .  .      675 

on  scrotum  . .     G81 

constitutional     sym- 
ptoms with  .  .     422 

in     epithelioma      of 

labium  majus      . .     423 

penis         . .         676,  677 

perineum  . .     678 

scrotum    . .        679,  765 

epitheliomatous 

718,  738,  739 

pain  without  signs 

of  inflammation  in  739 

herpes  genitalis       . .     830 

zoster        . .  . .     479 

in  Hodgkin's  disease     017 

inflammatory  675,  676,  738 

from  local  irritation      738 

sepsis  .  .     421,  422 

in  lymphadenoma  . .     738 

lymphatic  leukaemia      739 

melanotic  sarcoma. .     423 

pediculus  pubis       . .     738 

primary  syphilis 

675,  678,  681 

secondary  carcinoma 

423,  769 

in  sypliilis     . .         209,  769 

m-etliral  discharge  . .     422 

lymphadenomatous    . .       59 

position  of       . .  . .     738 

sarcomatous     . .  . .     739 

from  soft  sores  on  penis 

675,  676 

suppurating,         from 

balanitis        .  .  . .     675 

tuberculous      . .  . .     738 

lumbar,   enlarged  in  car- 
cinoma of  rectum       . .     636 

testis         . .         520,  766 

mastoid,     earache     from 

inflammation  of  .  .      230 
mediastinal  (and  see  Lym- 
phatic glands.  Bronchial) 
enlarged          . .        . .    422 
fibroid  lung  and  bron- 
chiectasis from    . .     324 

hiccough  due  to     . .     343 

in  Hodgkin's  disease     617 

lymphadenomatous        334 

obstructing  bronchus     324 

pyrexia  due  to        . .     773 

tachycardia  from  772,  773 

.r-rays  in  diagnosis  of    617 


936 


LYMPHATIC    GLANDS,    MEDIASTINAL— MALARIA 


Lymphatic  glands,  mediastiiml,  contd. 

primary    new     growth 

arising  from  . .     826 
sarcoma  of       . .    •      . .     322 

—  -  -  in  secondary  carcinoma     419 
secondary   deposits    in, 

causing   paralysis   of 
vocal  cord    . .  . .     538 

suppuration  in  . .     417 

tuberculous,     hiccough 

due  to  . .  . .     343 

irritating  vagus  nerve  772 

obscure  ill-health  due 

to 773 

obstruction   to  right 

bronchus  from     . .     773 

—  mesenteric,  enlarged     . .     422 

in  lymphatism         . .     423 

palpable    in    epigas- 
trium        . .  . .     725 

seldom  palpable  . .     422 

tuberculous,    intestinal 

obstruction  from     . .     151 

—  occipital,  enlarged,  in  Ger- 

man measles      417,  418,  410 

Hodgkin's  disease   . .     419 

impetigo  of  the  scalp     419 

leukaemia      ..  .;     419 

pediculosis  capitis  417,  419 

seborrhneio     dermat- 
itis of  scalp  . .     419 

syphilis  417,  419 

tuberculosis  . .     419 

—  pelvic,  enlarged  . .         . .    422 
in       carcinoma       of 

bladder     ..  ..307 

rectum      . .  . .     636 

epithelioma  of  bladder    630 

popliteal,      abscess     from 

suppuration  of  . .     762 

enlarged  . .  . .     702 

from  local  joint  infec- 
tion . .  . .     423 
septic  absorptions      423 

—  portal,  enlarged,  jaundice 

from 362 

leukfemic       .  .58,  362,  366 

lymphadenomatous 

362,  366 

jaundice  in  . .     366 

malignant     . .  . .     362 

pressure     on     portal 

vein  by         58,  692,  696 

tuberculous..  58,  362 

ascites  with         . .       59 

bile-duct  obstruction 

from      . .  . .     366 

jaundice  with       59,  366 

malignant  58,  365,  422 

secondary  to  colon.  .     366 

ovary         . .  . .     367 

pancreas    . .  . .     366 

rectum      . .  . .     366 

stomach    . .  . .     366 

obstruction    of    bile- 
duct  by      .  .        58,  365 

—  pre-auricular,        various 

causes  of  enlargement  of  419 

—  retroperitoneal,  carcinoma 

of,  obstruction  to  inferior 
vena  cava  by  . .  . .     825 

secondary  to  ovary        826 

testis         . .  . .     826 

varicose     abdominal 

veins  from  . .     825 

enlargement  of  . .     422 

sarcoma  of       .  .  .  .     825 

—  submaxillary,      enlarged. 

various  causes  of       419,  420 

from  carious  teeth..     419 

malignant 

419,  420,  749,  812 

pain  in         . .  . .     419 

in  pharyngitis         . .     419 


Lymphatic   glands,     submaxillary, 

enlarged,  contd. 
from   septic    absorp- 
tion from  mouth       419 

suppurating..  ..     419 

-  septicaemia  from. .     614 

leucocytosis  in     . .     400 

in  tonsillitis  419,  708 

-  Supraclavicular,  enlarged     421 
from     abdominal 

growths,  various . .     421 

in  carcinoma  of  colon    091 

mamma    . .        421,  743 

stomach   ..351,  421,  691 

malignant  peritonitis       57 

secondary  growth  in     9, 123, 

223,  278,  351,^421,  691,  803,  812 

-  -  syphilitic       417,  209,  260,  533, 

605,  675,  678,  681,  813 

tuberculous,  matting  of 

417,  420 

in  spinal  caries  . .     564 

LYMPHATIC      GLAND      EN- 
LARGEMENT,   general 

account  of  ,     . .  . .     416 

("and  see  under  Lymphatic 

G-lands,  Abdominal ; 
Lymphatic  Glands,  Ax- 
illary ;  etc.) 

ascites  in  . .  . .       64 

blood  count  to  exclude 

leukaemia  in  . .     419 

in  chloroma      . .  . .     599 

German  measles  . .     253 

Hod?kin's disease  42,59, 

64,  70,  303,  416, 
599,  617,   695,  715,  734 

leprosy  . .  . .  . .     424 

leukaemia        31,  59,  76 

599,  617,  093 

lymphosarcoma  695,  715 

multiple  benign  sarcoid     451 

mycosis  fungoidss       . .     804 

in  prurigo  feros  . .     532 

ringworm  . .  . .     275 

Still's  disease  . .  . .       40 

syphilis  533,  675,  738 

tuberculosis        419,  421,  738 

•  leukaemia    (see    Leukaemia, 
Lympliatic) 

-  obstruction,       abdominal, 

ascites  in. .  . .  . .       58 

asymmetrical  oedema  from  450 

from  cellulitis      . .  . .     455 

elephantiasis  from        450,   810 

Lymphatism 423 

-  deaths    under    ana?sthetics 

due  to 423 

-  doubtful  whether  it  is  really 

a  pathological  state       . .     423 

-  enlarged  lymphatic  glands  in     423 

-  infantile  convulsions  in     . .     170 
Lymphocytes 28 

-  in  cerebrospinal  fluid     139, 

339,  340,  489,  558,   643 

tuberculous   meningitis 

558,  043 

general     paralysis      of 

insane           . .        139,  269 
tabes 489 

-  in  blood,  in  typhoid  fever  402, 097 

-  large    hyaline,    relative    in- 

crease in  malaria  303,  369, 

377,  402,  615,  649,  698 

-  in  Hodgkin's  disease  . .       76 

-  pernicious  anaemia  . .       76 

-  in    leukaemia        32,  59,  366,  693 

-  normal  blood  count  . .       28 
Lymphoma  (see  Lymphadenoma) 
Lymphosarcoma,    absence    of 

leucocytosis  in     . .  . .     695 

pathognomonic       blood 

changes  in        .  .  .  .     417 

-  of  abdominal  wall  . .     715 


Lympliosarcoma,  contd. 

-  affection  of  spleen  slight  in  417 

-  albuminuria  in        . .          . .  17 

-  anaemia  in    . .          . .          . .  715 

-  of  caecum 729 

-  cervical  glands        . .          . .  421 

-  distinction   between   Hodg- 

kin's disease,  lymphaden- 
oma, and. .          . .          . .  695 

-  eosinophilia  in         . .          . .  249 

-  generalized   enlargement  of 

lymphatic  glands  in 

416,  417,  695,  715 

-  jaundice  in  . .          . .          . .  306 

-  rapidly  fatal              . .        417,  695 

-  relation  of  chloroma  to      . .  44 

-  similarity  to  acute  lymph- 

adenoma  . .          . .          . .  417 

MCBUENBY'S  point,  ten- 
derness over,  in  appen- 
dicitis         500 

M'Call      Anderson,     psoriasis 

rupioides  of          . .          . .  654 

Mackenzie,  re  heart  pains     . .  778 

-  re  pain  in  the  back  from 

disease    of    the  rectum. .  788 

heart  (Fig.  204)     . .  788 

liver  (Fig.  204)        . .  788 

stomach  (Fig.  204). .  788 

uterus  (Fig.  204)     . .  788 

lI'Kerron,    re    fatal    infantile 

metrostaxis          . .          . .  430 

Macrocytes  (Plate  II,  Fig.  B)  28 

MACULES        423 

-  absence  of  subjective  sym- 

ptoms with          . .          . .  424 

-  of  early  nodular  leprosy  . .  450 

-  in  erythema  multiforme    . .  531 

-  itching  in  drug  rashes      . .  424 

-  in   measles   . .          . .          . .  607 

-  subcutaneous,  in  typhus  fever  099 

-  syphilitic,  (Fig.  121)           . .  425 

becoming  papules         425,  532 

colour    brought    out    by 

coolness            . .          . .  420 

diagnosis  from  drug  rashes  426 

measles             . .          . .  426 

seborrhoea  corporis     . .  426 

tinea  circinata             . .  426 

versicolor     . .          . .  426 

distribution         . .          . .  425 

evanescence  of    . .          . .  425 

measles-like  character  of  425 

Maculo-papules           . .        424,  528 

jMadura  foot 809 

Magnesium  in  intestinal  sand  652 

-  phosphates,  acid  and  alka- 

line reactions  of             . .  573 
"  Main  bote  "  in  Friedreich's 

disease      . .          . .          . .  104 

Main-en-GrifEe  (see  Claw-hand) 
Main   succulente    in   syringo- 
myelia         128 

Malar  flush  in  mitral  stenosis 

61,  526,  773 
of  myxoedema        43,  259,  454 

-  process,  hyperplasia  in  acro- 

megaly        632 

Malaria 34 

-  acetonuria  in           . .          . .  4 

-  active  congestion  of  liver  in  371 

-  aestivo-autumnal,  jaundice  in  371 

-  ague-cake  spleen  in. .          . .  693 

-  albuminuria  in        . .          17,  301 

-  algidity  in    . .          . .          . .  35 

-  anaemia  in    27  37,   303,  459,  698 

-  blood  changes  in                 . .  34 

-  brachial  neuralgia  in          . .  492 

-  cachexia  from   114,  459,  401,  574 

-  characters  of  atticks  in     . .  649 

-  characteristic  pyrexia  of    34,  698 

-  Cheyne-Stokes  respiration  in  125 

-  chill  in          615 


MALARIA— MASTODYNIA 


937 


Malaria,   contd. 

-  cirrhosis  of  liver  in. . 

-  cold  and  hot  stages  of 

-  coma  in        . .  . .  35, 

-  crescents  in  blood  in  (Plate 

XII,  Fig.  E,  p.  696)     . . 

-  cure  by  quinine       583,  649, 

-  diagnosis    from    abscess   of 

liver  369,  371, 

-  -  pyaemia     .  .  .  .        615, 

-  -  relapsing  fever    . . 

-  -  typhoid  fever 

-  Jiazo-reaction  in    . . 

-  diminution  of  leucocytes  in 

-  eosinopliilia  in 

-  functional  bruits  in 

-  gansrene  in 

-  geographical  distribution  of 

693, 

-  ha?mat€mesis  in       294,  302, 

-  hsematuria  in  . .        301, 

-  ha?moglobinuria  m 

-  hyperpyrexia  in 

-  impotence  in 

-  jaundice  in  . .  301,  362, 

-  leucocvtosis    uncommon    in 

371,  400,  615, 

-  leucopenia  with       303,  369, 

-  -  relative  increase  iu  large 

hvaline  Ivmphocytes  in 
303,  369,  37i,  402,  615,  649, 

-  loss  of  weight  in 

-  malignant,  coma  in 

-  -  diagnosis  from  yellow  fever 

301, 

-  menorrhagia  in 

-  CBdema  of  legs  in  459, 

-  pain  and  tenderness  in  the 

scalp  from 

-  parasites  in   blood   in  (Plate 

XII,  p.  696)    35,  369,  371 
583.  615,  649,  650,  693, 

most  typical  stage  at  onset 

of  ague  fit 

rapid  disappearance  after 

quinine 

-  peripheral  neuritis  in 

-  pernicious,  crescents  in 

-  polyuria  in  . .  . .         581, 

-  purpura  in    . . 

-  pyrexia  due  to      .  .609,  615, 

-  quinine  in  diagnosis  of    615, 
dosase  of . . 

-  relationship    to   blackwater 

fever 

-  relative  increased  leucocyte 

count  in   diagnosis   from 
hepatic  abscess  . .        401, 

-  rigors  in       . .  . .         647, 

-  skin    pigmentation    in     424, 

-  spleen,  enlarged  in  302,  303, 

692,  693, 

-  sweating  in. . 

-  thyroid  gland  swelling  in  . . 

-  tinnitus  from 

-  wasting  from 
Malformations,  congenital  (see 

Congenital  Malformations) 
Malignant  disease,  absence  of 
pyrexia   as  a  rale  in 

-  -  albuminuria  in    . . 

-  -  amenorrhoea  in  . . 

ansemia  in  . .  37, 

bed-sore  in 

chylous  ascites  in 

eosinophilia  in      . . 

functional  bruits  in 

loss  of  elasticity  of  skin  in 

multiple  serositis  in 

pains  in  limbs  in. . 

pigmentation  of  the  skin  in 

simulated   by   alcoholism 

loss  of  weight  due   to 

old  age 


Malignant  disease,  conld. 

371 and  syphilis,   not  distin- 

583  J  guished  by  pyrexia    . . 

136  I  -  (and  see  Carcinoma ;  Epithe- 
lioma :  Sarcoma  ;  etc.) 
373     -  endocarditis  (see  Fungating 
650  I  Endocaditis) 

-  scarlet  fever  (see  Scarlatina 
408  :  JIaligna) 

650     Malingering,  aortic  aneurysm 
373  invading  spine,  mistaken 

615  for 

198     -  apparent  hyperpyrexia  in 
698  I  -  bullae  caused  by     .  . 

248  -  carcinoma    invading    spine 
106  mistaken  for 

282     -  convulsive  form  of  160,  169, 
464, 
698     -  distinction  from  hysteria  . . 
303     -  fatigue  in     . . 
305     -  hsematemesis     from     swal- 
315  lowing  blood  in  . .        294, 

344     -  htematuria     simulated     by 
347  I  aniline  dyes  in    . . 

371  I  -  haemoptysis  in 

-  imitation   of  deafness  by . . 

649  ' epileptic   convulsions  by 

402  I fits,  describe:!      . .  '. . 

paraplegia  by      . .         562, 

-  -  strychnine    poisoning   by 
698  ! tetanus    by 

848  -  insomnia  type        . .         356, 
136     -  lockjaw  variety  of 

-  nemrasthenia  simulating   . . 
373     -  oedema  of  limbs  induced  by 
428     -  pain-in-the-chest  type 
461     -  perspiration  in 

-  professions  of  insomnia  in 

-  quivering  of  eyelids  in 

-  risus  sardonicus  variety  651, 
373,     Mallein  in  diagnosis  of  glanders 

698     JIalpresentations,     dystocia 
due  to 
Malt  liquors  as  cause  of  obesity 
Malta  fever,  absence  of  diar- 

371  rhoea  in    . . 

6 agglutinating  reaction  in 

373  507, 

583 arthritis  in  .  .         376, 

596  I bacteriuria  in 

622 bronchitis  in 

698 characteristic     tempera- 

615  ture  chart  of  (Fig.  163) 

-  constipation  in   . . 

-  diagnosis     from    typhoid 
fever 

-  enlargement  of  spleen  in 

402 gastric  derangements  in 

648 geographical   distribution 

575 goat's  milk  as  source   of 

615,  infection  in      . .         507, 

698 headache  in 

615 micrococci    in    blood    in 

792  507,  612, 

794 orchitis  in 

69 perspiration  in    . . 

pyrexia  in      506,  609,  611, 

rheumatic  pains  in  limbs 

in  .  .  . .  503, 

617 rigors  rare  in 

17 technically  a  septicaemia 

23     Mamma,    deficiency    of    deep 

616  tenderness  in,  in  locomotor 
718  ataxy 

58     Mammary  abscess  (see  Abscess 

249  ilammary;    and  Mastitis, 
106  Acute) 

718     -  neuralgia   (see  Mastodvnia) 
123     -  swelling  742,  743",  744, 

503     Manchester  epidemic  of  arseni- 
718  cal  neuritis  . .  77, 

849  Mandible  (see  .Taw) 

I  Mania,  acute,  inplumbism 
849  1  38,  139, 


173, 
652 
389 
464 

295 

820 
317 
191 
160 
173 
567 
464 
464 
359 
801 
787 
457 
479 
464 
359 
160 
652 
603 

227 
453 

612 

612 

507 

83 

507 

612 
506 

612 
507 
507 
506 

612 
507 

650 
507 
506 
612 

506 
647 
650 


Mania,   conld. 

-  delirium  in  . .  . .  . .     195 

-  insomnia  in..  ..         356,358 

-  pupils  in       . .  . .  . .     594 

-  temporary  following  epileptic 

convulsions  . .  . .     169 

JIannerisms,  motor  tics  as    . .     160 
Manson,  re  dhobie's  itch        . .     275 

-  re  yaws  and  syphilis  . .     450 
Manufacturing   districts,   gas- 
tric ulcer  in         . .  . .     298 

MARASMUS 426 

-  in  cyclical  vomiting  of  infants 
426,  843 


-  from  defective  feedin; 

-  infantile,  gangrene  in 

-  keratomalacia  with 

-  subnormal  temperature  in 

-  tuberculous,  tubercle  bacilli 

in  faeces  in 
Marie,    re    spondylose    rhizo- 

melique     . . 
Marriage,  when  permissible  in 

case  of  urethral  discharge 
Marrow,     hyperplasia     of    m 

leuksmia 

in  pernicious  anaemia    . . 

Marsh  cachexia 

Marsh's  test 95 

Mask  facies  of  paralysis  agitans  265 
Massage     in     avoidance     of 

contractures 

-  effects     on     clironic     rheu- 

matic pains 

-  influence  on  cedema  of  legs 

in  convalescence . . 

-  in      insomnia     with      high 

blood-pressure     . . 

-  of  prostate  . . 

-  in  rheumatoid  arthritis     . . 
Masseter  muscle,  paralysis  of 
Mast-cells 
Mastication  difhcult,  in  bulbar 

paralysis  . 


427 
282 
807 
621 

427 

787 

209 

776 
776 
115 


165 


507 

459 

359 
208 
379 
775 
92 

159 


etiology    of 


trigeminal 


-  imperfect, 

dyspepsia 

-  influence      < 

neuralgia 

-  muscles  of,  in  bulbar  palsy 
Mastitis,  acute,  due  to  cracked 

nipples 

fluctuation  in  breast  in . . 

formation  of  abscess  in. . 

during  lactation 

in  the  new-born  . . 

pain  in  the  breast  in     . . 

during  pregnancy 

at  puberty 

purulent   discharge   from 

nipple  in  . .         20S 

pyrexia  in 

shivering  at  onset  of 

skin  red  and  cedematous  in  743 

swelling  in  breast  in      . .     743 

-  -  not  uncommon  in  virgins     743 

-  chronic,  characters  of  swell- 

ing in         .  .  . .  743,  745 

diagnosis  from  carcinoma 

43,  745 


354 

495 
687 

743 
743 
743 
743 
743 
743 
743 
743 

743 
743 
743 


fibro-adenoma. . 

enlargement    of    axillary 

glands  in 

-  -  forming  cyst  202,  743, 
frequent       affection       of 

opposite  breast  in 

from  tuberculosis 

purulent  discharge  from 

nipple  in 

vague  pains  and  tender- 
ness in  breast  in 

-  serous  discharge  from  nipple 

in  . . 
Mastodynia,   association    with 
pelvic  disease 


744 


938 


MA  STOD  YNIA—MED  ULLA     OBLONG  A  TA 


479 
479 


547 
327 


263 
229 


254 
58C 


498 

17 

20 

..     376 

..     282 

03,  42C,  668 

..     426 


of 


Mastodynia,  contd. 

-  iu  pregnancy  or  lactation . . 

-  pain  in  the  chest  from     477 

-  redness,  swelling,  and  ten- 

derness of  breast  in 
Mastoid  abscess  (see  Abscess, 
Mastoid; 

-  disease,     cerebral     abscess 

due  to 
headache  in 

-  -  spastic     brachial    mono- 

plegia due  to  . . 

-  process,  hrperplasia  in  acro- 

megaly 
tender  in  otitis  media  . . 

-  swelling    with    thrombosed 

cavernous  sinus  .  . 

Masturbation,   priapism  from 

Match  manufacture,  phos- 
phorus poisoning  from 

Matches  in  urethra    . . 

Match-heads,  jihosphorus 

poisoning  from  taking  .  . 

Maxillary  segmental  area,  pain 
in,  in  iritis  and  glaucoma 

Measles,  albuminuria  in 

-  albumosuria  in 

-  arthritis  in  . . 

-  cancrum  oris  in 

-  coryza  in 

-  cough  in 

-  crescentic      character 

eruption  in 

-  dehrium  in  . . 

-  diasBosis  from  dengue 

erythema  scarlatii orme  . . 

German  measles  . . 

macular  syphilides 

small-pox. . 

-  diazo-reaction  in     . . 

-  and  diphtheria  associated 

-  empyema  after 

-  eosinophilia  after   . . 

-  epistaxis  at  onset  of 

-  eruption  macular  in 

-  gangrene  in. . 

-  German       (see        German 

Measles) 

-  infantile  convulsions  in 

-  Koplilrs  spots  in    . . 

-  laryngitis  in . .  ..         226. 

-  leucocytosLs  uncommon  in 

-  loss  of  smell  sensation  in  . . 

-  malignant,  hfemoptysis  in 

-  menorrhagia  in 

-  nerve  deafness  after 

-  cedema  of  face,  neck,  and 

arms  from 

-  pain  in  limbs  at  onset  of  . . 

-  purpura  in  . .  . .         596, 

-  rigors  in      . .  . .        647, 

-  scaly  eruption  with 

-  simulating  a  cold  . . 

-  sore  throat  in 

-  swelling  of  eyes  and  face  in 

-  talipes     from     thrombosis 

following 

-  Tooth's    peroneal    atrophy 

after  . .  . .  71, 

-  tuberculosis  following 
Meat-fibres     in     motions     in 

chronic  pancreatitis 
Meatus  urinaria?,  redness  of 
small,    frequent   micturi- 
tion from 
Jlockel's  diverticulum  causing 

acute  obstruction 
Median  nerve,  muscles  supplied 

by 

paralysis  of 

skin  distribution  of 

spinal  roots  derived  from 

-  paralysis,  diagnosis  of  Volk- 

mann's  contracture  from 


426 
194 

506 


170 
203 
465 
400 
668 
.318 
428 
190 

461 
505 
597 
650 
655 
203 
670 
459 

131 

560 
427 

1.35 

207 

438 

151 

550 
552 
659 
550 


Mediastinitis,  acute,causes  of 

episternal  fullness  in 

fiillness      of      intercostal 

spaces  in 

mediastinal      crepitation 

resembling  pleural  fric- 
tion in  . . 

pain  behind  sternum  in 

rarity  of  .  . 

tenderness  in  back  from 

over  sternum  in 

-  chronic   (see    Mediastinum, 

Fibrosis  of) 
Mediastinum,  abscess  in  (see 
Mediastinitis,  Acute) 

-  aneurvsm  in  (see  Aneurysm) 

-  caseous  glands  in  (see  Lym- 
phatic Glands,  Mediastinal) 


484 
483 
483 
786 
483 


826 


826 

776 

242 
484 
484 

185 


128 

422 
484 
826 
826 
343 

773 
484 
123 


-  congenital  fibroma  of 

-  dermoid    cyst    of,    varicose 

thoracic  veins  from 

-  disease  of,  tenderness  in  the 

chest  from 

-  fibrosis   of,    adherent    peri- 

cardium associated  with 

age  incidence  of . . 

anasarca  in 

aneurysm  and  new  growth 

simulating  one  another 

ascites  in..  ..     61,63,484 

cardiac  troubles  in        . .     484 

clubbed  fingers  in 

diagnosis    from    enlarged 

bronchial  glands 

dyspnoea  in 

fibrous,  in  rheumatism  . . 

gummatous 

hiccough  in 

irritation  of  vagus  nerve 

by         . .  . .         772 

lividity  in 

obscure  cases  of . . 

obstruction    to    superior 

vena  cava  by  .  .461,  746,  826 
oedema  of  face,  neck,  and 

arms  from  296,  458,  461 

pain  in  the  chest  in      . .     478 

behind  stsmum  in      . .     484 

palpitation  from  526,  528 

paralysis  of  vocal  cord  from  538 

pleurisy  and   pericarditis 

preceding 
sense    of    tightness    and 

dragging  in  the  chest  in 

shght  degrees  of  chronic 

tachycardia  from 

tuberculoas 

varicose  thoracic  veins  from 

484,  826 

-  gumma  of,  efiects  of        . .    458 
obstruction    to    superior 

vena  cava  by  . .  . .     461 

cedema  of  face,  neck,  and 

arms  from       . .        458,  461 

-  hydatid  cyst  of       . .  . .     826 
varicose  thoracic  veins 

from. . 

-  lymphatic  gland,  affections 

of  (see  Lymphatic  (Jlands, 
ilediastinal) 

-  new   growth    in,    alteration 

of  voice  in 

anasmia  in 

ascites  in 

bronchial  stenosis  in  . . 

cachexia  in      . . 

clubbed  fingers  from . . 

compression  of  lung  by 

cough  and  expectoration 

in       . .  . .        176,  483 

cyanosis  in       . .  . .     296 

diagnosis  of     .  .  . .     465 

from  aneurysm       296,  483 

bronchial  glans       . .     422 


343 

484 

63 

772 

826 


826 


483 
483 
61 
324 
483 
128 
667 


Mediastinum,  new  growth  in,  could. 

disturbance  of  heart  in     483 

dyspnoea  in 

enlarged    right    supra- 
clavicular gland  in 
fibroid  lung  and  bron- 
chiectasis from 

gangrene  of  lung  in   . . 

hsematemesis  froni     294,  296 

haemoptysis  iu  176,  483 

hiccough  in      . .  . .     343 

illustrative  case  . .     296 

inequality  of  pulses  from   593 

irritating  vagus   nerve 


483 
421 


324 
288 


773 

582 
777 
777 
343 
465 


121 


483 
465 


96 


48  S 


mistaken  for  astlima .  . 

hysteria 

intercostal  neuralgia 

obstructing  bronchus . . 

great  veins   . . 

superior  vena  cava  461, 826 

trachea         . .  . .     710 

oedema   of  face,   neck, 

and  arms  from  456, 458, 461 

orthopncea  from       465,  407 

pain  in  the  chest  in  478,  483 

side  and  down  arm  in  483 

pleuritic  effusion  in    . .     121 

pressure  on  trachea  and 

bronchi  in     . .  . .     483 

pyrexia  in        . .  . .     483 

sense    of    tightness    of 

chest  in         . .  . .     48' 

skodaic  resonance  due  to  607 

stridor  from    . .  . .     710 

symptoms,       physical 

signs    and  effects   of 

tachycardia  from 

tightness  in  chest  from 

tracheal  obstruction  by 

varicose  thoracic  veins 

from     296,  343,  465. 

483,  773,  826 

a;-rays  in  diagnosing  422, 

465,  474,  483,  582 

-  rupture  of  aneurysm  into. .     140 

-  sarcoma  of,  illustrative  case 

-  tumour  of  (iacluding  aneur- 

ysm), general  diagnosis  of 
displacement    of    cardiac 

impulse   in 

intercostal  nerve  pain  in 

interscapular  pain  in     . . 

local    bulging    of     chest 

wall  from 
mechanical  explanation  of 

orthopnoea  in  . .         465,  467 
muscular  atrophy  in  arm 

from     . .  . .  . .        74 

unilateral      enlargement 

of  chest  from.  . .  . .     192 

a;-rays  in  diagnosis  of  422,  474 

from  asthma  . .     582 

-  veins,    obstruction    in   new 

growths  of  pleura  .  .     118 

Medical  examination  for  life 
assurance,  transient  poly- 
uria due  to         . .         581,  583 

-  men,  digital  chancre  in  . .  266 
Medicines  causins  ptyalLsm  .  .  590 
Mediterranean  Malta  fever  in 

506,  613 
Medulla     oblongata,     bulbar 
paralysis  due  to  lesion  in 
159 

degeneration      of,      from 

alcoholism 
Cheyne-Stokes    respira- 
tion from 

dissociative    anaesthesia 

from  . . 

hiccough  from . . 

paralysis  of  vocal  cords 

from  . .  538,  539 


30 


193 


641 


124 


666 
343 


MEDULLA    OBLONGATA— MENINGITIS.    SPINAL 


939 


Medulla  ohluiii/alu,  could. 

degeneration      of,      from 

plumbism     . .          . .  225 

syphilis              . .          . .  224 

liaMnorrhage  into,  diagnosis 

from  bulbar  palsy      . .  687 

dysartliria  from      . .  687 

iiiUucnee  on  blood  distri- 
bution      619 

heat  distribution         . .  610 

lesions  causing  ataxy     . .  08 

diabetes  mellitus     . .  585 

polyuria        .  .         583,  585 

softening     in,     diagnosis 

from  bulbar  palsy       . .  687 
from  dysarthria       . .  687 

-  -  spastic  paralysis  of  upper 

limb  from         . .          . .  547 

-  -  tumour  of,    asj'mmetrical 

muscular  atrophy  in  . .  GST 

diagnosis    from    bulbar 

palsy 687 

dysarthria  in    . .          . .  687 

laryngeal  paralysis  due 

to       ..          .".          ..  539 

-  -  vomiting  centre  in         . .  842 
ilegaloblasts    . .          . .          . .  28 

ifegdlocytes  (Plate  II,  Fig.  B)  28 

-  in  pernicious  anosmia  . .  76 
ilegalospores  in  ringworm  . .  273 
Meige's  disease  . .  45C,  460 
MEL./ENA  (and  see  Blood  per 

Anum)       .  .          .  .          . .  428 

Meiancholia,  catalepsy  with  .  .  651 

-  high  blood-pressure  in       . .  96 

-  insomnia  in..          ..          ..  358 

-  irritability  in           .  .          . .  360 

-  perversion  of  appetite  in    . .  50 

-  speechlessness  in    . .          . .  682 

Melanogen        . .          . .          . .  821 

Melanotic  carcinoma  of  genital 

organs  or  extremities     . .  802 
naicroscope  in  diagnosis  of  802 

-  sarcoma  of  eye,  enlargement 

of  pre-auricular  gland  in  419 

inguinal  glands              423,  739 

IVlelanuria        ..        ..      820,  821 

-  bromine  water  test  for      . .  821 

-  ferric  chloride  test  for       . .  821 

-  du3  to  melanotic  sarcoma 

423,    821,  822 

-  simulated  by  alkaptonuria  822 
indicanuria           .  .         821,  822 

-  sodium  nitroprusside  test  for  821 

-  urine  darker  on  standing  . .  821 
Melon-seed     bodies     in  teno- 
synovitis . .          . .          . .  179 

Membrana  tympani,   appear- 
ance of  in  otitis  media  .  .  230 

-  -  In'peraemic  and  swollen  in 

otitis  media      . .          . .  469 

petechiiE  on     . .          . .  468 

lacerated  in  fractured  base  467 

perforated  in  otitis  media  4G9 

rupture  from  foreign  body 

in  meatus         . .          . .  468 

head    injuries    without 

fracture         .  .          .  .  468 

in  otitis  media            . .  230 

Membrane  in  faeces  (see  Foeces, 

Mucus  in) 
Membranes,  adherent,  dystocia 

due  to 227 

-  early    rupture   of,    dystocia 

due  to      ...          . .          . .  227 

Membranous  colitis  (see  Colitis, 
Membranous) 

-  dysmenorrhoea  described  219,  220 

-  rhinitis  (see  Rhinitis,  Mem- 

branous) 

-  vasrinitis,  Hakes  from  . .  211 
MEMORY,  LOSS  OF  (.Amnesia)  25 
due    to    frontal    cerebral 

tumour..          ..          ..  798 


Memory,  loss  of,  could. 
for  recent  events  in  alco- 
holic peripheral  neuritis  505 

-  detects  in  general  paralysis  172 

-  illusions  of,  in  chronic  alco- 

holism         172 

-  for  written  words,  centre  for 

storage  of            . .          . .  683 

Meniere's  disease,  cause  of  190,  828 

coma  in    .  .          .  .          . .  828 

deafness  in           .  .          .  .  828 

nausea  in. .          . .          . .  828 

pallor  of  the  face  in       . .  828 

recurrence  of  attacks  in  828 

sudden  onset  of  vertigo  in  828 

syphilis  of  ear  simulatins  828 

tinnitus  in           . .        794,  828 

vertigo  due  to     . .        828,  847 

-  -  vomiting  from      828,  844,  847 
Meningeal     ha;morrhage    (see 

Hasmorrhage,  Meningeal) 
Meninges,     not    coloured    in 

jaundice    . .          . .          . .  361 

-  disease  of  the  cervical,  pain 

in  the  upper  extremity  in  491 

-  new    growth    of,    compres- 

sion of  cord  by    . .          . .  561 
pain  in  the  back  in        . .  476 

-  spinal      tumours      causing 

hyperassthesia      . .          . .  667 
paraplegia        . .          . .  561 

-  tumour  of,  headache  in     . .  327 
Meningitis,  albuminuria  in   . ,  17 

-  bedsore  in    . .          . .          . .  286 

-  cerebral  symptom  of        558,  563 

-  Cheyne-Stokes  respiration  in  125 

-  choroidal  tubercles  in        . .  341 

-  coma  in        . .          . .        136,  642 

-  constipation  in        . .          . .  149 

-  convulsions  in  139,  169, 172, 

173,   341,  558,  563,  642 

-  deafness  from         . .         . .  191 

-  diagnosis      of    encephalitis 

from          ..          ..        139,  558 
from      fungating      endo- 
carditis..         ..          ..  614 

otitis  media         . .          . .  229 

superior  longitudinal  sinus 

thrombosis  from         . .  558 

-  in  fungating  endocarditis..  614 

-  giddiness  in             . .          . .  642 

-  headache  in  139,   326,   327,  328, 

350,   359,  563,   622,    642,  847 
worse  at  night   . .            . .  326 

-  hemiplegia  in          ..        340,  341- 

-  hydrocephalus  due  to       . .  557 

-  hyperpyrexia  in      . .          . .  344 

-  increase  in  specific  gravity 

of  cerebrospinal  fluid  in  338 

-  incontinence    of   urine   and 

fspces  in    . .          . .          . .  642 

-  infantile  diplegia  due  to    . .  556 

-  insomnia   in . .          . .          . .  356 

-  irritability  in . .  ..      350,359 

-  Kernig's  sign  in      . .          . .  350 

-  leucocytosis  in        . .          . .  401 

-  lumbar    puncture    in    dia- 

gnosis of  ...328,  464,    563,  643 

-  muscular  twitchings  in      . .  642 

-  occipital  headache  in         . .  327 

-  opisthotonos  in       . .          . .  464 

-  optic  neuritis  in    139,  341, 

464,  563,  642 

-  pain  in  the  back  in        475,  476 

-  paralyses  in              . .          . .  642 

-  paraplegia  from       556,  561,  563 

-  photophobia  in       . .          . .  350 

-  polymorphonuclear   cells  in 

cerebro-spinal  fluid  in     . .  643 

-  pulse-rate  in            . .          . .  98 

-  purpura     in     diagnosis     of 

cerebrospinal  fever  from 

otiier  forms  of     . .          . .  598 


Meningilis,  contd. 

-  pyrexia  in   . .  . .        558, 

-  rarity  of  rigors  in    . . 

-  retraction   of   tlie    head    in 

328,  359,  641,  642,  699, 

-  rigidity  of  face  muscles  from 

-  sensory  disorders  in 

-  simulat<id  by  diphtheria   . . 

encephalitis  . .        558, 

laryngeal  obstruction     . . 

retro])har}nigeal     abscess 

superior  longitudinal  sinus 

thrombosis        558,  643, 

-  simulating  dyspepsia 

-  stiff-neck  in  .  .         328, 

-  strabismus  in  . .        350, 

-  tache   ct'r^brale  in.. 

-  tenderness  of  scalp  in       781, 

-  trismus  simulated  by 

-  tubercles  of  choroid  in  (Plate 

VIII,  Fig.  W,  p.  463)  341, 

-  unilateral  convulsions  in  170, 

-  vomiting  in    139,  174,  341, 

558,   5G3,   622,   642,    844, 

-  basal  and  epidemic  cerebro- 

spinal,   relationships    be- 
tween 
loss  of  convergent  accom- 
modative   reflex    with 
retention  of  light  reflex 

-  cerebrospinal,    antimeningo- 

coccal  serum  in  diagnosis 
of 

bacteriological  examina- 
tion of  cerebrospinal 
fluid 

Cheyne-Stokes  respira- 
tion in  . . 

coma  in  epidemic 

epidemic  character  of  598, 

fluid  changes  in    338,  339, 

head  retraction  in        328, 

hyperpyrexia  in . . 

intense  occipital  head- 
ache in . . 

leucocytosis  in    . . 

lumbar  puncture  in 

purpura  in     596,  597,  598, 

rigors   in . . 

stifE  neck  in 

universal  jsain  and  tender- 
ness in . . 

vesicular  skin  eruption  in 

-  chronic,     paraplegia     from 

(see     also     Pachymenin- 
gitis)   

subjective  smell  sensations 

from 

-  meningococcal 
arthritis  in 

Cheyne-Stok£S  respiration 

in 

-  coma  in    . . 
-  duration  of 

head  retraction  in 

hemiplegia  in      . .         337, 

hyiaerpyrexia  in 

occipital  headache  in     .  . 

lumbar  puncture  in 

polymorph,     leucocytosis 

in  cerebrospinal  fluid  in 

pyrexial  crises  in  344, 

retraction  of  the  head  in 

Stiffness  of  neck  in 

and  tuberculous  distin- 
guished . . 

-  post-basal    (see    Meningitis, 

Meningococcal) 

-  pneumococcal 

polymorph,  leucocytosis  in 

cerebrospinal  fluid  in . . 

-  spinal,  diagnosis  of  sciatica 

from  pain  due  to 
tetanus  from  . . 


642 
651 

709 
801 
5fia 
642 
643 
642 
642 

651 
350 
70» 
35» 

771 
783 
801 

,"^63 

17a 

359, 

847 


598 

125 
136 
643. 
64a 
641 
344 

32S 
401 
328 
643 
647 


64a 
643 


66» 

404 
376 

125 
136 
642 
328 
338 
314 
328 
328 

33ft 

642 
641 
328 

642 


042 
339 


487 
162 


940 


MENINGITIS,  SPINAL— MESENTERIC    GLANDS 


ileninjitis,  spinal,  contd. 

Meningocele,    diagnosis   from 

Mental  altitude,  contd. 

-  -  opisthotonos  in  . .        4G3, 

461 

dermoid  cyst 

254 

tetanus,    strychnine   poi- 

 pain  on  moving  neck  and 

-  dystocia  due  to 

227 

soning,  and  liysteria  . . 

464 

head  in 

162 

-  of  face,  illustrated  (Fig.  75) 

254 

-  causes  of  dyspepsia 

354 

priapism  in 

586 

-  paraplegia  due  to  . .       556, 

557 

-  changes     due     to     frontal 

pyrexia  in 

464 

-  pulsation  in 

254 

cerebral  tumour . . 

798 

-  staphylococcal        . .       102, 

642 

-  unilateral  exophthalmos  due 

in    general    paralysis    of 

polymorph,     leucocytosjs 

to 

254 

the  insane 

269 

in  cerebrospinal  fluid  in 

339 

Meningococci  {Plate  XII,  Fig. 

-  deficiency    in    acquired    in- 

- Streptococcal 

642 

N,  p.  696) 

fantile  paralysis.  . 

155 

—  -  polymorph,     leucocytosis 

-  in  cerebrospinal  fluid       340, 

643 

in    congenital    defect    of 

in  cerebrospinal  fluid  in 

339 

-  Gram-negative 

643 

cortex  . . 

558 

-  suppurative    from    bacillus 

-  meningitis  due  to  . . 

172, 

syphilis 

260 

coli  communis     . . 

642 

339,  464 

643 

delay  in  acquiring  speech 

cavernous    sinus    throm- 

-  occurrence  within  leucocytes 

613 

due  to  . . 

682 

basis 

234 

-  of  Weichselbaum               172, 

340 

and  infantile  convulsions 

170 

Cheyne-Stokes     respira-  ' 

Meningo-myelitis,  gangrene  m. 

282 

in  infants,  insomjiia  in  . . 

357 

tion  in  . . 

125 

Msningo-myelocele,  movement 

lalling  with 

688 

comi  in   . .          . .        136, 

137 

with  resniration  in  (Fig. 

in  Little's  disease 

154 

from  diphtheria  bacilli  . . 

642 

lb,  p.  254) 

764 

loss  of  power  of  speech  m 

682 

facial  erysipelas . . 

642 

Menopause,  calcium  deficiency 

priapism  in  certain  con- 

 fatal  in  two  or  three  days 

642 

at  the 

433 

ditions  of 

585 

hyperpyrexia  in 

344 

-  epistaxis  at  the 

251 

-  degeneration  in  myxoedema 

460 

from  etlimoidal  air-celLs 

612 

-  eructatio  nervosa  at 

267 

-  disease,  ptyalism  in 

591 

infection    of    the    frontal 

-  flushing  at  the 

268 

-  emotion,  ptyalorrhoea  from 

592 

air-cells 

642 

-  menorrhagia  at 

430 

-  excitement    giving    rise    to 

naso-pharynx  . . 

642 

-  m.etrorrhagia  at,    causes  of 

433 

hfemoglobinuria 

315 

sphenoidal  air-cells     . . 

642 

-  obesity  developing  at  the. . 

454 

-  failure  in  chronic  chorea  . . 

156 

mastoid  disease 

642 

-  pliantom  tumour  at  the    . . 

7G1 

-  hebetude     after      epileptic 

otitis  media         . .          98, 

642 

-  priapism  at  male    . . 

586 

convulsions 

169 

—  -  pediculosis  capitis 

642 

-  tinnitus  increased  bv 

793 

-  incapacity     in     congenital 

polymorphonuclear    cells 

MENORRHAGIA,  causes,  etc. 

428 

spastic  paraplegia 

131 

in  cerebrospinal  fluid  in 

558 

-  from  anaemia           . .          36, 

430 

-  nerve,  skin  distribution  of 

659 

pyrexia  in 

642 

-  endometritis 

220 

-  overwork,  headache  from  327 

329 

retraction  of  the  head  hi 

641 

-  at  menopause,  from  arterio- 

 temporary  impotence  from 

347 

—  -  from  scalp  sepsis 

642 

sclerosis     . . 

430 

-  symptoms  in  alcoholic  peri- 

 suppuration     in     antrum 

high  blood-pressure 

430 

pheral  neuritis    . . 

505 

of  Highmore   . . 

642 

-  puberty  due  to  sarcoma  . . 

430 

Dercum's  disease 

455 

-   —  in  tlie  nose 

642 

-  with  pyosalpinx 

632 

hydrophobia 

162 

orbit 

642 

-  salpingo-odphoritis. . 

760 

-  under-developraent  in  cretin- 

 tachycardia  in     . . 

98 

-  uterine  fibroid         . .        758, 

759 

ism 

259 

typhoid  bacilli     . . 

642 

Menstrual  onset,  menorrliagia 

Mercury,  amenorrhcea  due  to 

23 

various  causes  of 

642 

and  metrorrhagia  at 

435 

-  anrcmia  due  to        . .          37, 

797 

-  syphilitic,  atrophic  palsy  of 

Menstruation,  abnormalities  of 

-  anuria   in     . .          . .            4 

5,  48 

one  leg  from 

543 

fsee     also    Amenorrhoea ; 

-  bleeding  gums  from              8^ 

,  86 

dysarthria  from . . 

687 

Dysmenorrhcea  ;     Menor- 

- cachexia  from 

115 

—  -  increased     intracranial 

rhagia  ;  Metrorrhagia)    22 

431 

-  cerebral  symptoms  due  to 

797 

pressure  in 

687 

-  absent 

22 

-  dangers  of,  in  nephritis     . . 

590 

involvement     of     cranial 

-  continuance      possible      in 

-  deafness  from 

191 

nerves  in 

687 

pregnancy 

758 

-  in  diagnosis  of  svphilis    226, 

279, 

lumbar  puncture  in  dia- 

- efl'ect  of  ovarian  secretion  on 

430 

387,   520,   521,    604,    640, 

65S, 

gnosis  of 

48S 

pituitary  secretion  on  . . 

430 

674,  677,  681,  769,   808 

813 

spinal,  girdle  pain  in 

289 

sexual  intercourse  on     . . 

431 

-  foul  taste  from 

774 

trigeminal  neuralgia  in.. 

496 

suprarenal  secretion  on . . 

430 

-  and    iodide,    effect    of,    on 

-  tuberculous  (and  see  Menin- 

 thyroid  secretion  on 

430 

gumma     .  . 

677 

gitis)         . .          . .         173, 

699 

-  from  endometritis  . . 

210 

in  diagnosis  of  gumma . . 

279 

—  -  age  incidence  of  . . 

642 

-  excessive     at     one      single 

-  loss  of  taste  due  to 

774 

Cheyne-Stokes     respira- 

period, causes  of 

428 

-  purpura  from 

596 

tion  in  . . 

125 

-  flashing  with 

268 

-  salivation  from    37,  86,  590 

797 

choroidal  tubercles  in  642, 

699 

-  headache     with 

329 

-  spongy  gums  from  . . 

295 

—  -  coma  in    .  . 

136 

-  meanirig  of . . 

758 

-  stomatitis  due  to,       37,  86, 

convulsions  in     . . 

612 

-  pain     and     tenderness     in 

295,    590,   774,   797, 

815 

diagnosis    from    typlioid 

back  from 

789 

-  swelling  of  cheeks  due  to  . . 

86 

fever     . .          . .         611, 

612 

-  recurrent  paui  in  right  iliac 

-  tremor  fi-om         37,  77,  795, 

797 

duration  of 

642 

fossa  with,  due  to  appen- 

 simulating     disseminated 

gastro-intestinal  symptoms 

dicitis        . .          . .   " 

737 

sclerosis 

797 

in 

174 

-  relation  to  conception 

758 

paralysis  agitans 

797 

headaclie  in 

612 

-  single      profuse,      nervous 

-  poisoning  m  hat-makers     . . 

38 

hyperpyrexia  in . . 

343 

causes  of 

430 

albuminuria  in    . . 

10 

irregular  pyrexia  in 

642 

-  suppressed    . . 

22 

leucopenia  in 

401 

lumbar  puncture  in  dia- 

- swelling  of  thyroid  gland  in 

791 

mirror-makers 

.38 

gnosis    . . 

699 

-  tinnitus  increased  by 

793 

muscular  atrophy  in 

77 

lymphocytosis  in  cerebro- 

- vicarious 

303 

necrosis  of  jaw  from 

747 

spinal  fluid  in  339,  558, 

643 

epistaxis  of 

251 

neuritis  from     . .             77, 

551 

mental  apathy  in 

174 

h^Bmatidrosis  in 

715 

in  rabbit-skin  curers 

38 

optic  neuritis  in..        612, 

699 

haemoptysis  in    . .        318, 

319 

thermometer-makers 

38 

paralyses  in 

612 

Measuration  in  ascites,  method 

51 

MERYCISM 

431 

—  -  pyrexia  in            .  .        622, 

642 

-  in  ovarian  cyst 

53 

-  diagnosis  from  flatulence  . . 

431 

relatively  slow  pulse-rate  ii 

771 

Mental  anguish  in  angina    . . 

481 

pyrosis 

4.'{1 

retraction  of  abdomen  in 

612 

-  apathy  in  tuberculous  menin- 

- vomiting  simulated  by 

842 

head  in            ..        611, 

699 

gitis 

174 

Mesenteric  embolism  (see  Em- 

 from  tuberculous  bronchial 

-  area,  referred  pain  in 

498 

bolism,  Mesenteric) 

glands  . . 

427 

-  attitude     in     disseminated 

-  glands  (see  Lymphatic  Glands 

vomiting  in 

699 

sclerosis    . . 

174 

Mesenteric)     . . 

MESENTERIC   FLEX  US— MI  LI  UM 


941 


Mesenteric  plexus,  meteorism 

from  interference  witli  . .  432 

thrombosis  of  (see  Tlirom- 

bosis,  Mesenteric) 

Mesentery,  hydatid  disease  o£  720 

-  thickened    and    contracted 

in  tuberculous  peritonitis  50 

-  tumour  of,   diagnosis  from 

renal  tumour       . .          . .  394 
Metabolism,  congenital  errors 

of,   causing   alkaptonuria  822 

-  errors  of,  causing  obesity  . .  4u.'5 

coma  due  to        . .          . .  I'iii 

Metacarpal  bone?,  affection  in 

yaws          . .          . .          .  .  4 19 

chondroma  of  (Fig.  195)  754 

Metatarsal  bones,  in  yaws   . .  449 

-  niural^'ia,    symptoms     and 

causes       . .          . .          . .  488 

Metallic  taste  in  major  trige- 
minal neuralgia  . .          . .  405 

METEORISM 431 

-  abdominal  swelling  from  . .  715 

-  diminished  liver  dullness  in  71(i 

-  displacement  of  heart  in    . .  710 

-  in  hysteria,   importance   of 

excluding  organic  basis  for  433 

-  simulating  free  gas  in  peri- 

toneum     .  .          .  .          .  .  710 

Metheemoglobin          ■■  12 

-  in  hicmoglobinuria            304,  314 

-  spectral  absorption  band  of  95 

-  urine  black  from    . .          . .  821 

-  spectroscope  in  diagnosis  of  821 
Metha?moglobina;mia,  account 

of  ..  ..  ..187 

-  cyanosis  in  . .          . .        184,  187 
Methffimoglobinuria  (see  Hsemo- 

globinuria) 

Methyl-orange  test  for  free  HCl  355 

Methylene  blue,  blue  urine  after  823 

green  urine  from. .          . .  823 

staining  of  mucus  by     . .  444 

test  of  pancreatic  diFeaso  304 

pyloric   obstruction    . .  71 3 

for,  in  urine     . .          . .  823 

in  vesico-vaginal  fistula  442 

Methylsanthin  bases,  uric  acid 

derived  from        . .          .  .  817 

Metritis,  tenderness  of  uterus  in  221 

-  chronic,  dvsnareunia  from  221 
METRORRHAGIA      ..         ..433 

-  in  acute  inversion  of  uterus  587 

-  in  acute  yellow  atrophy  . .  370 

-  anaemia  with           . .          . .  30 

-  definition      . .          . .          . .  428 

-  due  to  blood  changes       433,  435 

-  from  ruptured  tubal  gestation  640 
METROSTAXIS                       ..  435 

-  aneemia  with           . .          . .  30 

-  definition      . .          . .          . .  428 

:Microblast3 28 

^licrocephaly,  dwarfism  with  214 

-  infantilism  with     . .          . .  215 
Micrococcus  catarrhalis,  acute 

tonsillitis  from    . .          . .  670 

causing  colds       . .          . .  203 

laryngitis  from   . .          . .  670 

in     nasal     or     bronchial 

secretions  in  influenza  505 

pharyngitis  from             . .  670 

uretilritLs  due  to             . .  83 

-  melitensis  infection,  bacter- 

iuria  In     . .          . .          . .  83 

-  -  in   Malta   fever  507,  612 

-  rheumaticus    in    fungating 

endocarditis         . .          . .  237 

-  tetragenus  in  sputum        . .  705 
iIicrocyt;s  (Plate  II,  Fig.  B)  28 
Microides  in  ringworm          . .  273 
Micromelia       .  .          . .          . .  214 

Micropsia         ..         ..        840,  841 

-  from  cannabis  indica         . .  841 

-  often  unexplainable           . .  841 


273 


511 


511, 

631 

439 

511 

442 

442 

437 

094 

632 

84, 

016 

Microsomia  (see  Dwarfism) 
Microscope    in    diagnosis   (see 

Histology) 
Microsporon   Audouini         272,  273 

-  canis 272,   273 

-  felincum       . .  . .         272,  273 

-  furfur  in  dhobie's  itch       . .     275 
in  tinea  versicolor  . .     276 

-  minutissimum  in  dhobie's  itch  275 

erythrasma  . .  . .     276 

mycelium  and  spores  of        277 

-  tardum         . .  . .        272,  273 
Microsporosis  . . 

-  plcomorphism  in     .  . 

MICTURITION,  ABNORMAL- 
ITIES OF  (and  see  Incon- 
tinence oE  Urine)  . .     437 

with  irritable  bladder    . .     443 

in  prostatic  enlargement      311 

-  changes  in  stream  of  urine  in    438 

-  differences  day  and  night. .     438 

-  difficulty      of,      in      acute 

prostatitis 

prostatic  abscess 

starting  . . 

urethral  stricture 

-  disorders  of,  from  diseases 

of  nervous  system 
through  fistuke   . . 

-  frequency  of.. 

in  appendicitis    . . 

bacilluria  .  . 

bladder  tumours    47,  311,  512, 

514,  630,  032 

-  -  cystitis     . .  221,  028,  031,  817 

in    descending    ureteritis     515 

distinction  from  polyuria     581 

in  general  peritonitis     . .     044 

-  -  impacted  ureteral  calculus    514 
implication  of  bladder  in 

neighbouring  growth . .     632 

-  -  importance   of   iiric   acid 

crystals  in 

increased,  causes  of 

from  irritable  bladder  . . 

movable  kidney  . . 

on  movement,  in  vesical 

calculus  . .        513 

normal 

oxaluria    . . 

pelvic  affections 

prostatic  abscess 

enlargement       441,  581,  817 

prostatitis..  ..        207,511 

pyelitis     . .  . .  . .     025 

renal  calculus      . .  . .     308 

colic      . .  . .  . .     615 

from  renal  infection       . .     624 

single     simple     tilcer     of 

bladder  ..  ..     630 

in  tuberculous  bladder 

.306,  312,  .513,  581,  629 

cystitis  . .  . .     028 

kidney     135,    300,  310,  312, 

620,  029,  094 

in  ulceration  of  the  bladder  630 

uninfluenced    by   rest   in 

vesical  tuberculosis    . .     513 

in  ureteric  calculus      135,  311 

impacted  514,  627 

urethral  stricture  . .     581 

in  urethritis        . .  . .     207 

vesical  calculus  312.  513, 

627,  628,  029 

-  impossible  in  uretliral  rupture  308 

-  involuntary  (see  Enuresis) 

in  epilep.sy  . .  . .     040 

-  mechanism  of  control  of  442,  443 

-  nervous  mechanism  of      . .     437 

-  painful         441 


817 
437 
443 
310 

628 
437 
471 
817 
511 


in  acute  cystitis 

prostatitis 

urethritis 

-  appendicitis 


. .  627 
..  207 
207,  675 
. .     6.32 


Jliclurition,  jminlul,  conld. 

carcinoma  of  urethra     . .     209 

in  implication  of  bladder 

in  neighbouring  cancer     032 

pain  in  penis  alter  512, 

515,  629 

with  prostatic  abscess  . .     207 

from  soft  sores  of  urethra     209 

ulceration  o£  the  bladder     OS*) 

urethritis..  ..  ..     675 

vesical  growth    . .  47,  032 

-  precipitate,     with     inconti- 

nence of  faeces    . . 

-  scalding  in  bacteriuria 
gonorrhcea 

-  sudden     stoppage    by    im- 

paction of  calculus       210, 

-  urgent  desire  for    . . 
Mid-brain,  tumour  of,  deafness 

from 

defective  reaction  of  pupil 

to  light  with 

eccentric  pupil  from 

fifth  nerve  anaesthesia  from  798 

third  nerve  paralysis  from     798 

unilateral  tremor  from  . .     798 

weakness  of  upward  move 

ment  of  eyeballs  with 
Middle  cerebral  artery,  speech 

centres  supplied  by 

-  cutaneous  nerve,  skin  distri- 

bution of . . 
Middle-ear  deafness  . . 

-  in£lammation(see  Otitis  Media) 
Mid-orbital    segmental    area, 

pain     in,     in     errors     of 

refraction 
Midwives,  chancre  of  finger  in 
Migraine,    absence    of    optic 

neuritis  in 

-  acetonuria  in 

-  amblyopia  with 

-  central  scotoma  in  836 

-  headache  m  326, 329, 837,  840,837 

-  hemicrania  in         ' . .  . .     838 

-  hemianopsia  in  333,  336,  836 

-  hyperaesthesia  acustica  in. .     190 

-  monocular  blindness  in    830,  840 

-  nausea  in     . .  . .  . .     847 

-  short  duration  of  blindness 

in  840 

-  sudden  blindness  from      . .     839 

-  temporary  aphasia  in       . .     686 

-  transient  polyuria  after  581,  582 

-  transitory    visual    disturb- 

ance in     . .  . .  . .     329 

-  tinnitus  in   . .  . .  . .     794 

-  unilateral  headache  in       . .     326 
hemianopsia  in  . .  . .     333 

-  vertiffo  in     . .  . .  . .     828 

-  vomiting  m     329,  837,  838,  840, 

844,  847 

-  xanthoma  planum  with    . .     80-5 
Milia  of  acne  . .  . .  . .     530 

Miliaria,    relation    to    hidro- 

cystoma    . . 

-  rubra,       distinction      from 

eczema 

pricking  and  tingUng  in 

vesicles  in 

-  vesicles  with 
Miliary   abscess    of   the   new- 
bom,  dermic  pustules  in 

-  benign  lupoid,  diagnosis  of 

lupus  and  sarcoma  from 

-  papular  syphilides,  descrip- 

tion of      . . 

diagnosis  of  lichen  scro- 

fulosorum  from 

-  tuberculosis  (and   see  Men- 

ingitis)       

Milium,  character  of  papule  of 
Milium-like  bodies   in   mouth 

in  Fordyce's  disease 


348 

84 
769 

313 
4.> 

190 

798 
798 


798 
684 


659 
190 


498 
266 

582 

4 

836 

838 


831 

831 
831 
831 
714 

601 

451 

532 

530 

394 
528 

403 


942 


MILK— MOUTH 


Hilk,     caseons    glands    from 

Mitral  stenosis,  conXd. 

Mononuclear  cells   (see   Lym- 

343,  427, 

773 

embohe  infarction  of  lung  in 

320 

pihocytes) 

— 

caras,  jnfaintile  colic  due  i>o 

136 

after  endocarditis 

240 

Monoplegia,  abnormal  gait  in 

278 

— 

iiscsiiaise    from    nipple    at 

enlarged   right   xentricle 

—  brachial    (see    Paralysis    of 

abncsnnal  time    .  . 

202 

in 

243 

Extremity,  Upper) 

— 

goaf sj  as  source  ot  infec- 

false  bradxeardia  in 

97 

—  crural  (see  Paralysis  of  one 

taon  in  UTalta  iexer 

507 

fibroid  hmg  and  bronchi- 

Extremity, Lower; 

- 

iKTeiaxm  in  ike  neir-bcKm. . 

743 

ectasis  from     . . 

324 

-  inf antile 

155 

— 

-  at  pubeirr 

743 

general  account  of 

245 

-  talipes  in     . . 

131 

— 

■DLLbarenloMS  from   S43,  42  <, 

hEemoptxsis  in    . .        317, 

320 

Mons  xeneris,  herpes  of 

830 

564,  691,  773, 

848 

heart  failure  in  . . 

464 

Monsters,  dystocia  due  to 

227 

- 

-caberraikjiQS  peritoTittififrom 

651 

historx    of    acute    rheu- 

Moore's test  for  glycosuria 

290 

— 

jellow,  in  jaimdioe 

361 

matism  or  chorea  in  320 

773 

Mooren's  ulcer,  account  of 

807 

13 

TlVgr'c   f^raTnp 

177 

induration  of  lungs  in  . . 

245 

age  incidence  of. . 

807 

1! 

jliT  aseitffi  . . 

58 

hxiditx  in 

764 

radium  in  the  relief  of 

807 

— 

urlELe  ("see  Ghjlnria) 

malar  fiush  in     . .        •:26, 

773 

Morbus  cEeruleus.  causes  of 

579 

Wilroy's  lisease,  cedema  of  leg 

mechanism  of  bruits  due  to 

107 

clubbed  fingers  in         128, 

129 

iii  r^j.jf.  127,12<<j  456,  460 

461 

hsemoptxsis  in 

320 

polycythaemia  in 

579 

— 

-  T-'iiTS-Iologieal  ea.nses  of  . . 

57S 

nutmeg  hxer  in  . . 

764 

-  cordis  (see  Heart  Disease) 

— 

-  relarion  to    angionenrcsis 

460 

CEdema  of  legs  in 

764 

sine  murmure      . .        176, 

331 

— 

—  siEanliting  lirighT's  disease 

460 

orthopncBa  in     . .        464, 

764 

-  coxae  senilis . . 

384 

ii 

^Trr..-T-r    T.gT-— ,-)T-:^ 

S?J 

T.  .'-:  Station  in     . .        525, 

i-t.-e      congestion     of 

526 

—  maculosus  of  Werlhof      596, 
Morgagni,    hydatid    of,     cyst 

600 

2u 

iter's'  anamii.  occjIt  iisicor- 

ri.ari  it  .  . 

;-- 

:-:-gs  in 

245 

arising  from 

521 

— 

tJSLEigmilS    . . 

4-:.i 

T  rr:  :.dic  cxanosis  from. . 

579 

Morgan's  bacillus  I.  in  zymotic 

— 

jLiiisii    (see    CiniLCSis    of 

;.  ; -T i-Tthsmia  in  38,  579, 

580 

diarrhoea  . . 

426 

I.TiT-.d 

I L-— aria   in   clearing   up 

Morison,  re  pancreatitis 

485 

- 

-iT.Trm   (see     A-nVrlBStonram 

of  effusion  in  . . 

582 

Morning  cough 

176 

Xmoden^ile ) 

presjBtolie  bruit   due   to 

—  diairhcea 

197 

i. 

:rrTii'  districts,  sasizie  lileer  in 

298 

320,  580, 

790 

-  sickness,    in    chronic    alco- 

>1rrr(y-Tna"k-ers.    meremy  ©oi- 

thiill  due  to    . . 

790 

hohc  gastritis 

297 

stjuTQCT  2n 

38 

pulmonary  aUieroma  in 

cirrhosis  of  hxer. . 

410 

Hitral  area 

789 

245,  320, 

323 

Morphia,  abdominal  pain  from 

473 

— 

-  STSDolic  broils  oxer      101, 

102 

regurgitation  from    107, 

247 

-  albu-minuria  from   . . 

16 

— 

and  aortdc  disease  oomiiaed 

237 

pulsation  of  lixer  in 

764 

—  amenoirhcea  from  . . 

23 

- 

disease,     aeoentoaiion      of 

rapid  irregular  heart  in 

61 

-  Cheyne-Stokes      respiration 

heart  sounds  in  . . 

=> 

rarity  before  pubertx    . . 

62 

from 

125 

— 

-  oerebral  embolism  from  1S8 

155 

reduplicated     pulmonarj 

-  coma  due  to 

137 

— 

—   diTriTTiisT^safl  arij'iptnt*'  m    .  .. 

49 

second  sound  in 

639 

-  habit,  symptoms  worse  when 

— 

-  xenons  congestion  of  lirer  in407 

second  sound  ia. . 

108 

drug  is  not  being  taken 

527 

— 

resurgitation.'  in    adherent 

shortness  of  breath  in  . . 

578 

—  iTifa utile  convulsions  from 

170 

I'erieax'ixam     . . 

243 

slapping,      short        jBrst 

—  leucopenia  from 

401 

— 

-  from  alcioholism. . 

243 

sound  in          . .        320, 

526 

-  multiple  prick  marks  from 

— 

-  boae  disease  leading  to  . . 

241 

smaH,  intermittent  pulse  in 

245 

habit  of  injecting 

527 

— 

-  eai'diac  impulse  displaced 

tachycardia  from         245, 

772 

-  palpitation  from         . .    525, 

527 

otmrards  in     . . 

332 

thrombotic  infaTCtion   of 

-  reducing  body  in  urine  due  to 

290 

— 

-  eanses  and  signs  of 

lung  in. . 

320 

-  tremor  from            . .        795, 

797 

102,  M3, 

239 

xariouB  bruite  of  107,  108, 

109 

Morphoea,  baldness  from 

84 

— 

—  clubbed  nngers  in 

128 

lIoebius'B  mxopathx,  nbriilaiy 

—  diagnosis  from  lines  albicante 

5  402 

— 

-  enlarged  left  xentricle  in 

232 

contractions  rare  in 

158 

from  leucodermia 

575 

- 

-  from  loag-eontinued  orer- 

-  sign  in  Graxes"  disease     244, 

253 

—  pigmentation  of  the  skin  in 

424 

exertion 

244 

Hole,  epithelioma  starting  in 

803 

Morton's  disease 

488 

— 

-  s-sneral  aocxrant  of,  238. 

239, 

—  hxdatidiform,     chorion-epi- 

Morvan's disease       . .       112, 

285 

240,  241,  242, 

243 

thelioma  following 

434 

muscular  atrophy  in 

73 

— 

-  hsemoptrsis  in    . . 

320 

xaH'inal  discharge  from. . 

211 

painless  whitlows  in 

285 

- 

-  heart  f  liilTrre  in  . . 

464 

—  pigmented    lumbar    xrith 

superficial  gangrene  in  . . 

285 

— 

-  hjpienrojhj  of  the  heart  in 

102 

spina  bifida  occulta 

557 

syringomyeha  and 

563 

— 

-  impulse  disjilaeed  in 

102 

-  sarcoma  starting  in 

803 

Mosquito  bites,  lumpy  swell- 

— 

-  onhopncfca  in 

464 

—  tubal,  origin  of 

436 

ings  from 

747 

— 

—  palpitation  in 

525 

Mollities    ossium,    association 

and  malaria 

34 

- 

—  shortness  of  breath  -vnxh 

103 

■H-ith  pregnancy  • . 

369 

pruritus  from 

588 

— 

-  STstohc-  t'roit  of  . . 

102 

description  of"    .. 

269 

xesicles  from 

834 

- 

thriH  due  to    . . 

790 

distinction  from  fragiiitas 

Motor  aphasia  (see  Aphasia,  Motor) 

— 

Stenosis        

2 

ossium  . . 

269 

-  ties,  origin  of 

159 

— 

-  aJ.isenc*  of  bniii  isftih    61, 

526 

geographical  distribution 

269 

Mottling    of    lung    apices    in 

— 

enlarged  left  xentriele  in  526 

spontaneous  fracture  in 

269 

phthisis     . . 

120 

- 

histarx  of  acute  rheu- 

MoDuscum contagiosum,  char- 

Moulds in  sputum 

705 

matism  Txith 

61 

acters  of  . . 

805 

Mountain    air,    shortness    of 

— 

-  aeoentnaied  second  sound 

distinction  from  myKoma 

805 

breath  due  to 

101 

in 

330 

microscope  in  diagnosis  of 

805 

Mountaineering,  ep^taxis  from 

251 

— 

-  age  incidence  of . . 

no 

simnlatinsr  chancre 

805 

"  Mousey "     smell    in    f  axus 

— 

—  albuminuria  in   . . 

18 

teratosis  f  oBicularis   . . 

806 

270,  271, 

272 

— 

-  ascites  in. .          . .           61 

764 

xaricella 

805 

Mouth,    affection  by    bullous 

- 

-  blood-pressure  in        18.  64,  96 

—  fibrosum  of  xulxa   . . 

771 

eruptions 

114 

— 

-  bronnhial  st>enosis  in     . . 

324 

Mongolism  desmbed 

216 

-  affections   of,   causing   dys- 

- 

-  cardiac  bmiis  -srith 

773 

—  d^tinguished   from    "  myx- 

phagia  (and  see  Stomatitis^ 

225 

- 

impulse  displaced  in  . . 

345 

cedeme  iroste  "   . .       " . . 

216 

-  athetotic  moxements  of    . . 

154 

- 

'_-  eereiTal  embolism  in    .. 

338 

—  double-iointedntss  in 

216 

-  bitter  taste  in,  in  actixe  con- 

- 

-  eharacteristac   thrifl   and 

—  f aeiffi  of 

263 

gestion  of  lixer  . . 

371 

•  bruit  of 

345 

diagnosis  from   cretinoid 

264 

-  bleeding  nasxi  of     . . 

325 

— 

—  ciobbed  fingers  in 

128 

—  heart  affection  -with 

21'j 

-  breathing,      adenoids      and 

- 

-  congestion  of  lixer  in    . . 

370 

-  illustrated  (Fig.  68) 

217 

tonsils   from 

672 

- 

-  diapram  <rf  broits  in 

i09 

—  imbecDity  prominent  in    . . 

216 

snoring  from 

669 

- 

—  digitalis  in  diagnosis  of. . 

61 

-  knock-inee  in 

216 

foul  taste  due  to . . 

774 

MOUTH— MUSCULAR    SPASM 


943 


403 
673 

446 

533 
774 

789 
774 
774 
774 
774 


701 


Mouth,  eonld. 

-  catarrh  of,  cheilitis  glandu- 

laris in 

-  cliiokeu-pox  eruption  in     . . 

-  congenital  syphilitic  condy- 

lomata of 

-  drooping    of    angle    of,    in 

fai-'ial  paralysis   .  . 

-  dryness  of  in  peritonitis  . . 

-  -  due  to  dru;^ 

-  -  pneumonia  . .  . .     7 
septicteraia           . .  . .     7 

-  -  severe  fevers       . .  . .     7 

typhoid  fever      . .  . .     7 

(and  see  Tongue,  Dryness  oO 

-  esL-hars   on,    in    irritant   or 

corrosive  poisoning        . .     674 

-  Fordyce's  disease  affecting      403 

-  haemorrhage  from,  in  purpura 

hiEmorrhagica      . .  . .     600 

-  herpes  zoster  of      . .  . .     831 

-  muscles    affected    early    in 

myasthenia  gravU    _     . .     225 
trichinosis  parasites  in  . .     801 

-  non  -  pathogenic     acid  -  fast 

bacilli  in  . . 

-  open  and  expressionless  in 

cretinism. .  . .  ■ .     258 

-  operation,      broncho-pneu- 

monia after  . .  . .     321 

-  pain  in,  causing    dysphagia     225 

-  pigment     deposits     in,     in 

Addison's  disease  574,  849 

-  small-pos  eruption  in       . .     673 

-  tremors  of,  in  chronic  alco- 

holism 

-  ulceration  within    . . 
Movable    kidney,    absence   of 

symptoms  in 

albuminuria  from 

confusion    with    enlarged 

kidney  . . 

-  -  with  constipation 

-  -  diasnosis    from    enlarsed 

gaU-bladder      . . 

Dietl's  crises  in     310,  729 

frequency  of  micturition310,4oS 

gastro-intestinal   disturb- 
ance in. .  . .  . .     310 

gastroptosis  with  . .     353 

hnematuria  from. .         304,  310 

hydroneplvrosis  from 

500,  583,  729 

intermittent     hematuria 

from 310 

jaundice  from      . .  . .     367 

kinking  of  ureter  in        . .     500 

lumbar  aching  in  . .     310 

-  -  pain  in      . .  . .        499,  500 

palpable  in  riszht  iliac  fossa  729 

polyiiria  in    "SIO,  581,  5S3,  729 

-  -  sickening     sensation     on 

compression  of 
simulated  by   appendicu- 
lar abscess 

-  -  -  colon  carcinoma 

enlarged  gall-bladder . . 

Fallopian  tube  affection 

gall-stone 

-  -  -  hydatid  cyst    . . 

-  -  -  mucocele 

omental  masses  . .     727 

ovarian  tumour  . .     727 

Eiedei's  lobe   . .        279,  727 

scybala. .  ..  ..     727 

simulating  biliary  colic  . .     500 

-  -  swelling  in  iliac  fossa  from     737 

symptoms  and  signs  of. .     727 

transient  polyuria  due  to 

hydronephrosis  from  581,  583 
undue    abdominal   aortic 

pulsation  associated  with  592 

vomiting  with     . .  . .     844 

.c-rays  in  diagnosis  of    . .     583 


88 


310 

8 


844 


367 


500 

727 
281 


Movements,  associated,  in 
parah-sis  of  cerebral 
origin        ..  ..  ..518 

-  in.    avoidance    of    contrac- 

tures        . .  . .  . .     105 

-  choreiform  (see  Contract  ions) 

-  inco-ordiuated  Csee  Ataxy) 

-  involuntary    fsee    Contrac- 

tions and  Athetosis) 

-  pain  in  limbs  on,  in  neuro- 

myositis   . .  . .  . .     504 

-  voluntary,      the      neuro- 

muscular mechanism  of         64 
Mucocele,  simple,  gaU-bladder 

enUirgement  from         280,  281 
Muco-membranous  colitis  (see 

Colitis^ 
Mucous    colic,    synonym    for 

muco-membranous  colitis     133 

-  colitis  (see  Colitis) 

-  membrane  lesions  of  syphilis, 

sptrochteta  pallida  m     . .     371 

affected  by  favus  . .     270 

hcemorrhage     from     (see 

Hemorrhage) 

herpes  of 

leprosy  nodules  on 

paUor  from  haemorrhage 

pemphigus,  etc.,  of 

pigmented    in    Addison's 

disease. . 

from  silver 

rinsworm  affecting 

septic  ulceration  of 

small-pox  eruption  on  . . 

varicella  eruption  in 

-  polypus  of  cervix  . . 

-  tubercles    developing    from 

papular  syphillde 

-  -  in  syphilis  ..         677, 

on  scrotum 

ilucus  in  the  gastric  juice  in 

gastritis     . . 

-  passage  of,  per  rectum 
MUCUS  IN  THE  STOOLS  (and 

see  Fipces,  ilucus  iui 
MUCUS  IN  THE  URINE 
associated  with  uric  acid 

deposit . . 

in  cystitis  . .        221, 

hasmoglobinuria  . . 

in  herpetic  urethritis 

metlaylene  blue  and  eosin 

staining  of 

simulated   by   tube-casts 

urates    . . 

with  tuberculous  kidney 

uric  acid  crystals 

ilulberry  rash  in  typhus  fever 
Multiple  abscesses  of  liver  (see 
Abscess,  Hepatic) 

-  benign     sarcoid,     diagnosis 

from  lupus  and  sarcoma 

-  neuritis  (see  Neuritis) 

-  serositis 
Mummification 
Mumps,  albumimu'ia  in 

-  diagnosis  from  acute  CEdema 

of  neck     . . 
cervical  adenitis 

-  dysphagia  in  . .        225, 

-  hydrocele  in 

-  leucocytosis  uncommon  in 

-  lymphocytosis    in    cerebro- 

spinal fluid  in      . . 

-  nerve  deafness  after 

-  orchitis  from       79,  517,  518, 

-  pain  in  neck  from  . . 

-  pancreatitis  from   . . 

-  ptyalism  from  difficulty  of 

swallowing  in 

-  rigors  in 

-  sore  throat  from     . .        671, 

-  stiff  neck  from 


830 
450 
646 
114 

849 
575 
272 
830 
605 
833 
587 

532 
678 
631 

352 
690 

443 
444 

810 
628 
314 

209 

444 
444 
815 
306 
816 
371 


123 

232 
16 

674 
674 
674 
522 
400 

339 

190 
765 
674 
116 

591 
647 
674 
674 


Mumps,  mntj. 

-  swelling  of  face  in  . .  . .     74t; 

in  salivary  glands  in       . .     671 

unilateral    becoming    bi- 
lateral in  . .  . .     C74 

-  testicular  atrophy  after     . .       79 

-  trismus  simulated  by         . .     801 
Murmurs,  cardiac  (see  P.ruits, 

Cardiac) 

-  vesicular(see  Vesicular  Munnors) 
Museae  voUtantes,  relieved  by 

epistaxis  . .  . .  . .     252 

Muscle  in  embryoma  of  kidney    395 

-  fibres  in  fiEces  In  pancreatitis 

117,  364 
Muscles,  chief  site  of  pain  in 
some    cases     of    chronic 
rheumatism  . .  . .     507 

-  condition  of  in  hemiplegia      33K 

-  tibrillar  contractions  of     . .     157 

-  heat    production   from    ac- 

tivity of 619 

-  hyperalgesia     of,     ui    peri- 

pheral neuritis    . .  . .     660 

-  importance     of     analyzing 

distribution  in  paralysis  of    549 

-  inhibitory    pains    in,    mis- 

taken "for  paraljrsis         . .     545 

-  innervated      by       brachial 

nerves,  table  of  . .  . .     550 
lumbar  and  sacral  plextises  543 

-  o£    lower    limb,    tables    of 

innervation  of    . .         542,  543 

-  normal  and  abnormal  elec- 

trical reactions  in  . .     633 

-  pain  in,  in  peripheral  neuritis  551 

-  rigidity  of  (see  Eigidity  of 

Muscles) 

-  rupture  of,  purpura  from  596,  597 

-  spontaneous  rupture  of,  pal- 

pation of  the  gap  in      . .     597 

special       UabiUty      of 

plantaris  longus  to       597 

-  strong  in  achondroplasia  . .     212 

-  sweUings  in,  in  trichinosis        504 

-  tenderness  of  (see  Tender- 

ness of  Muscles) 

-  thenar     and      hypothenar, 

spinal  nerve  roots  supplying 556 

-  trichinosis  parasites  in     504,  801 

-  wasted  (see  Atrophy,   Mus- 

cular) 

-  weak    in    osteogenesis    im- 

[  perfecta    . .  . .  . .     213 

osteomalacia        . .  . .     213 

I  Muscle-tone,  factors  influencing  161 

I  -  increased  in  brachial  mono- 

'  plegia        . .  . .  . .     546 

j  Muscular  atrophy  (see  Atrophy, 
I  Muscular) 

-  contractions   (see    Contrac- 

tions) 

I physiology  of      . .  . .     794 

I  -  distribution      of      braiiiial 

:  plexus,  table  of  . .  . .     550 

-  dystrophies  (see  Myopathy) 

-  exertion,  cramp  from        . .     177 
displacement    of    cardiac 

impulse  in       . .        330,  333 

-  hypenesthesia  in  neuritis  . .     105 

-  inaction  in  illness,  club-foot 

from  . .  . .  . .     133 

-  inco-ordination  in  neuritis        506 

-  over-strain,    acute    general 

pains  in  the  limbs  in      . .     503 

slight  pyrexLi  in . .  . .     503 

tenderness  of  muscles  in      503 

-  paralysis  (see  Paralysis) 

-  rheumatism  . .  . .     507 
diagnosis  of  tetanus  from    162 

-  rigidity  in  acute  polymyo- 

sitis   504 

-  spasm,  post-hemiplegic      . .     157 
(see  Contractions,  Spasmodic) 


944 


MUSCULAR    STRAIN— MYOPATHY 


Muscular  strain,  aortic  disease. 

Mycetoma,  atrophy  of  leg  in 

810 

Myelocytes,  contd. 

from          ..          .,        237 

238 

-  bacteriology  of 

809 

-  lymphatic  leukaemia 

32 

-  tencleriiess  fsee   Tenderness 

-  distinction     from      actino- 

- pernicious  anaemia 

30 

in  Muscles) 

mycosis     . . 

810 

—  splenic  anaemia 

64 

-  twitchings  and  anuria 

48 

-  general  account  of  . . 

809 

Myeloid  sarcoma  (see  Sarcoma 

in  urasmia 

45 

-  swelling  of  the  foot  in 

810 

Myeloid; 

-  wealcness  in  chorea 

15G 

iVIycosJS  fungoides,   cliaracters 

Myelomata,  Bence-Jones'  albu- 

 diffuse  Icypliosis  from    . . 

182 

of 803, 

804 

mosuria  with 

21 

lordosis  from 

183 

lymph,  glands  enlarged  in 

804 

Mylabris  used  by  malingerers 

ilusculature  of  the  psrineum, 

pruritus  in 

588 

as  vesicant 

113 

spinal  nerve  roots  supply- 

 simulated  by  eczema     . . 

804 

Myocardial    affections,    albu- 

ing  

543 

of  the  skin 

802 

minuria  in 

18 

Musculo-cutaneous    nerve, 

-  of  nails 

445 

age  incidence  of  . . 

103 

muscles  supplied  by 

550 

Mydriasis  (see  Pupils,  Abnor- 

- -  alcoholic   . , 

238 

-  -  numbness  in  distribution, 

malities  of) 

ascites  in 

01 

of  in  sciatic  neuritis  . . 

487 

Mydriatics  contraindicated  in 

Oheyne-Stokes  respiration 

sliin  distribution  of 

059 

glaucoma 

257 

in 

125 

spinal  roots  derived  from 

550 

-  dilatation  of  pupil  from    . . 

595 

congestion  of  liver  in     . . 

407 

Musculo-spiral  nerve,  muscles 

-  in  iritis 

257 

displacement  of  impulse  in 

330 

supplied  by 

550 

Myelitis,  acute  bedsore  in     . . 

286 

dyspnoea  on  exertion  from 

333 

skin  distribution  ol 

659 

hyperpyrexia  in 

344 

feeble   irregular   pulse   in 

333 

spinal  roots  derived  from 

550 

onset  of  paraplegia  due  to 

562 

feebleness  of  impulse  in. . 

333 

tenderness  over,   in   bra- 

- affecting  lumbar  section  of 

gallop  rhythm  in 

333 

chial  neuralgia 

491 

cord,  loss  of.  knee-jerks  in 

398 

heart  failure  from 

461 

-  paralysis 

552 

-  anaesthesia  from 

484 

improvement  under  digi- 

 history  of  use  of  crutch  or 

-  aortic  aneurysm   causing.. 

504 

talis 

526 

of  fractured  humerus  in 

549 

-  arms  not  usually  affected . . 

565 

Schott's      Nauheim 

in  lead  neuritis  . . 

77 

-  Babinski's  sign  in  . . 

82 

treatment     . . 

526 

-  bladder  spasm  in    . . 

443 

increase     of     pulse-rate 

handling  . . 

200 

-  causes  of   compression  pro- 

after exercise  in 

526 

-  vomiting  from 

843 

ducing  . . 

564 

insomnia  in 

356 

Mutism  in  dementia  . . 

682 

-  causing  contracture 

102 

oedema  of  legs  from      333 

461 

sudden  complete  restora- 

- chronic  cystitis  in  . . 

628 

palpitation  in      . .         333 

526 

tion  of  speech  in 

682 

-  compression    pain    in    um- 

 diiBculty    of    diagnosis 

Myalgia  of  the  back,  lumbago 

bilical  region  in  . . 

525 

from  dyspepsia 

526 

from 

507 

-  constipation  in 

149 

senile,  cardiac  impulse  dis- 

- chill  as  a  cause  of    . . 

507 

-  contractures  in 

164 

placed  in 

333 

-  chronic  general  pains  in  the 

-  diagnosis  of  progressive  mus- 

 shortness  of  breath  in  . . 

101 

limbs  in   ..          ..         503 

507 

cular  atrophy  from 

73 

soft  systolic  bruit  in 

333 

-  definition 

478 

-  difficult  micturition  in     440 

443 

in  Stokes-Adams'  disease 

97 

-  pain  in  chest  in      . .         477 

507 

-  dorsal,  loss  of  knee-jerks  in 

398 

symptoms  of 

103 

-  pleurodynia  from  . . 

507 

precipitate  defsecation  in 

348 

syncopal  attacks  in 

335 

-  simulating    occipital    Iiead- 

-  at    ninth    dorsal    segment. 

systolic  mitral  bruit  in  102 

103 

ache 

326 

analgesia  from  (Fie/.  179) 

663 

varieties  of            . .         54 

464 

-  stiff  neck  from 

507 

-  gangrene  in . . 

282 

Myocarditis,   acute,   in    acute 

-  tenderness  in  tlie  chest  from 

776 

-  girdle  pain  in          . .         289 

484 

rheumatism 

241 

of  muscles  in 

478 

-  due  to  influenza     . . 

565 

interstitial 

241 

Myasthenia  gravis,  absence  of 

-  in  lesions    at    lumbar     en- 

 parenchymatous 

241 

atropliy  of  muscles  in    . . 

687 

largement,     reaction     of 

-  bone  disease  leading  to    . . 

241 

bulbar    paralysis    distin- 

degeneration in  . . 

563 

-  causing  mitral  regurgitation 

guished  from    . . 

225 

wasting  in    . . 

563 

239, 

241 

characteristic  smile  of  . . 

260 

-  loss   of   convergent   accom- 

- dilatation  of  left  ventricle  in 

241 

chin-drop  in 

260 

modation  with  retention 

-  dyspnoea  in 

241 

closing  of  eyes  in  (Fig.  83) 

260 

of  light  reflex  in 

594 

-  feeble  irregular  pulse  in    . . 

241 

described . . 

225 

-  main  types  and  causes  of. . 

564 

-  pain  and  tenderness  in  the 

dysarthria  in 

087 

-  pain  in  the  back  in. . 

475 

back  from 

789 

dysphagia  in       . .        225, 

842 

-  paralysis     of     bowel     and 

-  palpitation  in 

241 

early      supervention      of 

meteorism  in  . . 

432 

-  precordial  pain  and  distress  in  241 

fatigue  on  faradism  in 

634 

-  paraplegia  due  to   . . 

561 

-  pysemic 

241 

electrical  reaction  in  dia- 

- relation  of  injury  to 

564 

-  signs  of  cardiac  failure  in  . . 

241 

gnosis  of 

225 

of  syphilis  to       . .         504 

565 

-  sudden  collapse  in  . . 

241 

facial  asymmetry  in 

261 

-  retention  of  urine  in 

441 

Myoclonus       

160 

facies     described     (Fic/s. 

-  scarlet  fever  causing 

565 

-  clonic  contractions  of 

101 

83,  84) 

260 

-  sensory  disorders  in 

563 

-  convulsions  with     . . 

109 

marked  variation  of  sym- 

- simulating     amyotropliic 

-  in  epilepsy  . . 

100 

ptoms  with  condition  of 

lateral  sclerosis  . . 

74 

-  hysteria 

100 

rest  or  fatigue  in 

087 

-  spastic     paralysis     of     one 

Myokymia   of  calf  muscles  in 

—  nasal  quality  m  voice  in 

087 

leg  in 

540 

intermittent  claudication 

490 

ocular  palsy  in   . . 

087 

-  transverse,  diagnosis  of  polio- 

- definition  of 

490 

ptosis  in  . . 

590 

myelitis  from 

74 

Myoma  cutis,  contraction  under 

ptyalism  in 

591 

Tooth's  atrophy  from 

74 

the  influence  of  cold 

805 

regurgitation      of      food 

knee-jerks  in 

398 

distribution   of    . . 

805 

through  nose  in 

202 

main-en-griffe  in 

74 

Myopathy,  absence  of  sensory 

thinning  of  tongue  in     . . 

087 

paraplegia  due  to 

562 

changes  in 

70 

tiring  of  knee-jerk  in     . . 

399 

reflexes   in            .  .    74,  82 

398 

-  affecting  quadriceps  muscle. 

-  -  weakness     of     zygomatic 

sphincter  troubles  in     .  . 

74 

loss  of  knee-jerks  in 

398 

and  risorius  muscles  in 

260 

-  from  typhoid  fever 

565 

-  distinction  from  neuritis  70, 

561 

Jlycelium,    Gram-staining,    in 

-  of     upper     dorsal     region, 

-  electrical  reactions  in 

70 

pus  in  actinomycosis 

748 

priapism  in 

586 

-  fibrillar  contractions  rare  158 

549 

-  in  erytlirasma 

277 

Myelocytes,  characteristics  of 

-  heredity  in  . .          . .  70,  560, 

501 

-  of  favus 

270 

(Ptale  II) 

29 

-  infantile  and  juvenile  types  of  561 

-  microsporon    minutissimum 

277 

-  in   Hodgkin's   disease 

-  Landouzy  -  Dejerine,      bi- 

- ringworm 

272 

41,  76,  303 

695 

lateral  facial  palsy  in     . . 

087 

-  tinea  versicolor 

276 

-  leukaemia         31,  64,  76,  302, 

692 

-  lordosis  of,  illustrated 

183 

MYOPATHY— NEEDLEWOMEN'S    CRAMP 


945 


Mi/opalfi;/,  contd. 

-  ncuropatliic  muscular  atrophy 

simulating  . .  . .     158 

-  ooular  symptoms  of  .  .      -GO 

-  jiaralysis  of  nrm  in. .  ..     555 

-  paraplegia  in  children  from 

5G0,  5C1 

-  ]Jouting  lips  in  (Fig.  81)    . .     i'GO 

-  iiseudo-hypertrophic  . .     5G0 

-  reflexes  in    . .  . .  . .       70 

-  scoliosis  due  to       . .        180,  181 

-  transverse  smile  of  (Fig.  82)     260 

-  varieties  of . .  . .  . .     158 

Myopathic     facies     described 

(Figs.  81,  82)  . .  . .  260 
Myopia,  crescents  in  . .  461,  4G2 
influence  of  age  on        . .     462 

-  -  ophthalmoscopic   appear- 

ance of  (Plate  VII)   461,  462 

-  divergent  squint  due  to     . .     709 

-  large  pupil  in  . .  . .     594 

-  nyctalopia  from       .  .  .  .     841 

-  posterior  staphyloma  in    . .     4G2 
.Myosis     (see     Pupil,     Abnor- 
malities of) 

Myositis,  acute  general  pains 
in  limbs  in 

-  intercostal,    pain    in    chest 

from 
tenderness   in  chest  from 

-  from  invasion  of  muscles  in 

trichinosis 

-  ossificans,  trismus  simulated 

by  

ifyotic  drugs,  constriction  of 

pupil  from  use  of 
Myotonia  atrophica,  fibrillary 

contractions  rare  in 
Myxoedema,  abnormal  breadth 

of  nose  in 

-  absence  of  sweating  in 

-  affection     of     hands     and 

feet  in 

-  age  incidence  of 

-  amenorrhaea  in        . .         23, 

-  brittle  striated  nails  in 

-  broad  features  in    . .        454, 
fingers  and  hands  in 

-  coarse  dry  skin  in  . . 

-  cyanosis  in  . . 

-  Dercum's  disease  simulating 

-  diagnosis     from     paralysis 

agitans 

-  dryness  of  skin  in  . . 

-  facies  of  (Figs.  76,  77) 

-  falling  out  of  hair  and  eye- 

brows m  . . 

-  fruste,  described     . . 

-  hypothermia  in 

-  illustrated  (Figs.  76,  77)  43,  258 

-  increasing  obesity  in  259,  454,  460 
weight  in  . .  . .     585 

-  intellect,  changes  in  43,  454,  585 

-  intellectual  dullness  in      . .     585 

-  leucocytosis  in         . .  . .     400 

-  malar  flush  of         . .  . .     454 

-  mental  changes  in  43, 454, 4G0,  585 

-  oedema  of  legs  in    . .  . .     461 

-  polyuria  in  583,  585 

-  pseudo-oedema  of  legs  in  . .     585 

-  puffy  eyelids  of      . .  . .     259 

-  sallow  complexion  of         . .     259 

-  scanty  hair  in         . .  . .     259 

-  sex  incidence  . .  . .     460 

-  slowness  of  speech  in        . .     259 
pulse  in    . .  . .  98,  259 

-  subcutaneous  hyperplasia  in     259 

-  swelling  of  legs  in  . .  . .     460 
lips  in       . .          . .  . .     259 

-  symptoms  of  . .  . .       42 

-  thickening  of  ears  in         . .     259 

-  thyroid  treatment  in         . .     259 

-  -  in  diagnosis  of       454,  460,  585 

-  urine  in        . ,  . .  . .     460 


503 

776 
776 

504 

801 

595 

158 

259 

585 

455 
460 
430 
259 
585 
454 
259 
259 
455 

259 

585 
259 

454 
216 
345 


Myxoma,  characters  of 

-  distinction  from  moUoscum 

contagiosum 

N^EVI,  blood  oozing  :  of  skin 
and  mouth 

-  capillary,     diagnosis     from 

])urpura    . . 

macules  due  to   .  . 

NAILS,  AFFECTIONS  OF 

by  favus  .  .  .  .         271, 

-  brittle 

-  -  striated  in  myxoedema  . . 

-  capillary  pulsation  in 

-  disorders  of  nutrition,  dia- 

gnosis from  ringworm    . . 

-  eczema  of,    diagnosis   from 

ringworm  of  nails 

-  egg-shell,  relation  to  hyper- 

idrosis 

-  epidermolysis  bullosa  affecting 

-  exfoliation  in  ringworm    . . 

-  gouty,  diagnosis  from  rmg- 

worm  of  nails     . . 

-  greyish  stains   of,    in   ring- 

worm 

-  onychomycosis  of   . . 

-  orange-rind  type,  in  eczema 

-  psoriasis  of,  "diagnosis  from 

ringworm  of  nails 

-  reddening  of,  in  onychia  . . 

-  rheumatic,    diagnosis    from 

ringworm  of  nails 

-  ringworm  of  (see  Ringworm 

of  Nails) 

-  sliedding  of..  ..  85, 

-  staining   in   dyers,    washer- 

women, jewellers 

-  in  syringomyelia     . . 

-  thick,  brittle  in  ringworm . . 

-  transverse  ridging  of 

-  trophic  changes  of  in  acute 

illness 

-  white  spots  on,  origin  of  . . 

-  yellow  stains  in  favus    . . 
Nanosomia  (see  Dwarfism)    . . 
Naphtha,  hasmoglobinuria  from 

-  peripheral  neuritis  from    . . 
Naplithol,  h?emoglobinuria  from 
NAPKIN-REGION  ERUPTIONS 
Narcotic    poisoning,    Cheyne- 

Stokes  respiration  ua     . . 
Nares,  pruritus  of 

-  working  of  in  pneumonia  . . 
Nasal  bones,  necrosis  of,  anos- 
mia from . . 

causes  of 

foul  breath  due  to 

obstruction  to  nose  by 

in  syphilis 

-  diphtheria,  how  to  recognize 
Nasal  discharge  (see  Discharge, 

Nasal) 

-  inflammation,  referred  pain 

in  fronto-nasal  and  mid- 
orbital  areas  in   . . 

-  nerve,   skin    distribution  of 

-  obstruction   (see  Nose,  Ob- 

struction  of) 

-  process,       hyperplasia        in 

acromegaly 

-  secretion,  micrococcus  catar- 

rhalis  in,  in  influenza 

-  sinuses,  dilatation  of  :  com- 

pression of  optic  nerve  by 

sudden  blindne-^s    from 

Naso-labial  area,  pain  and 
tenderness  in,  in  caries  of 
canine  tooth  (Fig.  132). . 

-  folds,    affection    by    sebor- 

rhoeio  eczema 

inequality  in  hemiplegia 

obliteration  of,   in  facial 

paralysis 


595 
423 
444 
275 
445 
269 
233 

275 

275 

445 
445 

275 


498 
659 


263 
505 


840 
839 


533 
337 


Naso-pharynx,  libro-sarcoma  of   669 

-  lipjulaciic  in  catarrh  of       .  .      327 

-  intoctioii,  meningitis  from. .     642 

-  otitis  media  from  . .  . .     230 

-  new     growths     in     causing 

epistaxis  . .  . .  . .     250 

Nausea 

-  absent  in  cerebral  vomitin: 


134, 


847 

847 

..  845 

..  472 

..  846 

.  .   671 

302,  370 

..   368 

75,  297 

..  268 

.  '  ..   84 

..   365 

.  .   350 

299,  351 

.  .  298 

297.  352,  S45 

.  .  473 


giiatric  crises 

-  in  acute  gastritis    . . 

general  peritonitis 

pancreatitis 

rheumatism 

yellow  atrophy  . . 

-  alcoholism    . . 

-  arsenical  poisoning 

-  associated  with  flushing 

-  with  bacteriuria 

-  catarriial  jaundice 

-  early  plithisis 

-  gastric  carcinoma 
ulcer 

-  gastritis 

-  intestinal  colic 
obstruction  . .  . .     846 

-  lead  poisoning         . .  . .       77 

-  Meniere's  disease    . .  . .     828 

-  in  migraine  . .  . .  . .     847 

-  onset  of  scarlet  fever        . .     843 

-  in  phosphorus  poisoning  . .     373 
-portal   obstruction..  ..     300 

-  preceding  haematemesis     . .     316 

-  in  tuberculous  peritonitis. .     719 

-  undue  abdominal  aortic  pul- 

sation       . .  . .  . .     592 

Neck,   acne   vulgaris    of      531,  604 

-  actinomycosis  of     . .  . .     810 

-  acute  oedema  of,  diagnosis 

from  mumps       . .  . .     674 

-  cellulitis    of    (see    Cellulitis 

of  Neck) 

-  glands   of   (see    Lympliatic 

Glands,  Cervical) 

-  long,  in  phthisis     . .  . .     191 

-  motor  tics  affecting  . .     160 

-  muscles    affected    early    in 

myasthenia  gravis  . .     225 

in     Henoch's     chorea 

electrica        . .  . .     157 
clonic  contractions  of    . .     161 

-  oedema  of  (see  CEdema  of  Neck) 

-  pain  in  (see  Pain  in  Neck) 

-  pigmentation  of  the  skin  in 

xerodermia  pigmentosuna     804 

-  rigidity    of,    from    cervical 

caries        . .  . .  . .     708 

-  scars  in,  from  scrofulodermia     449 

-  seborrhcea  of  447,  656,  657 

-  segmental    areas    of  (Figs. 

132,  135) 497 

-  short,  in  apoplectic  cases  . .     191 
in  emphysema     . .  . .     192 

-  stiffness     of,     in    muscular 

rheumatism  . .  . .  162 
m  tetanus              162,  463,  652 

-  tumour  in  posterior  triangle 

of,     simulating     brachial 
neuritis     . .  . .  . .     492 

-  veins,  diastolic  collapse  of, 

in  adlierent  pericardium  104 
Necrobiosis  in  fibroids  . .  759 
Necrosis,    arthritis   from   (see 

Arthritis,  Acute  Secondary) 

-  of  bone  (see  Bone,  Necrosis  of) 

-  of  cartilage  in  lupus  vulgaris     448 

-  extremities,     recurrent     in 

Raynaud's  disease  . .     284 

-  fat  (see  Pat  Necrosis) 

-  jaw  (see  Jaw,  Necrosis  of) 
Necrospermia,  sterility  due  to 

706,  707 
Needles  in  the  rectum  . .     635 

Needlewomen's  acroparsesthesia  493 

-  cramp  .  .  . .  .  .     494 

6o 


94^ 


NEEDLING— NEURA  STHENIA 


Needling  of  antrum  of  High- 

Nervous  causes,  jaundice  due 

237 

Seuralgia,  brachial,  conld. 

more 

502 

to 

tenderness  over  nerves  in 

491 

-  of  chest  in  empyema 

186 

-  diarrhcea,  chronic  . . 

197 

posterior     triangle     of 

pyopneumothorax 

712 

-  diseases,    abnormalities     of 

neck  in 

491 

pyo-,       hsmo-,        and 

micturition  in      . .         440, 

442 

tingling  with    nerve  ten- 

hydropneumothorax 

711 

amenorrhoea  in   . . 

23 

derness  in 

491 

exploratory 

577 

of  children,   tea-drinking 

-  facial  from  suppuration  in  a 

-  in    diagnosis    of    distended 

causing.. 

357 

tooth         

497 

ilio-psoas  bursa  . . 

734 

constipation  in   . . 

149 

varieties  of 

495 

-  -  subphrenic  abscess 

720 

loss  of  knee-ierks  in 

398 

-  in  inferior  dental  nerve,  dia- 

Jfegro cacliexy 

115 

from  round-worm  infection 

569 

gnosis  of  . . 

502 

Neisser,    gonococcus    of    (see 

spasmodic       contractions 

-  intercostal,  aortic  aneurysm 

Gonococci) 

a  minor  sign  in 

159 

mistaken  for 

777 

Xeoplasms    (see     Carcinoma, 

—  excitability    in    exophthal- 

 diagnosis  from  intercostal 

Sarcoma,  etcj 

mic  goitre 

792 

nerve    pain    from    or- 

Nephritis  (and    see    Brighfs 

night  terrors  iu  . . 

447 

ganic  disease  . . 

478 

Disease     and     Granular 

-  exhaustion,  convulsions  from 

169 

after  herpes 

478 

Kidney) 

insomnia  in          . .         356, 

358 

influence  of  breathing  on 

478 

-  ascending,  hyperpyrexia  in 

344 

spasmodic  contraction  from  159 

mediastinal   new   growth 

chronic,  albuminuria  in  8, 10, 11 

—  factors   in   acromegaly   and 

mistaken  for   . . 

777 

-  ascites  in 

54 

myxcedemg 

.=585 

-  -  pain  in  epigastrium  in  . . 

485 

-  anuria  in      . .          . .          .Ac 

,  48 

-  heredity  in  pavor  nocturnus 

357 

increased  on  movement 

-  chronic  ascending  . .          . .  8,  10 

-  instability    in    infants,    in- 

or breathing 

478 

-  in  epidemic  jaundice 

372 

somnia  in 

357 

in   the   left  hypochon- 

-  febrile  albumtriuria  and     . . 

17 

—  mimicry  of  joint  affections 

389 

drium  in 

499 

-  ia  pregnancy 

11 

-  symptoms  in  acute  yellow- 

right  hypochondrium  in 

501 

-  rigors  in 

647 

atrophy  of  liver  . . 

370 

pneumonia  mistaken  for 

-  suppurative,  albumimu-ia  from  646 

cirrhosis  of  liver . . 

410 

480, 

777 

bacteriuria  from 

64G 

ovarian  insuificiency 

454 

points  of  maximum  ten- 

- -  casts  in  the  urine  from  . . 

646 

-  system,  effeot  on  phosphorus 

derness  in 

478 

hfematuria  from 

646 

excretion     of     wear    and 

spinal     caries     mistaken 

pyrexia  in 

646 

tear  of 

572 

for         ..          ..        181, 

777 

pyuria  from 

646 

Nervousness  due  to  alcohol. . 

797 

tender  points  along  nerve 

sunulated  by  appendicitis 

646 

-  alcoholism  sunulated  by  . . 

797 

in           ..            478,  485, 

499 

acute  general  peritonitis 

646 

-  in  Graves*  disease     253,  772 

849 

tenderness  in  the  chest  from  776 

tenderness    in    loin    with 

646 

-  polyuria  due  to                581, 

582 

along  affected  space  in 

478 

vomiting  in 

646 

-  tachycardia  from   . . 

772 

diagnosis  of     . . 

501 

Xephroma,  liwmaturia  in  304, 

307 

-  tremor  due  to        . .        795, 

797 

-  intestinal 

134 

-  origin  in  adrenal  rests 

307 

-  with     undue      abdominal 

-  in  the  lower  jaw 

501 

-  slow  growth  of 

307 

aortic  pulsation. . 

592 

diagnosis  of 

501 

Nerve  deafness  and  its  causes 

190 

Neuralgia   in   astigmatism    . . 

498 

-  mammary  (see  ilastodynia) 

-  fibres,    opaque,    normal    in 

-  conditions  mistaken  for     . . 

783 

-  metatarsal    . . 

48S 

rabbit 

462 

-  from  dental  caries            330 

502 

-  minor,  pain  in  face  secondary 

opaque,  of  retina,  ophthal- 

—  diagnosis  from  headache  . . 

330 

to  local  disease  . . 

496 

moloscopic  appearance 

-  earache  in    . . 

230 

two  types  of  pain  in 

496 

of  (Plate  ril)  .. 

462 

-  from    errors    of    refraction 

498 

-  obturator 

488 

-  roots,    affections    inTolving 

-  examination    of    urine    for 

-  ovarian,  simulating  appen- 

eighth cervical  and  first 

sugar  in  all  cases  of 

488 

dicitis 

729 

dorsal,      oculo  -  pupillary 

-  in  heels  in  calcanodynia  . . 

488 

-  paresthetica,  flat-foot  hi.. 

488 

phenomena  in     . . 

494 

-  pain  in  chest  from. . 

477 

increase  on  standing 

488 

of  brachial  plexus,  table 

-  -  upper  jaw  in 

502 

in  obesity 

488 

of  muscular  distribution 

556 

-  paroxysmal  headache  in  . . 

326 

pain    along    external  cu- 

- spinal,    inflammation    near 

-  ptyalism  due  to     .  . 

591 

taneous  nerve  in 

488 

posterior    root    ganglion, 

-  tender  spots  in 

33i! 

tender    spot    below    an- 

anaesthesia in 

494 

-  tenderness  of  scalp  from  781, 

782 

terior  iliac  spuie  in     . . 

488 

muscular   wasting  in 

494 

-  tinnitus  with 

794 

-  phrenic,   simulated   by  dia- 

 radicular  paui  in     . . 

494 

-  trismus  from 

801 

phragmatic  pleurisy 

479 

-  supply  of  ascending  aorta  481 

778 

-  abdominal 

473 

hepatic  disorders 

479 

diaphragm 

779 

entero-spasm  in  . . 

473 

peritonitis 

479 

-  -  heart         . .          . .        481, 

778 

evil  effects  of  morphia  in 

473 

splenic  disorders 

479 

-  symptoms     in     functional 

exclusion  of  spinal  disease 

spinal  caries    . . 

479 

paralysis  of  vocal  cords. . 

538 

in  diagnosis  of 

473 

pain    on    coughing    and 

-  of    A^'risberg,    skin    distri- 

 general    abdominal    pain 

breathing  in    . . 

478 

bution  of . . 

659 

from 

473 

round  site  of  insertion 

-  trunk,   severe   pain    associ- 

 sex  incidence  of . . 

473 

of  diaphragm 

478 

ated  with  anaesthesia  due 

-  anterior  crural 

488 

-  supra-orbital,   in  iritis   and 

to  complete  lesion  of     . . 

475 

-  brachial,  absence  of  atrophy 

cyclitis 

256 

Nerves,  brachial,  table   show- 

or anaesthesia  in. . 

492 

-  trigeminal    (see  Trigeminal 

ing  muscles  innervated  by 

550 

in  alcoholism 

492 

Xeuralsia) 

-  of  lumbar  and  sacral  plexuses. 

always  unilateral 

492 

Neurasthenia,     absence     of 

tables    showing    muscles 

from  cervical  rib 

492 

muscular  wasting  in 

787 

distributed  to     . .        542, 

543 

constant      aching      pain 

-  acute  general  pains  in  the 

-  normal  and  abnormal  elec- 

with   exacerbations    in 

491 

limbs  in    . . 

503 

trical  reactions  in 

633 

in  diabetes 

492 

-  aggravating  menstrual  pain 

220 

-  olfactory,  abnormalities  of 

669 

diagnosis  of 

492 

-  ankle  clonus  in 

787 

-  -  congenital     absence     of. 

from  muscular  rheum- 

- Babmski's  sign  not  present  in 

787 

anosmia  from . . 

669 

atism 

492 

-  constipation  in 

144 

-  sensory  skin  distribution  of 

flushins  and  hyperidrosis  in  491 

-  dy^menorrhoea  in  . .        219, 

220 

(Fig.  174) 

659 

in  soutv  diathesis 

491 

-  dyspepsia  in 

506 

-  thickening     of,    in    leprosy 

424 

influenza  . . 

492 

-  effect  on  phosphorus  excre- 

 von      Kecklinghausen's 

malaria     . . 

492 

tion           

572 

disease  . . 

804 

pain  in  the  arm  in 

491 

-  eructatio  nervosa  in 

267 

-  (and  see  the  various  nerves 

in  rheumatic  diathesis  . . 

491 

-  headache  in            . .        500, 

788 

by  name) 

skin  iiyperaesthesia  in   . . 

491 

-  byperaesthesic  spots  with  . . 

667 

NE  URA  ST  HEN  I A  —NE  UROSIS 


947 


Neurasthenia,  contd. 

Neuritis,  multiple  peripheral,  contd. 

Neuritis,  multiple  peripheral,  contd. 

-  and    hysteria,    difficulty   o£ 

alcoholic,  loss  of  memory 

simulated  by  growths  of 

distinguishinn; 

788 

for  recent  events  in 

505 

pelvis  or  cauda  equina 

562 

-  ill-effect  of  worry  on 

788 

lying  without  wish  to 

muscular  atrophy  . . 

69 

-  imaginary  sexual  disorders 

deceive  in 

506 

slight  deg.ees  of 

508 

in 

506 

an;esthesiain66,488,492 

,551 

some  varieties  of 

507 

-  impotence  in 

347 

anosmia  in 

609 

sphincters    seldom    in- 

- increase  in  deep  reflexes  in  . . 

506 

arsenical       38,  87,  285, 

492, 

volved  in     . . 

505 

knee-jerks  in       . .         397 

787 

506,  551, 

575 

spread  of  pain  to  trunk  in505 

-  influence  on  dysmenorrhoea 

219 

paralysis  early  in    . . 

506 

symptoms  and  signs  of 

75 

of  law  suit  in 

788 

atrophy  and  paresis  in 

285 

iu  syphilis       . .        506, 

507 

-  insomnia  in. .          . .        356, 

358 

bilateral  facial  palsy  in 

687 

talipes  from     . . 

131 

-  intention  tremor  in 

800 

causes  of 

72 

tenderness  of  limbs  in 

505 

-  irritability  in          .  .         3G0, 

788 

causing  ataxy . . 

66 

muscles  in      489,  506, 

551 

-  loss  of  strength  in  . . 

506 

chronic 

507 

nerve  trunks  in 

489 

-  overwork,    worry,    and    de- 

 pains  in  limbs  in  . . 

503 

tendon  reflexes  in 

66 

bility  as  causes  of 

506 

contractures  in  163, 165 

390 

tremor  in 

285 

-  oxaluria  with 

471 

cramps  in         . .        179, 

505 

in  tuberculosis 

506 

-  pains  in  arms   in  (and    see 

dead  fingers  in 

505 

-  olfactory,  from  ammonia  . . 

669 

also     Pains     in     Various 

deep  reflexes  increased 

anosmia  from 

669 

Organs) 

494 

at  Qrst  in     . . 

505 

part  of  peripheral  neuritis 

009 

-  -  back  in    . . 

494 

in  diabetes  69,  282,  492, 

507 

from  snuff 

609 

head  in     . . 

494 

diagnosis  of    . . 

506 

-  optic  (see    Optic    Neuritis) 

limbs    in   . . 

506 

from     acute      polio- 

- peripheral    . .         390,  489, 

503 

and    tenderness    in    head 

myelitis    . . 

559 

-  of  pudic  nerve,  dyspareunia 

from 

782 

locomotor  ataxy     . . 

502 

from 

221 

scalp  from 

784 

myopathy    . . 

70 

-  retrobulbar  (see  Retrobulbar 

-  palpitation  in            506,  525, 

527 

primary        muscular 

Xeuritis) 

-  polyuria  in   . .          . .         581 

582 

dystrophy 

560 

Neurocardiac  disease,  shortness 

-  pseudo-neuralgia  in 

498 

diphtheritic 

of  breath     in 

101 

-  psychalgia  in 

494 

66,  77,  224,  506,  559 

640 

Neurofibromata,    absence    of 

-  from  pyorrhcea  alveolaris . . 

87 

affecting  heart 

640 

tenderness  in 

478 

-  ready  fatigability  in 

788 

eye  symptoms  in     . . 

77 

-  distribution  of 

804 

-  rigidity  of  the  spine  in 

788 

regurgitation  of  food 

-  multiple  benign  false  neuro- 

- sex  incidence  of 

506 

through  the  nose  in559 

640 

mata  on  the  nerves 

478 

-  simulated  by  phthisis 

347 

dysphagia  due  to 

224 

-  pain  in  the  chest  from 

477 

malingering 

787 

electrical  reactions  in   66,  69 

-  simulating  rheumatic  nodules 

804 

organic  disease   .. 

788 

extensors  more  affected 

-  subcutaneous  in  von  Reck- 

 nerve  lesions    . . 

347 

than  flexors  in 

550 

linghausen's  disease 

781 

-  sphincters  unaffected  in  . . 

787 

gait  in  . . 

66 

Neuroma,      brachial    neuritis 

-  subjective  sensations  in     . . 

506 

gangrene  in     . .         282, 

285 

from 

492 

-  subnormal  temperature  in 

506 

in  gouty  subjects 

507 

-  single,     false,      pain     over 

-  tenderness  of  the  scalp  from 

781 

glove      and      stocking 

affected  nerve  in 

478 

spine  in    . .          . .         784 

788 

anaesthesia  in  (Fig.llo 

660 

tenderness  to  pressure  of 

478 

-  traumatic,  account  of 

787 

glycosuria  with          507, 

5.51 

-  of  vulva 

768 

-  tremor  in     . . 

795 

hyperaesthesia   in 

Neuromata,  multiple,  false  (see 

-  from  tumour  of  trigeminal 

505,  506, 

666 

Neurofibroma  ta) 

nerve 

783 

hyperalgesia  with  cuta- 

Neuromimesis. . 

389 

Neuritis,  dyspareunia  from  . . 

222 

neous  anf&sthesia    660 

661 

Neuromyositis,    general    pains 

-  early    stages    of    paralysis 

inco-ordination  in 

506 

in  the  limbs  in  . .         503 

504 

agitans  mistaken  for     . . 

548 

infantile  paralysis  from 

559 

-  loss  of  reflexes  in    . . 

504 

-  examination    of    urine    for 

influenzal          . .        500, 

507 

sensation  in 

504 

sugar  in  all  cases  of 

488 

from  lead      38,  77,  492 

506 

-  pain  in  limbs  on  movement  in  504 

-  pain  in  the  arm  from 

545 

leprosy  . . 

551 

-  tenderness  in  limbs  in 

504 

-  sciatica  due  to 

487 

loss  of  ankle-jerk  in  . . 

488 

-  vasomotor    phenomena     in 

-  tenderness  in  the  spme  in. . 

785 

deep  reflexes  in   398, 

extremities  in 

504 

-  tremor  in     . . 

77 

505,  559 

562 

Neuropathic     muscular   atro- 

- brachial,      almost       always 

knee-jerks  in 

488 

phies  (and   see    Atrophy, 

bilateral    . . 

492 

mercurial         . .   37,  77, 

551 

iluscular) 

diagnosis    from    cervical 

motor  weakness  in   505, 

562 

claw-hand  from 

159 

pachrmeningitis 

492 

muscular  atrophy  in  75, 

390, 

fibrillary  contractions  in 

158 

rib 

492 

488,  492,  506,   559,   562, 

849 

following    acute    polio- 

 spinal  disease 

492 

numbness  and  tingling 

myelitis 

158 

glands  in  axilla 

492 

in  the  extremities  in 

505 

gradual  onset  of 

159 

spinal  gliosis   . . 

492 

cedema  of  legs  in 

459 

sensation  normal  in    . . 

1.59 

tumour 

492 

offactory  nerves  affected 

simulating  rickets 

158 

from  subclavian  aneur- 

in 

669 

sphincters  normal  in  .  . 

159 

ysm    . . 

492 

pain  in                505,  551, 

559 

Neuro-retinitis   (see    Retinitis 

tumour      in     posterior 

legs  in 

488 

and  Optic  Neuritis) 

triangle  of  neck 

492 

limbs  in 

66 

Neurosis  (and    see    Hysteria ; 

generally  part  of  a  multiple 

on  movement  in     . . 

661 

and  Neurasthenia) 

peripheral  neuritis      . . 

492 

worse  at  night  m    . . 

489 

-  abdominal  distention  in    . . 

465 

neuromata     of     brachial 

paraplegia  due  to   557, 

-  angina  pectoris  type  of     . . 

482 

plexus  as  caase  of 

492 

561, 

.562 

-  belching  variety  of 

267 

pain    and    tenderness    in 

perforating  ulcer  of  foot  inS09 

-  bladder  varieties  of 

443 

arms  in 

492 

pins  and  needles  in    . . 

505 

-  cheilitis  exfoliativa  in 

403 

-  intercostal,    sites    of   maxi- 

 plantar  reflexes  in         66 

,  81 

-  coloured  sweat  due  to 

714 

mum  tenderness  in 

777 

purpura  in       . .        596, 

599 

-  disseminatad  sclerosis  simu- 

 tenderness  in  chest  from 

776 

reaction  of  degeneration 

lating 

565 

-  multiple    peripheral,     acute 

in      69,  488,  506,  559, 

562 

-  distinction  from  hysteria  . . 

527 

pains  in  limbs  in 

503 

reflexes  in  398,  505,  559, 

562 

-  exaggerated  knee-jerk  in.. 

44 

alcoholic    66,  285,  492, 

scoliosis  in       . .        180, 

181 

-  hiccough  in 

342 

505,  549,  550,  551, 

599 

sensory  changes  in  505, 

551, 

-  lachrymal     . . 

203 

Eorsakow's  psychosis 

505 

559,   660,  661,  666, 

669 

-  leading  to  amputation 

457 

948 


NEUROSIS— NUTMEG-GRATER    SKIN 


Xeurosis,  contd. 

NODULES       

448 

]\'ose,  contd. 

-  occupation  Csee  Occupation 

-  "  craggy,"    in    tuberculosis 

-  epithelioma  of 

420 

Neuroses) 

of  testis    . . 

519 

-  examination  of,  in  obscure 

-  oedema  of  leg  from . . 

457 

-  developing     from     papular 

pyrexia     . . 

620 

-  cesophagLsmus  tj'pe 

484 

syphilide  . . 

532 

-  foreign  body  in 

204 

-  pruritus  a  symptom  of 

588 

-  differentiation     of     papules 

epistaxis  from            250 

252 

-  ptyalorrhoea  as  a  . . 

592 

from 

528 

-  gangrene  of,   in  Raynaud's 

-  pyrexia  due  to        . .         609 

,618 

-  leprous,  simulating  erythema 

disease 

284 

-  spastic  constipation  and  .. 

145 

nodosum 

450 

-  hypertrophy  of 

268 

-  tremor  in     . . 

795 

-  subcutaneous 

18 

-  inabiUty     to     blow,     from 

-  vasomotor    . . 

634 

:  in  acute  rheumatism  121, 

pain  of  inflamed  frontal 

albuminuria  in   . . 

16 

375, 

804 

sinus          . .       •  . . 

205 

Neurotrophic  causes  of  testi- 

 simulated  by  neuro- 

-  infantile    convulsions    from 

cular  trophy 

79 

fibromata . . 

804 

diseases  of 

170 

Neutrophile  corpuscles 

28 

due  to  colloid  milium     . . 

805 

-  lupus  of       . .          . .        204, 

448 

-  myelocytes,    characteristics 

from  epithelioma 

803 

-  massive,  in  acromegaly    . . 

263 

of  (Place  IP, 

29 

in  erythema  keratodes  . . 

451 

-  membranous    exudation    in 

204 

New-born,  breast  changes  in. . 

743 

multiforme 

531 

-  new  growths  affecting 

204 

-  epiphysial  afEections  in 

752 

firm  rounded,  on  elbows 

-  obstruction  by  adenoids    . . 

668 

-  hiemoglobinuria  in 

315 

and  knees,  in  jaundice 

360 

causes  of  . . 

668 

-  miliary  abscesses  of 

601 

in  gonorrhoeal  arthitis  . . 

375 

dislocation  of  nasal  septum 

668 

-  milk  secretion  in     . . 

743 

from  iodides  or  bromides 

112 

hypertrophic  rhinitis    204 

668 

-  pemphigus  of 

446 

in  leprosy 

75 

loss  of  taste  due  to 

774 

-  uterine  hsemorrhage  in     435, 

436 

lupus  erythematosus 

714 

by  necrosis  of  bones 

668 

New  growths  (see  Abdomen  ; 

vulgaris            . .         448 

808 

polypi 

668 

Lung  ;  Mediastinum;  Pel- 

multiple,  eosinophilia  with 

452 

septal  spur 

668 

ris ;  Pleura  ;  Spine ;   etc., 

neurofibromata 

804- 

syphilis 

668 

Carcinoma,  Sarcoma,  etc.) 

osteo-arthritis 

375 

-  pemphigus,  etc.,  of 

114 

New  Zealand,  hydatid  cysts  in 

323 

von       Recklinghausen's 

-  picking    from    presence    of 

Xicotine,  tremor  from 

797 

disease  . . 

804 

intestinal  parasite 

568 

Night    blindness     in    kerato- 

with  varicose  veins 

450 

-  projecting,  in  microcephaly 

214 

malacia     .  . 

807 

-  in  sycosis  vulgaris  . . 

602 

-  redness  in  cirrhosis  of  liver 

410 

nyctalopia 

841 

-  of  tubercular  leprosy   (Fig. 

-  regurgitation  of  food  through 

-  -  in  retinitis  pigmentosa . . 

838 

124)           

450 

the  (see  Regurgitation  oJE 

-  startings  in  hip  disease     . . 

357 

-  xanthoma  planum  .  . 

805 

Food  through  the  Nose) 

in   tuberculous  disease  of 

Noises  in  the  ears  (see  Tinnitus) 

-  rhinoscleroma  of     . . 

805 

joints 

385 

-  headache  from 

329 

-  iu  rickets     . . 

212 

-  sweating  of  phthisis       319, 

-  in  head  from  cerebral  aneu- 

- rodent  ulcer  of 

808 

577, 

714 

rysm          

328 

-  undue  dryness  of,  from  fifth 

Barlow's  disease 

714 

-  tmnitus  increased  by 

793 

nerve  paralysis   . . 

668 

infantile  scurvy  . . 

714 

Noma    . . 

282 

-  varicose  veins  in     . . 

251 

in  rickets . . 

714 

-  bleeding  gums  in    . .            8C 

,  88 

Nostril,  circinate  syphiloderm  of  532 

-  terrors 

357 

Normoblasts    . . 

28 

-  collapsed,  snoring  due  to.. 

669 

-  -  in  children           . .         357 

447 

Nose,    abnormal    breadth     in 

Nuck,   hydrocele  of  canal   of 

NIGHTMARES 

447 

cretinism . . 

258 

(see  Hydrocele  of  Canal  of 

Nipple,   affected  by  scabies  . . 

832 

inyxcedema 

259 

Nuck) 

-  blood  discharge  from       202, 

745 

-  accessory  sinuses,  dilatation 

Nuclein      bases,      uric      acid 

-  cracked 

743 

of,       unilateral      exoph- 

derived  from 

817 

-  discharge  from 

201 

th<3lmosia           ..         254 

255 

-  derivation  of  urinary  phos- 

- normal  discharge  from 

201 

foul  taste  from   infec- 

phorus from 

571 

-  Paget's  disease'of  . . 

802 

tion  of 

774 

Nucleo-proteid     in     acute  ne- 

- purulent  discharge  from  202 

743 

inflammation  of,  causing 

phritis 

12 

-  retraction  of,  in  carcinoma 

snoring 

669 

-  cerebrospinal  fluid 

339 

of  breast  . . 

745 

septic  arthritis  from  . . 

375 

in  meningitis  . . 

643 

normal  in  some  cases     . . 

745 

suppurating,     cavernous 

-  and    phosphates,    diflBculty 

in  Paget's  disease         802, 

803 

sinus  tlirombosis  from 

253 

of  distinguishing  in  urine 

471 

Nitric  acid  causing  bullte     110 

112 

earache  from 

230 

-  in  urine,  from  bladder  irri- 

 test  for  albumosuria         i 

,  20 

meningitis  from 

642 

tation  in  oxaluria 

471 

albuminuria,        signifi- 

- acute  catarrh,  from  arsenic 

668 

effect  on  boiling  test  for 

cance  of  brown  ring 

in  common  cold 

668 

albumin 

471 

with  . . 

348 

hay  fever 

668 

fallacies  in 

471 

bile  pigment    . . 

819 

loss  of  smell  from 

668 

method     of     overcoming 

indican . . 

821 

at  onset  of  measles    . . 

668 

fallacies  due  to 

472 

used  by  malingerers 

112 

from  pofciss.  iodide 

r.fiS 

tests  for  . . 

5,  6 

Nitrogen    m    urine    in    phos- 

- affection  by  acne  vulgaris 

531 

thrown    down   by    acetic 

phorus  poisoning 

373 

-  bleeding  from  (see  Epistaxis) 

acid 

472 

Nitroprusside  test  for  aceton- 

-  blowing,     violent,     causing 

Numbness,      in     dissemmated 

uria 

4 

subcutaneous  emphysema 

231 

sclerosis    . . 

665 

for  melanuria 

824 

-  broad  and  flat  in  Mongolian 

-  of  the  fingers  (see  Sensation, 

Nits   in  hair,   enlargement  of 

idiocy 

263 

Abnormalities  of) 

occipital  glands  with     .  . 

419 

-  carcinoma  of  (see  Carcinoma 

-  with  flushing 

208 

Nocturnal      emission,       albu- 

of Nose) 

-  of  foot  in  sciatica  . . 

487 

minuria  from 

19 

-  catarrh  of,  snoring  due  to 

669 

-  hands  in  acroparsesthesia  . . 

493 

and  oxaluria 

472 

-  cerebrospinal  fluid  from,  in 

-  in  paroxysmal  tachycardia 

772 

-  enuresis       

247 

fractured  skull    . . 

138 

-  peripheral  neuritis  . . 

505 

in  children,  from  oxaluria 

471 

-  coloured  sweat  of  . . 

714 

-  tabes  dorsalis 

664 

-  pain  in  gout 

38 

-  crusts  in,  in  atrophic  rhinitis 

204 

Nummular  sputum  (see  Spu- 

 tuberculous     disease     of 

-  depressed  at  the  bridge  in 

tum,  Nummular) 

joints    . .          . .         357 

385 

achondroplasia    . . 

212 

Nursery  maids,  scoliosis  in  . . 

181 

Node  on  bones  from  injury  . . 

750 

congenital  syijhilis  (Fig. 

Nurses,  chancre  of  finger  in  . . 

266 

in  secondary  syphilis     . . 

752 

78) 

259 

Nutmeg-grater  skin   in   kera- 

- -  typhoid  fever 

752 

-  discharges    from    (see    Dis- 

tosis pilaris 

531 

Nodes,  Ifeberden's  (Fir;.  109) 

charge,  Nasal) 

prurigo  ferox 

531 

380, 

452 

-  epistaxis  due  to  tumour  . . 

250 

xerodermia 

531 

NUTMEG    LIVER— (EDEMA 


949 


Nutmeg  liver 370 

ascites  with         . .  . .       55 

clironic  nephritis  . .       14 

(see  Liver,  Congestion  o£ 

Venous) 
pain    and    tenderness    in 

back  from        . .  . .     789 

-  -  uroerytlirin  in  urine  from     819 
Nyctalopia     in     disseminated 

clioroido-retinitis  . .     841 

-  from  liigh  myopia  . .  . .     841 

-  retinitis  pigmentosa  . .     841 

-  scurvy  . .  . .  . .     841 

Nylander's   reagent,   effect  of 

alkaptonuria  on  . .     822 

for  elvcosuria      . .  . .     290 

NYSTAGMUS 452 

-  from  yellow  spot  affections     83G 

-  amblyopia  in  . .  . .     830 

-  in  cerebellar  lesions  09,  643 

-  choroiditis 830 

-  disseminated  sclerosis 

174,  547,  800,  838 

-  in  Friedreich's  ataxy  71,  131,  560 

-  liippus  with. .  ..  ..     595 

-  macular  coloboma  with    . .     836 

-  from  oplithalmia  neonatorum 

830,  839 

-  persistent  hyaloid  artery  . .     836 

-  retinitis         836 

-  syringomyelia  . .         128,  554 

-  vertigo  due  to         . .  . .     827 

OBEEMEIERI,  spirochfete  of 

(Plate  XII,  p.  096)         33,  649 
OBESITY         453 

-  abdomijial  swelling  from  715,  718 

-  from  alcohol  . .  . .     849 

-  amenorrhoea  with  . .  . .       23 

-  anaemia  in   . .  . .  . .       30 

-  chronic  glycosuria  and      . .     292 

-  constipation  of       . .        143,  148 
-^diagnosis  of  ascites  from  . .       53 

-  deficient     ovarian    activity 

with  707 

-  difficulty      of      abdominal 

examination  in  . .  . .     718 

-  -  in      diagnosing     femoral 

swelling  m       . .  . .     732 

-  fatty  heart  in  . .        103,  241 

-  linese  albicantes  in..  ..     402 

-  in  myxoedema         . .  . .     460 

-  neuralgia  paraesthetica  from 

long  sitting  in     . .  . .     488 

-  relation  of  pancreatitis  to. .     153 

-  sterility  due  to        . .        706,  707 
Obliquus    inferior,    effects    of 

-    paralysis  of  . .  . .     201 

OhstipationCand  see  Constipation) 

-  faecal     accumulations    from     092 
Obstruction  of  bile-ducts  (see 

Eile-ducts) 

-  duodenal    ("see    Duodenum, 

Obstruction  of) 

-  intestinal  ("see  Intestinal  Ob- 

struction) 

-  of  the   larynx  (see  Larynx, 

Obstruction  of) 

-  lymphatic   (see   Lymphatic 

Obstruction) 

-  of  nose  (see  Nose,  Obstruc- 

tion of) 

-  a?sophageal  (see  CEsophagus, 

Obstruction  of 

-  portal  vein  (see  Portal  Vein, 

Obstruction  of) 

-  pyloric    (see    Pylorus    Ob- 

struction of) 

-  of  the  trachea' (see  Trachea, 

Obstruction  of) 

-  ureter  (see  Ureter,  Obstruc- 

tion of) 
Obturator      externus,     nerve 

supply  of. .         . .         . .     542 


89,  94 
.  351 
.  117 
.      197 


Obturator,  contd. 

-  hernia  (see  Hernia  Obturator) 

-  intcrnus,  nerve  supply  of..     542 

-  nerve,  muscles  supplied  by     542 

paralysis,   symptoms   of        541 

spinal  roots  derived  from     542 

-  neuralgia  in  hip-joint  disease    488 
from  obturator  liernia  . .     488 

-  -  rarity  of 488 

Occipital  area,  referred  pain  in, 

in  affections  of  tongue..     498 

-  cortex,    lesions    of,   causing 

hemianopia  81,  595,  837 

-  glands  enlarged  (see  Lymp- 

hatic Gland,  Occipital) 

-  headache     (see     Headaclie, 

Occipital) 
Occult  blood  in  stools 

in  gastric  carcinoma 

pancreatitis 

test  for 

Occupation,  causing  aortic  disease237 

-  changes  in  nails  due  to     . .     444 
deafness    . .  . .  . .     191 

-  in  diagnosis  of  plumbism  130,  173 

-  eruptions,  bullous  . .        110,  112 

-  incidence  of  anthrax        603,  746 

-  of  epithelioma  of  scrotum 

679,  765 

-  influence  on  acroparaesthesia    493 

-  laborious,  causing  enlarged 

heart         . .  . .         232,  244 

-  neiu:oses  (cramp)     177,  494,  795 

local  injury  giving  rise  to     177 

tremor  in..  ..  ..     795 

-  nystagmus  from     . .  . .     453 
Ocular    muscle    abnormalities 

in       congenital       exoph- 
thalmos    . . 

behaviour       of       double 

images  in  paralysis  of 

-  palsies,  abnormal  gait  due  to  277 

diplopia  in  . .  . .     200 

Ocuio-pupillary  fibres,    spinal 

nerve-roots  supplying    . . 

-  symptoms,    absence    of,    in 

Klumpke's  palsy 

in  involvement  of  eighth 

cervical  and  first  dorsal 
roots 

paralysis    from    htemato- 

myelia  . . 

with    radicular    pain    in 

arms 

in  spinal  lesions  of  eighth 

cervical  and  first  dorsal 
segments 

in  syringomyelia  128,  554 

Ochronosis  in  alkaptonuria  575,  822 
^  822 
822 
87 
749 
749 
749 
749 


247 
201 


556 
553 


494 


494 


553 


575, 


-  from  carbolic  acid 

-  general  account  of 
Odontomata 

-  age  incidence  of 

-  definition  of 

-  diagnosis  of. . 
from  sarcomata 

-  examination     for 

teeth  in  cases  of 

-  innocent  nature  of. . 

-  trismus  simulated  by 

-  a;-rays  in  diagnosis  of 
(Edema    of    abdominal 

from  ascites 
with  redness,  in  tuber- 
culous peritonitis   . . 

-  in  acute  nephritis    311,  458,  746 
polymyositis        . .  . .     504 

-  angioneurotic     (see    Angio- 

nfurotic  O^ldema) 

-  of  ankles  in  cirrhosis  of  liver    410 

-  in  anthrax    .  .  .  .         603,  746 

-  apparent,  of  myxoedema   . .       43 

-  of  arms  from  superior  vena 

cava  obstruction  . .     826 


missmg 


W-i)ll 


749 
749 
801 
749 

717 

691 


Qidenia,  cuntd. 

-  ascending,  case  of 

-  with      a.scites     in     chronic 

peritonitis 

-  in  chronic  modiastinitis 

-  with  myxoedema 
(EDEMA,   ASYMMETRICAL 
of  arm  (one;  from  oijstruc- 

tion  to  innominate  vein 

caused  by  ligature 

of  one  leg  from  tljrombosis 

-  of    back    from    obstruction 

to  inferior  vena  cava 

-  in  beri-beri. . 

-  Bright's  disease  12,  311,  458, 

-  of  conjunctiva,  conjunctivitis 

distinguished  from 

of    Bright's    disease    and 

heart  disease   . . 

-  due  to  erysipelas    . . 

-  of     eyelids,      angioneurotic 

(Fig.  128)  457,  458, 

simulating    acute     ne- 
phritis (J'fsr.  128)    .. 

in  conjunctivitis. . 

glaucoma 

Graves'  disease  . . 

from  iridocyclitis 

with  ptosis  in  conjuncti- 
vitis 

from  thrombosis  of  caver- 
nous sinus 

-  extreme,  buUiB  in    . .        110, 

-  Of  face         

angioneurotic    oedema 

(Fig.  28,  p.  124)        458, 

and  arms  in  growths  of 

the  lung 

and  eyes  in  trichinosis   . . 

illustrated  (Fig.  72) 

neck,  and  arms,  causes  of 

but  not  of  legs,  list  of 

causes  of . . 

or  neck,  inflammatory   . . 

in  nephritis         . .         458, 

round   syphilitic  chancre 

superior  vena  cava  obstruc- 
tion 

-  of  feet  in  chlorosis..  41, 

in  erythema  keratodes   .. 

erythromelalgia 

and     legs    in    mitral  re- 
gurgitation        238,  239, 

-  in  fungating  endocarditis      9 

-  general,      from       fungating 

endocarditis 

in   nephritis 

subacute  nepliritis 

-  of    head    and    neck,    illus- 

trated (Fig.  T2)  .. 

-  influence  of  attitude  on     . . 
gravity  on 

-  and   infiltration  of  skin   in 

acute  eczema 

-  of  labia  in  acute  nepliritis 

-  labium    minus,     unilateral, 

causes  of . . 

-  of  larynx 

acute,  causes  of  . .        466, 

stridor  from    . . 

in  Bright's  disease        185, 

orthopnoea  in 

from  potassium  iodide  185, 

suffocative 

from  various   ulcerations 

of  

-  of  legs  in  ankylostomiasis 

-  -  with  ansmia  from  haemor- 

rhage . . 

in  aortic  disease . . 

with  ascites 

and  back  in  inferior  vena 

cava  obstruction 
causes  of..    ..    459, 


484 
460 
455 

826 
457 
825 

825 

75 

746 


256 
746 

746 

458 
590 
257 
261 

256 

590 

651 
112 
458 

746 

185 
504 
234 
458 

461 

458 
746 
747 

740 
303 
451 
490 

240 
,  10 


466 

126 

234 
457 
458 

608 
458 

770 
073 
709 
709 
406 
465 
465 
673 

466 
570 

461 

233 

51 

60 
461 


950 


(EDEMA    OF  LEGS— OPTIC    ATROPHY 


(Bdema  of  legs,  cuntd. 

from    chronic    bronchitis 

and   empliysema 

in  heart  failure   . . 

hereditary  trophcedema 

mitral  stenosis     . . 

myocardial    degeneration 

portal  obstruction 

tricaspid   regurgitation.. 

-  linefe  albioantes  in 

-  local      and      transient,     in 

angioneurotic  oedema    . . 

-  of  loin  in  perinephric  abscess 

-  in  mastoid  region  in  caver- 

nous sinus  tlirombosis   .  . 
from  lateral  sinus  throm- 
bosis 

-  of  meatus  urinarius 

-  Of  neck  {Fig.  72)    . . 
acute,      diagnosis      from 

mumps 
and  arms  from  mediastinal 

growth . . 
and   head   from   superior 

vena  cava  obstruction 

-  -  various  causes  of 

-  of   the   orbit   from    throm- 

bosis of  cavernous  sinus 

-  of  palms  in  erythema  kera- 

todes 

-  penis  in  acute  nephritis     .  . 

-  pitting  on  pressure  in 
absent  on  pressure 

-  with  pleural  effusion 
in  Bright's  disease     . . 

-  polyuria  in  clearing   up   of 

582,  584 

-  of  prepuce  in  balanitis      . .  ,  674 

-  relation  to  angioneurosis  in 

ililroy's  disease   . . 

-  from  renal  tumour. . 

-  retinal,  in  optic  neuritis    .  . 

-  of  scalp  in  acute  nephritis. . 
from    thrombosis    of    the 

superior       longitudinal 
sinus 

-  of  scrotum  in  acute  nephritis 

-  skin  of  breast  in  mastitis  . . 

-  soles  in  erythema  keratodes 

-  sufEocative,     simulated     by 

laryngeal  paralysis 
CEDEMA,  SYMMETRICAL 

-  of  umbilicus  in  tuberculous 

peritonitis 

-  universal 

-  -  causes  of  . . 

-  of  vulva,  causes  of. .  768,  770 
(Esophagismus,  general  account  484 
CEsophago-bronchia)      fistula, 

gangrene  of  lung  in  . .  288 
rEsophagoscope  . .  . .     297 

(Esophagus,      affections      of, 

causing  food  regurgitation  841 
causing  ptyalism        .  .     591 

-  branches  of  vagus  of,  rela- 

tion to  cough 

-  carcinoma  of  (see  Carcinoma 

of  CEsophagus) 

-  chicken-pox  eruptions  in  . . 

-  cicatricial     stricture,     dys- 

phagia in. . 
progressive  emaciation  In  484 

-  diseases   of,    pain    in   chest 

evoked  by  swallowing  ii 

-  epithelioma   of  ("see   Carci- 

noma of  ffisophagus) 

-  foreign  bodies  in  (see  Foreign 

Bodies  in  Oisopliagus) 

-  idiopathic  hypertrophy  of 
dilatation  of        . .         225, 

-  lesions    of,   causing    subcu- 

taneous emphysema 

-  obstruction      by    abnormal 

subclavian  artery 


246 
61 
461 
764 
333 
300 
106 
402 

746 
392 

254 

651 
209 
234 

674 

296 

826 

458 

651 

451 
458 
456 
456 
121 
122 


460 


462 
458 


651 
458 
743 
451 

539 
457 

57 
457 
460 


175 


673 

484 


484 


231 
223 


(Esophagus,  obstruction  of,  contd. 

acetonuria  in       . .  . .         4 

anaemia  in  . .  .  .        37 

aneurysm      222,  474,  482,  841 

constipation  due  to        . .     144 

diagnosis  from  CESophag- 

ismus     . .  . .  . .     484 

diverticula  . .  . .     841 

-  -  fibrous  stricture       . .   222,  841 

by  gastric  growth  . .     223 

malignant  disease  483,  841 

pain  in  the  chest  in       . .     478 

pressure  pouches  . .     841 

-  -  spasm       . .  225,  484,  841 
thyroid  gland  tumour  . .     792 

-  pain  in,  causing  dysphagia       225 

-  pemphigus,  etc.,  of  114,  841 

-  pouch  of,  dysphagia  from . .     224 

-  rupture  of  aneurysm  into  140,  482 

-  sensory  area  corresponding  to  222 

-  small-pox  eruption  in       . .     673 

-  spasm  of      . .  . .  . .     225 

-  spasmodic  stricture  of  (see 

CEsophagismus) 

-  stenosis  of,  from  a  bone     . .     222 

-  tenderness  in  the  chest  from 

afEections  of         .  .         776,  779 

-  tumour  of,  tracheal  obstruc- 

tion from  . .  . .     465 

-  varix  of,  haematemesis  from 

rupture  of  . .         294,  296 

Oidium    albicans    in    sputum 

88,  705 
705 
705 


-  tropicale  in  Ceylon 

haemoptysis  from 

phthisis     simulated      by 

lesions  due  to 
Old   age,  constipation  in 

epistaxis  in 

Heberden's  nodes  in 

insomnia   in 

kyphosis  in 

loss  of  weight  due  to 

cedema  of  legs  in 

vasomotor  disease  in 

priapism  in         . .         585, 

simulation    of   malignant 

disease  by  loss  of  weight  in  840 

sterility  due  to   . .  . .     706 

subconjunctival     hsemor- 

rhage  in 

ulceration  of  the  leg  from 

Olfactory  neuritis 

Oligemia 

OligochromEemia  (see  Ansemia) 

Oligocythsemia 

Oligo.spermia  706 

Oliguria  in  acute  nephritis    .  . 

-  in  heart  failure 
Olivo-ponto  cerebellar  atrophy, 

ataxy  and  tremor  in 
Omentum,  abscess  of . . 

-  cysts  of 
pelvic  swelling  due  to    . . 

-  fat    necrosis    in,    in     acute 

pancreatitis    153,  43],  646,  846 

-  hernia  of  (see  Hernia,  Omental) 

-  hydatid  disease  of  .  .  .  .      720 

-  infiltration   of,    in   tubercu- 

lous peritonitis    .  . 

-  normal  situation  of 

-  tumour  of,   in  chronic  peri- 

tonitis      .  .  472,  691,  724 
diagnosis  from  renal  tu- 
mour    . .          . .  . .     394 

jaundice  in  . .         362,  367 

palpable  inumbilicalregion  728 

pelvic  swelling  due  to   . .     757 

physical  signs' of. .  ..     406 

simulating  enlarged  liver 

367,  406 

spleen  . .  . .     729 

movable  kidney  . .     727 

tuberculous  . .  . .     367 


705 
143 
252 
452 
358 
183 
849 
461 
459 
586 


25R 

810 

669 

26 

26 

707 

12 

15 

799 

724 
724 
757 


56 

722 


Onions,  foul  breath  from      .  .        9>> 
Onychia,  causes  of     . .  . .     445 

-  and     tuberculous     changes 

in  eyelid  associated  . .  4 15 
Onychogryphosis,    association 

with  ichthyosis  . .  . .     445 

Onychomycosis  . .  . .     445 

-  in  favus       . .  . .  . .     275 

Onychorrhexis  . .  . .     445 

Oozing     after    operations     in 

jaundice   . .  . .  . .     598 

Operation,      abdominal      (see 
Laparotomy) 

-  anal,  coli  bacilluria  after  . .       83 

-  anuria  following     . .  45,  4S> 

-  in  diagnosis  of  actinomyces     736 

new  growth  of  epididymis     767 

of  testis        . .  . .     766 

torsio  testis  . .  . .     521 

-  gangrene  of  lung  after      . .     288 

-  genital,  coli  bacilluria  after        83 

-  hypothermia  after  . .     346 

-  importance     of     early,     in 

pneumococcal  arthritis  . .     375 

-  infarct  of  lung  after  .  .     322 

-  injury  causing  extroversion 

of  bladder  ..  ..     587 

-  neurasthenia  after. .  . .     787 

-  cedema  after  . .  . .     456 

-  pseudo-elephantiasis  from        456 

-  pyaemia  from  . .         372,  649 

-  rectal,  coli  bacilluria  after  83 

-  retention  of  urine  after       49,  441 

-  surgical  emphysema  after        231 

-  tetany  after  .  .  . .      802 

-  on  tonsils,  cure  of  enuresis  by  248 

-  urinary  fistulse  after  . .     442 
Ophthalmia,  gonorrhoeal       . .     376 

-  neonatorum  . .        . .     255 

amblyopia  from  . .  . .     836 

corneal  opacity  from     836,  839 

gonococcal  arthritis  from      376 

nystagmus  from    453,  836,  83i> 

perforation  of  cornea  from    830 

polar  cataract  from       . .      836 

total  blindness  from       . .     83i> 

Ophthalmic  nerve,  herpes  of        781 
Ophthalmoplegia  (and  see  Stra- 
bismus ;    and    Pupils)    in 
bulbar  paralysis  . .  . .     159 

-  in  plumbism  .  .  .  .        38 
OPHTHALMOSCOPIC        AP- 
PEARANCES,   notes    on 
(Plates  VI 1,    VIll)        ..     461 

OPISTHOTONOS  ..463 

-  in  hysteria  ..  ..  ..     162 

-  meningitis    .  .  .  .  . .      642 

-  strychnine  poisoning         . .     652 

-  tetanus  162,  652,  802 
Opium,  headache  from  . .     328 

-  constipation  relieved  by  . .     744 

-  poisoning,   bilateral  loss  of 

movement  in       . .  . .     345 
Cheyne-Stokes       respira- 
tion in. .          . .  . .     125 

coma  from  137,  344,  345 

diazo-reaction  in  . .     198 

hypothermia  in   . .         138,  344 

pinpoint  pupils  in         138,  345 

pontine  haemorrhage  simu- 
lating     345 

Oppler-Boas  bacillus  in  gastric 
contents    in   gastric    car- 
cinoma   351,  353,  355,  845,  84G 
Opponens  minimi  digiti,  nerve 

supply  of . .  . .  . .     550 

-  poUicis,  nerve  supply  of    . .     550 
Opsonic  index  in  diagnosis  of 

gonorrhoeal  arthritis      . .     376 

tuberculous  caecum    . .     736 

testis  . .  . .     519 

^  Optic  atrophy  from  atoxyl     .  .     836 

from   cerebellar  tumour       643 

colour-blindness  from     . .     840 


OPTIC  A  TROPH  Y—OSTEO-A  RTHRITIS 


951 


<')/)lic  nlrapliii,  could. 

total  bliiKiuess  from       . .     839 

in    con'-reiiital    cerebral 

diplegia  ..  ..800 
dilatation    of    sphenoidal 

sinus      . .  . .  . .     255 

disseminated       choroido- 

retinitis  . .  . .     838 

sclerosis      IVi,  5-17,  505,  838 

Friedreich's  ataxy  71,  560 

glaucoma  . .  . .     838 

-  -  hereditary  . .         837,  838 

with  idiocy  .•.  ..     557 

from  lead. .  .  .  . .     83G 

in  Little's  disease  . .     154 

peripheral  constriction  of 

field  of  vision  in         . .     838 

primary,  ophthalmoscopic 

appearance     of    (Plate 

Vlll) 4(i2 

from  quinine       . .  . .     836 

-  chiasma,    lesion   in   causing 

total  blindness    . .  . .     839 

-  -  -  hemianopsia     . .  . .     335 
Optic   disc,    ophthalmological 

appearances     of     (Plates 
VII,    VIII)  ..  .  .     461 

coloboma  of         .  .  . .     462 

in  disseminated  sclerosis 

800,  838 

glaucomatous  cupping  of 

(Plate  VIII,  p.  463)  257,  838 
hi  tobacco  amblyopia    . .     836 

-  nerve,  compression  of,  by  dila- 

tation of  nasal  sinuses  840 
lesions,  sudden   blindness 

from 839 

new  growths  of,  increasing 

hypermetropia  with  . .     255 

-  -  -  -  unilateral  exophthal- 

mos in      . .  . .     255 

and  tracts,  connections  of, 

illustrated  (Fig.  101)..     334 

-  neuritis  (Ptoe  VIII,  Fig.  K, 

p.  463)  139,  598,  840 

absence  in  migraine       . .     582 

in  acute  encephalitis      . .     139 

from  atoxyl         . .  . .     836 

cerebellar  abscess  . .     565 

tumour..  ..         565,  643 

cerebral  htemorrhage     . .       98 

tumour     (Plate      VII, 

Fig.  K,  p.  461)        98,  173, 
292,  341,  350,  547,  686,  782 
with  Oheyne-Stokes  respir- 
ation    . .  . .  . .     125 

in  cases  of  convulsions  . .     172 

-  -  diabetes    . .  . .  . .     292 

-  -  diagnosis  of  hypertrophic 

astigmatism  from       . .     463 

in  dilatation  of  sphenoidal 

sinus      . .  . .  . .     255 

-  -  fungating  endocarditis 

9,  10,  76,  314,  598,  613 
from  increased  intracranial 

pressure  . .  . .     686 

lateral  sinus  thrombosis       651 

lesions  of  central  nervous 

system  . .         328, 585 

meningitisl39,  341,464,563,642 

otitis  media         . .  . .     230 

-  -  from  plumbism  . .  38,  139,  836 

-  -  quinine     . .  . .  . .     830 

-  -  recent,     ophthalmoscopic 

appearances    of    (Plate 

VII) 462 

retinal  oedema  in  . .     462 

from  retrobulbar  neuritis     840 

simulating     albuminuric 

retmitis  . .  . .     462 

in  spinal  meningitis        . .     464 

superior  longitudinal  sinus 

thrombosis       . .  . .     139 

-  -  swelling  of  disc  in         . .     462 


Ojitic  neuritis,  conld. 

in  tuberculous  meningitis 

612,  699 
uncommon    in    dissemin- 
ated sclerosis   . .  . .     565 

-  radiations,  lesion  in  causing 

lu^iuianopsia         .  .  .  .     334 

-  thalamus,  liyperpyrexia     ..     344 
lesion  of,  causing  dissocia- 
tive anaistliesia  ..     666 

-  -  intention  tremor.  .  .  .     800 

-  tract     lesions,    hemianopsia 

from  .  .  . .  334,  595 

rarity  of  blindness  from     839 

pupil  reflexes  in         594,  595 

Oral  sepsis,  anfcmia  in  . .       36 

in  etiology  of  dyspepsia       354 

gastritis  from      . .  . .     352 

septicasmia  from  . .     650 

Oranges,  sore  fingers  from  . .  266 
Orators,  pharyngitis  in  . .     673 

Orbicularis  palpebral,  epiphora 

from  paralysis  of . .  ..     250 

hysterical  spasm  of         . .     166 

watchmaker's  cramp  of. .     177 

weakness  in  myopathy..     260 

Orbit,  cellulitis   of,    cavernous 

sinus  thrombosis  due  to  253, 254 

-  disease  of,  headache  in     . .     327 

-  growth  in,  diplopia  from  . .  200 
unilateral  exophthalmos     254 

-  ivory  exostosis  of  . .  . .     754 

-  cedema     of,     from     throm- 

bosis of  cavernous  sinus      651 

-  periostitis  of,  unilateral  ex- 

ophthalmos due  to         . .     254 

-  suppuration   in,   meningitis 

from  ..  ..  ..642 

-  tumour  of,  epiphora  from. .     250 
pulsatile,    due  to  arterio- 
venous   aneurysm       .  .      764 

due  to  osteosarcoma. .     764 

unilateral     exophthalmos 

due  to  . .  . .        254,  255 

Orchitis,  acute,  association  with 
epididymitis  (and  see  Epi- 
didymitis;  and  Epididymo- 
orchitis)    . .  . .  . .     765 

due  to  mumps     . .  . .     765 

post-typhoidal     . .  . .     765 

scrotal  swelling  due  to  . .     765 

due  to  urethritis. .  ..     765 

-  atrophy  of  testis  after  79,  454,  519 

-  causes  of      . .  . .  . .       79 

-  chronic,      diagnosis       from 

syphilitic  orchitis  . .     520 

history  of  injury  in        . .     520 

tuberculous    (see    Testis, 

Tuberculous) 

-  diagnosis  from  sarcoma     . .     520 

-  due  to  gonococci     . .  . .     454 

-  liability      of     undescended 

testis  to  recurrent         . .     523 

-  in  Malta  fever         . .  . .     507 

-  scrotal  sores  due  to  . .     679 

-  syphilitic,    absence   of   pain 

on  pressure  in     . .  . .     520 

thickening    of    cord  in     519 

aching     in     inguinal     or 

lumbar  region  in        . .     519 

atrophy  of  testicle  after       519 

congenital  . .  . .      519 

diagnosis     from     chronic 

orchitis  .  .  .  .     520 

neoplasm  .  .  .  .     520 

diffuse  interstitial  . .     519 

enlargement  of   testis  in 

519,  520 

gummatous  . .  . .     680 

epididymis  unaffected  in  519 

nodules  on  testis  in  . .     519 

hydrocele  with    . .  . .     519 

prostate     and     vesiculae 

seminalcs  unaffected  in     520 


Orchitis,  syjthililic,  rmitd. 

sense    of    weight    in    the 

scrotum  in       .  .          .  .  519 

tendency  to  involvement 

of  botii  testes  in         .  .  520 

Orcin  in  Bial's  test    . .          .  .  290 
Organ  of  Corti,  nerve  deafness 

from  changes  in  . .          . .  190 

Orientation,  jihysiology  of  199,  200 

ORTHOPNtEA                         .-  464 

-  acute,  fruiii  jiulmonary  em- 

bolism      . .      .    •  •          . .  320 

-  in  chronic  nephritis            . .  14 

-  dyspnoea  with          . .          . .  220 

-  in  heart  disease      . .         358,  704 
and  lung  diseases  186,  359 

-  laryngeal  or  tracheal  obstruc- 

tion, diagnosis  of           . .  465 

-  mechanics  of           . .          . .  359 

-  in  mitral  stenosis  . .          . .  764 

-  with  pleuritic  elTusion      121,  122 

-  in    severe    bronchitis    and 

emphysema          . .          .  .  186 

-  from  thyroid  gland  tumour  792 
Orthostatic  albuminuria       . .  19 
Orthotonus  in  tetanus          . .  162 
Osazone     crystals     in     Cam- 
midge's  test         . .          . .  115 

in  m-ine  testing  . .          . .  290 

varieties 291 

Osmic  acid  test  for  chyluria. .  126 

Ossicles,  caries  of        . .          . .  470 
Ossification,    excessive   foetal, 

dystocia  due  to  . .          . .  227 

-  premature  in  infantilism  . .  214 

in  progeria           . .          . .  214 

••  of  tendon  simulating  exos- 
tosis . .  . .         754,  763 

Osteitis,  chronic,  of  head  and 
neck  of  femur  after  ty- 
phoid fever          . .          . .  376 

of    lower    end    of   femur, 

diagnosis  from  endosteal 

sarcoma            . .          . .  763 

-  deformans  (i^i!7«.47, 48,  p.l82)  753 

bending  of  bones  in      183,  753 

death  from  multiple  sar- 
comata of  bones  in    . .  753 

diagnosis  from  syphilitic 

osteitis. .          . .          . .  753 

dyspnoea  in         . .          . .  758 

-  -  illustrated             . .          . .  182 

increased  size  of  head  in  183 

kyphosis  in  . .  ..183 

lengthening  of  bones  in  753 

neuralgic  pains  in           . .  753 

senile  nature  of  . .          . .  753 

thickening  of  bones  in  . .  753 

-  syphilitic 782 

diagnosis  from  osteitis  de- 
formans          . .          . .  753 

-  tuberculous,   secondary   ar- 

tliritis  from          . .          . .  378 

Osteo-arthritis           . .        . .  39 

-  afebrile  course  of  . .          . .  384 

-  affection  of  spine  in           . .  384 

-  of  ankle        384 

-  bony  outgrowths  in  383,  384 

-  confusion     with     syphilitic 

pains         386 

-  crepitus  in  . .          . .          . .  179 

-  destruction  of  cartilage  in  384 

-  diagnosis  from  other  forms 

of  arthritis           . .          . .  385 

-  -  gout           383 

rheumatoid  artliritis     379,  384 

sciatica      .  .          . .          .  .  384 

-  dwarfism  from         .  .          .  .  214 

-  eburnation  of  bone  in        .  .  384 

-  of  elbow 384 

-  enlargement  of  joint  in     .  .  384 

-  erosion  of  cartilage  in        .  .  384 

-  fixation  of  joint  in  .  .          .  .  384 

-  flail  joint  from        .  .           .  .  384 


952 


OSTEO-ARTHRITIS—0  VARY 


Osleo-arthritis,  contd. 

Osteomyelitis,  contd. 

Otitis  media,  contd. 

-  crrating  of  joint  in  . . 

384 

-  acute 

750 

thrombosis      of     cranial 

-  Heberden's  nodes  in 

384 

arthritis    from    (see    Ar 

sinus  from 

650 

-  liip  frequently  afiected  in. . 

384 

thritis.  Acute  Secondary) 

lateral  sinus  or  jugular 

-  Of  knee        

384 

diagnosis  from  erythema 

vein  in 

123 

localized  tenderness  in  . . 

384 

nodosum 

751 

tinnitus  in 

470 

pain  in      . . 

384 

necrosis  of  bone  in 

751 

tuberculous,    ab.sence    of 

semimembranosus    bursa 

-  chronic,  diagnosis  from  en 

pain  and  pyrexia  in    . . 

469 

frequently  distended  in 

762 

dosteal  sarcoma . . 

757 

deafness  and  tinnitus  in 

469 

sensation,    on   palpation, 

long  duration  of . . 

751 

perforation  of  tympanic 

of  wet  sand  in  a  bag  . . 

384 

-  -  swelling  on  a  bone  from 

751 

membrane  anteriorly  in  469 

stiiEness  in 

384 

-  gummatous 

752 

rapid  bone  destruction  in 

469 

-  and  kyphosis           . .        183 

214 

-  suppurative,  anaemia  in     . 

39 

unilateral  headache  in  . . 

326 

-  locking  of  joint  in  . . 

384 

Osteopsathyrosis,     dwarfism 

vertigo  due  to     . .        470 

828 

-  loose  body  in  joint  in 

389 

from    " 

213 

vomiting  from    . .        229, 

844 

-  monarticular  type  . . 

384 

Osteosarcoma,  crepitus  in     . 

179 

Otorrhagia 

468 

-  muscular  atrophy  slight  in 

384 

-  egg-shell  crackling  in     17 

7,  764 

OTORRHEA 

467 

-  nipping  of  synovial  fringes  in 

389 

-  of  orbit,  pulsatile  . . 

764 

-  in  caries    of    ext.    auditory 

-  outgrowths  of,  simulated  by 

-  pulsation  in . .           177,  17 

0,  764 

meatus 

469 

. ,   dorsal  "  pads  "  on  fingers 

Os  uteri  stenosed,  a  cause  of 

-  cerebellar  abscess  . . 

565 

(Figs.  114,  115)  . . 

385 

dysmenorrhcea    . . 

219 

-  from  condylomata  of  meatus  469 

-  preference  for  large  joints. . 

384 

pin-hole    . . 

219 

-  diphtheria    . .          . .        469 

602 

-  primary  afEection  of  carti- 

Otalgia (see  Earache) 

-  examination  of  ear  in 

470 

lage  and  bones  in 

384 

Otitis,     acute     hemorrhagic 

-  from  suppurating  sebaceous 

-  similarity    to    arthritis    in 

with  hemophilia 

468 

cyst  of  meatus    . . 

469 

syringomyelia 

388 

influenza 

468 

-  tenderness  of  ear  in 

469 

tabetic  artliritis 

388 

pain  in. . 

468 

Otosclerosis,  deafness  in 

829 

-  in   small  joints 

384 

petechia   on  tympanic 

-  fixation  of  stapes  in 

190 

-  spondyhtis  deformans  with 

787 

membrane  in 

468 

-  middle-ear  deafness  in 

190 

-  subcutaneous  nodules  in  . . 

375 

-  media,     acute,    paroxysma 

-  tinnitus  clue  to        . .        793 

829 

-  swelling  of  bones  in 

754 

pain  with  pyrexia  preced 

-  vertigo  due  to 

829 

in  femoral  region  from  . . 

734 

ing  discharge  in. . 

469 

Otoscopy  in  cases  of  otorrhoea 

470 

-  temporo-mandibular          230 

,384 

adenoids  causing . . 

2.30 

Ova    of    ankylostomura    duo- 

-  -  simulating  trismus 

801 

and  albuminuria 

13 

denale  in  faeces  . . 

94 

-  thickening  of  synovial  mem- 

 broncho-pneumonia  in  321,  578 

-  bilharzia,   illustration 

93 

brane  in    . . 

384 

bubbling    noises    in    ear 

in  urine    . . 

313 

-  ulnar    deviation     in     (Fig. 

due  to  . . 

793 

-  distoma  hepaticum 

364 

108)          380, 

385 

cerebellar  abscess  from  . . 

644 

pulmonale  in  sputum   . . 

325 

-  of  WTist 

384 

cerebral  abscess  from 

-  intestinal  parasites,  examin- 

Osteo-arthropathy, bony  swell- 

98, 173,  341 

ation  of  fpecps  for  (Fiijs. 

ing  in 

754 

cervical  glands  enlarged 

420 

152,  154,  p.  569^    94,  569, 

570 

-  enlarged  fingers  in . . 

128 

characters  of  discharge  in 

469 

-  paragonimus  "Westermani  in 

-  hypertrophic  pulmonary   .. 

390 

chronic,     characters      of 

sputum 

705 

apparent  enlargement  of 

discharge  in     . .        468,  469 

Ovarian  abscess 

621 

joints  in 

390 

complications  of . . 

98 

Ovaritis,     undue      abdominal 

in  bronchiectasis 

390 

convulsions  from 

229 

aortic  pulsation  suggesting 

592 

chronic  empyema 

390 

-  -  deafness  hi          . .        190,  470 

-  diagnosis     from     recurrent 

clubbing  of  fingers  with 

390 

delirium  in 

229 

appendicitis                   729, 

737 

-  -  -  confusion  with  acromegaly  391 

diagnosis  of  cerebrospinal 

-  dysmenorrhaja  due  to 

737 

enlarged  bones  in  (Fig. 

fluid  from  a  serous  dis- 

- ovaries  enlarged  and  irregu- 

118;  

390 

charge  from     . . 

468 

lar  from    . . 

220 

fingers  in 

128 

meningitis  from 

229 

Ovary,  absence  of  activity  of 

707 

erosion  of  cartilage  m 

390 

eczema  of   ext.   auditory 

sterility  due  to   . . 

706 

in  fibrosis  of  lung 

390 

meatus  in 

468 

-  atrophy  of  . . 

24 

greater     frequency     in 

empyema  from   . . 

123 

-  carcinoma  of  fsee  Carcinoma) 

upper  extremity     . . 

390 

in  enteric  fever  . . 

648 

-  cyst  of,  albummuria  from 

17 

with  subclavian  aneurysm391 

external  ear  swollen  and 

ascites  in 

58 

thickening   of   synovial 

inflamed  in 

469 

dipping  in  through  fluid 

membrane  in 

390 

gangrene  of  lung  from  . . 

287 

in  diagnosis  of 

759 

Osteochondritis,  syphilitic    . . 

386 

headache  in         .... 

327 

bearing-down   pain   from 

473 

Osteoscopic  pains,  pains  worst 

hyperagsthesia  acustica  in 

190 

cha.racliers  of  fluid  from 

52 

on  getting  warm  in  bed 

503 

lateral    sinus    thrombosis 

diagnosis  from  ascites 

in  secondary  syphilis     . . 

503 

from      . .          . .        186,  578 

52,  717,  759 

761 

Osteogenesis  imperfecta,  brit- 

 membrane  hyperaimic  and 

distended  bladder 

730 

tle  bones  in 

213 

swollen  in 

469 

fibromyoma  of  uterus 

429 

dwarfism  due  to  (Fig.  65) 

212 

meningitis  from 

642 

liydati'd  cyst  . . 

761 

leading  to  osteomalacia 

213 

optic  neuritis  in  . . 

230 

kidney  tumour 

393 

softening  of  bones  in    213, 

214 

pain  in  the  ear  in         22 

1,  470 

pancreatic  cyst 

758 

Osteoma  (Fig.  194)    . . 

754 

paralysis  of  chorda  tym- 

phantom  tumour 

433 

-  exophthalmos  due  to 

255 

pani  from 

775 

renal  tumour  . . 

392 

-  of  jaw 

748 

perforation    of    tympanic 

retroperitoneal    lipoma 

761 

-  pelvic,  dystocia  due  to     . . 

227 

membrane  in  . . 

469 

from  unruptured  ectopic 

Osteomalacia  described 

213 

pneumococcal 

375 

gestation 

760 

-  dwarfism  in             .  .        212, 

213 

polypi  in  ear  from 

468 

urachal  cyst     . .         730 

761 

-  eosinophilia  in 

248 

pulmonary  embolism  from 

dysmenorrhcea  with 

219 

-  following  osteogenesis  imper- 

123, 186,  578 

felt   per  rectum . . 

638 

fecta 

213 

pyrexia  in 

229 

frequent  micturition  from 

438 

-  kyphosis  or  scoliosis  from 

214 

referred  pain  in   vertical 

gas  in 

711 

-  muscular  weakness  in 

213 

and  temporal  areas  in    498 

impacted,    frequent  mic- 

Osteomyelitis, albumosuria    in 

20 

in  scarlet  fever  . . 

674 

turition  with  . . 

438 

-  eosinophiUa  in 

248 

septicajmia  from 

614 

jaundice  in 

367 

-  fungating  endocarditis  from 

314 

suppurative..          ..     230,498 

ieucocytosis  with  suppur- 

- of  ilium 

737 

tenderness  over  mastoid  in    229 

ating     . . 

400 

-  rigors  m       . .          . .         648 

649 

of  scalp  in                  781 

,  783 

median  position  of 

392 

OVARY— PAIN 


953 


Ocary,  cijsl  of,  mntd. 

Ovary.,  luinour  of,  conld. 

Oxaluria,  conld. 

nephritis  from     . . 

8 

absence     of      distmctivo 

-  frequent  micturition  from 

438 

-  -  obstructing  labour 

228 

blood  changes  in 

691 

-  hoBmaturia  in          . .        3U4, 

311 

inferior  vena  c;.va 

825 

menstrual  disturbance  in 

429 

-  lumbar  aching  in  . . 

311 

obvious  pelvic  origin  of 

392 

movement  with  respira- 

- nocturnal  enuresis  and    248, 

471 

-  -  palpitation  from           526, 

528 

tion  . . 

691 

-  normal  amounts  of 

471 

pelvic  swelling  due  to  . . 

757 

ascites  witli          367,   393, 

759 

-  from  oxalic  acid  poisoning 

297 

physical  signs  of .  .52,  717, 

759 

breaking  down,  anaemia  in 

39 

-  pain  in  the  testicle  in 

524 

pneumaturia  caused  by 

57G 

diagnosis   from  jiregnant 

-  in  paijcroatitis 

116 

ruptured   . . 

730 

uterus  . . 

758 

-  priapism  from 

585 

-  -  -  spasmodic  pelvic   pain 

renal  tumour  . . 

391 

Oxybutyric  acid  in  urme        4, 

292 

from . . 

509 

splenic  tumour 

691 

Oxygen,  effect  on  convulsions 

172 

simulating  sciatica 

74 

tuberculous  peritonitis 

691 

Oxyhaemoglobin 

12 

solid  feel  in  very  tense 

758 

uterine  fibroid           758, 

759 

-  reduction     by     ammonium 

succussion  splash  in 

711 

difficulty  of  diagnosis  of 

759 

sulphide    .  . 

314 

-  -  swelling     in     iliac    fossa 

direction  of  growth 

393 

-  spectral  absorption  band  of 

95 

due  to  . . 

737 

double,  amenorrhoea  with 

-  in  urine  in  hiemoglobinuria 

314 

—  twisted,  ascites  with     . . 

759 

24,  429,  691, 

759 

Oxyphile  corpuscles  . . 

28 

constipation  with 

153 

dyschezia  from  . . 

1.50 

Oxyuris  vermicularis  . . 

569 

deep-seated  pelvic  pain 

dystocia  due  to  . . 

227 

bleeding  and  mucus  due  to 

93 

in 

508 

fixation  of  growtli  in     . . 

759 

no  blood  cliangcs  with  . . 

33 

diaijnosis   from   appen- 

 uterus  with  tenaculum 

description  of 

94 

dicitis  with  pregnancy 

7G1 

in    examination    tor 

eosinophilia  with 

249 

dysmenorrl)  oea 

220 

pedicle  of    . . 

758 

grinding  of  teeth 

293 

pain    in   right   side    of 

impaction  of,  sacralgia  in 

509 

priapism  from     . . 

585 

abdomen  in 

500 

jaundice  in          . .        362, 

367 

Ozaena  . .          . .          . .          99, 

204 

simulating   renal    colic 

392 

length   of  uterme   cavity 

Ozonic  ether  test  for  pus 

623 

spasmodic  pelvic    pain 

usually  unaltered  in  .  . 

429 

from . . 

509 

menstruation  undisturbed 

PACHYMENINGITIS,  head- 

 tumoiur  from   .  . 

153 

by         ..          ..         758, 

759 

ache  in     . . 

327 

vaginal  examination  in 

microscope      for      exact 

-  cervical 

493 

diagnosis  of . . 

500 

diagnosis 

759 

claw-hand  in       ..         127 

128 

varicose  abdominal  veins 

often     inseparable     from 

radicular  pain  in  arm  in 

493 

from 

825 

uterus   . . 

759 

simulating  bracliial  neu- 

- dermoid  cyst  of,   diagnosis 

pedicle  of             . .        75S, 

759 

ritis 

492 

from  ectopic  gestation.. 

760 

pelvic  swelling  due  to  757 

758 

-  chronic    hypertrophic    ha;- 

-  disease  of,  anaemia  in 

36 

physical  signs  of . . 

691 

morrhagic,  alcoholism  and 

causing  araenorrhoea        23 

,  24 

rapid  emaciation  in 

759 

.S3Tphilis  causmg  . . 

563 

eosinophilia  in    . . 

24S 

secondary  portal  glands  in 

367 

diagnosis    of    spinal 

-  -  pain  in  the  back  in 

476 

simulating  movable  kidney 

727 

caries  from 

563 

-  -  referred      pain     in     area 

sterility  due  to  . . 

706 

paraplegia  from 

563 

of  tenth  dorsal  nerve  in 

509 

uterus  drawn  up  by 

691 

-  paralysis  of  upper  extremity 

vomiting  with     . . 

844 

vaffinal    examination    in 

from 

555 

-  ex'cision  of,  obesity  after  . . 

454 

diagnosing 

691 

Pacific  Islands,  filariasis  in  . . 

33 

-  fibroma  of,  ascites  with    . . 

759 

Over-eating,  active  congestion 

Pads,  association  with  Dupuy- 

-  growths  of,  amenorrhoea  with 

24 

of  liver  fi-om 

371 

tren's  contraction 

385 

-  hj-pera;sthesic  patches  over. 

-  obesity  from 

453 

-  confusion  with  osteo-arthritic 

in  hysteria 

667 

Over-exertion,  acute  dilatation 

out-growths 

385 

-  imperfectly     developed     in 

of  heart  due  to    . . 

243 

fibrous  nature  of . . 

385 

infantilism 

218 

-  causing     mitral    regmrgita- 

-  on  dorsal  aspect  of  fingers 

-  inflamed  (see  Ovaritis) 

tion           ..          ..         239, 

243 

(Fi(is.  114,  115)   . . 

385 

-  in  inguinal  canal,   diagnosis 

-  cramp  from . . 

177 

-  supraclavicular,  in  cretinism 

259 

from      fibromyoma      of 

-  enlarged  heart  from         232, 

243 

Paget's  disease,  age  and  sex 

round  ligament  . . 

741 

-  tenderness  of  spine  from    . . 

785 

incidence  of 

802 

-  insufficient      activity       of, 

Overgrowth     of     tibia     after 

crusts  in  . . 

803 

amenorrhoea  from 

707 

injury 

132 

description  of 

802 

anremia  from  .  . 

23 

Over-work,  brachial  neuralgia 

distinction   from   eczema 

803 

^ nervous  symptoms  in 

454 

from 

491 

duration  of 

802 

obesity  in          453,  454, 

707 

-  cramps  from 

177 

intractability  of .  . 

803 

-  pain    in,     diagnosis     from 

-  dyspepsia  from 

354 

retraction  of  the  nipple  in 

803 

ureteral  calculus . . 

627 

-  insomnia  from 

357 

Pain,  absence  of,  in  progressive 

-  prolapsed,  pelvic  pain,  from 

508 

-  loss  of  weight  due  to 

848 

muscular  atrophy 

545 

dyspareunia  from 

221 

-  malarial  relapse  due  to     . . 

36 

-  acute  in  furunculosis  of  ear 

469 

-  region  of,  hypersensitive  in 

-  neurasthenia  from . . 

506 

general,  in  limbs  in  inflam- 

hysteria   . . 

509 

-  night  terrors  from . . 

447 

mation  of  lung 

503 

pain  in,  in  carcinoma  of 

-  pain  in  back  from . . 

476 

in  hysterical  joint 

83 

cervix    .  . 

510 

-  spasmodic  contraction  from 

159 

-  anaesthetic  skin 

475 

-  referred  pain  m,  in  extra- 

Oxalate  of  calcium  in  urine, 

-  caused  by  pressure  of  aortic 

pelvic  disease. . 

509 

("see  Oxaluria) 

aneurysm    on  oesophagus 

482 

in  hysteria 

509 

Oxalic  acid    poison  mg,  coma 

-  described  as  colic  by  patients 

133 

limits  of 

509 

due  to      . .          . .        137, 

346 

-  as  epileptic  aura,   in  brain 

in  pelvic  disease 

509 

hypothermia  from     . . 

346 

lesions 

81 

-  sclerosis  of,  pelvic  pain  from 

508 

oxaluria  from. . 

297 

-  at  external  abdominal  ring. 

-  secretion  of,  effect  on  men- 

OXALURIA  

470 

in  epididymo-orchitis     . . 

518 

struation  . . 

430 

-  catarrli  of  urinary  passages 

from  ureter  calculus 

514 

-  shifting   dullness    in   flanis 

from 

444 

-  generalized,  in  acute  polio- 

with malignant  tumours  of  393 

-  diagnosis  from  renal  calculus 

311 

myelitis    . .          . .        555 

559 

-  small  cystic,  dysmenorrhcEa 

-  "  dumb-bell  "     crystals     in 

-  importance    of  presence  or 

in  . . 

219 

urine  in  (Fig.  130) 

470 

absence      of     tenderness 

-  and    thyroid   gland,    inter- 

- dyspepsia  in 

311 

with 

475 

relationship 

454 

-  after  eating  rhubarb,  goose- 

- from  inflammation 

478 

-  tumour   of  ("and   see  Carci- 

berries, or  tomatoes 

311 

-  inliibitory,    in   joints,    mis- 

noma    of     Ovarv ;     and 

-  "  envelope  "  crvstals  in  lu-ine 

taken  for  paralysis 

545 

Ovary,  Cyst  of)  " 

m  (Fig.  130)" 

470 

-  insomnia  from 

356 

954 


PAIN,    LIGHTNING— PAIN    IN  EXTREMITIES 


Fain,  contd. 

-  lightning,  of  tabes  . .        350,  562 

-  loss  of  weight  due  to         . .  848 

-  over  lower  part  of  sternum, 

heartburn  causing           . .  48i 

-  on  moving  neck  and  head, 

in  spinal  meningitis       . .  162 

-  in  muscles  and  joints    mis- 

taken for  paralysis         . .  545 

-  niggling,   in    legs,  in  tabes 

dorsalis     . .          . .          . .  489 

trichinosis            . .        504,  801 

-  in  paralyzed  muscles  in  mul- 

tiple neuritis        .  .          . .  551 

-  perinephric  abscess            . .  392 

-  peripheral  neuritis       66,  559,  661 

-  popliteal  abscess     . .          . .  762 

-  preceding    the    eruption    in 

herpetic    trigeminal  neu- 
ralgia       . .          . .          . .  496 

-  pricking,  in   glans  penis  in 

tubsrculous  cystitis        . .  628 

-  in  plumbism            . .          . .  136 

-  pyelonephritis         . .          . .  394 

-  relief  by  salicylates  in  acute 

rheumatism          . .          . .  375 

-  severe,  associated  with  anfes- 

thesia        . .          . .          . .  475 

in  lower  spine,  in  gumma 

of  Cauda  equina         . .  563 

-  significance    of    absence    or 

presence     of,     in     trans- 
verse myelitis     . .          . .  564 

-  from  spasm  of  levator  ani  221 

-  subnormal    temperature    in 

conditions  associated  with  621 

-  supra-orbital,  from  eyestrain  495 

-  and     swelling    of     external 

auditory  meatus  in  furun- 

culosis       . .          . .          . .  469 

-  in    syphilis  . .          . .          . .  386 

in       syphilitic      pseudo- 
paralysis          ...          ..  387 

-  universal    in     cerebrospinal 

meninsitis            . .          . .  643 

PAIN,  ABDOMINAL..         ..  472 

in  acute  gastritis            . .  845 

from  aneurysm  . .        299,  368 

in  appendicitis    . .          . .  133 

biliary  colic  Cand  see  Colic)  846 

from  corrosive  poisoning  297 

-  -  diaphragmatic  pleurisy..  645 

-  -  in  duodenal  ulcer            . .  300 
extra-uterine   gestation 

436,  500,  646 

general  in  gastric  crises  . .  473 

Henoch's     purpura 

380,  381,  600,  846 

-  -  influenza  . .          . .          . .  505 

intense  from    perforative 

peritonitis                   644,  721 

intestinal  neuralgia        . .  134 

obstruction  133,153,350,846 

in  lead  neuritis  . .          . .  77 

mesenteric    embolism    or 

thrombosis       . .          . .  90 

pancreatic  hsemorrhage . .  292 

pancreatitis       90,  292,  646,  846 

due     to     perforation     in 

typhoid            . .           .  .  622 

peritonitis  . .        472,  718 

pneumonia  . .         133,  645 

Pott's  disease      . .          . .  134 

relapsing  fever                . .  373 

(right  side)  in  hepatoptosLs  407 

salpingitis     . .          . .  500 

twisting    of     pedicle 

of  ovarian  cyst  . .  500 

-  -  in  ruptured  tubal   gesta- 

tion  ..  ..        500,  640 

presnancy    . .           . .  760 

spasmodic,    from     intus- 

sus<:;cption         .  .          . .  727 
from  spondylitis  deformans   787 


90 

92 

592 

627 

442 

488 


421 


Pain,  abdominod,  contd. 

in  subdiaphragmatic  pleu- 
risy          133 

thoracic  diseases             . .  133 

from  torsion  of  retained 

testis     . .          . .          . .  742 

tuberculous  peritonitis   56,  719 

ulceration  of  the  intes- 
tine . . 

from  ulcerative  colitis  . . 

undue  aortic  pulsation  .  . 

due  to  lureteral  calculus 

-  in  anal  region  after  micturi- 

tion in  vesical  carcinoma 

-  ankle  and  foot  in  anterior 

crural  neuralgia 

-  In  ankle  (see  Joints,  Affec- 

tions of) 

-  in  aortic  aneurysm,  mode  of 

production 

-  arm  (see  Pain  in  Extremity, 

Upper) 

-  axilla  from  enlarged  axillary 

glands 

right,  from  hepatic  abscess  651 

PAIN  IN  BACK  (and  see  Back- 
ache)        . .          . .          . .  474 

from  abdominal  aneurvsm 

222,  296,  299,  322,  728,  789 

aortitis      . .          . .          . .  789 

arteriosclerosis     . .          . .  789 

in  biliary  colic     . .          . .  500 

carcinoma  of  rectum     . .  636 

from  cholangitis..          ..  789 

clironic  pancreatitis        ..  135 

colitis        789 

with  compression  paraplegia  78C 

from  constipation           .  .  789 

coronary  artery   sclerosis  789 

disease  of  the  rectum  (Fig. 

204,  p.  788)     ..150,636,788 

uterus  (Fig.  204)        788,  789 

examination  of  chest  and 

abdomen  in     . .          . .  47G 

from  gall-stones. .  500,  789 

gastric  ulcer        .  .  298,  789 

carcinoma        . .          . .  789 

gastritis    . .          . .          . .  789 

heart  disease  (Fig.  204)  788,  789 

in  hysteria           . .          . .  788 

inflammation  of  uterus   . .  789 

invagination  of  rectum..  150 

during  labour      . .          . .  789 

from  hver  disease (/"ifir.  204)  788 

malignant  disease  of  the 

vertebrae           . .          . .  786 

menstruation       . .          . .  789 

myocardial  fibrosis        . .  789 

in  neurasthenia  .^          ..  494 

new  growth  of  liver       . .  789 

nutmeg  liver       . .          . .  789 

from  pleural  adhesions..  789 

new  growth      . .          .  .  789 

pleurisy    . .          . .          . .  789 

in  relapsing  fever           . .  698 

from  renal  calculus       . .  500 

sex  incidence  of..          ..  789 

from  spinal  caries           . .  785 

stomach  disease  (Fig.  204)  788 

with  stone  in  pancreas  135 

tricuspid   regurgitation..  789 

with  typhoid  spine         .  .  787 

PAIN,   BEARING-DOWN      ..  473 

-  in  bladder  due  to  bacilluria  616 

stone          818 

tuberculous  cystitis       . .  629 

vesical    carcinoma       438,  630 

-  In   bone  an  early  symptom 

in  endosteal  sarcoma    . .  756 
in  scurvy-rickets            . .  753 

-  in  breast  in  mastitis         .  .  743 

mastodynia           . .          .  .  479 

multiple  cystic  disease  . .  744 

-  cardiac  (see  Heart) 


PAIN  IN  CHEST  ..477 

aneurysm  . .         322,  848- 

from  angina  pectoris      . .     7  78 

anginal,  during  formation 

of  dissecting  aneurysm     482 

from  biliary  colic  . .     846 

and  at  bottom  of  sternum 

in  diseases  of  oesophagus  484 

from  disease  of  wall       . .     477 

dyspepsia  . .  . .     779 

flatulence..  ..  ..      779 

gall-stones  . .  363,  846 

gastric  ulcer        . .  . .     779' 

hepatic  abscess  . .  .  .     779 

intercostal  myositis       . .     776- 

pleurisy  (see  Pleurisy) 

pneumothorax  (see  Pneumo- 
thorax) 

pulmonary  embolism  185, 

320 

splenic  infarction 

spondylitis  deformans    . . 

subphrenic  abscess 

superficial  inflammation 

-  in  chondromata 

-  with  cystic   kidney  disease 

-  delirium  due  to  severe 

-  dull  boring,  in  tabes  dorsalis 

-  in  dysmenorrhoea,  its  varie- 

ties described 
spasmodic 

-  in  ear   (and  see  Ear,  AfEec- 

tions  of) 

from  acute  otitis  media 

(behind)  in  mastoid  abscess 

glaucoma 

lateral  sinus  thrombosis 

with  middle-ear   deafness 

in  otitis  media    . .        229, 

-  elbow  (see  Joints,  Afllections 

of  ;  Arthritis  ;  and  Osteo- 
arthritis) 

PAIN,  EPIGASTRIC 

from    undue     abdominal 

aortic  pulsation 

in  arsenical  poisoning 

carcinoma  of  stomach 

catarrlial  jaundice 

corrosive  poisons 

from  duodenal  ulcer 

gall-bladder  disease 

gall-stone  obstruction  280, 

-  -  gastric    crises     in     tabes 

dolorosa 

disorders 

ulcer     . .  40,  295, 

gastritis     . . 

hypersthenic  dyspepsia  . . 

irritant  poisons  . . 

from  liver  disease 

with  obstruction  to  small 

intestine 

pancreatic  colic  . . 

diseases 

pancreatitis    135,  280,  431 

from  pericarditis 

phosphorus  poisoning    . . 

tabes  dorsalis 

in  variola 

-  in  ervthromelalgia 
PAIN   "    IN         EXTREMITY, 

LOWER 

from     arterial     throm- 
bosis 

in  bladder  affections  . . 

carcinoma  of  cervix    .  . 

of  the  spbie  . . 

diabetes  . .  . .       75 

embolism  . .  . .     286 

hip  disease       . .  . .     357 

early,  insomnia  from  357 

popliteal  aneurysm     .  .      762 

-  -  spinal  caries     . .  . .     785 

-  -  spondylitis  deformans       787 


321 
699 
787 
720- 
478 
755 
310- 
195 
664 

219. 
509 


409 
230 
257 
651 
190 
470 


484 


..  592 
92,  297 
299,  691 
. .  365 
.  .  845 
..  295 
..  779 
363 


485 
779 
298 
298 
354 
845 


153 

135 
486 
724 
777 
373 
847 
301 
284 

486 

286 
491 

rao 

543 


PAIN    IN    EXTREMITIES— PAIN,   PELVIC 


955 


PAIN  IN  EXTREMITY,  UPPER 

anassfchesia  witli 

-  -  -  from  aneurysm  222, 

in  angina  pectoris      350, 

aortic  incompetence   . . 

atrupliic  palsy  with    . . 

in  axillary  abscess 

from  cardiac  or  aortic 

disease 

cervical  caries  . . 

rib     . .  128,  554, 

pachymeningitis    128, 

deformity    of    cervical 

spine  in 

-  -  -  in  inflammation  of  spinal 

nerve  near   posterior 
root  fjanglion 

-  -  -  loss  of  tendon  jerks  in 

arm  with 

lumbar  puncture  in  dia- 
gnosis of  cause  of  . . 

in  malignant  disease  of 

cervical  spine 

from  neuritis  . . 

oculo-pupillary    pheno- 
mena with    . . 

radicular,   in   interven- 
tricular tumour 

shooting  down  in  medi- 
astinal growth 

multiple      cystic 

disease  of  breast 

spastic  paraplegia  with 

in  syringomyelia 

tenderness   of    cervical 

spine  in 

a:-ray    examination 

cervical  spine  in 

PAIN  IN  THE  EYE  .. 

from  conjunctivitis 

-  -  corneal  ulceration 

cyclitis 

from  eyestrain     . . 

in  glaucoma 

from      inflamed 

sinus 

in  influenza 

from  iritis 

relief    under    the 

atropine 

-  -  retrobulbar  neuritis 
PAIN  IN  THE  FACE.. 
in  antral  empyema 

-  after  food  in  gastric  ulcer  89, 

-  flitting  from   joint  to  joint 

in  acute  rheumatic  arthritis 

-  in  foot  as  aura  in  Jacksonian 

epilepsy    . . 

in  metatarsal  neuralgia 

from  suppurating  corn  . . 

-  forehead    from    iritis    and 

cyclitis 

-  over  gall-bladder  from  gall- 

stones      . .  . .        280, 

-  in  general  congestion  of  liver 

-  girdle  (see  Girdle  Pain) 

-  in  great  toe  in  anterior  crural 

neuralgia   . . 
in  gout  .  . 

-  groin  from  renal  calculus  308, 
colic 

-  hands  in  acropariesthesia  . . 

-  in  head  (see  Headache) 

-  round  the  heart  in  stomach 

disorders  . . 

-  in  heels  in  calcanodynia   . . 

-  hips  from  spondylitis  defor- 

mans (and  see  .Joints, 
Affections  of  ;  Arthritis  ; 
and  Osteo-arthritis) 

-  "  hunger  "  ('see  Hunger  Pain) 
PAIN  IN  HYPOCHONDRIUM, 

LEFT        

from  gastric  disorders 


of 


495, 


frontal 
205, 


255,  256, 
use    of 


494 

494 

494 

493 
545 

494 

493 

483 

447 
494 
554 


300 
407 


381 
846 
500 
493 


484 
488 


787 
500 


PAIN  IN  HYPOCHONDRIUM, 

RIGHT 499 

abscess  of  liver           . .  309 

in  active  congestion  of 

liver 371 

acute  yellow  atrophy. .  370 

from  biliary  colic        ..  135 

distoma  hepaticum     . .  364 

dragging  in   carcinoma 

of  liver         . .          . .  412 

general  congestion  of 

liver           . .          . .  407 

hepatoptosis             . .  407 

gall-bladder  disease   . .  779 

gall-stone  . .         135, 363 

from  hepatic  abscess  369,651 

liver  disease     . .          . .  779 

in  movable  kidney     . .  500 

phosphorus   poisoning  373 

-  in  hypogastrium  in  bacteri- 

uria           .  .          . .           84,  616 

-  -  from  cystitis           312,  627,  631 

with  obstruction  in  colon  153 

from  prostatitis  . .          . .  631 

retention    of   urine         . .  45 

urachal  cyst          .  .          .  .  730 

PAIN  IN  ILIAC  F0SS;E       ..  501 

from  faecal  obstruction  501 

right,  from  appendicitis 

135,  313,  729,  736,  737,780 

appendicular      colic 

in 134 

carcinoma  of  caecum  729 

some  causes  of        . .  134 

recurrent  at  men- 
strual periods,  due 
to  appendicitis   . .  737 

to    tenderness 

of  ovary  . .  737 
spastic  constipation  145 

-  in  inguinal  glands            675,  676 
region  in  acute  epididymo- 

orchitis             . .          . .  517 

in  carcinoma   of  cervix  510 

due  to  retained  testis  740 

-  intercostal,  from  aneurysm  222 

herpes  zoster       . .          . .  777 

in  mediastinal  tumour  . .  478 

from    pressure    on   inter- 
costal nerve     . .          . .  479 

spinal  abscess       . .         . .  479 

caries    . .          . .          . .  478 

growth 479 

injuries              .  .          . .  479 

PAIN,  INTERSCAPULAR     ..  474 

from  gallstones    .  .          . .  474 

in  gastritis           . .          . .  484 

from  spinal  caries            . .  474 

PAIN  IN    JAW                        ..  501 

-  in  joints  (and  see  Artliritis ; 

and     Osteo-arthritis^    in 
acute  rheumatism            .  .  671 
in  association  with  anti- 
toxic serum  rashes     . .  597 

erythema  nodosum        . .  450 

hfemophilic   arthritis     . .  388 

Henoch's  purpiu-a         380,  600 

-  -  hysteria 389 

intermittent  hydrartlirosis  387 

nodular  leprosy  . .          . .  450 

peliosis  rheumatica        .  .  599 

in  pneumococcal  arthritis  375 

sudden,    in   displacement 

of  semilunar  cartilage  388 

syphilitic  synovitis         . .  386 

in  tuberculous  disease  . .  385 

-  in    kidney,    pricking,    with 

calculus    . .          . .          . .  306 

-  knee  in  hip-joint  disease    . .  278 

in  osteo-arthritis            . .  384 

(and    see    Joints,    Affec- 
tions of) 

-  labium    majus    from    renal 

calculus    . .          . .          . .  135 


PAIN  IN  LIMBS,  GENERAL  '>0l> 

as    a    rule    worse    on 

movement    . .          . .  50.^1 

in  alcoholic  neuritis       . .  78 

dengue      . .          . .          . .  506 

Landry's  paralysis          . .  567 

in  neuromyositis             . .  504 

paralysis  agitans. .          . .  796 

peripheral  neuritis         . .  66 

tabes  dolorosa     . .          . .  507 

yellow  fever         . .          . .  372 

-  in  liver,  with  cholangitis   . .  650 

cholycystitis         . .          . .  650 

from  pyle[jhlebitis          . .  640 

secondary  carcinoma      . .  412 

venous  congestion           . .  407 

-  in  loin  (and  see  Backache  ; 

and   Pain    in  the    Back;, 
aching,     from      movable 

kidney       . .          . .          . .  .31l> 

in  anuria  . .          . .          . .  45 

and   back   in   phosphatic 

diabetes            . .          .  ■  57? 

in  bacteriuria      . .           84,  OIG 

with  calculus  in  pancreatic 

duct      . .          . .          . .  13.5- 

chronic  pancreatitis       . .  13.> 

due  to  colitis       . .          . .  727 

in  epididymo-orchitis     . .  518 

from  fscal  accumulations  393- 

in  influenza         . .          . .  610 

malignant  growth  of  colon  393- 

of  kidney     . .          .  .  39-> 

perinephric  abscess        . .  500 

polycystic     disease      of 

kidneys             . .          . .  39(> 

from  prostatitis  . .          . .  491 

referred  from  opposite  side  394 

from  renal  calculus  46,308,846- 

colic      . .          . .          .  .  516- 

infarction         . .          . .  314 

lesions  . .          . .          . .  306. 

tuberculosis      . .          . .  309' 

stone  in  pancreas           . .  135 

thickening  round  appendix  39.^ 

ureteric  calculus  . .          . .  13» 

-  lumbo-sacral  region,  attacla 

of,  in  pyosalpinx            . .  632 

-  malar    region    from     iritis 

and  cyclitis         . .          . .  256 

-  on  micturition  (see  Micturi- 

tion, Painfril) 

-  in     mid-orbital    region     in 

astigmatism          .  .          .  .  49S 

-  mouth  from  corrosive  poison- 

ing              297 

-  nail  in  onychia        . .          . .  445 

-  naso-labial    area    in    caries 

of  canine  tooth  (Fig.  132)  497 

-  in  neck,  (and  see  Sore  Throat; 

and  Stiff  Xeck)   .  .          .  .  70S 

in  aortic  aneurysm          .  .  482 

cervical  cari&s     . .         673,  70S 

from  fracture  of  cervical 

spine     . .          . .          . .  70!> 

in  liyoid  area  in   tongue 

affections          . .          . .  498 

in  ear  disease          . .  4'.iS 

from  mumps        .  .          . .  C74 

referred,  segmental  areas 

of            4!)S 

in  syringomyeha             . .  •'iol 

-  neuralgic,  in  osteitis  defor- 

mans        . .          . .          . .  755 

disseminated  sclerosis    . .  665 

-  nose  from  iritis  and  cyclitis  2^6 

-  "  ovarian   region  "    due    to 

hj-steria     . .          . .          . .  509- 

PAIN,   PELVIC                      ..  50S 

from  appendicitis            . .  032 

cryptomenorrhoea           . .  22 

in  ectopic  gestation        . .  760 

with  salpingo-oophoritis 

220,  760 


956 


PAIN,    PENILE— PALMS 


PAIN.  PENILE 

510 

Pain  in  shoulder,  contd. 

Palate,  contd. 

from  alieotion.  of  trigonal 

right,  from  biliary  colic  135 

500 

-  paralysis  of..        ..       224, 

775 

regioa  of  bladder 

441 

carcinoma  of  liver 

412 

from   bulbar   or   pseudo- 

 ill  carcinoma  of  bladder 

from  gall-bladder  disease 

779 

bulbar  paralysis 

640 

311,  441,  512 

630 

gall-stones       ..135,363 

778 

causes  of . . 

640 

cystitis     . .          . .         441 

512 

hepatic  abscess  309,  409 

651 

m  diphtheria         77,  181, 

on  erection  in  ohordee  . . 

516 

liver  disease    . . 

779 

640,  687 

842 

with  prostatitis 

515 

-  in    side  (left)   hi   injury  of 

ascribed  to  influenza . . 

640 

with  hacmaturia,  in  vesi- 

spleen 

700 

course  of 

640 

cal  disease 

306 

mediastinal  growth 

483 

Klebs-Loffler  bacilli  in  . . 

640 

from  herpes 

515 

in  pneumonia 

372 

nasal  quality  of  voice  in  040 

,687 

impaction  of  calculus 

pyonephrosis 

624 

regurgitation     of     food 

210,  311 

441 

-  in  soles  of  feet  in  gout 

382 

through  the  nose  in  . . 

640 

after  micturition,  causes  of 

513 

gonorrhoeal  arthritis  . . 

376 

after  removal   of   tonsils 

during  micturition        512, 

515 

-  spastic  constipation 

144 

or  adenoids 

640 

from  penile  hajmatoma  . . 

51G 

-  spinal  region  (see  Pain  in  Back) 

syphilitic 

040 

prostatitis 

441 

-  spleen   in    fungating    endo- 

- pemphigus,  etc.,  of 

114 

renal  tuberculosis 

629 

carditis     . . 

237 

-  perforation  of,  diagnosis  of 

scalding     . . 

207 

-  sternal  region  (see  Pain  in 

cause   of   . . 

640 

from  tuberculous  bladder 

Chest) 

malignant 

640 

441 

628- 

-  behmd  sternum  m  growth 

mercury    and    iodide    in 

ureteral  calculus  impacted 

in   anterior   mediastinum 

483 

diagnosing  cause  of    . . 

640 

near  bladder    . . 

627 

-  sudden    intense,     in    tabes 

microscopic    examination 

vesical  calculus   312,  441, 

dolorosa    . . 

507 

of    edge    of    ulcer    in 

628 

629 

-  in  teeth  from  glaucoma    . . 

257 

diagnosiag  cause  of    . . 

040 

PAIN  IN  PERINEUM,  causes 

516 

-  temporal  region  from  disease 

regurgitation      of      food 

ill  acute  cystitis  . . 

627 

of  upper  bicuspids 

783 

through  nose  from 

040 

bacteriuria 

84 

heart  disease  . . 

783 

syphilitic 

237 

from  ectopic  testis 

516 

lung  disease     . . 

783 

traumatic 

640 

gouty  eczema 

516 

stomach  disease 

783 

tuberculous 

640 

in  prostatic  disease     442, 

PAIN  IN  TESTICLE 

517 

"Wassermann's     test     in 

491, 

631 

in  testicular    abscess     . . 

680 

diagnosing  cause  of  . . 

640 

-  precordial   (and  see  Heart; 

due  to  new  growth 

766 

-  reflex,  absent  in  hysteria  . . 

509 

and   Pain    in    Chest),    in 

from  renal  calculus       308, 

840 

impaired  in  bulbar  palsy 

687 

acute  dilatation  of  heart 

243 

ureteric  calculus 

135 

-  sarcoma  of  . . 

640 

endocarditis     .. 

239 

-  in  thighs,  from  carcinoma  of 

-  scarring  of,  from  sjiihilis  . . 

237 

from  ruptured  valve  . . 

23S 

rectum 

93 

-  squamous-celled    carcinoma 

in  angina   pectoris 

582 

in  obturator  hernia 

740 

of 

670 

aortic  disease 

233 

from  renal  calculus 

308 

-  syphilitic  ulcer  on  . .         237 

,813 

incompetence  . . 

481 

ureteric  calculus . . 

135 

spirochaetes  in  scraping 

arteriosclerosis    . . 

14 

-  in    throat    from    corrosive 

from  . . 

640 

clironio  nephritis 

14 

poisoning   (and   see    Sore 

-  tuberculosis  of        . .         640 

673 

from  dyspepsia  . . 

481 

Throat) 

297 

sore  throat  from 

670 

fibroid  heart 

■241 

-  toe  from  ingrowing  nail 

486 

tubercle  bacilli  in  scrap- 

 flatulent     dyspepsia,    in- 

- tongue  from  carcinoma     . . 

812 

ing  from 

640 

crease  after  exertion  . . 

481 

trigeminal  neuralgia 

495 

usually    associated    with 

onset  after  a  meal  . . 

481 

-  tooth  from  dental  caries    .  . 

496 

phthisis  or  lupus    . . 

640 

in  myocardial  affections 

18 

-  due   to  twisting   of   pedicle 

-  unaffected     in     herpes     of 

myocarditis 

241 

of  ovarian  cyst  simulating 

tongue 

831 

pericarditis           . .        480 

777 

renal   colic 

392 

-  unilateral  palsy  of,  absence 

-  from      pressure     on      ceso- 

PAIN    IN    UMBILICAL    RE- 

of articulatory  defect  in 

687 

phagus,  in  aortic  aneur- 

GION          

524 

PALLOR          

27 

ysm 

482 

due  to  sebaceous  cy^t 

324 

-  acute,  in  duodenal  ulcer    . . 

300 

-  rectal,  from  abscess 

6. -So 

-  urethral  due  to  epithelioma 

767 

in  gastric  ulcer  . . 

298 

prostatitis            . .         628 

,  631 

with  discharge    . . 

441 

-  in  acute  nephritis  . . 

48 

rectal  carcinoma 

636 

from  impacted  calculus  441 

,442 

-  cachexia  alkalina    . . 

115 

—  referred  (see  Referred  Pain) 

-  along  vertebral  column   in 

-  an    indication    or    not    of 

-  renal,  with  bladder  tumours 

311 

neurasthenia 

494 

anaemia     . . 

27 

in  renal  angle  from  ureter 

-  in  vulva  (and  see  Dyspareunia) 

-  in  infantile  scurvy  . . 

599 

calculus 

514 

after  micturition,  in  cystitis  442 

-  from   internal    haemorrhage 

colic  (see  Colic) 

with  vesical  carcinoma 

442 

646 

780 

tuberculous  kidney 

312 

in  kraurosis 

770 

-  local,    symmetrical,    of    ex- 

-*in retention  of  urine 

440 

prolapse       of       urethral 

tremities,    in   Eaynaud's 

-  sacral     region,     from     car- 

mucous membrane 

770 

disease     . . 

490 

cinoma  of  rectum 

93 

from  ureteric  calculus  . . 

135 

-  in  M^ni^re's  disease 

S2S 

—  over    saero-iliac  joint   from 

urethral  caruncle 

770 

-  pyoneplirosis 

390 

joint  disease 

739 

varicocele  of  vulva 

770 

-  tuberculous  joints  . . 

39 

—  In"   scalp,      from     diabetes 

-  wrist  (see  Joints,  Affections 

Palmar    fascia,     Dupuytren's 

mellitus    . . 

784 

of  ;  Arthritis  ;  and  Osteo- 

contracture of     . . 

167 

liysteria    . . 

784 

arthritis) 

Pahnaris  brevis,  nerve  supply 

malaria     .  . 

784 

Painful  coitus  (see  Dysparaunia) 

of 

550 

neurasthenia 

784 

-  micturition  (see  llicturition. 

-  longus,  nerve  supply  of     . . 

550 

rheumatism 

784 

Painful) 

Palms,    arsenical    hyperkera- 

 syphilis     . . 

782 

-  swallowing  (see  Dysphagia) 

tosis  of 

87 

-  scapular    region     in    some 

Painter's  cramp 

177 

-  burning   pain   in,    in   acro- 

cases  of  cervical  rib 

492 

Painters,  plumbism  in 

136 

paraBsthesia 

493 

-  in  shoulder,  due  to  coronary 

Palate,  ataxy  of 

69 

-  congenital  syphilitic  condy- 

sclerosis   . . 

778 

-  bilateral  paralysis   of,   dys- 

lomata of 

446 

in  diapliragmatic  pleurisy 

480 

arthria  from"        .  .         '686 

,087 

-  papulo-squamous     syphilo- 

—  gastritis    . . 

778 

-  carcinoma  of 

673 

derms  of 

532 

phthisis     . . 

778 

-  cleft  (see  Cleft  Palate) 

640 

-  pityi-iasis  rubra  pilaris  of  . . 

658 

referred  from  diaphragm 

779 

-  endothelioma  of     . .         42f 

,640 

-  prm-itus  of  . . 

588 

left,  in  abscess  of  left  lobe 

-  cumma  of    . .          .  .         670 

,073 

-  tingling  and   numbness   in, 

of  liver 

409 

-  inflammation  of 

673 

in  acroparaesthesia 

493 

PALPEBRAL    FISSURE— PAPULES 


957 


Palpebral  fissure,  narrowing 
of,  in  cprvical  sympa- 
thetic paralysis  . . 

-  -  -  in  lesions  o£  8th  cervical 

and   1st    dorsal    seg- 
ments 

-  -  slanting  direction  in  Mon- 

golian idiocy  . . 

unequal,      confusion      of 

ptosis  with 

-  -  widened  in  facial  paralysis 
PALPITATION 

-  from  abdominal  pain 

-  in  acute  endocarditis 

-  aortic  disease 

-  in  chlorosis  . . 

-  chronic  nephritis     . . 

-  enlarged   heart   from   over- 

exertion   . . 

-  exophthalmic  goitre  792, 

-  fibroid  heart 

-  with  flushing 

-  heart  disease  . .        o.'iS, 

-  mitral  regurgitation 

-  myocardial  degeneration  . . 

-  myocarditis . . 

-  neurasthenia 

-  with  parenchymatous  goitre 

-  paroxysmal  tachycardia   . . 

-  in  stomach  disorders 
Palsies  (see  Paralyses) 
Pancreas,  affections  of,  fatty 

diarrhoea  in 

glycosuria  in  some  cases  of, 

360,   486 

-  -  microscopical  characters  of 

fceces  in 

pain  in  epigastrium  in    . . 

palpable  tumour  in  some 

reaction  in  urine  in 

tenderness  in  epigastrium 

from 
^  calculus  of   . . 

-  carcinoma  of  (see  Carcinoma 

of  Pancreas) 

-  cyst  of,  absence  of  "  edge  " 

and  "  notch  "  in  tumour 

due  to 

Cammidge's    reaction    in 

diagnosis  of     . . 

chronic  indigestion  with 

diagnosis  of  ascites  from 

from  ovarian  cyst 

ferments  in  fluid  from  . . 

general  account  of 

glycosuria  with  . . 

inflation    of    stomach    in 

diagnosis  of 

jaundice  with 

pale  bulky  stools  with  . . 

pelvic  swelling  due  to    . . 

-  -  simulating  hepatic  cyst. . 
usually  behind  stomach 

-  defects    tested    by    Sahli's 

corpuscles 

-  epigastric  swelling  due  to. . 

-  extract  of,  in  infantilism   . . 

-  lesions  of,    subphrenic    ab- 

scess from 

-  normal  situation  of 

-  swelling    of,    ana?sthetic    in 

diagnosis  of 
physical  signs  of . . 

-  tumours  of,  causing  jaundice  366 
Pancreatic   artery   opened  by 

gastric  ulcer        . .  . .     298 

-  calculus  (see  Calculus) 

-  catarrh,  jaundice  and  colicky 

epigastric  pam  in  . .     365 

-  colic,  signs  and  symptoms  of    135 

-  diarrhoea,  white  stools  in  . .     197 

-  disease  and  infantilism       .  .     216 

glycosuria  in        . .  . .     292 

tests  for  presence  of       . .     30-1 


247 


553 

203 

590 
533 

525 
528 
239 
233 
303 
13 

244 
,  797 
241 
208 
481 
238 
333 
241 
500 
792 
772 
484 


480 


177 
486 
486 
480 

779 


090 


724 
53 

758 
53 

724 
724 

090 
724 
724 


090 


210 
724 
216 


720 


724 
724 


from 


361 


210 


394 
090 
360 
690 


116 
90 
116 
117 
591 


Pancreatic  disca.sc,  coitld. 

undigested      muscle      in 

stools  in 

-  hajmorrhage   (see     Ha;mor- 

rhage,  Pancreatic) 

-  incompetence,  signs  of 

-  jnicf  find  fnt  iliLrestion 
Pancreatic  reaction  (see  Cam 

midge) 

-  tumour,      diagnosis 

renal  tumour 

splenic  tumour 

jaundice  in 

physical  signs  of. 

(see  also  Pancreas,  Cyst  of ; 

and  Carcinoma  of  Pancreas) 
Pancreatitis,   bile  pigment  in 

urine  in    . .  . .  . .     110 

-  Cammidge's  reaction  in    115,  280 

-  causes  of      . .  . .  . .     116 

-  a  common  cause  of  diabetes     117 

-  diagnosis  of  . .  . .     485 

-  faeces  in 

-  hsemorrhage  from  bowel  in 

-  indicanuria  in 

-  occult  blood  in  iceces  in     . . 

-  ptyalism  in  . . 

-  acute,    "  acute     abdomen  " 

due  to      . .  . .         431,  485 

biliary  colic  in    . .  . .     153 

collapse  from      . .        292,  724 

constipation  in 

153,  292,  724,  846 

epigastric  pain  from      . .     724 

fat  necrosis  with  153,  431,  846 

frequent  absence  of  rigid- 
ity of  abdomen  in 

glycosuria  in 

immediate  laparotomy  in 

laparotomy  in  diagnosis  of 

724^ 

meteorism  in 

nausea  in 

pain  in  epigastrium  in  . . 

pancreas  seldom  felt  in 

passage  of  flatus  in 

pyrexia  from 

severe  abdominal  pain  in 

292,  484,  846 

shock  and  collapse  in     . .     484 

simulating  intestinal  ob- 
struction . .         431,  846 

perforated  gastric  ulcer     431 

tenderness  over  pancreas 

in  846 

vomitmg  in  292,  724,  844,  840 

—  hjemorrhagic,  abdominal 

distention  with  . .     640 

fat  necrosis  with         . .     646 

hiccough  in     . .  . .     342 

laparotomy  in  diagnosing  646 

pain     in     upper     part 

of  abdomen  from  . . 
simulating  general  peri- 
tonitis 

intestinal  obstruction 

tympanites  with 

vomiting  and  constipa- 
tion with 

-  chronic,      bulky      offensive 

stools  in  . . 

Cammidge's    reaction    in 

135,  280 

clay-coloured  stools  with 

cysts  resulting  from 

diagnosis  from  gall-stones 

265,  363 

new  growth      . .  . .     265 

enlarged  gall-bladder  in       135 

epigastric  pain  in  135,  486 

tumour  from  . .  . .     724 

fat  in  stools  in     155,  265,  292 

fatty  iridescent  stools   in     364 

gall-bladder  enlargement  in  280 


431 

292 
431 

846 
431 

840 
431 
724 
153 

724 


646 

646 
646 
646 

646 


364 

724 
724 


Pancrealilis ,  chronic,  contd. 

gall-stone  disease  and    135,  486 

glycosuria  in        135,   292,   724 

-  -  jaundice  in  135,  280,  292,  301 

363,  724 
obstruction    of    common 

bile-duct  in  . .  . .  302 
paroxysmal     epigastric 

pain  in  . .  . .     280 

pigmentation  in..         135,  292 

recurrent  jaundice  in    303,  724 

rigors  in  . .  . .         135,  292 

tenderness  and  pain  in  . .     724 

undigested  meat  in  stools  in  292 

-  -  wasting  in  . .  135,  292 
Pandemic  chorea  ..  156,157 
Pannus  in  trachoma  . .  . .  807 
Panophthalmitis  from  corneal 

ulceration             . .          . .     806 
-diphtheritic 807 

-  gonococcal   . .  . .  . .     807 

-  from  herpes  frontalis         . .     807 
Papilloma  of    bladder,  carci- 
noma simulating  . .     030 

cystoscopyin  441,512,514,630 

cystitis  from        . .  . .     630 

diagnosis  from  carcinoma     030 

fragments  in  urine        300,  630 

hsematuria  from 

304,  305,  311,  514 

pain  in  penis  from  511,  513,514 

profuse   recurrent  hsema- 

turia  in.  .  . .  . .      512 

pyuria  due  to      . .        623,  630 

retention  of  urine  from . .     441 

simulated     by     ureteral 

calculus  . .  .  .     514 

sloughing  of         .  .  .  .      630 

sudden,     profuse,     pain- 
less hsemorrhage  in    . .     305 

stoppage  of  urine  by  439,  514 

urethra  obstructed  by   . .     514 

-  -  villous       . .  . .        308,  511 

-  bleeding  gums  due  to  86,  8S 

-  duct,       bloody       discharge 

from  nipple  in      . .  .  .      202 

-  of  kidney,  hematuria  in  304,  30S 

haemonephrosis  in  . .     308 

hydronephrosis  in  . .     308 

renal  enlargement  in     . .     308 

-  of     larynx     mistaken     for 

asthma 582 

-  rectal  haemorrhage  from    . .       93 

-  of  scrotum    . .  . .  . .     679 

sloughing,  diagnosis  from 

hernia  testis     . .  . .     681 

-  ureteral        . .  . .  . .     SOS 

-  urethral         209 

-  vulval,  gonorrhoeal  . .     709 
Papillomatous    ovarian    cyst, 

ascites  in              . .          . .       58 
PAPULES        528 

-  absence  of  scarring  from  . .     528 

-  in  anthrax  . .  . .  . .     003 

-  congenital  syphilis..  ..     446 

-  in  dermatitis  herpetiformis      831 

-  development  into  pustules      601 

-  in  eczema     . .  . .  . .     831 

folliculorum         . .  . .     528 

marginatum  .  .  . .     275 

-  granulosis  rubra  nasi         . .     714 

-  herpes  zoster  . .  . .     830 

-  impetigo  contagiosa  . .     831 

-  Jacquet's  infantile  erythema    446 

-  lichen  planus  . .        657,  832 
ruber  planus       . .  . .     658 

-  lupus  vulgaris         . .  . .     80S 

-  and     nodules,      differences 

between    . .  . .  . .     448 

-  in  pityriasis  rubra  pilaris  . .     058 

-  scabies  . .  . .  . .     831 

-  of  severe  goose-skin  528,  530 

-  small-pox  . .  . .     005 

-  sycosis  vulgaris       . .  . .     002 


938 


PAPULES— PARALYSIS    OF    HAND 


Papules,  contd. 

Paralysis  agitans,  contd. 

Paralysis,  could. 

-  syphilis  425, 446, 532,604,709 

,832 

slowness  of  speech  in     . . 

259 

-  conditions  simulating 

545 

-  syphilitic,  anal  and  genital 

447 

sphincters  normal  in 

796 

—  and  cramp  associated 

177 

-  in  typhoid  fever 

697 

stiffness  in 

541 

-  of  cranial  nerves  in  cerebral 

-  typhus  fever            . .        371, 

699 

tremor  in     541,  794,  795, 

798 

syphilis     . . 

173 

-  vaccinia 

834 

absent  early  in 

548 

muscular     atrophy  in 

75 

-  varicella       . .      -    . . 

833 

-  in  alcoholic  neuritis 

551 

-  crossed  (see  Hemiplegia) 

Papulo-pustules,  description  of 

528 

-  amyotrophic  lateral  sclerosis 

131 

-  of  detrusor  muscle,  difficult 

Papule  -  squamous      syphilo- 

-  of  anterior  crural  nerve   . . 

541 

micturition  from           440, 

443 

derms 

532 

-  Of  arm  (see  Arm,  Paralysis  o 

f) 

-  diaphragm  after  diphtheria 

77 

Papula-vesicles,  description  of 

528 

monoplegia  of 

547 

in  Landry's  paralysis     . . 

567 

Paracentesis  abdominis,  chronic 

-  atrophic,     in    acute    polio- 

 unilateral. . 

341 

peritonitis  from  repeated 

55 

myelitis    . . 

128 

-  diphtheritic,    muscular  at-. 

necessity  for  catheteriza- 

- of   back    muscles,    scoliosis 

rophy  in.. 

76 

tion  before 

717 

from          . .          . .         180, 

181 

palatal       . .          . .         559 

650 

perihepatitis  from 

60 

-  bilateral  adductor  in  hysteria 

798 

regurgitation      of      food 

-  thoracis,   haemoptysis   after 

317 

supranuclear  facial,  in  cere- 

through nose  in 

202 

liydropneumothorax  from 

712 

bral  diplegia         154,  535, 

686 

-  Duchenne's,  injury  at  birth 

pneumothorax  from     577, 

578 

-  birth,  athetosis  from 

155 

causing     . . 

552 

Paracusis     Willisii,     in     oto- 

- Brown-Sequard     type    (see 

-  Erb's,  extent  and  causes  of 

552 

sclerosis    . . 

190 

Brown-Sequard) 

-  of  ext.  popliteal  nerve,  signs 

543 

Paradoxical     dilatation     in 

-  bulbar,  atrophy  of  muscles 

rectus,  effects  of . . 

201 

hour-glass  stomach 

353 

of  hand  in 

687 

with  facial  paralysis  . . 

536 

Paraesthesia  (and  see  Sensation, 

mastication  in 

687 

PARALYSIS    OF   EXTREMI- 

Abnormalities of) 

tongue  in           591.  641, 

686 

TIES         ..          ..         539 

545 

-  in    arms  from    pressure    of 

diaonosis    from    bilateral 

in  diphtheria         . .         77 

640 

cervical   rib   on   brachial 

supranuclear  facial  para- 

 from    syphilitic    pseudo- 

plexus 

593 

lysis       

536 

paralysis 

387 

-  disseminated  sclerosis 

565 

bulbar  haemorrhage    . . 

687 

PARALYSIS  OF  EXTREMITY, 

-  hysteria 

166 

myasthenia  gravis 

225 

UPPER     

545 

-  subacute  combined  degener- 

 pseudo-bulbar  . . 

641 

hand  in  Tooth's   pero- 

ation of  the  cord 

493 

softening 

687 

neal  atrophy 

71 

-  tabes  dorsalis 

493 

tumour  of  bulb 

687 

importance    of  history 

-  transverse  myehtis 

74 

difficulty    of   speech   and 

in     .  . 

545 

Paraffin  workers,  epithelioma 

swallowing  in  .  . 

159 

withoutmuscular  atrophy  540 

of  scrotum  in 

679 

dribbling  of  saliva  in     500 

641 

PARALYSIS    OF    ONE     EX- 

Parageustia 

774 

dysarthria  from . . 

686 

TREMITY,  LOWER     539, 

540 

Paragonimus         AVestermani, 

dysphagia  in 

leg      with       muscular 

hEemoptysis  from 

705 

159,  224,  641,  687 

842 

atrophy 

541 

Paraldehyde,  foul  taste  from 

774 

electrical      reactions      of 

spastic,  electrical  re- 

Paralysis of    abdommal   mus- 

tongue muscles  in 

687 

actions  in 

540 

cles            

181 

fibriUary   contractions    of 

from  tumour  of  cauda 

-  agltans,   absence  of  tremor 

tongue  in         . .         159 

686 

equina 

74 

with 

796 

gangrene  of  lung  in 

288 

without    muscular 

bent  and  rigid  carriage  in 

796 

gradual  progress  of        641 

686 

atrophy     . . 

539 

bread  -  crumbling        and 

insidious  onset  of 

686 

-  of  eye  muscles  in  myasthe- 

cigarette-rolling move- 

 lesions  causing     .  .          641 

686 

nia  gravis 

225 

ments  in 

796 

loss  of  taste  due  to         774 

,775 

PARALYSIS,   FACIAL  (Figs. 

defective  winking  in 

262 

nerves  afEected  in 

159 

136-140) 

533 

differentiation  of  myxoe- 

ophthalmoplegia  in 

159 

athetosis  with 

530 

dema  from 

259 

palatal  paralysis  in 

640 

atrophy  of  face  from    . . 

75 

expressionless  face  in    259 

796 

paresis  of  lips  and  tongue  in  641 

Bell's,  contracture  from 

165 

exuberant  laughter  in   . . 

262 

vocal  cords  in  . . 

687 

bilateral,  interference  with 

facies  described  (Fig.  86) 

261 

progressive  muscular  atrophy 

labial  articulation  in. . 

687 

festinating  gait  in         278, 

796 

associated  with            73 

641 

in     Landouzy-Dejerine 

flexion  of  arm  in 

548 

reflexes  in 

687 

myopathy     .  . 

687 

gait  in      . .   278,  541,  548 

796 

regurgitation     of     food 

peripheral  neuritis 

687 

general  account  of 

796 

tlirough  nose  from 

202 

ptyalism  in 

591 

influence  of  will  on  tremor  of  796 

-  cardiovascular  lesions  in    . . 

546 

and  brachial  monoplegia 

547 

sleep  on  tremor  of 

796 

-  cerebral,    associated    move- 

 contracture  from           534 

537 

msomnia  m 

358 

ments  in  . . 

548 

epiphora  in 

250 

lateropulsion  in  . . 

796 

convulsions  of  children  in 

169 

and  hemiplegia  . . 

336 

loss  of  power  in  one  arm 

-  from  cerebral  tumour 

350 

herijes  with 

536 

in  early  stgaes  of 

548 

-  of  cervical  sympathetic,  ab- 

 keratitis  from 

807 

in  one  leg  in 

541 

sence  of  blushing  in     247 

590 

nerve,     syphilitic    (Figs. 

mistaken  for  hysteria    . . 

548 

diminished    tension    of 

158,   159)          ..         589 

590 

neuritis 

548 

lobe  of  eye  in 

594 

peripheral 

536 

monotonous  voice  in     . . 

796 

enophthahnos  in 

247 

simulated  by  facial  hemi- 

 muscular  rigidity  in 

796 

loss  of  pupillary  sensory 

atrophy  (Fig.  141)     . . 

537 

weakness  in     . . 

796 

reflex  in       " . 

594 

supranuclear 

534 

normal  reflexes  in 

541 

palpebral  fissure  dimin- 

 taste  defects  in  . .         774 

775 

paresthesia  in     . . 

706 

ished  from          247, 

546 

-  of  fifth  nerve,  abolition  of 

-  -  propulsion  in 

796 

ptosis   from       247.  590, 

594 

wihktng  reflex  in 

807 

ptyalism  in 

591 

pupil  constricted  from 

anosmia  from.  . 

608 

reflexes  normal   . .        548, 

796 

247,  546,  590,  595, 

792 

arrest     of     lachrymal 

retraction  of  eyelids  in  . . 

262 

pupils  unequal  in 

595 

secretion  in. . 

807 

retropulsion  in    . . 

796 

stimulation    of,    dilata- 

 dryness  of  nose  from . . 

668 

shuffling  in          . .         541, 

796 

tion  of  the  pupil  in  594 

595 

hypopyon  from 

807 

simulated     by     cerebral 

sweating  due  to 

247 

insensibility  of  cornea  in 

807 

softening 

796 

from  thyroid  gland  tu- 

 keratitis  from . . 

807 

mercurial  tremor 

797 

mour.  . 

792 

-  general,  of  insane  (see  General 

writer's  cramp 

177 

-  of     ciliary      muscle     after 

Paralysis  of  the  Insane) 

slow    emotional   develop- 

diphtheria                77,  224, 

640 

-  of    hand,     ischa-mic,    from 

ment  in 

262 

-  circumflex  nerve     . . 

552 

injury  to  forearm 

552 

PA  RA  L  YSIS,  HPPOGLOSSA  L—  PA  RA  TH YROID 


959 


I'lirali/.iis,  cmiUl. 

J'arali/.iis,  could. 

-  liy|KiL'loss;il,      atroiiliy       oC 

-  ill  ]M'riplicral  neuritis  (see  Neu- 

toii;,'iio from 

7") 

ritis,  Multiple  Peripheral) 

-  ill  hy.st(,'ria     (see     iiystoria, 

-  of  pliarynx,  progressive     . . 

224 

I'ara lysis  in) 

-  iiriinary  muscular,  patient's 

-  infantile,  abnormal  gait  in 

■s^a 

method  of  raising  himself  in 

132 

-  -  acquired, choreiform  move- 

 talipes  in 

132 

ments  in 

155 

-  progressive    bulbar,     fibril- 

  clefeetive  speecli  in    . . 

15.5 

lary  contractions  in      158, 

159 

epilepsy  from.  . 

105 

-  pseudo-bulbar  (see  Pseudo- 

- -  -  mental  deticicucy  in  . . 

155 

bulbar  Paralysis) 

tremors  in 

155 

-  pseudo  -  hypertrophic     (see 

tropliic  lesions  in 

155 

Pseui  lo-hy  pwtrophic  Mus- 

- -  of  arm,  (Fiy.  7)  . . 

70 

cular  I'aralvsis) 

cousins  claw-foot 

127 

-  jitosis  due  to (I'if/s.  156-159) 

590 

muscular  atrophy  in 

70 

-  ptyalism  from  difficulty  in 

—  -  plantar  rellex  in . . 

81 

swallowing  in 

591 

preceded  by  paraplegia 

544 

-  retention  of  urine  from 

441 

reaction  of  degeneration  in 

131 

-  of  sciatic  nerve,  causes  and 

scoliosis  from 

180 

signs  of    . . 

542 

talipes  in             . .          71, 

131 

talipes  from     . . 

132 

ulceration  of  the  leg  in  . . 

811 

-  serratiis  niagnus 

551 

-  -  vasomotor    and     trophic 

-  sixth  nerve,  effects  of 

200 

lesions  in 

131 

-  sometimes  absent  with  cere- 

- of  inferior  oblique,  effects  of 

201 

bral  liirmorrliage 

138 

rectus,  eltects  of . . 

liOl 

-  from    spinal    cord    lesions, 

-  intercostal  muscles  in  Lan- 

pain in     . . 

545 

dry's   paralysis    . . 

567 

muscles,  scoliosis  due  to 

181 

-  internal  popliteal  nerve    . . 

543 

-  superior  oblique,  effects  of 

201 

rectus,  effects  of . . 

201 

rectus,  effects  of . . 

201 

-  intestine,  in  cord  affections 

432 

-  supranuclear 

534 

-  Jacksonian  epilepsy  with.. 

101 

-  -  facial  bilateral  (Fig.  140) 

535 

-  Klumpke's,  cause  and  effects 

553 

-  of  suprascapular  nerve 

551 

-  Landry's  (see  Landry's  I'aral} 

sis) 

-  tliird  nerve  . . 

595 

PARALYSIS,  LARYNGEAL.. 

537 

from    tumour   of   mid- 

- -  abductor,  orthopna.-a   In 

465 

brain  . . 

798 

bilateral,  aphonia  in 

687 

-  tibial  muscles,  talipes  from 

132 

from  bronchial  glands  . . 

422 

-  tongue  in  bulbar  paralysis 

641 

cancer  of  cesophagus 

296 

progressive 

224 

central    nervous    system 

-  transient,      in    Jacksonian 

changes  in 

539 

epilepsy    . . 

161 

diagnosis  from  laryngitis 

537 

-  in  tuberculous  meningitis. . 

612 

dyspucea  from     . . 

53!) 

-  uhiar  (and  see  Ulnar  Paralysis) 

gangrene  of  lung  m 

288 

disturbed  function  in  other 

in  myasthenia  gravis     . . 

225 

parts  with 

574 

progressive 

224 

diagnosis   of   Volkmann's 

simulating        suffocative 

contracture  from 

552 

oedema.. 

539 

loss  of  sensation  in 

128 

traclieotomy  required  for 

539 

-  of  vesical  sphincter,  inconti- 

- -  urgent  dyspnoea  from   . . 

537 

nence  of  urine  from 

440 

(aiid  see  Paralysis  of  Vocal 

-  vocal  cord  by  aneurysm    . . 

222 

Cord) 

bilateral 

538 

vascular  degeneration 

in  bulbar  palsy 

687 

associated  with 

539 

dry  cough  due  to 

175 

lesions  of  internal  caji- 

functional 

538 

sule  causing 

flO 

lesion  of  one  recurrent 

-  of  both  legs  (see  Paraplegia) 

laryngeal  nerve 

687 

-  lips  in  bulbar  paralysis 

641 

voice  little  altered  in 

687 

progressive 

224 

from  mediastinal  fibrosif- 

538 

-  median  nerve 

552 

stridor  from    . . 

710 

-  motor  nerves  of  bladder    . . 

443 

syphilitic 

710 

-  nioath  in  myasthenia  gravis 

225 

from     thyroid      gland 

~  multiple,  of  cranial  nerves, 

tumour 

792 

syphilitic  . . 

590 

unilateral  organic 

538 

-  in  multiple  neuritis  (see  Kcu- 

-  Volckmann's 

72 

ritis,  Multiple  Peripheral) 

I'arametric  abscess  (see  Abscess 

-  of  muscles  of  back,  lordosis 

Parametric) 

from 

183 

Parametritis,  peritonitis  from 

644 

-  musculospiral          . .          77, 

552 

-  swelling  in  iliac  fossa  due  to 

737 

-  of  neck  muscles  in  myasthe- 

Paramnesia in  clironic  alcohol- 

nia gravis 

225 

ism 

172 

-  obturator  nerve,  signs  of  . . 

541 

Paramyoclonus  multiplex    160, 

799 

-  ocular  muscles  in  diphtheria 

640 

clonic  contractions  of    . . 

161 

(see  Strabismus;  andl'iipil 

retraction  of  the  head  in 

641 

Abnormalities  of) 

I'araiiliimosis,  jiain  in  penis  in 

515 

-  orbicularis        palpebrarum. 

PARAPLEGIA 

556 

epiphora  from     . . 

250 

-  abnormal  gait  in     .  . 

278 

keratitis  from . . 

807 

-  from    affection    of   cervico- 

-  of  palate 

640 

dorsal  cord 

555 

after  diphtheria             2'2i 

842 

-  athetosis  in. . 

154 

-  -  (.l3fsphagia  from . . 

224 

-  ankle-clonus  in          41,  494 

786 

-  -  stertor  from 

707 

-  ataxic          . .         493,  561 

565 

syphilitic,  associated  witli 

abnormal  gait,  due  to    . . 

277 

other  cranial  nerve  palsy 

610 

Uabinski's  sign  in 

82 

Paraplegia,  utatic,  con  Id. 

cord  lesions  in     . .  . .     565 

extensor  plantar  response     493 

imjiotence  in       . .  . .     346 

increased  tendon  jerks  in      493 

-  -  ijaru'Sthesim  in    . .  . .     493 
spastic  paraplegia  in       . .     493 

-  from  bilateral  cerebral  soften- 

ing  563 

-  causes  of,  in  adults  . .     561 
in  children            .  .  . .      556 

-  combined  scleroses  of  the  cord 

493,  667 

-  from  compression     270,  194,  786 

lialiiiiski's  sign  witli       . .      786 

girdle  sensation  in  . .     289 

increased  knee-jerks  with     786 

pain  in  the  back  with    . .     786 

retention  of  urine  in      . .     441 

tenderness  of   spine  with     786 

zone  of  hyperesthesia  in     786 

-  congenital    spastic,    diffuse 

kyphosis  with      ..  ..      182 
talipes  in          . .  . .     131 

-  contractures  in       ..  ..164 

-  diminished  power  of  mictu- 

rition in  . .  . .  . .     443 

-  in  disseminated  sclerosis  . .     547 

-  extensor  plantar  response  in    494 

-  in  Friedreich's  ataxy         . .       71 

-  functional     .  .  .  .  .  .     567 

-  girdle  sensation  in..  ..     289 

-  hysterical     . .  . .  . .       69 

-  increased  knee-jerk  in        . .     494 

-  infantile        . .  . .  . .     155 

convulsions  with. .  ..     170 

-  Landry's  paralysis..  ..     567 

-  in  Little's  disease   . .  . .     154 

-  from   malignant  disease   of 

the  vertebra;       . .  . .     786 

-  meteorism  with      . .  . .     432 

-  from  primary  lateral  sclerosis  567 

-  radicular  pain  in  arm   in..     494 

-  sensory  disorders  with      ..     563 

-  simulated  by  malingerers  567.  786 

-  spastic  439 

and  ataxy  . .  . .     565 

exaggerated  knee-jerkwith   397 

of   infants   and   children, 

athetosis  in     . .  . .     154 

primary,  impotence  in    . .     346 

from    spinal   caries        . .     558 

talipes  in  . .  . .     131 

-  sphmcter  trouble  with 

348,  411,  786 

-  in  spinal  caries        . .  . .     181 
loss    of    sphincter    ani 

control  in         . .  . .     558 

-  due  to  spinal  hoemorrhage       787 

-  sudden,  from  spinal  caries      270 

-  from    superior    longitudinal 

sinus  thrombosis  . .     643 

-  syringomyelia  . .        73,  554 

-  transverse  myelitis..         ..       73 

-  typhoid  spine  . .  . .     787 
Parasites  in  blood  in  malaria 

(see  Malaria) 

-  bile-duct  obstruction  from       364 

-  cachexia  from         . .  . .     114 

-  disco vcrv  of  vjixa  in  faaces       621 
PARASITES,  INTESTINAL(see 

Worms,   Intestinal) 

-  pruritus  caused  by  . .     588 
Parasitic  affections,  anaemia  in 

33,  37,  459 

albuminuria  in    . .  . .       17 

Charcot-Leyden    crystals 

in  stools  in      . .  . .     118 

eosinophil  ia  in     . .  .  .      249 

oedema  of  legs  in  459,  461 

-  jaundice        .  .  .  .  . .      361 

Parath3^roid     glands,     clonus 

from  excision  of  . .  . .     161 

-  insufficiency,  tetany  from..     178 


960 


PARATYPHOID    FEVER— PEMPHIGUS 


Paratyphoid  fever,  agglutina- 
tion test  for        . .        611,  697 

B.  paratyphosus  in        . .     697 

bacteriuria  in      . .  . .       83 

diagnosis  from  tuberculosis  611 

influenza  . .  . .     611 

typhoid  fever  . .        611,  697 

-  -  prolonged  pyrexia  in      . .     609 
splenic  enlargement  in  692,  697 

-  -  symptoms   like   those    of 

benign  typhoid  . .     Oil 

Paraxanthin  bases,  uric  acid 

derived  from       . .  . .     S17 

Paresis  (see  Paralysis) 
Parietal  lobp,  aura  in  tumour  of     SI 
Paris,  ringworm  parasites  in 

272    273 
Parkinson's  disease  (see  Par- 
alysis Agitans) 
Paronychia,  causes  of  . .     445 

Parotid  abscess,  discharge  through 

auditory  meatus  . .     470 

Parotiti  S,  acute  specific  (see  Mumps) 

-  diagnosis  from  periostitis  . .     747 

-  earache  from  . .  . .     230 

-  epididymo-orchitis  in        . .     517 

-  pain  in  the  face  from        . .     495 

-  swelling  of  face  in  . .  . .     746 

-  testicular  abscess  in  . .     680 
Paroxysmal     hoemoglobinuria, 

general  account  of         . .     315 

-  headache    in    disseminated 

sclerosis    . .  . .  . .     328 

in  neuralgia         . .  . .     326 

-  movements  in  epilepsy     . .     160 

-  pain  in  intestinal  colic     133,  472 

-  tachycardia,  brought  on  by 

fright  or  shock    ..  ••     772 

destinetion  from  Graves' 

disease  .  .  . .  . .     772 

duration  of  attacks  in    . .     772 

faintness  from     . .  .  .      772 

general  account  of         . .     772 

lack  of  strength  in         . .     772 

numbness   of    extremities 

in  .:  ..  ..772 

palpitation  in      . .         525,  772 

pins   and   needles   in   ex- 
tremities in     . .  . .     772 

pulse-rate  in        . .  . .     772 

sex  incidence  of  . .  . .     772 

Parrot's   nodes   in  congenital 

syphilis     . .  . .    _  427,  752 

Parturition  (see  Labour)  --'       ^ 
Passion,    rupture    of    cortical 

veins  during        . .  . .     131 

Patellar  clonus,   indicative  of 

organic  nervous  disease       398 

method  of  eliciting        . .     398 

Patent  ductus  arteriosus,  ab- 
sence of  cyanosis  with  129, 184 

symptoms  with       . .     790 

bruit  of  . .        104,  184 

no  clubbed  fingers  with     129 

persistent,        cyanosis, 

clubbed  fingers,   and 
polycythemia  rare  in     579 
systolic  thrill  due  to  184,  790 

-  foramen    ovale    causes    no 

symptoms  .  .  . .     184 

-  septum      ventriculorum, 

bruits  of       104,  105,  184,  579 

clubbed  fingers  witli  . .     129 

cyanosis  from. .  . .     184 

enlarged  heart  in        . .     244 

morbus  ca?ruleus  from      579 

and  pulmonary  stenosis 

associated     . .         244,  579 

systolic  bruit  of         . .     579 

thrill  with        . .  . .     184 

Paver  nocturnus         . .  . .     357 

Pavy's  albuminuria  . .  .  .       19 

-  solution    in    estimation    of 

glycosuria  . .         290, 291 


Pawlik's    grip    in    abdominal 

palpation  in  pregnancy  228 
Pears,  false  intestinal  sand  from  653 
Peas,  oxaluria  from    .  .  .  .     471 

Peau  lisse  with  syringomyelia     128 
Peckham  fat  boy       . .  . .     454 

Pectinens,  nerve  supply  of    . .     542 
Pectoralis  major,  nerve  supply     550 

pseudo-h3'pertrophy  of..      560 

spinal  nerve  root  supplying  556 

wasting  in  phthisis        . .       72 

-  ramor,  nerve  supply  of      . .     550 
Pectoriloquy     with     bronchi- 
ectasis      . .  . .       324,   703 

-  in  fibroid  lung        . .         232,  246 

-  lobar  pneumonia    . .        186,  702 

-  phthisis         . .  . .  . .     319 

Pediculi,    carbolic   acid    com- 
press for,  carboluria  from     822 

Pediculosis,  anaamia  from     . .     419 

-  cervical  gland  enlargement 

in  .  .     417,  419,  421,  708 

-  diagnosis  from  prurigo      . .     532 

-  eosinophilia  in        . .  . .     249 

-  irritation   of    skin  at   back 

of  neck  with    . .  . .     419 

-  pruritus  in  . .  . .  . .     588 

-  purpura  due  to      . .         596,  597 

-  scalp  tender  from  . .         780,  781 

-  stifi:  neck  from        . .  . .     708 

-  pubis,    enlarged    glands    in 

groin  from  . .  . .  738 
extent  of  infection  in     . .     447 

-  vestimentorum,  purpura  from  597 
Peelinc  ('see  Desquamation) 
Peliosis  rheumatica,  absence  of 

valvular  heart  disease  in      599 

age  and  sex  incidence  of      600 

distribution         . .  . .     599 

erythema  in         . .  . .     600 

joints  affected  in  . .     599 

purpura  in  . .         596,  599 

pyrexia  in  . .  . .     599 

relation  to  acute  rheum- 
atism   . .  . .         121, 599 
slight    influence    of    sali- 
cylates in         . .  . .     600 

soreness  of  throat  in      . .     599 

theory  of  origin  of         . .     600 

Pelvic  grip  in  abdominal  palpa- 
tion in  pregnancy  . .     228 

-  pain  (see  Pain,  Pelvic) 

-  peritonitis  (see  Peritonitis, 

Pelvic) 
Pelvimeter,  Skutch's,  use   of, 

in  pregnancy      . .  . .     228 

Pelvis,  abscess  of  (see  Abscess, 

Pelvic) 

-  adhesions     causing      acute 

intestinal  obstruction    . .     152 

-  affections,  frequency  of  mic- 

turition w'ith       ..  ..     817 

-  beaked  or  rostrate..  ..     212 

-  bones,  new  growths  of,  pelvic 

swelling  due  to  . .  . .     757 

-  cellulitis  of,  absence  of  local 

peritonitis  in       . .  . .     760 

always  due  to  labour     . .     760 

burrowing    along    round 

ligament  to  groin  . .  760 
diagnosis      from     pelvic 

abscess  . .  . .     760 

pelvic  swelling  due  to  757,  760 

uterus  fixed  by   . .  . .     760 

vaginal  fornix  bulged  by      760 

-  chondroma  of  . .        737,  761 

-  congestion  of,  causes  of    . .     508 
deep-seated  pelvic  pain  in     508 

-  contracted  in  achondroplasia    212 
dystocia  due  to  . .     227 

-  deformed  in  rickets  . .     212 

-  diseases  of,   constipation  in 

painful      . .  . .  . .     144 

diagnosis    from    lumbago     477 


Pelvis,  diseases  of,  contd. 

frequency  of  micturition  in  438 

mastodynia  in     . .  .  .     479 

sacralgia  in  . .  . .     509 

-  displacement     of,     causing 

prolapse  of  uterus  . .     586 

-  fracture  of (see  Fracture  of 

Pelvis) 

-  glands   enlarged    in,  causes 

identical  with  those  of  mes- 
enteric gland  enlargement    423 

-  growth     in,     bearing-down 

pain  from  . .  . .     473 

bilateral  hydronephrosis  in  311 

cartilaginous        . .  . .     761 

complicating  pregnancy        761 

continuity  with  pelvic  bones  761 

diagnosis    from    salpingo- 

oophoritis         . .  . .     761 

sciatica. .  . .  . .     487 

enlarged    mesenteric  and 

retroperitoneal  glands  in  422 

-  -  fixity  of    . .  . .         737,  761 

nephritis  from     . .  . .         8 

paraplegia  due  to  . .     561 

due     to     pelvic     abscess 

from  appendicitis       . .     632 

pelvic  swelling  due  to  . .     761 

rarity  of  . .  . .  . .     761 

rectal      examination      m 

diagnosing 


. .     487 

741, 761 

peripheral 


sarcomatous 

simulating 

neuritis  . .  . .     562 

talipes  from         . .  . .     131 

vaginal    examination    in 

diagnosing        . .  . .     487 

-  hfematocole  in  (see  Hsemato- 

cele.  Pelvic) 

-  impaction  of  lower  end  of 

spleen  in  . .  . .  . .     688 

-  infection     by     tuberculosis 

of  kidney  . .  . .     310 

-  Inflammation  in,  acute, severe 

pam  m  pelvis  in  . .  . .     508 

causing  amenorrhoea       23,  24 

diagnosis  from  sciatica  . .     487 

kinking  of  bowel  from  . .     147 

rectal     examination     in 

diagnosing        . .  . .     487 

simulating  sciatica         . .       74 

vaginal    examination    in 

diagnosing        . .  . .     487 

-  injury  or  inflammation  of, 

causing  nerve  paralysis        542 

-  method    of    measuring     in 

pregnancy  . .  . .     228 

-  sarcoma  of  (see  Sarcoma  of 

Pelvis) 

-  swelling  in  (see  Swelling  in 

Pelvis) 
due  to  urachal  cysts     . .     757 

-  tuberculous     disease,     ure- 

thral passage  of  faeces  in     264 

-  tumours  of,  or  cauda  equina 

simulating  neuritis  .  .      562 

diagnosis      from       renal 

tumours  .  .         392,  393 

difBcult  micturition  from 

in  female  . .  . .     439 

dislocated  spleen  causing     691 

dystocia  due  to   . .         . .     227 

muscular  atrophy  in      . .       74 

oedema  of  legs  from       . .     456 

physical  signs  of . .  . .     393 

Pemphigus,   affecting  fingers       266 

-  albuminuria  in        . .  . .       17 

-  bleeding  gums  in    . .  86,  88 

-  of  the  buccal  cavity        . ,     225 

-  buUsB  in      110,  111,  113,  602,  654 

-  crusts  in       . .  . .  . .     654 

-  diagnosis   from   cheiropom-  "  1 

pholyx      . .  . .  . .     832 

impetigo   . .  . .  . .     602 


PEMPHIG  US— PERIODIC   POL  Y  URIA 


961 


Pemphigus,  coiUd. 

-  eosinophilia  in        . .        114,  249 

-  foliaceus  distinguished  from 

pityriasis  rubra  . .  . .     658 

-  -  scales  and  crusts  in        . .     654 

-  marked    systemic    disturb- 

ance in     . .         . .  . .     602 

-  neonatorum  . .  . .     446 

-  -  bulks  in  ..  ..  110,  116 
relation  to  impetigo       . .     441 

-  pruritus  in  . .  . .  . .     588 

-  simulated  by  urticaria  bul- 

losa . .  . .  . .     850 

-  skin  stainins:  in       . .  . .     654 

-  vegetans,    distinction    from 

condylomata        . .  . .     654 

gangrene  from    . .  . .     654 

Pendulous  abdomen,   hepato- 

ptosis  in  . .  . .  . .     406 

in  cretinism         . .  . .     259 

Penguin-type  of  dwarf  . .     214 

Penicillium  glaucum  in  sputum  705 
Penile  pain  (see  Pain,  Penile) 

-  sores  Csee  Sores,  Penile) 

Penis,  absence  of  erections  of      346 

-  calculus    in,    frequency    of 

micturition  from  . .     438 

-  carcinoma  of  (see  Carcinoma 

of  Pente) 676 

-  chancre  on   . .  . .  . .  ,  676 

-  continual  erection  of  . .  '  585 

-  curved  (see  Chordee) 

-  diabetic  eczema  starting  on  4-17 
gangrene  of         . .  . .     266 

-  epithelioma  of  (see  Carcinoma 

of  Penis) 

-  erections  of  (see  Erections, 

Penile) 

-  fracture  of,  chordee  due  to     125 

-  gumma   of  cms,    diagnosis 

from    tuberculous    caries 

of  pubes  . .  . .  . .     767 

from  epithelioma        . .     677 

syphilitic  chancre       . .     677 

-  -  mercury    and    iodide    in 

diagnosis  of  . .  . .  C77 
origin   as   small   elevated 

nodule  . .  . .  . .     677 

sore  due  to  . .  . .     674 

ulcer     with     thin     edges 

and  yellow  sloughy  base    677 

-  hasmatoma  of  . .  . .     516 

-  cedema  of,  in  acute  nepliritis    458 

-  pain  in  (see  Pain  in  Penis) 

-  painful  erections  in  prostatic 

abscess      . .  . .  . .     515 

-  pustules  on,  in  herpes  pro- 

genitalis    . .  . .  . .     675 

-  sarcoma  of   crus,  diagnosis 

from  tuberculous  caries  of 
pubes        . .  . .  . .     767 

-  scabies  of     . .  . .  . .     447 

-  soft  sores  on  . .  . .     209 

-  swelling  of,  in  balanitis     . .     674 

-  ulceration  of  (and  see  Sores, 

Penile,  and  Carcinoma'  of 
Penis)        . .  . .  . .     674 

in  balanitis  . .  . .     674 

gummatous    (see    Penis, 

Gumma  of) 
from  herpes         . .         675,  830 

-  tuberculous         . .        •  •    674 
association     with     ad- 
vanced    tuberculosis 
elsewhere      . .  . .     677 

from  infection  in  Jew- 
ish circumcision      . .     677 

shallow,  painful,  mul- 
tiple ulcers  in  . .     677 

-  vesicles  on,   in  herpes  pro- 

genitalis  . .  . .     675 

Pentose,      distinction       from 

glucose  in  urine  . .  . .     290 

-  osazone  crystals  from       . .     290 


290 
290 

400 
355 

87 


648 


Petitose,  coiifcl. 

-  reduction  of  bismuth  by  . . 

-  in  urine,  tests  for  . .        115 
Peppermint    oil,    leucocytosis 

from 
Pepsin,  test  for 
Peptic  ulcers  . . 
Peptonuria  (see  Albumosuria) 
Perchloride  of  iron,  dryness  of 

mouth  due  to     . . 

extreme  thirst  due  to    . . 

Perforated  gastric    ulcer   (see 

Gastric  Ulcer.  Perforated) 
Perforating  ulcer  (see   L'lcers, 

Perforative) 

-  of  intestine  in  enteric  fever 

-  palate  (see  Palate,  Perfora- 

tion of) 
Peri-arthritis  (see  Arthritis) 
Pericardial  rub  (see  Eub) 
Pericarditis 

-  in  acute  rheumatism 

-  angina  pectoris  from 

-  in  Bright's  disease 

-  canter-rhythm  in   . . 

-  cardiac  dullness  increased  in     242 
impulse  displaced  in       . .     242 

-  characters  of  friction  sounds 

in 480,  481 

to-and-fro  104,  480 

-  clubbed  fingers  m  . . 

-  distinction  of  rub  from  bruit 

-  a  first  symptom  of  chronic 

nephritis  . . 

-  heart  failure  in 

-  and  mediastinitis   . . 

-  mitral    regurgitation    from 

239 

-  occurrence  without  pyrexia 

-  orthopnoea  in 


121,  671 
..  480 
15,  122 

242,  639 


128 
106 

15 

464 
61 

242 
622 
464 


pain  in  the  chest  in         478,  777 

epigastrium  from  . .     777 

precordial  from  . .        480,  777 

-  pale  anxious  expression    in     480 

-  palpitation  in  . .         525,  526 

-  persistence     of     rub     after 

commencement  of  effusion    480 

-  in  severe  blood  diseases    . .     122 

-  shortness  of  breath  in       . .     480 

-  suppurative,     from     acute 

necrosis  of  bones  . .     650 

from  periostitis  . .  . .     650 

in  pyoemia  . .  . .     650 

-  svstolic  bruit  in      . .        102,  104 

-  -  thrill  due  to        . .  . .     790 

-  tenderness  in  chest  from  776,  777 
Pericardium,  adherent         . .    464 

albuminuria  with  . .       18 

ascites  from  .  .  61,  62 

-  -  bruits  with  . .  . .     243 

-  -  cardiac  impulse  displaced 

m  242 

clubbed  fingers  in  . .     128 

diastolic  collapse  of  veins 

with 242 

shock  in  . .  . .     242 

dilated  precordial  veins  in    242 

general  account  of         . .     242 

heart  enlarged  in  . .     332 

failure  from     . .  . .     464 

mitral  regurgitation  from 

239,  242,  243 

obscure  cases  of  . .  . .     123 

orthopnoea  from . .  . .     464 

palpitation  in      . .         525,  526 

peculiarities     of     cardiac 

impulse  in        . .  . .     242 

physical  signs  of . .  . .       62 

precordial  bulging  in      . .     242 

-  -  signs  of    . .  . .        103,  104 

systolic  mitral  bruit  in  102,  103 

retraction  in       . .     103,  242 

therapeutic  test  of         . .     243 

varieties  of  . .  . .       62 


Pericardium,  conld. 

-  branches  of  vagus,  relation 

to  cough  . .  . .  . .     175 

-  diseases    of,    shortness    of 

breath  in  . .  . .  . .     101 

cyanosis  in  . .  . .     186 

displacement    of  impulse 

in  ..  ..         330,  332 

-  effusion  into,  compression  of 

lung  from  . .         32-i,  667 

-  -  and  enlarged  heart,  simi- 

larity of  symptoms    . .     242 
fibroid  lung  and  bronchi- 
ectasis from     . .  . .     324 

raising  of  apex  beat  in  . .     332 

skodaic  resonance  due  to     667 

swellingof  chest  wall  from     194 

-  infection    by    bacillus    coli     711 

-  opened    by    epithelioma    of 

oesophagus  . .  . .  711 
foreign  body  in  oesophagus    711 

-  rupture  of  aneurysm  intol40,482 
subphrenic  abscess         . .     711 

-  succussion  sounds  in  . .     711 
Perichondritis     of    arytenoid 

cartilages,  sore  throat  from  670 

-  thyroid  cartilage  simulating 

enlarged  thyroid  gland..  791 
Pericolitic  abscess  (see  Abscess, 

Pericolitic) 
Perigastric  abscess  (see  Abscess, 

Perigastric) 
Pericolitis    from    stricture    of 

intestine  . .  . .  . .     146 

Perihepatitis,  ascites  m         55,  60 

-  and  chronic  peritonitis       55,  412 

-  chronic  universal   . .  . .     412 

-  in  cirrhosis  of  liver  . .     409 

-  enlarged  liver  from  . .       55 

-  obscure  cases  of      . .  . .     123 

-  Irom  paracentesis  abdominis      60 

-  svphilitic      . .  . .  . .       60 

-  turned-up  liver  edge  in      . .       60 

-  in  venous  congestion  of  liver     407 
Perimeter     in     mapping     out 

hemianopsia        . .  . .     333 

scotomata  . .  . .     838 

Perinephric  abscess  (see  Abscess, 

Perinephric) 

-  effusion    of    blood    due    to 

injury  of  loin  .  .  .  .  392 
diagnosis      from       renal 

tumour. .  . .  . .     392 

possible  origin  from  renal 

suppurative  condition  392 
urinary  changes  with         392 

-  infiltration     in     malignant 

disease  of  colon  . .     393 

-  inflammation  causing  pleu- 

ritic effusion        . .  . .     123 

Perineum,  abscess  in,  leucocy- 
tosis from .  .  . .  . .     400 

-  bromidrosis  of  . .  . .     714 

-  chancre  of     .  .  . .  . .     678 

-  condylomata  on,  diagnosis  of    678 

-  ectopic  testis  in      . .        523,  740 

-  epithelioma  of  (see  Carcinoma 

of  Perineum) 

-  herpes  genitalis  of  . .  . .     830 

-  injuries  of,  causing  prolapse 

of  uterus  . .  . .     586 

-  Jacfj net's  erythema  of      . .     446 

-  lacerations    of,  dvspareunia 

from  . .       '  . .  . .     221 

-  micturition  through  fistula  in  442 

-  pain  in  (see  Pain  in  Perineum) 

-  rigidity  of,  dystocia  due  to     227 

-  sores  of  (see  Sores,  Perineal) 
Periodic  breathing  (see  Cheyne- 

Stokes  Eespiration) 

-  effusion  into  joint  in  inter- 

mittent hydrarthrosis   . .     387 

-  polyuria  without  apparent 

cause         . .  . .  . .     582 

61 


962 


PERIOSTEAL    ABSCESS— PERITONITIS 


Periosteal  abscess  (see  Abscess, 

Periosteal) 
Periosteum,  fibroroa  of,  rarity  of  755 

-  htBmorrhage  beneath,  in  scurvy  85 

-  lipoma  of,  rarity  of  . .     755 

-  recurrent  fibrosarcoma  of. .     204 

-  syphilitic  thickening  of     ..     519 

-  tender  in  infantile  scurvy..     599 

-  thickening  of,  in  acromegaly    753 
Periostitis,abscess  in  heart  from    650 

-  albumosuria  in        . .  . .       20 

-  alveolar,      diagnosis     from 

parotitis   . .  . .  . .     747 

-  anaemia  from  . .  . .       89 

-  acute  (and  see  Abscess)     . .     750 

-  -  simulated     by      scurvy- 

rickets..  ..  ..     753 

-  chronic,       diagnosis      from 

gumma     . .  . .  . .     752 

sarcoma  . .        756,  763 

-  -  long  duration  of . .  . .     751 

-  -  operation  in  diagnosis  of     751 

-  -  thickening  of  bone  from 

(Fig.  192)         . .  . .     751 

a;-rays  in  diasrnosis  from 

sarcoma      (Figs.    196, 
198,  199,  p.' 754,  756)..     751 

-  in  enteric  fever       . .  . .     648 

-gummatous..  ..  ..     681 

trigeminal  neuralgia  in         496 

-  of    mastoid    -process,    pain 

behind  ear  from . .  ..     230 

-'  orbital,  unilateral  exophthal- 
mos due  to  . .  . .     254 

-  pericarditis  from      . .         . .     650 

-  popliteal  swelling  due  to  761,  763 

-  syphilitic,    diagnosis     from 

periosteal  sarcoma         . .     756 

-  tuberculous,  bones  commonly- 

affected  by  . .  . .     752 

diagnosis  from  syphilitic       752 

Peripheral    nerve,    effects   of 

dividing    . .  . .  . .     661 

distribution    (Plate     XI, 

p.  663) 551 

lesions  causing  ataxy     . .       65 

muscular  atrophy  in  . .  72,  75 

-  neuritis  (see  Neuritis,  Multiple 

Peripheral) 
Perirectal  abscess  (see  Abscess, 

Perirectal) 
Perisplenitis,  friction  sound  in     499 

-  obscure  cases  of     . .  . .     123 

-  pain     in     left      hypochon- 

drium  in  .  .  . .  . .     499 

Peristalsis  and  borborygmi  . .       96 

-  palpable  in  intussusception         92 
PERISTALSIS,  VISIBLE,  con- 
ditions causing        . .    570,  571 

in  acute  obstruction       . .     152 

-  -  with  carcinoma  of  colon 

91,  145,  147 

-  -  in  chronic  intussusception 

92,  148 
constipation  due  to  deficient  143 

-  -  in  excluding  gastric  atony     713 
gastric,  due  to  pyloric  or 

duodenal  obstruction 
134,  352,  570,  713,  723,  725 

-  -  Hirschsprung's    disease 

148,  718,  724 

with  hypertrophic  stenosis 

of  the  pylorus . .  . .     845 

in  intestinal  colic  . .     473 

obstruction,    151,    152,    267, 

350,  431,  571,  723,  727 

thin  adults  . .  . .     724 

Peritoneal  adhesions  (see  Adhe- 
sions, Peritoneal) 

-  band,  intestinal  obstruction 

from  431 

-  cavity,  free  gas  in,  causing 

obliteration  of  liver  dull- 
ness . .  . .  . .     406 


Peritoneal  cavity,  contd. 

free  gas  in,  simulated  by 

meteorism         . .  . .     716 
gas  in  (see  Meteorism) 

-  fluid    in   (see   Ascites    and 

Peritonitis) 

encysted,   pelvic  swelling 

due  to  . .  . .        757,  761 

P_eritoneum,  diseases  of,  causmg 

ascites       . .  . .  .  .-53,  57 

-  hydatid  disease  of  . .  . .     720 

-  primary  carcinoma  of       . .        57 

-  rupture  of  aneurvsm  into..     482 
Peritonitis,  acute  general 

abdominal  distention  in 

134,  472,  644 

pain  from  472,  644,  718,  846 

after  abdominal  iujury  644,  646 

abortion  . .  . .     644 

operations        . .  . .     644 

from  abscess  of  kidney  . .     644 

liver      . .  . .  . .     644 

spleen   . .  . .  . .     644 

albumosuria  in    .  .  . .        20 

from  appendicitis  55,  431, 

644,  780 
bands  from,  causing  ob- 
struction 151,  152,  431 

borborygmi  absent  in  97, 

431,  644,  645 

-  from  Bright's  disease       14,  63 

-  carcinoma  of  the  colon  . .     645 

-  -  after  childbirth  .".  . .     644 
and  colic,  points   of   dis- 
tinction iDetween        . .     G44 

-  collapse  in  . .  . .     346 

-  constipation  in  . .        147,  153, 

472,  644,  718 

-  danger   of    morphia    ad- 

ministration in  . .     472 

-  diagnosis  of         . .  . .     431 
from  intestinal  obstruc- 
tion   . .          . .        431,  645 

laparotomy  in . .  . .     645 

suppurative  pylephlebitis  614 

-  diarrhoea  in         . .  . .     644 

-  drawing  up  of  legs  in     472,  644 

-  -  dry  furred  tongue  in      . .     431 
mouth  in  . .  . .     774 

-  dullness  of  the  flanks  iu. .     644 

-  -  from  duodenal  ulcer  55,644,780 

-  -  dysentery  . .  . .       55 

-  embolism  . .  . .  . .     432 

-  -  endometritis         .  .  .  .      644 

-  -  extreme  thirst  from       . .     789 

-  -  facies  Hippocratica  in  431,644 

■  -  a  first  symptom  of  chronic 

nepliritis  . .  . .       14 

■  -  fluid  in  abdomen  in       . .     644 

■  -  foul  breath  in      . .  . .       98 
taste  in            . .  . .     774 

■  -  frequency  of  micturition  in  644 

■  -  furred  tongue  in..  ..     774 

-  -  from  gastric  ulcer    55,  644,  780 

■  -  gall-bladder  rupture      281,  644 

-  -  general  account  of         . .     644 

■  -  gonococcal  . .  . .        55 

-  -  from  growth  in  hver     . .     412 

■  -  hiccough  in  . .  . .     342 

-  history  of  gastric  or  duo- 

denal ulcer  in  . .     431 

-  hypothermia  in  . .  . .     346 

-  immediate       laparotomy 

needed   for      . .  . .     846 

-  immobility     of     abdomi- 

nal wall  in       .  .  .  .     472 

-  impaired  note  in  flanks  in     431 

-  importance  of  early  dia- 

gnosis in  . .  . .     472 

-  indicanuria  in      . .  . .     349 

-  leucocytosis  in     .  .  472,  645 

-  liver  dullness  lost  in       404,  644 

-  meteorism  in       .  .         431,  644 

-  nausea  in..  ..  ..     472 


Peritonitis,  acvte  general,  contd. 

non-suppurative,  ascites  in     55 

causes  of  . .  . .       55 

pain  increased  by  pressure  in  473 

local  at  onset  of         . .     472 

paralysis  of  bowel  in      . .     472 

from  parametritis  . .     644 

perirectal  abscess  . .        55 

phrenic  neuralgia  simulating479 

pleuritic  effusion  from  . .     122 

pneumococcal      .  .  . .        55 

prostatic  abscess  . .       55 

pulse,   increasingly    rapid 

in  . .  . .        431,  472 

rapid  in  . .  . .     644 

wiry  in  . .  .  .     472 

pyoperitoneum  from     . .     717 

pyosalpinx  . .  55,  644 

pyrexia  in  134,  153,  155, 

472,  718 

retention  of  urine  in      . .     644 

retraction  of  abdomen  at 

onset  of  . .  . .     472 

rigid  abdomen  in  134,  153, 

431,  644,  846 

rub  over  liver  or  spleen  in    431 

from  ruptured  tubal  ges- 
tation . .  . .         646,  780 
septicemia  from. .  . .     60S 

—  Simulated  by  acute  hsemor- 

rhagic  pancreatitis     . .     646 

colic       . .  . .  .  .      645 

diaphragmatic  pleurisy     645 

d'issecting  aortic  aneur- 
ysm   646 

embolism  of  mesenteric 

artery  . .  . .      646 

pneumonia       . .         472,  645 

ruptured        abdominal 

aneurysm     . .  . .     64G 

suppurative  nephritis       646 

thrombosis    of   inferior 

vena  cava    . .  . .     646 

from    stercoral    ulcer    of 

bowel    . .  . .  . .       55 

supervention  on  intestinal 

obstruction       . .         431, 644 

—  tenderness  of  abdomen  in 

134,153 

—  thoracic  respiration  in  . .     644 

—  tuberculous  . .  . .       55 

—  from  tuberculous  ulcer  of 

bowel    . .  . .  . .       55 

—  in  typhoid  fever      55,  431,  648 

—  various  causes  of  . .     644 

—  -  vomiting  in  434.  472,  718, 

844,  84() 

—  wasting  with       . .  . .     718 

—  chronic,  "  doughy  "  feel  of 

abdomen  in         . .  . .     472 

—  dull  feeling  of  heaviness  in    472 

—  enlarged  abdominal  lym- 

phatic glands  in  . .     725 

—  fluid  in  peritoneal  cavity  in  472 

—  localized,  followed  by  con- 

stipation . .  . .     147 

—  loculated  ascites  -n-ith    . .       51 

—  masses  of  thickened  peri- 

toneum felt  in . .  ..     472 

—  -  omental  tumour  from  406,  472 
■ simulating  malignant 

growth  of  stomach     472 
• tumour  of  colon . .     472 

-  periliepatltis  in    . .  60,  412 

-  in  severe  ansmias         . .       64 

-  simple,  ascites  in  . .       55 

causes  of  . .  . .       55 

constipation  with        . .       56 

vomiting  with  . .       56 

-  tubercle   -the    commonest 

cause  of  . .  . .     472 

hydatid,  account  of  . .    719 

intestinal     adhesions     with 
ascites  in  . .  . .         . .       56 


PERI TONITIS,  MA  LIGNA  NT—PHA  R YNX 


063 


Peritonitis,  contd. 

-  malignant,    abdominal  dis- 

tention from       . .         . .  718 

ascites  from         . .          57,  718 

atypical    mitotic    figures 

in  cells  in         . .          . .  718 

diagnosis  o£         . .          . .  718 

haemorrhagic  ascitic  fluid 

with 718 

loss  of  weight  from      . .  718 

multinuclcar    endothelial 

cells  in  fluid  from  . .  718 
palpable  lump  in            . .  718 

-  pelvic,  causes  of     . .          . .  508 

deep-seated  jielvic  pain  in  508 

dysmenorrhita  from      . .  219 

-  -  from  infection  after  labour 

or  abortion  . .  . .  508 
pleuritic  effusion  from  . .  123 

-  tuberculous 422 

abdominal  distention  in  152 

masses  in         . .          . .  719 

pain  and  tenderness  in  710 

swelling  from..           ..  715 

acute         . .          . .          . .  55 

aftection  of  umbilicus  in  71G 

age  incidence  of  . .          . .  691 

anaemia  in           . .          . .  719 

ascites  in      50,  51,  56,  152,  691 

bands  or  adliesioas  from, 

causing  obstruction    151, 152 

blood  per  rectum  fron,  . .  719 

Calmette's  reaction  in  . .  091 

chronic  intestinal  obstruc- 
tion from         . .          . .  719 

constipation  in   . .          . .  719 

diagnosis  from  ascites  in 

cirrhosis  of  liver         . .  618 

ovarian  tumour           . .  691 

splenic  tumour            . .  691 

diarrhoea  in         . .          . .  719 

enlarjred  abdominal  lym- 
phatic glands  in         422,  725 
frecal  discharge  from  um- 
bilicus in      .  .         691,  716 
fistula  from      . .          . .  51 

-  -  inflammatory  and  caseous 

masses  in  abdomen  in  1 52, 422 
inoculation  of  guinea-pig 

in  diagnosing  . .          . .  57 

leucopenia  in       . .          . .  401 

nausea  in             . .          .  .  719 

obliterative  form           . .  719 

fx-dema  of  abdominal  wall  in  691 

omental  tumours  in       . .  724 

pain     in     the     umbilical 

region  in          . .          . .  524 

physical  signs  of            . .  691 

purulent   aiscliarge   from 

umbilicus  in  . .  . .  691 
pvoperitoneum  from      . .  717 

-  -  pyrexia  in  472,  618,  691 
siqiulated  by  cirrhosis  of 

the  liver  '        . .         618,  719 

malignant  disease      . .  724 

urachal  cyst    . .          . .  730 

swelling  in  left  hypochon- 

drium  in           . .          . .  691 

tuberculin  in  exclusion  of  719 

tuberculosis  elsewhere  in  691 

tuberculous  glands  with  691 

joints  with          .  .          .  .  691 

umbilicus  reddened  in    50,  472 

unsterilized    cow's    milk 

as  cause  of       . .          . .  691 

varieties  of          . .          . .  56 

V.  Pirrjuet's  reaction  in  691 

Peri-urethral  abscess  (see  Ab- 
*«t    scess,  Periurethral) 
Perleche  in  association   with 

impetiginous  stomatitis  404 

-  -  impetigo  contagiosa       . .  404 
vesicular  erythema        . .  404 


616 
574 


351 
361 

639 
36 

251 
76 

639 


Perleche,  contd. 

-  contagious  character  of    . .     403 

-  diagnosis  from  herpes       . .     404 
mucous  patches  of  syphilis    404 

-  licking  of  lips  in      . .  . .     403 

-  lips  liot  and  hyperaemic  in       403 

-  peculiarity  to  children       . .     403 

-  streptococci  as  cause  of     . .     403 
Pernicious  ansmia    . .  27,  30 

absence  of  leucocytosis  in       64 

albuminuria  in   . .  10,  17 

anaesthesia  from..  ..     667 

arsenic  in  . .  . .       38 

arsenical  neui-itis  in        . .       77 

ascites  in  . .  . .   62,  04,  122 

Habiaski's  sign  in  . .       82 

bleeding  gums  in  . .       85 

blood  changes  in 

30,  76,  303,  619 

canter-rhvthm    of    heart 

in  ■ 639 

characteristic     tempera- 
ture chart  of  (Fig.  167) 

cholasma  in 

colour  index  in 

26,  30,  64,  352,  616 

cord  changes  in       76,  82,  667 

diagnosis  from  carcinoma 

of  stomach      . .        303 

jaundice 

dilatation  of  heart  from 

fatty  change  in 

early  stages  of    . . 

epistaxis  in 

facies  in  . . 

fatty  heart  from 

-  -  haematemesis  in 

haemoptysis  in 

haemorrhage  from  mucous 

membranes  in 

hyperaesthesia  from 

impotence  in 

infarcts  in 

jaundice  in 

lemon-yellow  skin  in 

-  -  leucopenia  in 

loss  of  weight  in     30, 

marrow  changes  in 

megaloblasts  in  . . 

muscular  atrophy  in 

myelocytes  in 

nerve  deafness  in 

symptoms  in  . . 

noises  in  the  ears  from 

oedema  of  legs  in 

palpitation  from 

pearly  whiteness  of  con 

junctivae  in 

pericarditis  in     . . 

periodic  acute  diarrhcea  in    196 

peripheral  neuritis  in      76,  77 

pleuritic  effusion  in       . .     122 

poikilocytosis  in  . .     616 

progressive  weakness  in  30 

ptyalism  due  to  . . 

punctate  basophilia  in  . 

-  -  pyrexia  in  32,  616,  649 

prolonged  in    . .  . .     609 

rigors  ui    . .  . .  . .     649 

severe     and     progressive 

anaemia  in       . .         459,  649 

shortness  of  breath  in  . .     100 

simulated   by    ankylosto 

miasis    . . 

aplastic   antBmia 

gastric  carcinoma 

spleen  enlarged  in 

stomatitis  in 

sweats  in  . . 

-  -  tenderness  of  ribs  in 

of  the  sternum  in 

uric  acid  in 

urobilinuria  from  303,  361,  818 

wasting  in  . .  . .     649 


62 
294,  303 
..     318 


649 

..     667 

. .     347 

..       10 

. .     361 

616,  849 

..       40 

649,   849 

..     776 

..     303 

76 

29 

..     191 

..       30 

794 

459,  461 


361 
122 


590 
30 


570 
42 
..  351 
692,  695 
..  590 
..  649 
..  776 
. .  776 
..     817 


Peroneal  atropliy  (see  Tooth's 
Peroneal  Atropliy) 

-  muscles,  affection  in   infan- 

tile paralysis       ..         131,  132 

-  -  spinal  nerve  roots  supply 


nerve  supply  of  . . 

Perspiration  (see  Sweating) 
Pertussis  (see  Whooping-cough) 
Pes  cavus 
Possnries,     vaginal     discharge 


543 
542 


133 


210,211 


from 
Petechi;!}  (see  Purpura) 
Petit  mal         

headache  after    . . 

relation  of  aurae  to 

spasmodic  twitchings  in 

transitory  aphasia  in 

Petroleum,  constipation  bene- 
fitted by  use  of  . . 

Peyer's  patches,  enlarged  in 
lymphatism 

Pfeiffer's  bacillus  in  influenza 
505 

Phagedaena  oris 

-  of  leg  

Phantom  tumours 

abdominal   swelling  from 

amenorrhoea  with 

anaesthetic  in  diagnosing 

721 

bulging  abdominal  wall  in 

conditions  simulated  by 

diagnosis  of  ascites  from 

due  to  diaphragmatic  con- 
traction 

disappearance     on     deep 

breathing 
muscular  contraction  pro- 
ducing . . 

occurrence  at  menopause 

pelvic  swelling  due  to  757,  761 

persistence  during  sleep        721 

sex  incidence  of  . . 

signs  of     . . 

-  simulating    appendicular 

abscess 

cholecystitis     . . 

gastric  carcinoma 

gumma  of  the  liver     . . 

hepatic  abscess 

pregnancy        . .         721,  761 

suggestion  treatment  of       721 

Pharyngeal  branch  of  the  vagus, 

relation  to  cough  '. .     174 

Pharyngitis,  in  alcoholism     . .     136 

-  association  with  laryngitis.  .     673 
tonsillitis  . .  . .  . .     673 

-  cheilitis  glandularis  in       . .     403 

-  diagnosis  by  examination  of 

pharynx    . . 

-  from  excessive  smoking 
use  of  the  voice  . . 

-  exclusion  of  new  growth  in 

diagnosis  of 

syphilis  in  diagnosis  of  . . 

tuijerculosis  in  diagnosis  of  673 

-  gangrene  of  lung  in. .  . .     288 

-  hoarseness  from       . .  . .     673 

-  micro-organisms  causing   . .     670 

-  occupations  causing  070,  673 

-  ready  tiring  of  voice  in     . .     673 

-  sore  throat  from  670,  673 

-  submaxillary         lymphatic 

glands  swollen  in 

-  in  sl,^5hilis    . . 
Pharynx,  affections  of,  causing 

dysphagia  . .  22; 
ptyalism 

-  bleeding,  haematemesis  from 

swallowed  blood  in      294,  295 

-  carcinoma  of  (see  Carcinoma 

of  Pharynx) 

-  chicken-pox  eruption  m  670,  673 


171 
329 
81 
160 
686 

143 

423 

610 

86,  88 

.  811 

.   721 

713 

761 

761 

761 

433 

53 

761 

761 

721 
761 


721 
53 

721 
721 
721 
721 
721 


673 
673 
673 

673 
673 


419 


591 
591 


964 


PHARYNX— PHTHISIS 


Phari/7U-,  contd. 

Phosphorus  poisoning,  contd. 

Phthisis,  contd. 

-  gangrene  of  lung  after  opera- 

 delirium  ia 

373 

-  chronic,    fibroid    lung    and 

tion  on     . . 

288 

diagnosis  from  acute  yel- 

bronchiectasis from 

324 

-  paralysis  of  .  . 

775 

low  atrophy  of  liver    . . 

373 

clubbed  fingers  in         128, 

129 

-  progressive  weakness  of,  in 

diminution  of  chlorides  in 

gangrene  of  lung  in 

287 

bulbar  paralysis. . 

224 

urine  in 

373 

-  coagulation  of  sputum  in 

704 

-  rliinoscleroma  of     . . 

805 

drowsiness  in 

373 

-  consonating  rales  in 

319 

-  small-pos  eruption  in 

673 

from  eating  match-heads 

-  cough  in      . .  101,  175,  176, 

185, 

-  snail-track     ulcers    of,     in 

or  rat  paste 

373 

319,  480,  577, 

620 

secondary  syphilis 

672 

extreme  thirst  in 

373 

-  cretaceous  pellet  in  sputum 

704 

-  spasm  ot 

225 

fatty  lieart  from     62,  87, 

241 

-  cyanosis  in  . . 

185 

-  syphilitic  stenosis  of 

225 

liver  in             . .          87, 

414 

-  deficient  respiratory  move- 

- ulceration  of,  earache  from 

230 

great  destruction  of  albu- 

ment in    . . 

319 

Phenazone,  reducing  body  in 

minous  tissues  in 

373 

-  diagnosis  from  apical  bron- 

urine due  to 

290 

hajmatemesis  in..         294, 

297 

cho-pneumonia    . . 

321 

Phenol,  gangrene  from 

282 

haemorrhages  in  . . 

373 

of  fibroid  lung  from 

246 

Phenylalanin,   relation   of  al- 

 headache  in 

373 

from  gangrene  of  lung   . . 

321 

kaptonuria  to 

822 

increase  of  ammonia  co- 

sporotrichosis  of  lung 

322 

Phenyl-glucosazone  crystals . . 

290 

eflBcient  in  uriae  in 

373 

syphilis  of  bronchus     . . 

325 

Phenyl-lactosazone  crystals . . 

291 

jaundice  in          . .        362, 

373 

typhoid  fever 

611 

Phenylhydrazine      in      sugar 

liver  enlarged,  in           363, 

373 

-  diarrhcea  from 

197 

testing       .  .            115,  :390, 

818 

in  match  manufacture    . . 

87 

-  diazo-reaction  a  grave  sign  in 

198 

Phimosis  in  balanitis.  . 

674 

nausea   and   vomiting   in 

373 

-  early  shortness  of  breath  in 

101 

pain  in  the  penis  in 

515 

necrosis  of  jaw  from     87, 

747 

-  elastic  fibres  in  sputum     319 

701 

-  causing     infantile     convul- 

 pain  in  epigastrium  in    . . 

373 

-  empyema  from 

120 

sions 

170 

post-mortem  appearances 

373 

-  fatty  heart  in 

241 

-  chancre  obscured  by 

675 

priapism  caused  by 

586 

-  family  history  in     . . 

848 

-  enuresis  with 

248 

-  -  ptyalism  due  to  . . 

590 

-  fibroid 

129 

-  frequency  of  micturition  in 

438 

rapid  feeble  pulse  in 

373 

vocal  cord  paralysis  from 

538 

-  priapism  from 

585 

respiration  in  . . 

373 

-  foetid  sputum  in 

321 

-  pyuria  due  to 

631 

simulating  acute  gastritis 

845 

-  foul  breath  caused  by 

99 

Phlebitis,  csdema  of  one  leg  from  459 

suicidal  origin  of . . 

373 

-  -  taste  in     . . 

774 

-  -  face,  neck,  and  arms  from 

458 

tenderness  in  right  hypo- 

-  general,    diagnosis    from 

-  pain  in  the  leg  from 

486 

chondrium  in  . . 

373 

broncho-pneumonia 

615 

-  pyrexia  due  to 

621 

in  epigastrium  in 

373 

-  gingivitis  in 

87 

-  (and  see  Thrombosis) 

total    nitrogen    in    urine 

-  hsemoptysis  in                  123, 

176, 

Phlegmasia  alba  dolens,  after 

in 

373 

185,  317, 

319 

labour       . .          . .          . .  ■ 

810 

urinary  changes  in 

373 

various  causes  of 

319 

during  pregnancy 

810 

Phosphotungstic  acid  test  for 

-  headache  in . . 

328 

infective     thrombus 

albumose 

20 

-  hernia  of  the  lung  in 

194 

causing          .  .         45G 

810 

Phossv  jaw 

87 

-  hydropneumothoras  from 

712 

ulceration  of   leg  from 

810 

PHOTOPHOBIA 

574 

-  impairment  of  resonance  in 

319 

Phloroglucin  in  urine  testing 

290 

-  from  conjunctivitis 

255 

-  impotence  early  in. . 

347 

Phocomelus 

214 

-  corneal  ulceration   . . 

806 

-  indigestion  an  early  sign   . . 

350 

Phonation  (see  Speech) 

-  with  electric  blindness 

840 

-  insomnia  in.  . 

359 

Phosphates  in  acute  Bright's 

-  in  iritis 

255 

-  knee-jerks  exaggerated  in 

397 

disease 

12 

-  major    trigeminal  neuralgia 

495 

-  lardaceous  disease  from    10, 

096 

-  in  boiling  test  for  albumin 

5 

-  meningitis    . . 

350 

-  liability    to,    in    congenital 

-  dissolved  by  acid   . . 

623 

-  snow  blindness 

840 

heart  disease 

320 

-  effects     of    hsematuria     on 

Phrenic    nerves,    compression 

-  lichen    scrofulosorum    with 

529 

colour  of  . . 

12 

in  aortic  aneurysm 

482 

-  lining  of  cavities  by  granu- 

- and  nucleo-proteid,  difBculty 

diaphragm  supplied  by  779 

,842 

lation  tissue  in     . . 

701 

of  distinguishing  in  urine 

471 

diphtheritic  paralysis  of 

77 

-■  local  muscular  atrophy  in . . 

73 

-  physiology  of,  in  urine     . . 

572 

hiccough   in   irritation  of 

-  long  neck  and  sloping  shoul- 

- simulated  by  urates 

815 

342, 

343 

ders  in 

191 

-  turbidity   of  urine    due    to 

208 

-  neuralgia    (see    Neuralgia, 

-  loss  of  appetite  in 

319 

-  variation  in   amounts  nor- 

Phrenic)   . . 

478 

weight  in..          ..         319, 

847 

mally  excreted    . . 

572 

Phtheiriasis,  chloasma  in 

574 

-  malaise  at  onset  of . . 

620 

Phosphatic  diabetes  (see  Dia- 

Phthisical   cachexia,    albumi- 

- mistaken  for  rheumatism  of 

betes,  Phosphatic) 

nuria  in    . . 

17 

the  shoulder 

778 

PHOSPHATURIA 

571 

impotence  in 

347 

-  nausea  and  vomiting  in  early 

350 

-  absolute 

571 

Phthisis   (and  see   Pulmonary 

-  night  sweating  in    319,  577 

714 

-  diagnosis  from  chyluria     . . 

126 

Tuberculosis) 

-  pain    in    chest    in,    various 

pyuria 

623 

-  absence  of  abnormal  apical 

causes  of  . . 

480 

-  sacralgia  from 

510 

signs  in    . .          .  .          319 

577 

m  umbilical  region  in     . . 

525 

-  in  simple  ulcer  of  bladder 

630 

tubercle  bacilli  in  sputum 

704 

-  pleurisy  in,  chronic 

480 

Phosphorus     poisoning,     ab- 

- acute,  rigors  in 

647 

and  pneumothorax  in    . . 

578 

sence     of      leucin      and 

-  advanced,  indicanuria  in  . . 

349 

preventing  pnevmaothorax 

578 

tyrosin  from  urine  in     . . 

373 

-  alar  or  flat  chest  in. . 

191 

-  pleuritic  efiusion  in          123 

712 

acute  irritant  symptoms  in 

373 

-  albuminuria  in 

17 

-  pneumococci  in 

701 

albuminuria  in    . . 

17 

-  albumosuria  in 

20 

-  pneumothorax  from          577, 

578 

albumosuria  in    . . 

20 

-  anaemia  in   . .        27,  36,  39 

620 

-  prolonged  expiration  in     . . 

319 

anuria  in             . .             45,  48 

-  bronchial  breathing  in 

319 

-  prominence  of  one  clavicle  in 

319 

ascites  in 

62 

-  bronchophony  and  pectorilo- 

- ptyalism  in  . . 

591 

black  vomit  in    . . 

373 

quy  in 

319 

-  pulmonary  aneurysm  ua    . . 

319 

bleeding  gums  in             85,  87 

-  caseous  mass  iu  sputum  in 

704 

-  purpura  in   . . 

598 

burning  epigastric  pain  in 

373 

-  with    cavitation,    abundant 

-  pus    cells,   tubercle   bacilli. 

chemical  analysis  of  vomit 

845 

foul  sputum  in               651 

703 

elastic  fibres  in  sputum  in 

319 

collapse  in 

373 

affection  chiefly  of  upper 

-  pyrexia   the    earliest    sym- 

- -  coma  in     .  . 

373 

lobes     . . 

703 

ptom  in  many  cases  of   . . 

620 

concentrated  acid  urine  in 

373 

nummular  sputum  in     . . 

700 

-  pyrexial  albuminuria  in     . . 

17 

concentration  and  viscidity 

simulating    gangrene     of 

-  rapid  in  diabetes    . . 

292 

of  bile  in 

373 

lung 

288 

-  rarely  associated  with  tuber- 

 convulsions  in     . . 

373 

tubercle  bacilli  in 

703 

culous  joint  disease 

366 

PHTHISIS— PLEURIS  Y 


965 


PlilhisU,  conld. 

-  not  related   to  tuberculous 

cervical  glands    . .  . .     420 

-  retraction  of  cliost  wall    in     194 

-  rigors  in        . .  . .        048,  051 

-  secondary    pyogenic    infec- 

tion the  cause  of  many  of 

the  symptoms  of . .        G51,  701 

-  simulation  by  aneurysm    . .     322 

anorexia  nervosa  . .     850 

hydatid  cyst  of  lung       . .     323 

-  -  neurasthenia         . .  . .     317 

pneumonia  . .  . .     321 

sarcoma     . .  . .  . .     296 

-  sputum  in    . .  .  .1)9,  319,  577, 

578,  700,  701,  704 

-  staphylococci  in      . .  . .     701 

-  streptococci  in         . .  . .     701 

-  succnssion  sounds  in  cavity     711 

-  sudden  acute  pain  in  chest 

from  pneumotliorax  aris- 
ing in        . .  . .  . .     577 

-  suggested  by  cough  which 

wakes  patient      .  .  . .     176 

-  tenderness    in   chest   from 

778,  779 

-  testicular  atrophy  in  . .       80 

-  tiredness   at  onset  of         . .     620 
-.  tubercle  bacilli  m    . .         99,  577, 

578,  703,  704 

-  tuberculous  stomatitis  in  . .     591 

affection  of  mouth  with. .     814 

laryngitis  in         . .  . .     674 

ulceration  of  intestine      .  .      90 

of  palate  with..  ..     640 

tonsil  from       . .  . .     672 

-  unequal  vocal  fremitus  in  . .     319 

-  unknown  almost  in  infancy     427 

-  vomiting  in..  ..  ..     844 

-  wasting  in   . .  . .        185,  319 

-  a;-rays  in  detection  of     120, 

319,  736,  847 
Physiological  albuminuria     . .       19 

polyuria  in  .  .  .  .      584 

Physostigmine,  pupil  constric- 
tion from  .  .  .  .  . .      595 

Pianist's  cramp  . .  . .     177 

Pica 50,  115 

Picric    acid,    discoloration    of 

skin  and  conjunctiva  by     575 

poisoning,  xanthopsia  in      840 

test  for  glycosuria  . .     290 

Pied-en-grifEe  (see  Claw-foot) 
Pigeon  feeders,  aspergillosis  in     705 

-  iDreast  in  rickets    . .        191,  212 
Pigmentation,  buccal      38,  843,  849 

-  of  conjunctiva?  in  octaonosis    822 

-  scars  after  svphilides  ..      604 
PIGMENTATION   OF  SKIN  ..     574 

-  -  in  Addison's  disease  38,843,849 

arsenical  .  .88,  76,  87,  411,  423 

in  bronzed  diabei;es        ..     411 

chloasma  . .  . .     424 

clu-onic  pancreatitis       135, 

cirrhosis    . . 

-  -  from  drugs 
exophthalmic  goitre 

-  -  leucodermia 

malignant  disease 

morphcea 

rheumatoid  artln-itis 

syphilis 

sclerodermia 

Still's  disease 

tinea  versicolor  . . 

in   uterine  lesions 

von      Kecklinghausen's 

disease. .  . .         781 

xerodermia  pigmentosum 

Pigmented  crescents,  ophthal- 
moscopic appearances  of 
(Plalc  VIP, 
Pigments  in  urine,  abnormal, 
method  of  precipitation. . 


244, 


39, 


292 
40 
424 
792 
424 
718 
424 
378 
237 
424 
418 
276 
114 

804 
804 


Piles  (see  Ilaimorrhoids) 
Pillows  if  liigli  may  cause  head- 
ache on  rising      . .          . .  337 
Pilocarpine,  ptyalism  due  to. .  590 
Pimples  (see  Papules) 
Pinguecula,  conjunctivitis  dis- 
tinguished from  . .          . .  256 

-  from  exposure  to  weather. .  256 
Pink  eye,  epidemics  of           . .  256 
Pins  and  needles  in  extremi- 
ties in  paroxysmal  tacliy- 
cardia       . .          . .          . .  772 

peripheral  neuritis          . .  505 

-  in  oesophagus,  hiomatemesis 

from          297 

-  rectum          . .          . .          . .  635 

-  urethra         . .          . .          . .  210 

"  Pits  "  in  small-pox. .          . .  COS 

Pitting,  absence  of,  in  cedema 

from  obstructed  lymphatics  456 

-  on  pressure  in  (rdcma        . .  456 
Pituitary    body,    enlargement, 

polyuria  from      .  .          . .  585 
hypertrophy  of,  in  acro- 
megaly               335,  585,  749 
hemianopsia  from       . .  335 

-  secretion,  effect  on  menstru- 

ation        . .          . .          . .  430 

Pityriasis,  diagnosis  from  ring- 
worm of  scalp      . .          . .  274 

-  rosea,  distribution  . .          . .  658 

diagnosis  from  erythrasma  276 

pityriasis  rubra           . .  658 

psoriasis            .  .          .  .  658 

seborrhoea  corporis     . .  658 

syphilides         . .          . .  658 

tinea  circinata             . .  658 

versicolor      . .          . .  276 

macules  in            . .          . .  424 

pruritus  in            . .          . .  588 

rare  below  elbow  or  knee  658 

scales  in   . .          . .          . .  658 

-  rubra  (Plate  X)        .  .          . .  658 

absence  of  bullje  in         . .  658 

itching  in         . .          . .  658 

papules  in        . .          . .  658 

death  from           . .          . .  658 

diagnosis  from  eczema     . .  658 

erythema        scarlatini- 

forme            . .          . .  253 

pemphigus  foliaceus  . .  658 

pityriasis  rosea            . .  658 

psoriasis            . .          . .  658 

impaired  health  In         . .  658 

-  -  scales  in   . .          . .          . .  658 

sequel  of  another  lesion. .  658 

-  rubra  pilaris,  of  fingers    . .  266 

soles  and  palms      . .  658 

diagnosis  from  derma- 
titis exfoliativa        . .  530 

lichen  ruber  planus  530 

psoriasis        . .          . .  530 

distribution  of  .           . .  530 

health  unaffected  in   . .  530 

papules  in         528,  530,  658 

plucked-fowl  skin  in  . .  530 

pruritus  in       . .          . .  588 

scales  m           .  .         655,  658 

slightness  of  itching  in  530 

-  versicolor  (see  Tinea  Versicolor) 
Placenta,  adherent     ..          ..  227 

-  causes  of  delay  in  delivery  of  229 

-  origin  of  eclampsia  in         . .  172 

-  prtevia,    hcemorrhage    from 

436,  437 

need  for  early  delivery  in  437 

signs  of    . .          . .          . .  437 

Plague,     bacteriological     dia- 
gnosis i7i  . .          . .          . .  418 

-  gangrene  in..          ..          ..  282 

-  generalized     glandular     en- 

largement in         . .        416,  418 

-  purpura  in  . .          . .          . .  596 

-  rigors  in        . .          . .          . .  647 


Plantar       fascia,     gonococcal 

inllammation       . .          . .  376 

-  reflexes  (and  see  Babinski's 

sign)          81 

asymmetrical,  with  coma  137 

in  hysterical  monoplegia  541 

infantile  paralysis          . .  81 

paralyses  from  intra-  and 

extra-medullary  lesions  546 
relation    of    ankle-clonus 

to           44 

in  sciatica             . .          . .  487 

extensor   (see    Babinski's 

sign) 

Plantaris,  nerve  supply  of     . .  542 

-  longus,  liability  to  spontan- 

eous rupture         .  .          .  .  597 

Plants  as  cause  of  bullfe         . .  110 

Plethoric  habit,  epistaxis  from  252 
Pleura,    B.    coli   infection    of, 

causing  pneumothorax  577,  578 

-  carcinoma  of,  bloody  effusion 

in 118 

-  cohesion  of  layers  preventing 

traumatic  pneumothorax  578 

-  effusion  into,  fiom  bronchial 

obstruction           . .          . .  121 

-  endothelioma    of,    gangrene 

of  hand  from       . .          . .  287 

-  gas  in  (see  Pneumothorax) 

-  insensitiveness  of    . .          . .  777 

-  new  growth  of,  displacement 

of  cardiac  impulse  m      . .  330 

pain  and  tenderness  in 

back  from    . .          . .  789 

pleuritic  effusion  in 

118,  121,  322 

-  pneumothorax    from     gan- 

grene of  . .          . .        577,  578 

-  rupture  of  aneurysm  into  482 
Pleurisy  from  abscess  of  lungs  649 

-  in  acute  rheumatism          . .  671 

-  with  aortic  aneui-ysm         . .  482 

-  clubbed  fingers  in    . .          . .  128 

-  cough  from..          ..         176,  480 

-  danger  of  regarding  as  pleuro- 

dynia       . .          . .          . .  478 

-  disappearance  of  pain  with 

effusion  in            . .          . .  480 

-  distinction  from  pleurodynia  776 

-  with   effusion  in  chest  (see 

Pleuritic  Effusion) 

-  empyema  after        . .          . .  650 

-  in  enteric  fever        . .          .  .  648 

-  intercostal  tenderness  in    . .  479 

-  leucocytosis  moderate  in  .  .  401 

-  and  mediastinitis    . .          . .  61 

-  mistaken  for  hysteria         . .  777 

indigestion           . .          . .  351 

intercostal  nem-algia       . .  777 

-  pain  in  the  back  from        . .  789 

-  -  chest  in    . .          .  .478,  479,  480 

increased  by  movement  479 

relieved  by  unmobaliz- 

ing  chest      . .          . .  479 

epigastrium  in     . .          . .  485 

left  hypochondrium  in  . .  499 

limbs  in    . .          . .          . .  505 

right  hypochondrium  in  501 

-  in  phthisis    . .          . .         480,  578 

-  pleuropericardial  rub  in    . .  481 

-  in  pneumonia          . .          . .  480 

-  rigors  with  . .          . .          . .  650 

-  rub  in  ..  ..479,481,499 

-  secondary  to  abscess  of  liver 

409,  651 
subphrenic  abscess        501,  721 

-  shortness  of  breath  in        . .  101 

-  simulated  by  herpes  zoster  830 

-  systolic  thrill  due  to           . .  790 

-  tenderness  in  chest  from 

776,  777,  779 

in  back  from        . .          . .  789 

epigastrium  from            . .  779 


966 


PLE  URIS Y,  DIA  PHRA  GMA  TIC—PNE  UMONIA 


PleurUy,  contd. 

Flumbism,  contd. 

Pneumococci,  could. 

-  diaphragmatic,     abdominal 

-  cerebral  symptoms  in  (and 

-  pyelonepln-itis  due  to 

S3 

pain  in      . .          . .          133,645 

see  Saturnine  Encephalo- 

- in  sputum,   in  lobar  pneu- 

 rigidity  from    . . 

645 

pathy) 

38 

monia  (Plate  XII,  Fig.  0, 

distribution  of  paia  from 

779 

-  cohc  in         . .           136,  144, 

798 

p.   696)     

702 

frequent  absence  of  rub  in 

480 

-  coma  due  to  (see  also  Satur- 

 no  proof  of  pneumonia  . . 

702 

pain  in  chest  in   . . 

478 

nine  Encephalopathy)  137 

139 

-  ulcus  serpens 

807 

near  costal  margin  in. . 

473 

-  constipation  in  (Fig.  36,  p.  14 

^) 

-  urethritis  due  to 

83 

about  the  crest  of  the 

136,  144,  153,  507, 

798 

Pneumonia  (and  see  Broncho- 

shoulder in  . . 

479 

-  deafness  from 

191 

pneumonia),  abdominal  pain 

simulating    phrenic    neu- 

- deliriimi  due  to 

195 

in                              133,  472 

64.-, 

ralgia    . . 

479 

—  diagnosis  from  renal  colic. . 

500 

rigidity  in 

U45 

general  peritonitis 

645 

-  djrsphagia  from 

225 

-  absence  of  signs  in  chest  in 

shght  depression  of  liver  in 

405 

-  epileptiform  convulsions  in 

3  73 

some  cases  of  . . 

702 

Pleuritic  effusion  (and  see  Chest, 

-  foul  taste  in  mouth  from . . 

774 

-  albuminuria  in        12,  l.S,  1' 

,  18 

serous  effusion  in)         120 

121 

-  general  abdominal  pain  in . . 

473 

-  albumosuria  in 

20 

ajgophony  in 

332 

-  gout  in 

507 

-  anaemia  in,  suggesting  em- 

- -  ascites  with 

62 

-  granular  kidney  in  . . 

144 

pyema 

39 

blood-stained    from    new 

-  headache  in  . . 

328 

-  biliary  catarrh  in    . . 

372 

growth  in  lung            118 

322 

-  high  blood-pressure  in       485 

507 

-  bleeding  gums"  in     . . 

85 

from  inflammation     . . 

118 

-  impairment' of  sight  in 

77 

-  bromidrosis  with     . . 

714 

cardiac  impulse  displaced 

-  impotence  in 

346 

-  bronchial  casts  in  sputum. . 

704 

by          ..          ..232,330 

764 

-  infantili.«m  from 

215 

-  casts  in  sputum  in 

704 

-  character  of  fluid  in       118 

121 

-  intestinal  motor  activity  in- 

- Cheyne-Stokes     respiration 

in  chronic  nephritis,  afirst 

hibited  in . . 

144 

in  . . 

125 

symptom  of 

15 

-  irritabihty  in 

360 

-  consolidation  of  lung  in      . . 

372 

communicated  pulsation  in 

764 

-  lead  in  urine  in        . .         87 

525 

-  cough  from  . .          .  .175, 176 

372 

compression  of  lung  in  324 

331 

-  leucopenia  in 

401 

-  crisis  of,  need  for  stimulants 

-  -  confusion  of  hydatid  cyst 

-  meduUa  degeneration  from 

225 

at 

622 

of  liver  with 

415 

-  muscular  atrophy  in 

7 1 

profuse  perspiration  after 

702 

depression   of  liver  from 

-  neuritis  from 

sudden  drop  in  tempera- 

large right-sided 

405 

77,  131,  165,  492,  506,  507 

797 

ture  at  . . 

G22 

empyema  following 

119 

of  external  popliteal  nerve 

543 

-  cyanosis  in   . . 

186 

fibroid  lung  and  bronchi- 

- obscure  sources  of  . . 

77 

-  deep-seated  . . 

702 

ectasis  from 

324 

-  occupation  in  diagnosis  of. . 

473 

-  deficiency    of    chlorides    in 

heart  failure  from 

525 

-  optic  neuritis  due  to          139 

836 

urine  in    . .             186,  321 

372 

from  infarction  of  lung  . . 

123 

-  pain  in  epigastrium  in 

486 

-  delay  in  appearance  of  phj-- 

-  -  immobilization     of     dia- 

limbs  in    . . 

507 

sical  signs  in 

480 

diaphragm  by 

721 

umbiUcal  region  only  com- 

— delirium  in  . . 

194 

latent,  witli  shortness  of 

plaint  in  some  cases  . . 

525 

-  in  diabetes  . . 

292 

breath  . . 

101 

-  palsies  in 

144 

-  diagnosis  from  peritonitis  . . 

472 

from  new  growth         118, 

-  paralysis  of  limbs  in 

797 

suppurative  pylephlebitis 

614 

121,185 

322 

-  pimctate  basophilia  in 

30 

-  diazo-reaction  in     . . 

198 

palpitation  in 

525 

-  rise  of  blood-pressure  in.. 

485 

-  dry  mouth  in 

774 

particles  of  new  growth  of 

-  simulating  general  paralysis 

-  dullness  in  the  chest  from . . 

645 

lung  found  in  . . 

322 

of  the  insane 

797 

-  empyema  after         119,  323, 

650 

-  -  physical  signs  of . . 

192 

muco-membraneous  colitis 

486 

slight  value  of  leucocyte 

pneumotliorax  with 

480 

-  symptoms  of           . .             3S 

,  '<^ 

count  in  diagnosis  of  .  . 

401 

after  tapping  for       577 

578 

-  talipes  due  to 

131 

-  endocarditis  in        . .         103 

314 

shrinkage  of  one  side  of 

-  tetany  in 

178 

-  in  enteric  fever 

648 

chest  from        . .         193 

194 

-  tremor  in     . .          . .        795, 

797 

-  eosinophilia  after    . . 

248 

skodaic  resonance  over  . . 

667 

-  wrist-drop  in            . .  77,  507 

798 

-  fibroid    lung    and    bronchi- 

- -  tuberculous,  inoculation  of 

PNEUMATURIA 

576 

ectasis  from 

324 

guinea-pig  in    . . 

121 

-  association  with  foeces  per 

-  foul  taste  in. . 

774 

unilateral  enlargement  of 

urethram              . .        264 

633 

-  fungating  endocarditis  from 

314 

chest  from 

192 

intestinal  fistula 

576 

-  furred  tongue  in 

774 

a:-rays  in  diagnosis  of 

721 

Pneumobacilli   in   sputum   in 

-  gangrene  of  lung  from 

-  rub  Csee  Rub,  Pleuritic; 

lobar  pneumonia 

702 

287,  578,  703, 

712 

Pleurodynia,  definition 

478 

-  cerebrospinal  fluid  . . 

340 

-  gradual  resolution  in 

702 

-  distinction  from  pleurisy  . . 

776 

Pneumococcal  arthritis,  general 

-  hsemoptysis  in       ..317,  320 

321 

myalgia    . . 

507 

account  of 

375 

simulating  phthisis 

321 

-  pain  in  the  chest  in 

477 

-  infections,  bacteriuria  in    . . 

83 

-  heart  impulse  displaced  in 

330 

-  pneumonia  mistaken  for    . . 

480 

pleurisy  with 

122 

-  herpes  facialis  in     . .         186 

372 

-  tenderness  in  chest  from   . . 

776 

-  middle-ear  disease  . . 

375 

-  hyperpyrexia  in 

343 

of  muscles  in 

478 

-  peritonitis,  acute    . . 

55 

-  hypothermia  after  convales- 

Pleuropericardial rub  (seeEub, 

Pneumococci,  acute  laryngitis 

cence         . .          . . 

346 

1 'leuro-pericardiai; 

from     185,  226,  465,  466, 

■-  infantile  convulsions  from 

170 

Ple.xus   patellaj    nerves,   skin 

670,  673 

709 

—  in  influenza. .          . .         505 

610 

distribution  of     . . 

659 

tonsilhtis  from    . . 

670 

frequently  fatal  . . 

505 

Plucked-fowl  skin  in  pityriasis 

-  in  ascitic  fluid 

57 

sputum  like  that  of  muco- 

rubra pilaris 

530 

-  bronchopneumonia 

615 

purulent  bronchitis     . . 

702 

Plumbism,  albuminuria  in    . . 

16 

-  in  cerebrospinal  fluid 

340 

-  inhalation,  gangrene  of  lung 

-  amblyopia  with 

830 

-  circulating  blood     . . 

650 

Ul  . . 

703 

-  amenorrhcea  from  . . 

23 

-  empyema  from        . .         119 

122 

-  initial  rigor  in 

372 

-  anaemia  in     36,  37,  38,  13G, 

-  fungating  endocarditis      237, 

614 

-  jaundice  in  . .          . .         362 

372 

144,  507, 

798 

-  general  septiciemia 

642 

-  leucocytosis  m        . .  39,  401, 

645 

-  anuria  In     . .          . .            45 

,  48 

-  in  healthy  persons 

702 

-  liver  engorged  in    . . 

372 

-  arteriosclerosis  from  . .     144 

507 

-  meningitis  due  to    . .         339 

642 

-  lividity  in    . . 

645 

-  bleeding  gums  in  . .            85 

,  87 

-  in  nasal  discharge    . . 

203 

-  loss  of  knee-jerks  in 

399 

-  blue  line  on  gums  in       136, 

144, 

-  nephritis  due  to 

83 

-  mistaken  for  hysteria 

777 

473,  507,  525,  551,  645, 

798 

-  pharyngitis  from     . . 

670 

intercostal  neuralgia    480, 

777 

-  brachial  palsy  in     . . 

551 

-  in  phthisical  sputum 

701 

pleurodynia 

480 

-  cachexia  in  . . 

115 

-  pleurisy  from 

122 

-  pain  in  chest  in     ..372,478 

480 

-  central  scotoma  from 

836 

-  pyelitis  due  to 

625 

-  physical  signs  in       186,  701, 

702 

PNEUMONIA— PONS   VAROLII 


90/ 


Pneumonia,  contd. 

-  pleurisy  in  . .  122,  372,  480 

-  pneumococcal  arthritis  in..     375 

-  pneumococci   in  blood  in  . .     650 

-  -  in  sputum  in  (Plate  XII, 

p.  U9G)..  ..         321,  702 

-  pneumothorax  from  . .     578 

-  polyuria  after  .  .         582,  583 

-  prognosis  in  alcoholics       . .     194 

-  jiulse  relatively  slow  in      . .     372 

respiration  ratio  in         321,  372 

temperature   ratio    in    . .     097 

-  pyopneumothorax  from     . .     712 

-  pyrexia  in  321,  372,  G22,  702 
and  crisis  of        . .  . .     186 

-  resolution  delayed  in         . .     324 

-  respiration  rapid  m  372,  G45,  702 

-  -  ratio  ui      ..  321,  372,  691 

-  right  basal,  special  associa- 

tion of  jaundice  with     ..     372 

-  rigors  m  372,  647,  648,  650 

-  rub  in  . .  . .  . .     372 

-  secondary  to  abscess  of  liver    409 

-  septic,  gangrene  of  lung  from  703 
haemoptysis  in     . .  . .     371 

-  shortness   of  breath  in      . .     101 

-  simulated  by  general  miliary 

tuberculosis  of  lung        . .     703 

-  simulating  general  peritonitis  645 

-  skin  flushed,  dry,  pungent  in 

372,  702 

-  skodaic  resonance  with      . .     667 

-  spleen  enlarged  in..         692,  698 

-  sputum  rusty  in 

175,  186,  320,  372,  700,  701,  702 
various  colours  of  . .     702 

-  -  viscid  in  320,  321,  372,  700,  702 

-  sudden  onset  of         321,  372,  701 

-  technically  a  septiccemia  . .     650 

-  temperature  curve  (Fig.  188)  702 

-  urate  deposit  in       . .  . .     815 

-  vomiting  in..  ..  ..     622 

-  working  of  the  nares  in      . .     645 

-  .f-rays  in  diagnosis  (Fig.  99)     321 
Pneumonokoniosis    (see     Cir- 
rhosis of  Lung) 

Pneumoperitoneum,  causes  of     711 

-  succussion  sounds  in  . .     711 
PNEUMOTHORAX     ..  ..     577 

-  absence  of  breath  sounds  in     480 

pain  in  some  cases  of    . .     480 

symptoms  from  . .  . .     578 

vocal  fremitus  in. .  ..     480 

-  acute  dyspncea  in   . .  . .     185 
onset  in  half  the  cases  of      480 

-  causes  of       . .  . .  . .     577 

-  cyanosis  in  . .  185,  480,  577 

-  dyspnnea  in  . .  . .     480 

-  with  fluid,  succussion   with     193 

-  from  gangrene  of  pleura    577,  578 

-  heart  failure  in        . .  . .     464 
displaced  by 

232,  330,  480,  712,  721 

-  hremoptysis  from    . .  . .     577 

-  liver  depressed  by  . .  . .     405 

-  in  lobar  pneumonia  . .     578 

-  loss  of  movement  of  chest  on 

aft'ected  side  in    . .  . .     4§0 

-  onset  insidious  in  many  cases  480 

-  orthopnoea  in  . .  . .     464 

-  pain  in  the  chest  in   193,  478,  577 
aggravated  by  breath- 
ing in  . .  . .     480 

severe  sudden  at  onset     480 

-  partial  577 

-  in  phthisis 578 

-  physical  signs  of        193,  480,  577 

-  pleural  effusion  in  . .  . .     480 

-  prostration  in  . .  . .     480 

-  rapid  feeble  heart's  action  in     480 

-  sense  of  "  something  giving 

way  "  at  onset  of  . .     480 

-  simulated     by     subphrenic 

abscess      . .  . .  . .     578 


PneumoUtorax,  contd. 

-  symptoms  caused  by          . .  577 

-  tubercle  bacilli  in  sputum  in  578 
commonest  cause  of       . .  185 

-  tympanitic  resonance  in    . .  480 

-  unilateral    enlargement    of 

chest  from          .  .192,  193,  480 

-  .r-rays  in  diagnosis  of       480,  577 
Poikilocytosis  (Plate  II,  Fig.  E)  28 

-  in  pernicious  anajmia          . .  616 

-  severe  anaemias       . .          . .  620 
Poisoning    (and    see    various 

poisons,  e.g.  Arsenic ;  Cor- 
rosive; Irritant;  Opium; 
Phosphorus ;  Ptomaine  ; 
Shell-fish ;  Strychnme ; 
etc.) 

-  anuria  in  . .       . .  . .       45,  48 

-  bleeding  gums  hi   . .  85,  87 

-  clironic,  causing  amenorrhooa  23 
irritant,  diarrhoea  from  . .  197 

-  condition  of  skin  in             . .  195 

-  delirium  from          . .          . .  195 

-  diazo-reaction  in  some  cases  198 

-  fatty  degeneration  with  as- 

cites in      . .          . .          . .  62 

-  hfematemesis  in      . .        294,  297 

-  hypothermia  in  coma  due  to  346 

-  jaundice  due  to     . .        362,  373 

-  nystagmus  following           . .  453 

-  universal  oedema  from       . .  458 
Polariaietry    in    quantitative 

estimation  of  glycosuria  291 
Polio-encephalitis,        acquired 

paralysis  of  childhood  from  155 

-  athetosis  after         . .          . .  155 
Poliomyelitis,    acute   anterior, 

acute  onset  of      . .          . .  562 

-  -  in  adults                .  .           73,  562 

atrophic  palsies  in         128,  544 

claw-hand  in        . .          . .  127 

contractures  after         163,  165 

convulsions  in     . .        128,  555 

defects  of  growth,  deform- 
ities, etc.,  in     . .          . .  555 

diagnosis  from  peripheral 

neuritis             . .          . .  559 

electrical  reactions  in 

70,  555,  558,  559 

— ■  generalized  pains  in        . .  555 

headache  in         . .          . .  128 

infantile  paralysis  from  70,  559 

lymphocytosis  in  cerebro- 
spinal fluid  in              . .  339 
muscular  atrophy  in  para- 
lysis of..          ..70,  158,  558 

paralysis  of  arm  in          . .  555 

paraplegia  due  to  557,  561,  562 

pyrexia  in             . .        128,  555 

reflexes  in             . .       555,  559 

rigors  in    . .          . .          . .  647 

talipes  from         . .          . .  559 

vasomotor  changes  in    . .  555 

vomiting  in          . .         128,  555 

-  chronic    anterior,    fibrillary 

contractions  in    . .          . .  158 

-  claw-foot  from         ..          ..  127 

-  diagnosis  of  transverse  mye- 

litis from  . .          . .          . .  74 

-  Landry's  paralysis  an  acute 

variety  of              .  ,          . .  567 

Politzer's  acoumeter,  illustrated  188 
Polycystic    disease    (and    see 

Cystic  Disease)   . .          . .  48 

of  kidney,  general  account 

of           396 

POLYCYTH/EMIA  ..579 

-  m  congenital  heart  disease 

244.  247,  790 

-  cyanosis  and  enlarged  spleen  187 

-  delirium  from          . .          . .  195 

-  dyspnoea  associated  with  . .  580 

-  low  colour  index  with        .  .  580 

-  in  mitral  valve  disease       . .  38 


Polycythoemia,  contd. 

-  pulmonary  stenosis  . .     247 

-  shortness  of  breath  in         . .     100 

-  splenomegalic   (see    Spleno- 

megalic  Polycytha>mia) 
Polydipsia  (see  Thirst,  Extreme) 
Polymorphism  of  syphilides446',  533 
Polymorphonuclear     cells     in 
cerebrospinal     fluid       in 
meningitis  . .        558,  643 
in  normal  blood  count  . .       28 

-  leucocytosis  (see  Leucocytosis) 
Polymyositis,   acute,   anorexia 

in 504 

diagnosis  from  trichinosis     504 

erythematous  rash  in     . .     504 

oedema  of  extremities  in     604 

pain  in  muscles  in         503,  504 

-  -  pyrexia  in  . .  . .     504 

rigidity  of  muscles  in     .  .     504 

tenderness  of  muscles  in       504 

Polyorrhomenitis        . .  . .     123 

-  acute  hvdrocele  in. .  ..  522 
Polypus,  aural  408 
bleeding  from  ear  due  to      468 

-  -  deafness  from  . .  . .  190 
tinnitus  due  to     . .  . .     793 

-  nasal,   with  accessory  sinus 

inflammation        . .  .  .     255 

anosmia  from       . .  . .     60S 

epistaxis  due  to  . .  .  .      250 

headache  from     . .  . .     327 

-  -  impairment  of  taste  fi'om     775 

loss  of  taste  due  to         . .     774 

obstruction  to  nose  by  . .     668 

with  rhinitis         . .  . .     204 

snoring  due  to     . .  . .     669 

-  placental,  vaginal  discharge 

from  . .  . .  .  .     211 

-  rectal  635 

diagnosis  from  carcinoma 

of  rectum         . .         635,  636 

piles       . .  . .  . .     635 

difficulty  of  palpating    . .     635 

haemorrhage  in    . .  . .       93 

multiple  in  many  cases. .     635 

passage  of  blood  and  mu- 
cus in    . .  . .  . .     635 

-  urethral,  shown  by  the  endo- 

scope        . .  . .  . .     208 

-  uterine,  metrostaxis  from. .     436 

characters  of        .  .  .  .      435 

metrorrhagia  from        433,  435 

simulating    inversion     of 

uterus    . .         . .  . .     587 

malignant  growth      . .     435 

prolapse  of  uterus     . .     587 

vaginal  discharge  from..     211 

Polvplasmia     .  .  . .  .  .        26 

POLYURIA 581 

-  in  azotic  diabetes    . .         583,  584 

-  causes  of      . .  . .        581,  583 

-  in  chronic  nephritis     15,  48,  102, 

103,  303,  331,  437,  579,  583,  584 

-  clearing  up  of  serous  effusion  582 

-  diabetes  insipidus  . .  579,  789 
mellitus  292,  437,  507,  579,  789 

-  due  to  examination  for  life 

insurance..  ..         581,582 

-  hysteria        . .  . .  . .     789 

-  in  lardaceous  disease         48,  696 

-  with  movable  kidney        310,  729 

-  periodic         . .  . .  . .     581 

without  apparent  cause. .     582 

in  hydronephrosis  . .     500 

-  in  phosphatic  diabetes      . .     572 

-  polycystic  disease  of  kidneys    396 

-  polycythsemia  with  . .     579 

-  in  pregnancy  . .  . .     293 

-  pyelonephritis         . .  48,  626 

-  renal  tuberculosis  . .  48,  626 
Pons   varolii,  lesions  of  (and 

see  Haemorrhage,  Pontine) 
ataxy  with  . .  . .       68 


PONS    VAROLII—PRIMARY    MUSCULAR  DYSTROPHIES 


Pons  varolii,  contd. 

Postural  causes  of  tahpes     . . 

132 

Pregnancy,  contd. 

Chevne-Stokes  respiration 

-  changes,  influence  on  pains 

-  haemorrhage  in  early  months 

with 

125 

due  to  perigastric  adhesions  486 

usually  due  to  threatened 

. crossed  hemiplegia  vnXh. 

336 

-  influence  on  bruits. . 

105 

abortion   . . 

758 

deafness  from     . . 

190 

Pot-belly  in  rickets  . .         695, 

724 

-  heart  impulse  displaced  in  330 

,332 

hyperpp-exia  from 

346 

Potassium     chlorate,    haemo- 

-  hyperinvolution    of    uterus 

priapism  in 

586 

globinuria  from  .  . 

314 

after 

706 

spastic  paralysis  of  upper 

ptyalism  due  to 

590 

-  impetigo  herpetiformis  in 

113 

limb  from 

547 

purpura    from     . . 

596 

-  almost  impossible  with  car- 

Popliteal abscess  (see  Abscess, 

-  iodide  (see  Iodide  of  Potassium) 

cinoma  of  body  of  uterus 

436 

Popliteal; 

-  salts,  polyuria  after 

582 

-  importance  of  examination 

Popliteal  artery,  aneurysm  of 

Potmen,  plumbism  in 

136 

during 

227 

(see  Aneurysm,  Popliteal) 

Pott's  curvature,  shortness  of 

-  leucocytosis  normal  in 

399 

cedema  of  leg  from 

456 

breath  in . . 

101 

-  lineae  albicantes  in. . 

402 

-  exotosis  (see  Exotosis,  Popli- 

 local  prominence  of  spine 

-  mastodynia  in 

479 

teal; 

in   . . 

134 

-  menstruation    possible    up 

-  glands      (see      Lymphatic 

simulating  colic  . . 

134 

to  the  third  month  in    . . 

758 

Glands,  Popliteal) 

from  spinal  caries 

564 

-  method  of  examination  in 

228 

-  nerves,  external  and  inter- 

 tenderness  and  rigidity  of 

-  moUities  ossium  in 

269 

nal,  signs  of  para  lysis  of . . 

543 

spine  in 

134 

-  nephritis  in. .          . .        8,  11,  16 

talipes  from  paralysis  of 

132 

-  fractme  causing  talipes     . . 

132 

-  neuritis  of   . . 

75 

injury  of  internal,  causing 

Pouches,  oesophageal 

224 

-  occlusion  of  rectum  in 

638 

claw-foot 

12G 

bougie  in  diagnosis  of    . . 

842 

-.  palpation  of  foetal  parts  in 

758 

(see  also  External  Popli- 

 symptoms  produced  by 

842 

-  pelvic  swelling  due  to      757 

758 

teal  Xerve) 

.T-rays    and    bismuth    in 

-  phlegmasia  alba  dolens  in . . 

810 

-  swelling  (see  Swelling,  Popli- 

diagnosis of     . . 

842 

-  polyuria  in  . . 

293 

teal) 

Pouting  of  lips  in  mTopathy 

-  ptyalorrhoea  in 

592 

-  reins,  thrombosis  in 

456 

{Fig.  81)  . . 

260 

-  pyelitis  in    . . 

625 

-  vessels,  pressure   on  due  to 

"  Powdered  wig  "   deposit  m 

-  pyosalpinx  after     . . 

737 

separation    of   the    lower 

urine  in  oxaluria 

470 

-  relation    to     acute    yellow 

epiphysis  of  femur 

763 

Pozzi,     cochleate    uterus    of. 

atrophy     . . 

302 

PopUteus,  nerve  supply  of     . . 

542 

sterility  from      . .        219, 

706 

chorion  epithelioma 

434 

Porencephalus. . 

558 

-  syndrome  of,  in  endometritis 

429 

metrostaxis 

436 

-  cerebral  palsies  from 

155 

Preacher's  hand    (see     Claw- 

-  in   retroverted   uterus   (see 

-  convulsions  in          ..        170, 

172 

hand) 

Uterus,            Eetroverted 

-  dwarfism  with 

214 

Pre-aurioular  gland  (see  Lym- 

Gravid)    . . 

758 

Pork,  colic  due  to       . .          . . 

136 

phatic  Gland,  Pre-auricular) 

-  signs  in  ectopic  gestation. . 

760 

-  trichinosis     infection     from 

Precipices,   vertigo  on 

827 

of  normal              . .           52 

437 

504, 

801 

Precipitancy  of  defaecation  . . 

348 

-  simulating  ascites  .  .            52 

717 

-  urticaria  from 

746 

Precocity,  sexual,    suprarenal 

distended  bladder 

730 

Port  wine,  priapism  caused  by 

586 

tumour  associated  with 

729 

phantom  tumours  433,  721 

761 

Portal   glands  (see  Lymphatic 

Precordial     pain     (see     Pain, 

-  softening  of  fibroid  in 

759 

Glands,  Portal) 

Precordial) 

-  swelling  of  breasts  in 

743 

-  pyaemia  (see  Pylephlebitis) 

-  thrill  (see  Thrills,  Precordial) 

in  right  iliac  fossa  due  to 

737 

-  thrombosis    (see    Pylephle- 

- veins,   dilatation  of,  in  ad- 

 thyroid  gland  in. . 

791 

bitis,  Adhesive)  . . 

301 

herent  pericardium 

242 

-  tetany  during         . .            3, 

178 

-  vein,   obstruction,    albumin- 

Precordium, bulged  in  mitral 

after          . . 

802 

uria  in 

300 

regurgitation  in  children 

238 

-  thirst  increased  in. . 

293 

ascites  ui     58,  300,  301, 

696 

in  adiierent  pericardium 

242 

-  tinnitus  increased  by 

793 

causes    of         ..53,  692, 

696 

Pre-glycosuric  state,  obesity  in 

453 

-  tumour  with,  diagnosis  of. . 

759 

dilated  abdominal  veins 

Pregnancy,  acetonuria  in 

4 

-  ulceration  of  leg  in 

810 

in 

300 

-  acute  mastitis  in     . . 

743 

-  uraemic  amaurosis  in 

839 

gastric  congestion  in . . 

300 

-  albuminuria  in 

17 

-  uterine  casts  in 

220 

hoematemesis  in        294, 

301 

-  albumosuria  in 

20 

haemorrhage  in   . . 

435 

with  jaimdice            301, 

696 

-  amenorrhoea  due  to  23,   24, 

-  uterus  in 

7r.8 

nausea  in 

300 

350,  758, 

759 

-  varicocele  of  vulva  with    . . 

770 

obstruction  to  bile-dnct 

696 

-  amaurosis  in            . .        836, 

839 

-  vomiting  in..         ..579,  843 

844 

oedema  from    . . 

300 

-  with  appendicitis    . . 

761 

acetonuria  in 

4 

oesophageal  varices  in 

300 

-  appetite  increased  in 

293 

diagnosis  from  indigestion 

350 

spleen  enlarged     in  692 

696 

perverted  in          . .         50, 

774 

in  morning 

437 

vomiting  m.     . .        300, 

843 

-  ascending  nephritis  in 

16 

polycythaemia  in           579, 

580 

Porter-like  urine  in  septicemic 

-  bacilluria  in           16,  51,  82 

615 

toxic  factor  in 

843 

jaundice    . . 

372 

-  breast  changes  in    . .        350, 

743 

Pre-hemiplegic  chorea,  move- 

Porters, kyphosis  in  . . 

183 

-  bullous  eruption  in       •     . . 

111 

ments  in  . .          . .        156, 

157 

-  spinal  bursa  of 

183 

-  chorea  in     . . 

156 

Prepuce,  epithelioma  of,  enlarged 

Post-hemiplegic  athetosis     . . 

155 

-  constipation  following 

148 

inguinal  glands  from 

423 

-  chorea           . .          . .         156 

157 

-  diagnosis  of . . 

24 

-  herpes  of     . .          . .         209, 

830 

Post-mortem  wart     . . 

266 

from  ovarian  tumour    . . 

758 

-  swollen  and  oedematous  in 

Post-partum  haemorrhage  (see 

uterine  fibroid     . . 

758 

balanitis  . . 

674 

Haemorrhage,  Post-partum) 

-  discharge  of  milk  from  nipple 

-  ulceration  of,  in  balanitis  . . 

674 

Post-pharj'ngeal    abscess   (see 

during       . .          . .        201, 

743 

Presentations,  abnormal  foetal 

228 

Abscess,  Post-pharyngeal) 

-  dyschezia  in 

150 

Pressure,  relief  to   trigeminal 

Posterior     basal     meningitis 

-  dysmenorrhooa  cured  by  . . 

219 

neuralgia  by 

495 

("see  Meningitis) 

-  eclampsia  with       . .         160, 

172 

Presvstolic  bruit  (see  Bruit) 

-  inferior     cerebral     artery, 

-  efi'ect     on     neurotic     dys- 

PRIAPISM  (see  Erections, Penile) 

thrombosis  of,  ataxy  from 

666 

pareunia  . . 

22'' 

Pricking,  pruritus  described  as 

588 

dissociative  anaesthesia 

-  enlargement  of  uterus  in  . . 

350 

-  sensation     in     eyes,     from 

from  (Fig.  184) 

666 

-  epileptiform  convulsions  in 

109 

error  of  refraction 

328 

-  scapular  nerve,  mascles  sup- 

- fluctuation  in 

758 

in  miliaria  rubra 

831 

plied  by  . . 

550 

-  flushing  in   . . 

268 

Prickly  heat,  pruritus  in 

588 

spinal  roots  derived  from  550 

-  foetal  lieart  sounds  in 

758 

Primary  lateral  sclerosis  (see 

-  tibial  nerve,  skin  distribution 

659 

-  elycosuria  in           

293 

Sclerosis) 

Posthitis  a  cause  of  priapism 

585 

-  haematoma  of  vulva  in 

770 

-  muscular    dystrophies    (see 

Postural  albuminuria 

19 

-  haemoglobinuria  in. . 

315 

Myopathy) 

PRIMULA    OBCONICA—PSEUDO-HERMAPHRODITISM 


969 


Primula  obconica,  buUre  from 

110 

Proslate,  enlarged,  contd. 

Proslalitis,  cmtd. 

Printers,  plumbism  in 

13G 

changes  in  stream  of  urine 

-  urethral  passage    of    faeces 

Proctitis,  urethral  passage  of 

from 

439 

from          

264 

fieces  from 

204 

coud(!-  catheter  in         440 

441 

Prostration,  from  febricula   . . 

505 

I'roctoscope,  in  rectal  afleotions  100 

-  -  cystitLs  with 

G27 

-  in  Henoch's  purpura 

600 

Progeria,  anirina  pectoris  in  . . 

218 

diagnosis  of 

311 

-  influenza,     disproportion- 

- arteriosclerosis  in   . . 

218 

difficulty  in  micturition  in 

ately  severe  in   . .        505 

699 

-  baldness  in  (Fig.  70) 

218 

311 

439 

-  from  pneumothorax 

480 

-  emaciation  in 

218 

distended  bladder  from  52 

,  730 

-  profound,  in  traumatic  anuria    4') 

-  premature  decrepitude  in.. 

218 

frequency  of  micturition  in 

-  in  pyaamia   . .          . .        372, 

649 

ossification  in 

214 

311,  438,  440,  581 

817 

-  tropical  abscess  of  liver 

369 

Progressive    bulbar  paralysis, 

ncpliritis  from     . . 

8 

-  typhus  fever            . .         371 

,  698 

fibrillary   contractions   in 

priapism  from     . .        585, 

586 

-  after  urinary  operations    . . 

49 

(and  see  Paralysis,  Bulbar] 

in  prostatitis        . .        627 

631 

Protargol,  leucocytosis  from 

400 

158 

159 

of  puberty 

248 

Proteid,  Eence-Jones' 

21 

-  muscular  atrophy  16,  72,  73 

127 

pyelitis  in 

025 

Protozoa  in  malaria  (see  Malaria) 

absence  of  pain  in 

5^5 

pyonephrosis  from 

626 

Prurigo,  character  of  papule  of 

and     bulbar    paralysis 

rectal  examination  439, 441 

,638 

528,  531, 

532 

associated     . . 

G41 

residual  urine  with 

438 

-  diagnosis  from  eczema,  urti- 

 claw-hand  in   . . 

127 

retention  of  urine  with    45 

440 

caria,  psoriasis    . .         531, 

532 

contractures  in           163 

165 

septic  urethritis  from  self- 

scabies  and  pediculosis  . . 

532 

exaggerated  reOexes  in 

127 

catheterization  in 

680 

-  ferox,  age  incidence  of 

532 

fibrillary  contractions  in 

-  gonococcal  infection  of 

207 

characters  of  papules  of. . 

531 

158, 

159 

-  massage  of  . . 

208 

distribution  of     . . 

531 

palsy  of  one  leg  in 

544 

-  palpation  per  rectum 

307 

intense  itching  in 

531 

R.D.  in 

73 

-  sarcoma  of,  hard  fixed  swell- 

 lymphatic  gland  enlarge- 

simulated  hj  gonococcal 

ing  felt  per  rectum 

638 

,ment  in             . .         531 

,532 

arthritis 

377 

-  suppuration  in,  perineal  sore 

mitis 

531 

syringomejiia 

73 

from 

677 

pustules  in 

531 

Tooth's    peroneal    (see 

-  swollen  and  hot  and  tender 

relation  to  acanthosis    . . 

531 

Tnoth'sl 

in  acute  prostatitis 

207 

simulated  by  urticaria  . . 

531 

Professional  cramps  . . 

177 

-  tenderness  of,  in  acute  pros- 

 skin  changes  in  . . 

531 

Projection,  physiology  of 

199 

tatitis 

031 

-  pruritus  in  . . 

588 

Prolapse,  anal,  haemorrhage  in 

93 

prostatic  abscess 

G31 

-  simplex  aigu,  resemblance  of 

-  of     ovaries     (see     Ovaries, 

-  tuberculous,  absence  of  penile 

papular  erythemn  to 

531 

Prolapsed") 

508 

pain  in 

512 

PRURITUS  (and  see  Itching) 

588 

-  and  pilfi-S.  association  of  . . 

93 

associated   with   renal 

-  aflecting  napkin  region 

447 

-  of  urethral     mucous    mem- 

tuberculosis    . .        626, 

694 

-  ani  from  thread-worms 

569 

brane  simulating  urettiral 

tuberculous  bladder 

-  associated    with    cutaneous 

caruncle    . . 

770 

312,  441,  513,  629 

678 

diseases     . . 

588 

PROLAPSE  OF  UTERUS     .. 

586 

epididymis    . . 

629 

-  bath              

588 

albuminuria  from 

16 

testis             .  .518,  519 

678 

-  in  cheiropompholyx 

111 

anatomical  considerations 

586 

deposits  in 

6.30 

-  dermatitis  herpetiformis    . . 

113 

causing  cerebral  haemor- 

 epididymitis  with 

767 

-  herpes  gestationL«   . . 

111 

rhage     . . 

10 

pain  in  the  perineum 

516 

-  hiemalis 

588 

congenital  extroversion  of 

perineal  sinus  from 

678 

-  papules  causing      . .         528, 

533 

bladder  simulating     . . 

587 

prostatic  abscess  in 

6.32 

-  senilis 

588 

sacralgia  in 

509 

rectal  examination  in    307 

519 

-  tenderness  of  scalp  from  780, 

781 

-  -  simulated  by  inversion  of 

rounded    nodule    felt    in 

-  universalis    . . 

588 

uterus    . . 

587 

prostate  per  rectum  in 

678 

-  vulvas  from  thread-worms 

569 

polypus  of  cervix 

587 

secondary  tuberculosis  else- 

Prussic  acid    in   gastric   con- 

 ulceration  of  vagina  from 

211 

where  in  genito-urinary 

tents,  recognition  by  smell 

844 

-  -  vulval  swelling  due  to    . . 

768 

system  . . 

632 

Pseudo-angina  without  cardiac 

Proliferating       papillomatous 

Prostatectomy,  urethritis  fol- 

or vascular  disease 

483 

ovarian  cyst,  ascites  in  . . 

58 

lowing 

767 

-  diagnosis  from  true  angina 

Prolonged  pyrexia  (see  Pyrexia 

Prostatic  abscess  (see  Abscess, 

pectoris     . . 

482 

Prolonc'ed^ 

Prostatic) 

-  neurotic  origin 

482 

Pronators,  nerve-roots  supply- 

- calculus,  effects  of  . . 

512 

-  never  fatal  . . 

482 

ing     . . 

556 

-  threads   in   residual   gonor- 

-  occurrence  at  any  age 

482 

-  nerve  supply  of 

550 

rhceal  catarrh 

444 

-  onset  frequently  at  night. . 

482 

Proptosis  (see  Exophthalmos) 

Prostatitis,  bacteriuria  in 

83 

-  sex  incidence  of 

482 

Propulsion  in  paralysis  agitans 

796 

-  chronic,  muco-pus  in 

208 

toxic  (tobacco,  tea,  coffee) 

Prostate,  adenoma  of  307,  -ill 

511 

-  diagnosis  from  acute  cystitis 

627 

origin  of  some  cases  of 

482 

absence  of  penile  pain  from 

511 

-  difficulty  of  mictiurition  in. . 

511 

Pseudo-bulbar  paralysis    (see 

characters 

441 

-  following  urethritis 

also  Hemiplegia,  Double) 

686 

hematuria  in      . .         304, 

311 

206,  515,  627, 

631 

no  atrophy   of  tongue  in 

pain  in  perineum  in 

516 

-  frequency  of  micturition  in 

591, 

641 

rectal      examination      in 

438,  511, 

631 

bilateral  supranuclear  fa- 

diagnosis of     . .         512 

638 

-  from    non-gonococcal     ure- 

cial paralysis  in 

535 

-  calculus    of    (see    Calculus, 

thritis        . .          . .         206 

515 

and  bulbar  paralysis  dis- 

Prostatic) 

-  pain  in  hypogastrium  in    . . 

631 

tinguished         .  .         224 

641 

-  carcinoma  of  (see  Carcinoma 

legs  from  . . 

491 

dysarthria  in 

686 

of  Prostate) 

loins  from 

491 

facial  spasticity  in 

686 

-  disease    of,    pain    in  lower 

penis  in   441,  510,  511,  513 

515 

loss  of  control  of  emotion- 

extremity from   . . 

491 

perineum  in        .  .491,  516 

631 

al  expression  in 

686 

after  micturition  in     . . 

441 

rectum  from 

628 

palatal  paralysis  in 

640 

penis  from 

510 

suprapubic,  in     . . 

631 

ptyalism  in  " 

591 

perineum  in     . . 

442 

-  painful  erections  with 

515 

Pseudo-diarrhoea  in  dyschezia 

142 

-  enlarged       

311 

-  prostate  enlarged  in           627 

631 

Pseudo-elephantiasis    due    to 

-  -  age  incidence  of . . 

440 

hot  and  tender  in       207, 

631 

l_vmph-gland    obstruction 

456 

albuminuria  from 

IG 

-  pyrexia  in               ..207,  511 

631 

-  vulval  swelling  from 

768 

bilateral    hydronephrosis 

-  rectal  examination  of        511 

631 

Pseudo-hermaphroditism, 

from 

311 

-  retention  of  urine  due  to  207, 

631 

changes  of  genital  organs 

706 

bleeding  from 

305 

-  sequela  of  gonorrhcea 

515 

-  sterility  due  to 

706 

970 


PSEUDO-HYPERTROPHIC  PARAL.—PULMOXARY  TUBERC 


Pseudo-hypertrophic  muscular 
paralysis,  muscles  affected 
in  . .  . .  . .  555,  560 

age  and  sex  incidence. .     560 

difficnity  of  lifting  pa- 

Tient  by  shoulders  . .     561 

electrical  reactions  in  70 

familial  character  of  . .     560 

fibrUlarr     contractions 

rare  in  . .  . .     158 

mode  of  "  climbing  up 

himself"      ..  ..     560 

paraplegia  due  to       . .     557 

no  sensory  or  sphincter 

changes  in    . .  . .     560 

-waddling  gait  in        277,  561 

Pseudo-leukseniila      infantum 

(Fm.  2)     ..  ..  42,  694 

absence  of  leucocyiosis  in     694 

age  incidence  of  . .  . .     694 

ascites  in. .  . .  64,  122 

blood  changes  in . .  . .       64 

chronic,  cause  of . .  . .     694 

lymph  glands  not  enlarged 

in  5S9 

cedema  of  legs  from     459,  461 

pericarditis  in      . .  .  .^   122 

pleuritic  effusion  in        . .     122 

purpura  in  . .  . .     596 

recovery  from     . .  . .     694 

relation  to  rickets  or  con- 
genital syphUis  42,  695 

severe  anieniia  in  459,  694 

spleen  enlarged  in  Fig.  2. 

p.  42)       '  64,  599,  692,  694 

symptoms  of        . .  . .       42 

Pseudo-neuralgias,  diagnosis  of    498 
Pseudo-nystagmus      . .  . .     452 

Pseudo-cedema  of  legs  in  myx- 

cedema      . .  . .  . .     585 

Pseudo-pelade  of  Brocq        . .      85 

baldness  from      . .  . .     782 

relation  to  alopecia  areata     782 

sclerodermia    . .  . .     782 

tendarness  of  scalp    from     780 

Pseudo-tabes    . .  . .  . .       66 

Pseudo-trichinosis  (see  Poly- 
myositis, Acute) 
Pseudocyesis    . .  . .        166,  721 

Psoas  abscess  (see  Abscess,  Psoas) 
Psoas  bursa,   distended,  com- 

cated  pulsation  in  . .     741 
diagnosis   from    aneur- 
ysm of  external  iliac 
artery            . .  . .     741 

impulse  on  coughing  in     739 

ingninal  swelling  from 

distention  of  . .     741 

irreducibOity  of  . .     741 

isith   osteo-arthritis   of 

hip  joint       . .  . .     741 
position  external  in  fe- 
moral vessels  . .     7.39 

reducibUity      . .  . .     7-39 

translucency  of  . .     741 

-  muscle     suppuration     and 

lordosis 183 

Psoriasis,  afieetion  of  elbows, 
knees,  and  extensor  sur- 
faces by    . .  447,  530,  656 
of  nails  in           . .        275,  445 

-  age  incidence  of      . .  . .     533 

-  anidrosis  with  . .  . .     714 

-  baldness  from  . .  . .       84 

-  in  bathing-drawers  area    . .     447 

-  complexion  associated  with      657 

-  description  of  eruption  of..     657 

-  diagnosis  from   eczema     . .     657 

lichen  planus  . .  529,  627 

lupas  erythematosus      . .     657 

j>apular  syphilides  . .     533 

pityriasis  rosei    . .  . .     658 

rubra     . .  . .  . .     658 

pUsiris  . .  . .     530 


531, 


579, 
596, 


Psoriasis,  conid. 

-  diagnosis  from  prurigo 

f erox     . . 

ringworm  of  body 

scalp 

seborrhcea 

-  eosinophOia  in 

-  involvement  of  hps  in 

-  parts  specially  affected  by 

-  pityriasis  rabra  after 

-  pruritus  in  some  cases  of    . . 

-  recurrence  of 

-  scale.?  in       . .  .  .         655, 

-  of  scalp,  diagnosis  from  favus 

-  slightness  of  itching  with  . . 

-  sore  fingers  from 

-  rupioides  of  M'Call  Anderson 

-  and  KyphUis  distinguished. . 

-  unimpaired  health  with     . . 
Psorosperms,  method  of  demon- 
strating   . . 

Psychalgias  (see  Pseudo-netir- 
algia) 

-  neurasthenic  pain  with  no 

physical  basis 

Psychical  weakness,  motor 
ties  associated  with 

Psychosis,  Korsakow's,  in  al- 
coholic peripheral  neuritis 

Pterygium  of  nails 

Ptoniaine  poisoning,  acute 
diarrhcea  from 

agglutination    serum  test 

as  cause  of  bullous  der- 
matoses 

due  to  Graertner's  baeillns 

oedema  of  face,  neck,  and 

arms  in 

polycythaemia  in 

ptirpura  in 

severe  diarrhcea  in 

vertigo  from 

wasting  with 

PTOSIS  (/'if^s.  156-9). . 

-  from   cervical    sympathetic 

paralysis  .  .    247,  546,  594, 

-  of  colon,  constipation  due  to 

{Fig.'Z9) 

-  (and      see       Gastroptosis ; 

Glenard's  Disease;  Hepato- 
ptosis ;  Visceroptosis) 

-  in  conjunctivitis 

-  from  facial  paralysis  536, 

-  hysterical 

-  in  myopathy 

-  tabes 

PTYALISM 

-  bacteriology   in    dia,gnosing 

cause  of    . . 

-  from  fixation  of  jaw 

-  ftmctional     . . 

-  mercurial      . .  . .    37,  86, 

-  in  trigeminal  netu-algia 

-  Wassermann's  reaction  in.  . 
Ptyalorrhcea,  functional       590, 

-  relation  to  tic  douloureux. . 
Pubes,  acute  necrosis  of,  grave 

constitutional      symptoms 
in 
scrotal  swelling  due  to 

-  tuberculous   caries    of,  dia- 

gnosis   from    gumma    of 

crus  penis 

sarcoma  of  cms  penis 

Puberty,  acne  vulgaris  at 

-  albuminuria  of 

-  anorexia  nervosa  at 

-  breast  changes  at  . . 

-  delayed  in  infantilism 

-  effect  on  nocturnal  entiresis 

-  enlargement  of  jjrostate  at 

-  epi'staxis  of  .  .         251, 

-  menorrhagia  at 

-  mUk     in  breasts  at         202, 


532 
532 
275 
274 
656 
249 
403 
657 
658 
588 
533 
657 
271 
657 
266 
654 
658 
657 

803 

498 

494 

160 

505 
444 

196 
597 

114 

597 


597 
579 
827 
69 
589 

792 

147 


590 
589 
166 
260 
262 
590 


591 
591 
592 
797 
495 
591 
592 
592 


767 
767 


767 
767 
603 
19 
849 
743 
218 
248 
248 
252 
430 
743 


Puberty,  coiUd. 

-  premature    appearance    of,  j  ^ 

associated  with  liypeme- 
phroma     . .  .  .  . .     690 

-  priapism  at. .  . .  . .     586 

Pubic    hair,     early     develop-  :_  cj 

ment,  with  hypcmephro-      ►! 
ma  690 

-  region,  sycosis  vulgaris  of . .  602 
Puckering  of  skin  . .  . .  745 
Pudic    nerve    inflamed,    dys- 

pareunia  from     . .  . .     221 

Puerperal  fever,  endocarditis  in   103 

infection  of  uterus  in     . .     649 

offensive      vaginal      dis- 
charge in  . .  . .     649 

rigors  in  . .  . .         648,  649 

simulating  rheumatism . .     650 

-  infection,  pelvic  peritonitis 

from  508 

-  sepsis,  pelvic  abscess  from      760 

septicaemia  in      . .  . .     698 

Puffiness   of   ankles   in  acute 

nephritis  . .  . .  . .       48 

-  eyelids  in  myxoedema       . .     259 

-  face  in  acute  nephritis       . .       48 

-  joint  in  haemophilic  arthritis    388 
Pulmonary  and  aortic  regurgi- 
tation distinguished       . .     247 

-  aneurysm    (see    Anetnysm, 

Pulmonary) 

-  area,  systolic  bruits  over  104, 105 

-  artery,  arising  from  aorta. .     184 

-  atheroma,  mitral  stenosis  a 

cause  of   . .  . .  . .     323 

-  branches  of  vagus,  relation 

to  cough  . .  . .  . .     175 

-  diseases,  ascites  in  . .  . .  61 
causing     enlarged     right 

ventricle  . .  . .     246 

chronic,         hypertrophic 

osteo-arthropathy  in  (and 


see  Osteo-arthropathy) 
venous  liver  congestion 
in 


390 


407 
101 
321 


107 
107 


247 


247 
247 


105 
579 


shortness  of  breath  in    . . 

-  embolism  sudden  death  in 

-  gangrene  (see  Gangrene  of 

Lung 

-  osteo-arthropathy  (see  Osteo- 

arthi-opathy) 

-  regurgitation,'  catises  of     . . 

causing  diastolic  bruit    . . 

enlarged  right  ventricle  in 

245 
from  fungating  endocar- 
ditis 
mitral  stenosis     . . 

-  second   sound,  reduplicated 

in  mitral  regurgitation  . . 

-  stenosis,  acquired    . . 

-  -  bruits  of  104,  105, 184,  247 
clubbed  fingers  and  toes 

with      . .  104,  129,  247 

cyanosis  in  104,  184,  247 

dyspnoea  in  . .  . .     247 

with   patent    interventri- 
cular septum  . .        244,  579 

polycythaemia  in  247,  579 

right  ventricle  enlarged  in 

245,  246,  247 

symptoms  Of        . .  . .     247 

systolic  thrill  due  tol84,247,790 

-  svstolio  bruit  in  normal  chil- 

"  dren  105 

-  thrombosis  (.see  Thrombosis, 

Pulmonary) 

-  tuberculosis  (and  see  Phthisis) 
miliary,   absence   of  pul- 
monary signs  in  some 
cases  of 

quick  breathing  in . . 

pyrexia  with  weakness 

and  anorexia  at  onset 


612 

612 


CIS 


PULMONARY 

TUBERCULOSIS— PUPILS,    UNEQUAL 

97  r 

Pulmonary  tuberculosis,  contd. 

Pulse,  rapid,  contd. 

Pupil,  contd. 

pain  in  limbs  in  . .        503, 

505 

]meumothorax 

480 

-  in  Graves'  disease  . . 

201 

-  valve,  fungating  endocardi- 

 jiroportion     to    tempera- 

- immobile  in  epilepsy 

160. 

tis  of         

321 

ture  in  tropical  abscess 

general  paralysis 

172 

-  veins,     rupture     of     aortic 

of  liver. . 

408 

-  irregular,  due  to  adherence 

aneurysm  into     . . 

482 

relapsing  fever    . . 

698 

to  corneal  ulcer  . . 

594 

fulpy    knee    Csee    Arthritis, 

small  and  intermittent,  in 

dislocation  of   the   lens 

594 

Tuberculous,  of  Knee) 

mitral  stenosis 

245 

from  injury  to  tlie  eye  .  . 

593 

Tulsatile  liver  (see  Liver,  Pul- 

 with  subphrenic  abscess720 

721 

in  insanity 

595 

satile) 

-  relatively    slow   in  cerebral 

due  to  old  iritis  . . 

593- 

-  swelling  Csee  Swelling,  Pul- 

abscess     . .          . .        547, 

771 

persistent  pupillary  mem- 

satile) 

influenza 

771 

brane     . . 

593. 

ia  the   orbit  Csee    Orbit, 

tuberculous  meningitis 

771 

rupture  of  the  sphincter 

593 

Tumour  of  Pulsatile) 

typhoid  fever  196,  610, 

in  tabes     . . 

595- 

Pulsation  of  arteries  in  aortic 

697, 

771 

-  large  in  myopic  eyes 

594 

disease           23:!,  2l0,  247, 

764 

yellow  fever       301,  373, 

771 

-  membrane  persistent 

593 

marked    in   exophthalmic 

-  and     respiration    ratio     in 

-  peculiar  light  reflex  in  hemi- 

goitre                          2'J:-1 

764 

pneumonia 

372 

anopsia 

595 

-  capillary,  in  aortic  disease 

-  during  rigors 

646 

-  pinpoint,  in  opium  poison- 

lOG, 

240 

-  in  simple  colic        . .        133, 

645 

ing            ..          ..         138, 

345 

-  cessation  of,  in  one  or  other 

-  slow  in  cerebral  tumour    . . 

782 

pontine  haemorrhage 

138- 

of  the  accessible  arteries 

cretinism 

259 

-  reaction  in  hysteria 

160 

in  fungating  endocarditis 

613 

myxoedema 

259 

-  reactions  of,  in  hemianopsia 

336 

-  epigastric  Csee  Epigastrium, 

-  splashing,  in  aortic   disease 

240 

uroemic  amaurosis 

839- 

Pulsation  in) 

-  sudden   halving   in   Stokes- 

Pupil   reflex  to  light,  loss  of 

-  expansile  with  aneurysm  235, 

Adams  syndrome 

527 

Cand  see  Argyll  Robertson 

476, 

786 

-  and    temperature   ratio    in 

Pupil)       

594 

in  iliac  aneurysm 

741 

normal  conditions 

622 

in  alcoholic  intoxica- 

- in  eyeball  from  local  aneu- 

 in   pneumonia.. 

697 

tion 

594 

rysm 

255 

typhoid  fever             372, 

697 

bilateral  character  of 

594 

-  meningocele  . . 

254 

-  variations   in   mitral  regur- 

 in  cerebral  tumour . . 

594 

-  osteosarcoma           ..        177, 

179 

gitation     . . 

238 

in  70  to  90  per  cent 

-  pelvic  sarcoma 

741 

-  water-hammer,     in     aortic 

of    cases  of   tabes 

594 

-  psoas  bursa 

741 

regurgitation 

106 

epilepsy 

594 

-transmitted   aortic. 

306 

-  Csee   also   Bradycardia   and 

general    paralysis    of 

by  carcinoma  of  pancreas 

59 

Tachycardia) 

the  insane 

594 

ovarian  cyst 

691 

PULSES,  INEQUALITY  OF.. 

592 

due  to  injury 

594 

PULSATION.    UNDUE      AB- 

- unequal,  from  aneurysm 

in  some    intracranial 

DOMINAL  AORTIC 

592 

222,  236, 

732 

diseases     . . 

594 

age  and  sex  incidence 

592 

from  cervical  rib  128    493 

593 

mania 

594 

diagnosis  from  abdo- 

 congenital  cerebral  diplegia 

800 

never  found  in  health 

594 

minal  aneurysm  728 

764 

femoral,  from  iliac  aneu- 

 jmclear  lesion  causing 

594 

feeling  of  discomfort  in 

592 

rysm 

741 

retained  in    acute  en- 

- use  of  ear  in  detecting  slight 

235 

tibial,  in  popliteal  aneur- 

cephalitis . . 

594 

Pulse  in    acute    general    peri- 

ysm        

762 

stimulating    of     cer- 

tonitis                   431,  472, 

644 

Pulsus  paradoxus  in  adherent 

vical    sympathetic 

594 

yellow  atrophy   . . 

370 

pericardium 

104 

in  syphilis"    . . 

594 

-  in  aortic  disease'    106,  2."3, 

Puncta  laclirymalia,  mal-posi- 

tabes 

594 

234,  235,  237,  240,  247 

526 

tion  of,  causing  epiphora 

250 

tumour    of     corpora 

-  appendicitis 

736 

Punctate  basophilia  (Plate  //"> 

30 

quadrigemina 

594- 

-  in  catarrhal  jaundice 

365 

PUPIL,  ABNORMALITIES  OF 

593 

-  reflexes,  in  ciliary  paralysis 

594 

-  chart  of  rheumatoid  arthritis 

-  appearance  of,   in  conjunc- 

 description    of    the    four 

(Fig.  106) 

377 

tivitis,  iiitis,  and  glaucoma 

257 

normal  . . 

594 

-  collapsing,  in  aortic  regurgi- 

-  Argyll  Robertson  Csee  Argyll 

dilatatory  in  sensory  and 

tion                           240,  247 

526 

Kobertson  Pupils) 

emotional  reflexes 

594 

-  disproportionately   rapid  in 

-  blockage  of,  by  iritis 

839 

in  diphtheritic  neuritis  . . 

77 

rheumatoid  arthritis 

378 

-  changes  from  affections  of 

hemianopic,  description  of 

595. 

—  in  eiKJof'arditis 

239 

cervico-dorsal  cord 

554 

to  "  light  "  and  "  accom- 

- exhaustion     of     obstructed 

in  tabes    . . 

262 

modation  " 

594 

labour 

229 

-  contracted,  acute  encephalitis  594 

loss   of    "  convergent    ac- 

- feeble     and     irregular,     in 

brain     disease,     ultimate 

commodation  "  with  re- 

fibroid heart 

241 

replacement   of   dilata- 

tention  of    "  light,"   in 

in   toxic  cases  of  diar- 

tion in  all  cases 

594 

:neningitis 

594 

rhoea 

196 

cervical  svmpathetic  para- 

 myelitis 

594 

in  myocardial  degeneration 

lysis     '..          ..247,590 

,792 

paradoxical,  definition  of 

595. 

241,  333 

526 

in  hypermetropic  eyes  . . 

594 

retained  with  dilated  pupil 

-  increased  rate,  after  exercise. 

intracranial  abscess 

594 

in  acute  mania 

594 

in  dyspepsia 

526 

-  -  -  growth  . . 

594 

in  tabes  . . 

595. 

-  irregular  in  organic  cerebral 

paralysis  of  cervical  sym- 

 unilateral  . . 

594 

disease 

328 

pathetic 

546 

in  unilateral  lesion  of  optic 

tuberculoias  meningitis  . . 

174 

in  spinal  lesions  . . 

553 

tract      . .          . .         594 

,595. 

-  in  jaundice   . .          361,  365 

370 

tabes 

594 

-  size  of,  variations  with  age 

-  paroxysmal  tachycardia    . . 

772 

urajmia     . .          . .   45,  46, 

195 

of  patient 

594 

-  radial,  diminished  from  cer- 

- dilated  in  acute  mania     . . 

594 

Pupils,  small,  in  encephalitis 

594 

vical  rib    . . 

493 

from  belladonna 

773 

-  unequal,  in  aortic  aneurysm 

-  rapid    and     feeble  ;      from 

in  glaucoma 

840 

222 

595. 

corrosive  poisoning 

297 

with    retention    of     light 

carotid  aneurysm 

595. 

in  fevers   . . 

771 

reflexes  in  catalepsy  . . 

594 

coma 

137 

after  hajmorrhage        140, 

in  epilepsy 

594 

general  paralysis  172,  195 

,  595. 

298,   646,   717 

780 

stimulation  of  cervi- 

 in  glaucoma 

595 

and  irregular,  in  arsenical 

cal  sympathetic 

59^ 

iritis 

595. 

poisoning 

92 

-  double  aperture  of             198 

,  199 

from  use  of  mydriatics  . . 

595 

in  malignant  scarlatina . . 

301 

-  eccentric,   from   tumour   of 

myotic  drugs  .  . 

595 

phosphorus   poisoning   . . 

373 

mid-brain. . 

798 

m  organic  cerebral  disease 

328. 

972 


PUPILS,    UNEQUAL— PYLEPHLEBITIS 


Pupils,  unequal,  contd. 

Pus,  contd. 

Pycemia,  contd. 

from  physostigmine 

595 

—  collections,  indicanuria  due  to  821 

-  rigors  in 

possibly  of  no  significance 

-  in  expectoration     . . 

176 

372,  598,  647,  648,  649,  650 

in  slight  degrees 

595 

-  -  from   empyema   bursting 

-  septic  skin  rashes  in 

650 

in  tabes     . . 

595 

through  Ivmg  . . 

323 

-  and  septicaemia,  relationships 

third  nerve  paralysis 

595 

liver  abscess  ruptured  into 

between    .  . 

650 

trigeminal  neuralgia 

595 

lung 

369 

-  simulating  acute  rheumatism  650 

unilateral  cerrical  sympa- 

- extrapleural,  simulating  em- 

 enteric  fever 

650 

thetic  lesion     .  .          594 

595 

pyema 

119 

gout          

383 

—  -  from     unilateral      intra- 

- with  gas  in  pleural  cavity . . 

577 

-  subcutaneous  abscesses  in 

649 

cranial  lesion  . . 

595 

-  greenish  yellow,  in  pneumo- 

- from  subperiosteal  abscess 

750 

Purgatives,  colic  from 

1+1 

coccal  arthritis    .  . 

375 

-  sudden  onset  of      . . 

649 

-  constipation  due  to 

848 

-  under    pressure,     polymor- 

- suppuration  in  joints  in    . 

649 

-  in     distinguishing     scyhala 

phonuclear      leucocytosis 

-  suppurative    pericarditis  in     650 

from      other     abdominal 

associated  with  . . 

400 

-  sweating  in. .          . .         3' 

■2,  649 

tumours    . .          .  .          501 

723 

-  not  under  pressure,  no  leuco- 

- symptoms  of 

45 

—  intestinal  obstruction 

151 

cytosis  with 

400 

-  temperature   chart   of 

614 

-  loss  of  weight  due  to 

848 

-  per  rectum,  from  ruptured 

-  tenderness  in  spine    in     . 

785 

Purin  bases,  uric  acid  from  . . 

817 

abscess 

635 

-  thyroid  abscess  in. . 

792 

PURPURA       

595 

—  sterile  in  liver  abscess  burst- 

-  imafiected  by  quinine 

650 

-  albumosuria  in 

20 

ins  through  lung 

323 

-  vomiting  in. . 

649 

—  anfemia  with 

36 

PUS  IN   THE    STOOLS 

600 

Pyelitis            

16 

-  bleeding  gums  in    . . 

85 

in  anal  fistula     . . 

92 

-  aching  in  loin  in    . . 

625 

-  and  cerebral  embolism 

138 

colitis 

501 

-  in  acute  fevers 

625 

-  in  cerebrospinal  meningitis 

643 

dysentery . . 

501 

-  due  to  B.  coli 

625 

—  cirrhosis  of  liver 

696 

-  in  urine  (see  Pvuria) 

-  bilateral  in  cystitis 

625 

—  definition  of 

595 

PUSTULES      .." 

601 

-  cystoscopic  appearances  in 

-  diagnosis     from     capillary 

-  of  acne          

531 

(Plate  V,  Fig.  C,  p.  308)  6 

25,628 

naevi 

595 

-  in  bromide  eruption 

603 

-  diagnosis  from  chronic  cys 

—  ecchymoses  or  bruises  in  . . 

595 

-  congenital  syi'hilis . . 

446 

titis 

628 

-  eplstaxis  in. . 

251 

-  dermatitis  herpetiformis   . . 

831 

-  dry  harsh  skin  in    . . 

625 

-  from  flea  bites 

596 

-  dimpling  of,  in  large  acumi- 

- glazed  tongue  in      . . 

625 

—  in    fungatins     endocarditis 

nate  syphilides    . . 

604 

-  from  growth  in  bladder    . 

625 

38,  76,  237,  338,  610, 

613 

-  eczema 

831 

-  haematogenous  infection  in     625 

—  gastric  erosions  in . . 

298 

-  granulosis  rubra  nasi 

714 

-  hyperpyrexia  in      . . 

344 

-  haematemesis  in      . .        294, 

302 

-  herpes  progenitalis 

675 

—  infections  elsewhere  wich. 

625 

—  hematuria  in          . .         305, 

314 

-  impetigo  contagiosa 

654 

-  with  intestinal  afiections  . 

625 

-  haemoptysis  in 

318 

-  lichen  scrofulosorum 

529 

-  from  involvement  of  ureter 

—  Henoch's  (see  Henoch's  Pur- 

- malignant  (see  Anthrax) 

in  carcinoma  of  uterus  . 

625 

pura) 

-  microscopical    character    of 

-  kidney  enlarged  in            500,  625 

-  in  leukfemia 

31 

contents    . . 

601 

-  little  pus  in  acid  urine  in  . 

623 

—  menorrhagia  in       . .        428, 

430 

-  in  miliary  abscesses  of  new- 

-  micturition  frequent  in     438,  625 

—  metrorrhagia  due  to        433, 

435 

bom 

601 

-  pain  in  the  right  hypochon 

—  in    morbus    maculosus     of 

-  prurigo  ferox 

531 

drium  in  . . 

500 

Werlhof    ..          ..        596, 

600 

-  rhinophyma . . 

805 

-  pneumococcal 

625 

-  persistence  of  discoloration 

-  ring  of,  in  anthrax  . . 

603 

-  in  pregnancy 

625 

under  preKvure  in 

595 

-  scabies          . .           654,  831, 

832 

-  prostatic  enlargement 

625 

—  in  scurvy     . .          . .           85, 

302 

-  in  scrofulodermia    . . 

603 

-  pyonephrosis  from  ureteral 

—  scarlatma  maligna  . . 

301 

-  small-pox     . .             605,  655 

829 

obstruction  in      . . 

396 

-  from    septic     infection     of 

-  syphilis         .  .              440,  532 

833 

-  pvrexia  in    . . 

625 

umbilical  cord     . . 

90 

-  transition  of  papules  into  001 

,528 

-  pyuria  in     . .           500,  623,  625 

-  small-pox     . .          . .         301, 

605 

-  in  vaccinia    . . 

834 

-  from  renal  calculus  438,  62 

5,  627 

-  typhus  fever    . .          . .     371, 

699 

-  varicella 

833 

-  rigors  in       . .          . .         6- 

5,  648 

-  vibices  or  lines  in    . . 

595 

Pustules  in  varioliform  syphil- 

- simulating  nocturnal  enuresis  248 

—  yellow  fever             . .         301, 

373 

ides 

601 

-  staphylococcal 

625 

-  fulminans    ..        ..        596 

600 

-  from  vesicles 

829 

-  streptococcal 

625 

theory  of  causes  of 

600 

Putrefaction,  emphysema  from 

231 

-  in  stricture  . . 

625 

diagnosis  from  scurvy  . . 

302 

-  intestinal,  borborygmi  due  to 

97 

-  tenderness  in  loin  in 

025 

—  hjemosiderin  in  the  macules 

indicanuria  from  97,   349, 

821 

-  from  tubercle  of  kidney   438,  626 

foUowins  . . 

424 

-  ■-  muscle  fibres  in  fteces  in 

268 

-  in  tyiihoid  fever 

625 

-  haemorrhagica,    blood    per 

urinary  sulphates  in 

97 

-  urinarv  chansres  in..         018,  625 

anum  in  .  . 

90 

Pyaemia,  abscess  of  chest  wall  ia 

478 

-  from  urinary  obstruction  . 

625 

montli  in 

600 

in  heart  from 

650 

Pyelonephritis    (see  also  Pye 

- 

nose  in . . 

600 

-  diagnosis      confirmed      by 

litis)           

16 

hasmaturia  in 

600 

blood-cultures     . . 

598 

—  albuminuria  in  excess  of  the 

hemorrhage  from  bowel  in 

600 

from  malaria 

650 

pus  present  in     . . 

620 

purpuric  rash  in.  .         596, 

600 

-  diarrhoea  in 

649 

-  anuria  with . . 

45,48 

theory  of  causes  of 

600 

-  emaciation  in 

372 

-  due  to  bacillus  pyocyaneus       83 

-  macular       

423 

-  embolism  in 

649 

-  bacteriuria  in 

83 

-  rheumatica,  age  incidence  of 

380 

-  gangrene  of  lung  in 

288 

-  commonly  bilateral 

394 

diagnosis  from  Henoch's 

-  hyperpyrexia  in 

343 

-  haematogenous  infection  in     625 

purpura 

380 

-  jaundice  in  .  .          .  .         362, 

372 

-  kidney  enlarged  in . . 

394 

(see  Peliosis  Rheumatica) 

-  leucocytosis  in        . .         400 

649 

-  from    obstruction   in   lower 

-  simplex        . .        . .        596 

607 

-  metastatic  abscess  in 

649 

urinary  tract 

395 

-  subconiunctional,  causes  of 

256 

-  muscular  atrophy  in 

76 

-  polyuria  in 

626 

Pus   in  actinomycosis.  Gram- 

-  after  operations  and  wounds 

649 

-  pus  casts  in  urine  in 

626 

staining  mycelium  in     . . 

748 

-  peripheral  neuritis  in 

76 

-  pyuria  in     .  .            394,  62 

3,  625 

small  }-ellow  granules  in 

748 

-  portal  (see  Pylephlebitis) 

-  recurring  rigors  in  . . 

648 

-  cells,  gonococci  in  . . 

211 

-  progressive  loss  of  strength  in 

372 

-  renal  abscess  due  to 

625 

in  sputa  of  phthisis 

319 

-  prostration  in         . .         372, 

649 

calculus  causing  . . 

627- 

urethral  discharge  not  a 

-  purpura  in  .  .           .  .         596, 

598 

pain  in      . . 

394 

bar  to  marriage 

209 

-  from  pyorrhoea  alveolaris 

87 

-  uraemia  in    .  . 

625 

-  in  the  chest 

119 

-  pyrexia  in           343,  372,  614 

649 

Pylephlebitis,  adhesive,  ascites 

in  301 

—  chocolate  coloured 

279 

-  rapid  pulse  in 

372 

enlargement  of  spleen  in     301 

PYLEPHLEBITIS  -PYREXIA 


975 


301 

301 

301 

20 


369 

58 
649 
614 
614 
614 
614 
649 


Pi/lcplilcbitis,  adhesive,  contd. 

ha^matemesis  iu 

melaena  in 

-  -  sudden  onset  of  . . 

-  alburaosuria  in 

-  after  aijpeiidicitis  59,369,614,649 

-  duo    to   appendicitis   in   60 

per  cent  of  cases. . 

-  ascites  in 

-  colour  of  fieces  in   . . 

-  diagnosis  from  aiipeiidicitis 

peritonitis 

pneumonia 

typhoid  fever 

-  diarrhoea  m. . 

-  hasmatemesis  in      . .        -94,  301 

-  jaundice  in    59,  362,  370,  372,  649 

-  leucocytosis  in        . .  . .     400 

-  liver  enlarged  in      . .  . .     370 

-  multiple  abscesses  in    liver 

from  ..  369,  408,  649 

-  pain  in  liver  from  . .     649 

-  pleuritic  effusion  from       . .     123 

-  pyrexia  due  to  609,  621,  649 

-  rigoi-s  in       09,  362,  370,  648,  649 

-  septicfemia  from     .  .  614,  698 

-  tenderness  of  liver  from     . .     649 

-  vomiting  in . .  . .  . .     649 

Pylorus,    carcinoma    of   (see 

Carcinoma  of  Stomach) 

-  enlarged,     diagnosis     from 

enlarged  gall-bladder     . . 

-  hypertrophy  of,  in  congenital 

pyloric  stenosis    . . 

-  normal,  palpable  in  epigas- 

trium 
situation  of 

-  obstruction  of,  by  calcified 

retroperitoneal  cyst 
from  carcinoma  . . 

-  -  causing  constipation 
cicatricial 

-  -  colicky  pains  of 

congenital,  p.m.  findings  m   426 

due  to  spasm  from  wrong 

feeding  . .  . .     427 

persistent  vomiting    426,  845 

constipation  due  to        . .     144 

and  wasting  in. .  . .     845 

differentiation      between 

inflammatory  and  ma- 
lignant. .  . .  35; 

dipping  in  diagnosis  of  . . 

extreme  tlm-st  due  to 

flatulence      and        other 

symptoms  in    . . 

gastrectasis  from  712,  789 

HCl   in  stomach  contents     353 

history  of  previous  gastric 

ulcer      . .  . .  . .     352 

from      hj'-pertropliy       of 

pylorus  m  infants      . .     723 
increased    area    of    tym- 
panitic resonance  in  . , 

-  -  lactic  acid 

Offler-Boas  bacilli  m     . , 

sarcinaa  in  vomit  with 

353,  355,  713 

from  spasm  . .  . .     723 

spasm  of,  in  dyspepsia..     354 

perhaps  the  real   cause 

of  "congenital"  pyloric 
stenosis 

stagnation     of     stomach 

contents  in 
symptoms  produced  by 

-  -  torulaj  in  vomit  hi 

tumour  in 

visible  gastric  peristalsis  in 

134,  352,  570,  .'>71,  713 

vomiting  in  134, 

copious  in 

a'-rays  in  diagnosis  of 

yeasts  in  stomacli  m 


406 


426 


724 


713 
723 
144 
723 
134 


211 

626 
396 
624 
395 
396 
626 
626 


713 
134 
789 

267 


134 
3.'!3 
353 


426 

353 
845 
134 
353 


713 


843 
.  353 
.  134 
53,  355 


I'yodermia,  no  leucocytosis  with  400 
I'yometra,  metrostaxis  from       436 

-  in  old  women 
Pyonephrosis,  growtliof  bladder 

causuig 

-  diarrhcea  in 

-  disappearance  of  jiyuria  in 

-  fluctuation  in 

-  liydronophrosis  causing 

-  intermittence  in  size  in 
pyuria  in. .  . .        396, 

-  kidney  enlarged  in         391, 

394,  583,  624,  626 

-  pain  in  side  in         . .  . .     624 

-  pallor  in       .  .  .  .  .  .      396 

-  pelvic  swelling  due  to        . .     757 

-  polyuria  in  . .  . .  . .     583 

-  prostatic  enlargement  causing  626 

-  pyrexia  in    . .  . .        396,  624 

-  pyuria  in  396,  583,  623,  625,  626 

-  renal  calculus  causing  309, 

396,  626,  627 
tuberculosis  causing       . .     626 

-  round  smooth  outline  of  . .     395 

-  sense      of      tenseness    and 

elasticity  in 

-  symptoms  those  of  causative 

lesion  plus  suppuration. . 

-  sweating  in. . 

-  ureteral  obstruction  causing 

396,  625 

-  uretliral  stricture  causing. . 

-  urine  normal  in  "  closed  " 

-  uterine  carcinoma  causing . . 

-  .T-rays  in  (Fig.  97,  p.  309). . 
Pyopericardium,      cliurning 

sounds  in . . 

Pyoperitoneum  from  pneumo- 
coccal or  tuberculous 
peritonitis 

Pyopneumopericardium,  suc- 
cussion  sounds  in 

Pyopneumothorax 

-  from  bronclio-pneumonia 

-  cacliexia  witli 

-  due  to  gangrene  of  lung    .  . 

-  needling    of    claest    in    dia- 

nosis  of    . .  . .        711,  712 

-  from  obstruction  of  bronclius    712 

-  pneumonia  . . 

-  pulmonary  infarct. . 

-  pyrexia  witli 

-  rigors  with  . . 

-  simulated     by     subphrenic 

abscess 

-  subphrenic,  general  account 

-  succussion  sounds  with     . . 

-  .r-rays  in  diagnosis  of 
Pyorrhoea   alveolaris,  aneemia 

in 36,  39 

bleeding  gums  due  to     86,  87 

chronic  joint  lesions  from     278 

foul  breath  due  to  . .        99 

gastritis  from 

loss  of  weiglit  due  to     . . 

ptyalism  due  to . . 

purpura  from 

pyrexia  in 

retraction  of  gums  from . . 

secondary  effects  of 

septic  arthritis  from 

septiCcEmia  from 

stomatitis  from  .  . 

Pyosalpjnx       

-  aching  lumbo-sacral  pain  in 

-  acute  peritonitis  from 

-  albumosuria  in 

-  anaemia  in   . . 

-  diagnosis  from  appendicitis 

-  dysmenorrlioea  with         220,  632 

-  felt  per  rectum       . .  . .     638 
vaginam  . .          . .        638,  737 

-  frequency  of  micturition  in     438 

-  fullness  of  vaginal  fornices  in    632 


395 

626 
396 

627 
620 
626 
626 
396 

711 


717 

711 
577 
712 
712 
712 


712 

712 
712 

712 

712 
721 
711 
712 


297 

848 

590 

600 

620 

641 

87 

375 

698 

590 

760 

632 

55 

20 

39 

737 


Fyosalpinx,  could. 

-  infective  peritonitis  from  . . 

-  leucocyte  count  in  diagnosis 

from  typhoid  fever 

-  leucocytosis  in        . .         400, 

-  leucorrhcea  in 

-  malaise  in    . . 

-  pelvic  swelling  due  to 

-  periods  profuse  in  . . 

-  pleuritic  effusion  in 

-  pneumaturia  in 

-  after  pregnancy 

-  pus  in  stools  from  rupture  of 

-  pyuria  from  .  .  624, 

rupture  into  bladder  624,631 

spasmodic     pelvic     pain 

from     . . 

-  septicaemia  from     . . 

-  vaginal  discliarge  witli 
Pyramidal  tract,  lesions  of,  ab- 
sence of  abdominal  reflexes 
with  . .  . .         546, 

ankle-clonus  with 

effects  on  reflexes 

extensor  plantar  reflex 

with  . .  . .  82,  546, 

facial  paralysis  from . . 

mcreased  knee-jerk  witli 

paralysis  of  upper  ex- 
tremity due  to 
Pyrexia,     absent     in     spastic 

constipation 
endocarditis 

-  in  active  congestion  of  liver 

371, 

-  acute  gastritis 

mastitis    . . 

nephritis  .  . 

otitis  media 

pancreatitis 

poliomyelitis        . .         128, 

polymyositis 

prostatitis  207,  511, 

yellow  atrophy   . . 

-  in  alveolar  abscess . . 
echinococcus  disease 

-  anthrax 

-  antitoxic  serum  rashes 

-  appendicitis  133, 

145,  153,  31 

-  axillary  abscess 

-  bacteriuria  .  . 

-  bullous  dermatoses 

-  carcinoma  of  ctecum 

liver 

stomacli    . . 

-  in  catarrhal  jaundice 

-  cellulitis 

-  cerebellar  abscess   . . 

-  cerebral  abscess 

embolism 

tumour 

-  in    children,    a   bad  night 

suflicient  to  cause 

excitement  as  a  cause  of 

due  to  febricula  . . 

moderate,  with  tonsillitis, 

suggestive  of  diphtheria 

observations  on  . . 

onset  of  zymotic  disease 

causing 
of     unexplained     origin, 

discussion  of     . . 
without  discoverable  cause 

-  cholangitis   . .  . .        499, 

-  cliolecystitis 

-  cirrhosis   of   the   liver     40, 

362,  368, 

-  colic  .  .  . .  363,  500, 

-  convulsions  . . 

-  crises  of,  in  meningococcal 

meningitis 
in  pneumonia 

-  cystitis    . .  312,  512,  620, 


729, 


S9 


362. 


64-t 

401 
401 
632 
632- 
757 
632 
123. 
576 
737 
601 
632: 
,632 

509' 
698. 
737 


547 

547 

44 

547 
534 
546- 


145- 
103. 

407 
845- 
743. 

48. 
469- 
724 
555. 
504 
631 
370^ 
747 
416 
60.S. 
597 
135, 
730 
731 

84 
114 
729 
413 
229 
365. 
45^ 
565. 
341 
138. 
341 

021 

621 
621 

622 
621 

622 

618 
622 
650 
650 

410 
645 
622 

642 
186 
627 


974 


PYREXIA— PYURIA 


Pyrexia,  contd. 

-  distinguishing         intestinal 

obstruction  and  peritonitis 
133, 

pontine  h.'emorrliage  and 

opium  poisoning. . 

-  distoma  hepaticum  infection 

-  tlie     earliest    symptom    in 

some    cases    of    typhoid 
fever  and  phthisis 

-  in  endocarditis 

-  epidemic  jaundice  . . 

-  erysipelas  (Fig.  166,  p.  61-1) 

698, 

-  erythema  nodosum 

-  exhaustion     of     obstructed 

labour 

-  frequently  absent  in  tuber- 

culous disease  of  joints  . . 

-  in  fungating  endocarditis 

9,  10,   38,  76,  103, 
314,   368,  370,  593, 

-  from  gall-stones       278,  280, 

-  gangrene  of  king     . . 

-  gonorrhcea   . . 

-  gonorrhoeal  arthritis 

-  gout 382, 

-  gumma   formation   in   con- 

genital syphilis   . . 

-  Henoch's  purpura  .  . 

-  hepatic  abscess  324,  369,  408, 

-  herpes  zoster 

-  Hodgkin's  disease  . .        32, 

609,  616,  649, 

-  hysterical 

-  with  inflamed  axillary  glands 

-  influence  on  pain  in  limbs. . 
of    potassium    iodide    on 

syphilitic 

-  in  influenza       505,  010,  651, 

-  jaundice,     significance      of 

absence  of 

-  kala-azar 

-  leukfemia     32,  609,  617,  620, 

-  malaria  34,  35,  371,  615,  622, 

-  Malta  fever 

-  in  mediastinal  growth 

-  meningitis    . .  . .        622, 

-  Milroy's  disease 

-  neurotic        

association    with     pelvic 

symptoms 

diagnosis  of 

sex  incidence  of  . . 

-  otitis  media 

-  in  peliosis  rheumatica 

-  pelvic  peritonitis     . . 

-  in  perinephric  abscess 

-  periods  of,  in  leuiaemia     . . 

-  -  lymphadenoma   . . 

-  -  severe  anosmias  . . 

-  in  peritonitis  134,  153,  472, 

-  pernicious  ana3mia  32, 33,  616, 

-  pleurisy 

-  pneumonia  . .    186,  321,  372, 

-  pontine  haemorrliage 

-  due  to  prolonged  convulsions 

-  witli  prostatic  abscess 

-  post-critical,  in  pneumonia, 

suggestive  of  empyema 

-  post-operative,    not    neces- 

sarily infective  in  the  first 

forty-eight  hours 
PYREXIA,  PROLONGED 

in   Addison's  anaemia 

bacilluria 

blood  diseases 

broncho-pneumonia 

carcinoma  . .        609, 

children,  obscure  origin  of 

some  cases  of  . . 

cirrhosis  of   liver  609, 

erysipelas  (Fig.  106)     . . 

fatty  heart  from 


138 
364 


620 
622 
372 

746 
450 


386 

237, 
598 
363 
287 
620 
377 
455 

615 
380 
651 
496 

738 
618 
421 
50,8 

615 


362 

34 

649 

698 
611 
483 
642 
460 
609 

618 
618 
618 
229 
599 
700 
392 
620 
738 
620 
718 
649 
118 
622 
138 
169 
207 


623 
009 
009 
010 
609 
615 
618 

609 

018 

614 

62 


Pyrexia,  prolonged,  contd. 

in  fungating  endocarditis 

612, 

Hodgkin's  disease         609, 

infectious   diseases 

influenza  505,  009,  610,  651, 

leukjemia  . .        609, 

malaria 

-  -  Malta  fever  500,  609, 
miliary  tuberculosis 

neurosis    . . 

the    only    symptom    for 

weeks  in  some  cases  .  . 

in  pernicious  anaemia 

pylephlebitis 

sarcoma     . .  . .         609, 

septicemia     343,  609,  614, 

syphilis     . . 

toxic  absorption  (alimen- 
tary) in  children 

tuberculous  peritonitis  . . 

typhoid  fever 

typhus  fever 

-  in  renal  tuberculosis 

-  in  prostatic  afi;ections 

-  pseudo-leokffimia    . . 

-  with  pustular  syphilides    . . 

-  pyemia         . .  . .         372, 

-  pyelitis 

-  pylephlebitis 

-  pyonephrosis  . .        396, 

-  with  pyopneumothorax     . . 

-  relapsing  fever        . .  33, 

-  relatively  low  in  influenzal 

bronchopneumonia 

-  in  renal  colic 
tuberculosis 

-  rlieumatoid  arthritis 

-  rigors 

-  salpingo-oophoritis. . 

-  scarlet  fever 

-  septicaemia  . . 

-  in  septic  arthritis  . . 

-  severe  anemias  32 

-  with  sinus  thrombosis 

-  in  spinal  meningitis 

-  with  splenic  tumour 

-  subperiosteal  abscess 

-  subphrenic  abscess  501, 

-  sudden    drop    m.    crisis 

pneumonia 

in  typhoid,  suggestive  of 

perforation  . . 

-  due  to  suppurating  gums  . . 

-  in  suppurative  meningitis. . 
nepliritis  . . 

-  syphilis  371,  014,  615, 
influence     of     potassium 

iodide  on 

-  testicular  abscess    . . 

-  tonsillitis      . .  620, 

-  in  traumatic  aniuria 

-  tremor  from 

-  in  trichinosis 

-  tuberculous  meningitis 
peritonitis  56, 

-  with  typhoid  spine. . 

-  typhus  fever 

-  ulcerative  colitis 

-  urethritis 

-  after  urinary  operations 

-  in  von  Jaksch's  disease 

-  yellow  fever 

PYREXIA  WITHOUT  OB- 
VIOUS CAUSE,  blood 
cultures  in 

affections  of  gums,  nose, 

or  throat 

vagina,     rectum,     or 

urethra 

Calmette's  reaction  hi 

due    to    deep     caseous 

glands 
coli  bacilluria 


39, 


301, 


620, 
558, 


720, 
of 


622, 


504, 
472, 


301, 


623 
616 
009 
699 
617 
615 
Oil 
612 
618 

612 
016 
609 
617 
650 
614 

618 
018 
697 
610 
135 
511 
42 
607 
649 
625 
649 
024 
712 
373 

321 
500 
135 
378 
040 
760 
674 
650 
375 
649 
650 
162 
691 
750 
721 

022 

432 
620 
642 
640 

672 

615 

680 

672 

49 

795 

801 

174 

691 

787 

698 

727 

207 

49 

42 

373 


Pyrexia  icil/iout  ohvious  cause,  contd. 

ear  disease   . .    . .  620 

faecas  in     . .    . .  621 

fungating  endocarditis      623 

gall-stones        . .  . .     621 

genito-urinary  tubercle      621 

leucocytosis  in  . .     620 

osteomyelitis    . .  . .     620 

ovarian  abscess  . .     621 

parasites  in  blood      . .     020 

phlebitis  . .  . .     621 

pylephlebitis     . .  . .     621 

renal  or  vesical  calculus     621 

sores  on  fingers  or  toes      020 

Widal's  reaction  in     . .     620 

Pyriformis,  nerve  supply  of  . .     542 
Pyrocatechin  in  cerebrospinal 

fluid  203 

PyrogaUic   acid,  haemoglobin- 

uria  from               . .          .  .      314 
Pyrosis  (see  Heartburn) 
PYURIA  623 

-  with  albuminuria  . .  15,  623 

-  appendicitis  . .        313,  632 

-  bacilluria  83,  576,  615,  848 

-  due  to  biUaarzia  hfematobia     630 

-  casts     m,    in    pyelitis   and 

pyelonephritis  . .     628 

-  in  catarrh  of  urinary  pas- 

sages        . .  . .  . .     444 

-  catheter  in  diagnosing  renal 

from  vesical  causes  of  . .     624 

-  characters  of  deposit  in     . .     623 

-  contamination  with  a    leu- 

corrhoBal  discharge     . .     031 
pus   from    behind  a  phi- 
mosis . .  . .     631 

-  in  cystitis        221,  312,  512, 

623,  627,  628,  030,  631 

-  cystoscopic  appearances   in 

diagnosis    of    (Plate     V, 

Fig.  B,  p.  308)     .  .  .  .      024 

-  diagnosis  from  phosphaturia 

574,  623 
from  urates  in  urine       . .     023 

-  epithelial  cells  in  urine  in  . .     023 

-  examination    of    urine    for 

tubercle  bacilli  in  . .     026 

-  from  extension  of  ulceration 

of  intestme  to  bladder   624,  633 

-  due  to  iliac  abscess. .  ..     632 

-  intermittent,  in  pyonephrosis 

396,  626 

-  lavage  of  bladder  in  distin- 

guishing renal  and  vesical     624 

-  liquor  potassae  test  for       . .     623 

-  microscopic    characters    of 

pus  cells  in 

-  ozonic  ether  test  for 

-  in  papilloma  of  bladder 

-  due  to  pelvic  abscess 

-  persistent  in  gonorrhoea    . . 

-  due  to  prostatic  abscess     . . 
psoas  abscess 

in  pyelitis 


-  pyelonephritis 

-  pyonephrosis 

-  pyosalpinx  .  . 

-  in  renal  abscess 


623 

623 

630 

631 

626 

631 

632 

500,  623,  625 

394,  625 

..396,  583,  626 

..032 

.  .     626 


calculus      10,  40,  308,  312,  626 

enlargement         . .  . .     689 

-  -  tuberculosis  10,  136,  310, 

394,  019,  026 

-  -  tumoiu:  . .  10,  367 

-  due  to  rupture  into  bladder 

of  an  extra-urinary  abscess 

631,  632 

-  simple  ulcer  of  bladder     . .     630 

-  simulated  by  urates  . .     815 

-  sudden    cessation    in    pyo- 

nephrosis . .  . .  . .     624 

-  from  suppurative  nepliritis     646 
--  ureteral  calculus  514,  627 

-  urethral  stricture    . .  . .     631 


PYURIA— RECTUM 


975 


J^i/iiria,  contd. 

Riile.i,  contd. 

Reaction  of  degeneration,  contd. 

-  urethritis      . .          . .         030 

,  G31 

-  crepitant,   from  pulmonary 

partial 

634 

-  uriiiarj'  changes  with       62.'i 

,  U2 1 

infarction 

321 

in  peripheral  neuritis  66, 

-  ill  vesical  calculus.  .012,  513 

C29 

-  in  infarction  of  lung 

321 

g;i,  75,  '188,  506,  559 

562 

-  with  vesical  growth  47,  311, 

-  non-consonating,  with  bron- 

 progressive     muscular 

512 

G.HO 

chitis  and  emphysema  . . 

18G 

atrophy 

73 

tuberculosis            ."12,  513 

U28 

-  and  rhonchi  in  emphysema 

246 

in  Tooth's  neuro-muscu- 

-  sticky   basal,    in    inllucnzal 

lar  paralysis    .  .          132 

,560 

QUADE.ATTJS  femori;;,  iiorvc 

bronchopneumonia 

321 

transverse     myelitis     at 

supplj'  oi: 

512 

Banula,  ptyalism  due  to 

591 

lumbar  enlargement  . . 

563 

-  lumborum,  spinal  nerve  root 

Rarefaction  of  bones  in  tabetic 

-  of  vaginal  secretions 

210 

supplying 

513 

arthritis    .  . 

388 

-  Wassermann's  (see  Wasser- 

Quadriceps   extensor  femoris, 

Rash  due  to  drugs 

G03 

maun's  Reaction) 

clonus  o£  . . 

IGl 

serum  (see  Serum  Bashes) 

(and  see  Electrical  Reac- 

 nerve  supply  of  . . 

542 

-  erythematous,    at   onset   of 

tions) 

-  spinal  nerve  root  suppl3'mg 

543 

dengue 

506 

Reading,  difficulty  in,  due  to 

Quartan  fever 

34 

-  "  mulberry  "  in  typlius  fever 

371 

post-diphtheritic      ocular 

Quinine,  amblyopia  from 

83G 

-  "  petechial  "  in  typhus  fever 

371 

paresis 

640 

-  central  scotoma  from 

83G 

-  in  pyeemia  and  septicaemia 

650 

-  pain  behind  eye  intensified  by 

498 

-  cure  of  malaria  by  . . 

G49 

-  roseolar,  beginning  on  hands 

-  relation   of  word   blindness 

-  in  diagnosis  of  malaria    5S3, 

G98 

and  wrists  in  the  relapse  of 

to  power  of 

685 

-  dosage  in  malaria  . . 

G15 

dengue 

506 

Eeceptaculum     chyli,    ascites 

-  no  effect  of,  in  pj-femia 

G50 

-  in  secondary  syphilis 

615 

from  obstruction  of 

58 

-  headache  from 

32S 

-  typhoid  fever,  rose-red  flat- 

 rupture  of,  chyluria  from 

126 

-  lia?moglobinuria  from 

314 

tened  papules  in . . 

697 

Rectal  crises  of  locomotor  ataxy 

562 

-   influence  on  malaria  para- 

- typhus  fever,  charactera  of 

-  polypus    . . 

635 

sites 

371 

371 

699 

-  shelf  due  to  secondary  malig- 

- nerve  deafness  from 

191 

-  (and   see  Bullae;     Macules; 

nant  deposits  in  pelvis  . . 

639 

-  optic  neuritis  or  atrophy  from  83G 

Papules ;  Pustules  ;  Vesi- 

- tenesmus,    association  with 

-  purpura  from 

596 

cles  ;  etc.) 

bearing-down  pain 

473 

-  relation  to  blackwater  fever 

315 

Rat  paste,  phosphorus  poison- 

- trouble  in  cerebellar  tumour 

565 

-  scaly  eruption  due  to 

655 

ing  from  . . 

373 

disseminated  sclerosis    . . 

565 

-  tinnitus  from 

794 

strychnine  poisoning  from 

652 

locomotor  ataxy 

562 

Quinsy,  asymmetry  of 

671 

Rat-like  facies  of  microcephaly 

214 

transverse  myelitis 

74 

-  bursting  of  abscess  in 

671 

Bay  fungi  (see  Actinomycosis) 

(and  see  Incontinence  of 

-  dysphagia  in            .  .          225 

591 

Raynaud's  disease,  affection  of 

Faeces) 

-  enlargement    of    submaxil- 

extremities in 

284 

Recti  muscles,  divarication  of 

lary  lymphatic  glands  m 

419 

hands  in 

490 

(see   Divarication  of   the 

—  ptyalism  from 

591 

toes  m  . . 

490 

Recti) 

-  sore  throat  from     . . 

670 

albuminuria  in    . . 

17 

abdominal,      divarication 

-  stertor  from 

707 

alteration  of  response  to 

causing  visible  peristalsis  570 

-  trismus  simulated  by 

801 

galvanism  in   . . 

634 

Rectocele 

587 

Quotidian  fever 

34 

buUiE  in  . .          . .        110, 

112 

RECTUM,    ABNORMALITIES 

coma  m    . . 

136 

FELT  PER 

634 

EiLBBIT,  opaque  nerve  fibres 

diagnosis    from    erythro- 

-  abscess  of  (see  Abscess  Rectal) 

in  . . 

4G2 

melalgia           . .         284 

490 

sacrum  felt  per  . . 

638 

Kabbit-skin  workers,  mercurial 

intermittent  claudication  490 

-  ballooned,  with  obstraction 

153 

neuritis  in 

77 

senile  gangrene 

284 

-  blood   per   (see    Blood   per 

Habies,  delirium  in    .  . 

195 

gangrene    m    (Plate    IV, 

Anum  ;    and  Melsena) 

-  leucocytosis  in 

400 

and  Figs.  95-6)  282,  283 

284 

-  bulging  from  cystocele 

587 

-  slightness  of  fever  in 

195 

hcemoglobinuria  in 

315 

-  carcinoma  of  (see  Carcmoma 

Racing,  albuminuria  after     .  . 

19 

local  asphyxia  in 

490 

of  Rectum) 

lladial  artery  thick  and  tor- 

 syncope  in 

490 

-  congenital  absence  of  lower 

tuous  m  chronic  nephritis 

204 

cedema  of  face,  neck,  and 

portion  of 

637 

-  nerve,  skin  distribution  of. . 

659 

arms  from 

461 

-  constipation  from  stricture  of  150 

Radicular  pain  in  arm  (see  Pain 

legs  in  . .          .  .        459, 

461 

-  diseases  of,  pain  in  the  back 

in  Extremity,  Upper) 

recm-rent  necrosis  in 

284 

in  (Fig.  204,  p.  788)     476, 

788 

Eadium  in  relief  of  Mooren's 

severe  pain  in 

490 

lower  extremity  from 

491 

ulcer 

807 

simulated  by  cervical  rib 

493 

-  enlarged,  from  atony 

149 

Iladius,    myeloid   sarcoma   of 

ergotism 

287 

-  enterolith  in 

635 

(Fig.  197)           . .         755 

756 

sore  fingers  from .  . 

266 

-  examination  of,  in  abscess 

-  thickening  lower  end  of,  in 

swelling  of  hands  or  feet  in 

459 

of  sacrum 

638 

rickets      . .          . .         181 

182 

REACTION  OF  DEGENERA- 

 acute  prostatitis    511,  628 

631 

Railway  spine,  account  of     . . 

787 

TION         ..                    488 

633 

aneurysm  of  internal  iliac 

tenderness  of  tjie  spine  in 

784 

-  -  absent  in  myopathies    . . 

70 

artery   . . 

638 

tremor  in . . 

795 

in  acute  poliomyelitis  70, 

appendicitis         . .        729, 

736 

Rainbow  vision  in  conjuncti- 

555, 

558 

appendicular  abscess     . . 

638 

vitis          

840 

amyotrophic  lateral  scler- 

 colic 

135 

—  -  in  glaucoma        . .         257 

840 

osis        

565 

in  bearing-down  pain     . . 

474 

Rales,     apical,     from     aortic 

atrophic  palsy  of  arm    . . 

549 

-  -  bladder  affections        306, 

aneurysm 

322 

cervical  rib 

554 

307,  311,  312,  514, 

638 

-  bronchitie     . . 

192 

diagnostic  uses  of 

634 

calculous   disease   of   the 

-  characters  in  bronchiectasis 

faradic  current  in 

G33 

prostate            . .         512, 

515 

193, 

703 

galvanic  current  in 

633 

carcinoma  of  bladder  307, 

311, 

-  consonating,     with    fibroid 

indication  of  presence  of 

312,  512,  514,  628,  630, 

638 

lung 

232 

lower  neurone  lesion  . . 

634 

colon     . .          . .        367, 

501 

from  growth  of  lung 

322 

in  infantile  paralysis  131, 

liver 

60 

in  phthisis 

319 

558, 

559 

peritoneum 

57 

-  crackling,  in  empyemata  of 

methods  of  examining  for 

633 

rectum 

636 

children    . . 

119 

with  muscular  atrophy  . . 

69 

in  cases  of  diyluria 

126 

in  fibroid  lung   . .        246, 

332 

neuropathic         muscular 

1- 

of  coccyx 

635 

with    fibroid    lung    and 

-V 

atrophy 

159 

condition  like  pea  or  bean 

bronchiectasis 

324 

nuclear  facial  paralysis. . 

536 

in    submucous   coat   in 

from  obstructed  bronchus 

296 

paralytic  talipes..        130, 

131 

ruptured  rectal  abscess 

637 

976 


RECTUM— REFLEXES,    LOST 


Rectum,  examination  of,  contd. 

constipation         .  .  .  .     141 

cystic  disease  of  tlie  ovaries  638 

descending  uretliritis      . .     515 

diasrnosing  cause  of  pus  in 

stools    . .  . .       ■  . .     600 

in  cases  of  diarrhoea       . .     196 

distended  bladder  felt  on     638 

in  dyschezia        . .        119,  150 

dysmenorrhoea  of  virgins     219 

dyspareunia         . .  . .     221 

ectopic  gestation  . .     638 

enlarged     pelvic     lymph 

glands  .  .  . .         628,  630 

-  fibrous  stricture  of . .  . .     636 

-  fistula  of,  pneumaturia  from     570 

foreign  bodies  in. .  . .     635 

fracture  of  coccyx  .  .      638 

gonorrhoeal    enlargement 

of  vesiculiE  seminales . .     638 

hsematuria  . .  . .     307 

hydatid  disease  . .  . .       58 

impacted  calculus  139,  514,  627 

for  internal  haemorrhoids     635 

intestinal  obstruction    151,152 

intussusception  92, 148, 196,636 

ischiorectal  abscess         . .     638 

fossfe  . .  . .     635 

of  lower  end  of  ureter   . .     307 

in  lumbago  . .  . .     476 

malignant  iliac  glands  . .     422 

method  of  making  . .     634 

new  growth  of  ovaries   . .     638 

in  sacrum        635,  638,  761 

vagina  . .  .  .      638 

in  obscure  loss  of  weight     847 

pyrexia  . .  . .     620 

obturator  hernia . .  . .     740 

oedema  of  one  leg  . .     456 

ovarian  tumour  . .  . .     367 

in  parametric  abscess    . .     638 

paraplegia  from  peripheral 

neuritis  .  .  . .     562 

pelvic  abscess     . .  . .     760 

growth  . .  . .     487 

hsematocele      . .         . .     760 

inflammation   . .  . .     487 

pessary  in  vagina  . .     638 

for  polypus  . .  . .     635 

in  prostatic  abscess 

511,  632,  638,  678 

adenoma  . .         512, 638 

carcinoma        . .         512,  638 

enlargement       439,  441,  638 

tuberculosis     . .         307,  678 

pyosalpinx  . .  . .     638 

in  rectal  abscess  635,  637 

rectal  speculum  in  . .     635 

in  recto-vaginal  fistula  . .     636 

recto-vesical  fistula        . .     636 

of  sacrum  . .  . .     635 

in  sarcoma  of  prostate  . .     638 

sciatica     . .  . .  . .     487 

scybalous  mass  felt  on  . .     635 

sigmoidoscope  in  . .     635 

in    suspected    malignant 

disease  in  the  abdomen     638 

for  thickenmg  of  ureter. .     694 

in  tuberculosis  of  prostate     519 

testis     . .  . .  . .     519 

ureter    . .  513,  626,  629 

vesiculae  semmales     . .     638 

tumour  of  cauda  equina         74 

in  ureteral  calculus       627,  638 

uterine     enlargement    or 

retroversion     . .  . .     638 

vesical  calculus  . .  . .     638 

of  vesicute  seminales     . .     307 

vesicula;  seminales  palp- 
able only  when  diseased    638 

-  fibrous  stricture  of,  dyschezia 

from  . .  . .  . .     150 

-  hscmorrhage  from  (see  Blood 

per  Anum) 


Rectum,  contd. 

-  hair-ball  in  . .  . .     635 

-  inconthience   of   faeces   (see 

Incontinence^ 

-  invagination    of    dyschezia 

due  to  . .  . .     150 

-  lesions  of,  causing  surgical 

emphysema  . .  . .     231 

-  loaded,     causing     priapism 

in  elderly  men     .  .  . .     586 
dj^stocia  due  to  . .          . .     227 

-  malformations    of,    descrip- 

tions of  (Figs.  170-173)       637 
causmg  mtestinal  obstruc- 
tion      . .  . .  . .     151 

-  mode  of  examination  of    . .     634 

-  mucus    from     (see     PcEces, 

ilucus  in) 

-  new  growths  of,  sacralgia  in     510 

-  occlusion  by  foetal  head  . .     638 

-  operation  on,  coli  bacilluria 

after  83 

retention  of  urine  after       441 

-  pain  in  (see  Pain  Rectal)  . . 

m  acute  prostatitis         . .     628 

-  pemphigus,  etc.,  of  . .     114 

-  polypi  of  (see  Polypi,  Rectal) 

-  pressure    on,    bearing-down 

paui  from  . .  . .     473 
causing  dyschezia  . .     150 

-  proctoscope  examination  in 

strictui-e  of  . .  . .     150 

-  sense  of  fullness  and  weight 

in,  from  piles       . .  . .       92 

-  Stricture  of,  due  to  carcinoma 

of  rectum  . .  . .     636 

common  positions  of      . .      636 

constipation  from  . .      . .     150 

fibrous,  annular  or  tubular 

character  of     . .  . .     636 
rectal  examination  in     . .     636 

-  suppuration  romid,   scrotal 

fistula  from  . .  . .     679 

-  tenderness  per  (see  Tender- 

ness per  Rectum) 

-  ulceration  of  (see  Ulceration 

of  Rectum) 

-  villous  tumom's  of,  hfemor- 

rhage  in   . .  . .  .  .        93 

Rectus  abdominis,  local  rigidity  644 

contracted,        simulating 

intra-abdominal  tumour    723 

-  externus,  paralysis  of       . .     201 

-  inferior,  paralysis  of         . .     201 

-  mternus,  paralysis  of  . .     201 

-  superior,  paralysis  of        . .     201 
Recurrent     laryngeal      nerve 

paralysis,  causes   of  (and 
see  Paralysis  of  Vocal  Cord)  538 
Red  blood  corpuscles,  normal 

numbers  of  . .  . .     579 

-  nucleus,    intention  tumour 

from  lesion  of      . .  . .     800 

-  vision,  or  erythropsia         . .     840 
Red-currant-jelly  sputum     . .     322 
Redness    of    skin    (see    Ery- 
thema) 

Reducing     bodies     in     urine, 

drugs  giving  rise  to        . .     290 

other  than  glucose     . .     290 

REDUPLICATION  OF  HEART 

SOUNDS  ..  ..  2,  039 
in    acute   cardiac    dila- 
tation           .  .          .  .      243 

arteriosclerosis  . .     039 

diagnosis  from  canter- 

rhytlim         . .  . .     639 

mid-diastolic  bruit. .     639 

in  granular  kidney     . .     639 

hypertrophy  of  the  left 

ventricle       . .         . .     331 

mitral  stenosis  108,  320,  639 

regurgitation  . .     239 

relation  to  accentuation    639 


Redux   crepitations    in   lobar 

pneumonia  . .  . .     702 

Reeling,  from  cerebellar  lesions      69 

-  in  tabes  dorsalis    . .  . .     827 
Referred  pain,  absence  of  ten- 
derness on  firm  pressure     475 

in  affections  of  the  tongue     498 

area  of  10th  dorsal  nerve 

in  gall-bladder    disease     509 

intestinal  affections       509 

kidney     and     ureter 

disease      . .  . .     509 
uterine,  tubal  or  ova- 
rian disease         . .     509 
from    diseased   to    sound 

side  in  renal  disease  . .     394 

ear  disease  . .  . .     498 

errors  of  refraction        . .     498 

frontal  sinusitis  . .  . .     498 

glaucoma  . .  . .     498 

head  and  neck,  segmental 

areas  of  (Figs.  132-135)    498 
Head's   segmental   areas, 

in  visceral  disease      . .     498 

with  hypersesthesia      475,  494 

iritis  . .  . .  . .     498 

nasal  inflammation        . .     498 

neck  and  arm  in  angina 

pectoris  . .  . .     482 
shoulder  in  diaphragmatic 

pleurisy  . .  . .     480 

suppurative  otitis  media      498 

testicle,  causes  of  . .     524 

tuberculous  hip  disease . .     386 

Reflex  centres  in  spinal  cord, 
diagrams  illustrating  (Figs. 
146,  147)  .  .  '       .  .      566 

-  extensor   plantar    (see    Ba- 

binski's  Sign) 

-  winking,     abolition     of,    in 

paralysis  of  fifth  nerve  . .     807 
Reflexes,  abdominal,  absent  in 
amyotrophic  lateral  scler- 
osis . .  . .  . .     554 

disseminated  sclerosis       547 

lesion  of  pyramidal  tract  546 

pressure     on     cervical 

cord 494 

primary    lateral    scler- 
osis (Figs.  146,  147)     507 

spastic     paralysis     of 

upper  extremity     . .     547 

in   paralysis   from   intra- 

and  extramedullary  le- 
sions     . .  . .  . .     546 

spastic  paralysis  of  one  leg  540 

-  asymmetrical,  with  coma        137 

-  in  Brown-S^quard  paralysis     540 

-  corneal,  in  facial  paralysis      535 

-  in     congenital     defect     of 

cortex       . .  . .  . .     558 

-  deceptive,     in     paraplegias 

of  infancy  . .  . .     557 

-  deep,  in  "Werdnig-HofEmann 

paralysis  . .  . .  . .     158 

-  in  disseminated  sclerosis  174,  547 

-  during  epileptic  convulsions     109 

-  exaggerated     in     paralytic 

talipes     ..  ..        130,  131 

progressive  muscular 

atrophy  . .  . .     127 

-  functional  paraplegia         . .     567 

-  gastric  .  .  . .         591,  723 

-  general  paralysis     ..  ..      172 

-  hysteria     157,  166,  541,  518,  567 

-  increased  in  earliest  stages  of 

peripheral  neuritis         . .     505 
neurasthenia        . .  . .     506 

-  lost,  in  neuromyositis        .  .     504 
neuropathic         muscular 

atrophy  of  infants      . .     158 

peripheral  neuritis        505,  562 

in  transverse  myelitis  at 

lumbar    enlargement. .     563 


REFLEXES— RETINITIS   PIGMENTOSA 


977 


Reflexes,  contd. 

-  in  myopathies  . .  70,  560 

-  palate,  absent  in  liyst«ria..     509 
impaired  in  bulbar  para- 
lysis       087 

-  in    paralysis    from     intra- 

and  extrameduUary  lesions  o-lC 

-  -  due  to  peripheral  neuritis     659 

-  plantar  (see  I'lanfcir  Redoxes  ; 

and  Babinski's  Sign) 

-  pupillary  (see  Pupil,  Abnor- 

malities   of ;    and    Pupil 
Reflexes') 

-  retention  of,  in  encephalitis     594 

-  in  rickets     . .  . .  . .     158 

-  spastic  paralysis  of  one  leg     539 

-  transverse  mj-elitis  . .       7t 

-  unequal    and     exaggerated 

in  hemiplegia      . .  . .     337 

-  (and   see  Knee-jerk,  Pupil, 

and  Ankle-clonus) 
Refraction,  errors  of,  burning, 
pricking,   or  watering  of 
eyes  from  . .  . .     325 

-  -  defective     visual     acuity 

due  to 838 

headache  due  to  327,  328,  495 

hemicrania  due  to  . .     495 

migraine  due  to  ..  ..     495 

neuralgia  in  (and  see  Eye- 
strain)    498 

pain    and    tenderness    in 

mid-orbital  reijion  in.,     498 

strabismus  due  to  . .     709 

supra-orbital  pain  due  to     495 

Regeneration  of  cut  nerve, 
order  of  return  of  sensi- 
bility in 661 

- after  diphtlieria         77,  181 

REGURGITATION     of     food 

through  the  nose   202,  639,  640 

- in  bulbar  or  pseudo- 

bulbar paralysis. .     640 

diphtheria     77,  181, 

224,  559,  640,  842 
from  oesophageal  pouch        224 

-  milk  in  healthy  children  . .     842 

-  mitral  (see  Mitral  Regurgita- 

tion) 

-  pulmonary,  diastolic  bruit  in    107 

-  tricuspid     (see      Tricuspid 

Regurgitation) 
Reinforcem?nt   as    an   aid    in 

eliciting  Ihe  knee-jerk    . .     397 
Reinsch's  test. .  . .  . .       92 

Relapsing     fever,    abdominal 

pain  and  tenderness  in  . .     37.'. 

acute  onset  in     . .  . .     698 

blood   changes   in    (Plate 

XII,  p.  696)     . .  .  .        33 

chills  in 698 

contagious  character  of       698 

diagnosis  from  malaria..     373 

epidemic  character        . .     l!49 

epistaxis  in  . .  . .     373 

famine  in  etiology  of    373,  698 

general  account  of  . .     649 

geographical   distribution     649 

hfematemesis  in  . .  . .     873 

hyperpyrexia  in  . .  . .     344 

-  -  hypothermia     in    conva- 

lescence from  . .  . .     346 

jaundice  in  . .        362,  373 

liver  enlarged  in  . .     373 

pain  in  back  in  . .  . .     69S 

rapid  pulse  in      . .  . .     698 

rarity  of 698 

-  -  rigors  in  . .  647,  648,  649 
spirochfEta  ohermeieri  in 

the  blood  in  (Plate  XII, 
Fig.  /,  p.  690)  373,  649,  698 

spleen  enlarged  in  373,  692,  698 

sweating  in  . .  . .     698 

temperature  curve  of    373,  698 


Religious     excitement,     pan- 
demic chorea  caused  by 
Remittent  fever,  purpurn  in 
Renal    abscess    (see    Abscess, 
Renal) 

-  calculus  (see  Calculus,  Renal) 

-  cells   and    tube   casts   with 

cliyluria    . . 

-  clianges  of  arteriosclerosis 

-  colic  (see  Colic,  Renal) 

-  crises  of  locomotor  ataxj-  . . 

-  cystic  tumours,  albuminuria 


157 
596 


120 
14 


15 


352 
329 
359 

579 
579,  580 
..     583 

579 


582 


-  disease    (and    see     ISriglifs 

Disease),     blood-pressure 
high  in        . .  . .         96,  331 

chronic,  diarrlioea  hi       . .     197 

cystoscopic  appearances  in    624 

diminished  appetite  in  . .       49 

displacement    of    cardiac 

impulse  in       . .        330,  331 
dyspnoea  in         . .        579,  580 

-  -  eosinophilia  in  diagnosing 

asthma  from   . .  . .     249 

epileptiform  convulsions  in  172 

exaggeration  of  knee-ierks     397 

-  -  gastritis  in 

headache  in 

msomnia  in 

periodic  cyanosis  from 

polycythiemia  in 

polyuria  in 

shortness  of  breath  from 

-  dyspnoea,  asthma  mistaken 

for  

-  enlargement     (see     Kidney 

Enlarged) 

-  epithelium  in  urine  in  lu-e- 

teric  calculus 

-  pain  (see  Colic,  Renal ;  and 

Pain,  Renal) 

in   affected    side    in    im- 
pacted ureteral  calculus 

from  involvement  of  ureter 

in  carcinoma  of  bladder 

-  pelvis,    fistula    of,    causing 

pneumatiiria 
tailed  epithelial  cells  from 

-  suppuration,      absence      of 

leucocytosis  if  ureter  un- 
blocked    . . 

-  tube-casts  (see  Casts.Renal) 

-  Tuberculosis    (see     Kidney, 

Tuberculous  Disease  of) 

-  tumour  (see  Kidney,  Tumour 

of) 

-  veins,   thrombosis  of 
Rennin  in  stomach  contents, 

test  for  . . 
Reno-reflex  pain 
Residual  urine  with  prostatic 

enlargement 
Resin,  bullfe  in  workers  among 

-  a  source  of  fallacy  in  tests 

for  albumin 

Resonance  deficient,  from  an- 
eurysm 

in  bronchiectasis 

in  fibroid  lung 

from  growth  of  luni 

from  pulmonary  infarction  321 

in  phthisis  . .  . .     319 

skodaic  (see  Skodaic  Resonance) 


514 

514 


400 


8,  9 


394 


..  703 
324,  332 
..      322 


Resorcm,  black  urine  from 
Respiration,        Cheyne-Stokes 
(see    Cheyne-Stokes   Res- 
piration) 

-  influence  on  heat  loss 

-  jerky,  in  chorea 

-  puls3  and  temperature  ratio 

in  normal  conditions 

-  rapid  from  abscess  of  lungs 
phosphorus  poisoning 


820 


619 
156 

622 
649 
373 


pneumonia     186,  372,  645,  702 


Respiration,  contd. 

-  ratio  in  pneumonia  . .     697 

-  sighing  with  hremoperitoneum  717 

-  slow  in  cerebral  abscess    . .     547 

-  tlioracic    in    general    peri- 

tonitis      . .  . .  . .     044 

Respiratory    blood  pump    in 

orthopnoea  . .  . .     467 

-  distress,     severe,    diagnosis 

between  lungs  and  larynx 

as  site  of  origin  of  466,  167 

-  movements,  abdominal,  ab- 

sent in  ascites     . .  . .       51 
deflcient  in  phthisis       . .     319 

-  muscles,    effect    of    hydro- 

phobia on  . .  . .     103 

Responsibility,  loss  of  weight 

due  to 848 

Rest,   coma   as  indication  for     137 

-  influence    on    pain    due    to 

cervical  rib  . .  . .     491 

-  treatment    in    diagnosis    of 

chlorosis  ..  ..  ..        II 

-  urine  increased  during       . .     581 
Rests,    adrenal    (see    Adrenal 

Restsj 

Restlessness    in    acute    rheu- 
matism    . .  . .  . .     622 

yellow  atrophy  of  liver        370 

-  and  anuria  .  .  . .  .  .        48 

-  from  chronic  alcoholism  . .     797 

-  intestinal  colic        . .  . .     473 

-  rickety  children      . .        170,  782 
Retained    products    of    con- 
ception, metrostaxis  from     436 

-  testicle  (see  Testis,  Ectopic) 
Retching,  definition  of  .  .     842 

-  tenderness     in    epigastrium 

from  .  .  . .  .  .      779 

-  in  undue  abdominal  aortic 

pulsation  . .  . .     592 

Retention  of  urine  (see  Mictu- 
rition, Abnormalities  of  ; 
and  Urine,  Retention  of) 
Retina,  changes  m,  in  urcemia     329 

-  detachment  of  (Plate  VIII, 

Fig.  T)     ..         ..        463,  839 
sudden  blindness  from  . .     839 

-  oedema  of  in  optic  neuritis       462 
Retinal   artery    (central),  em- 
bolism    of,     ophthalmo- 
scopic     appearance      of 
(Plate   VHP)        ..  ..     403 

-  changes  in  chronic  nepliritis       48 

-  haemorrhage    (see    Hemor- 

rhage in  Retma) 

-  nerve  fibres,   opaque,   oph- 

thalmoscopic appearances 

of  (Plate   riP)    ..  . .     462 

-  vein,     central,    ophthalmo- 

scopic    apDearance     of 
tlirombosisof  (Plate  Till)    402 
Retinitis,  albuminuric,  ambly- 
opia with  nystagmus  from    836 

in  cerebral  haemorrhage 

138,  563 
with  Cheyne-Stokes  respi- 
ration   . .  . .  . .     125 

in  chronic  parenchymatous 

neptoitis  . .  . .     454 

renal  disease       1,  13,  14,  56, 

high  blood-pressure  con- 
ditions . .  . .  . .     526 

102,  103,  122,  240,  303 
ophthalmoscopic   appear- 
ance of  (Plate  VIII)  . .     402 

with  shortness  of  breath      101 

simulated       by         optic 

neuritis  . .  . .     463 

in  uraemia  350,  830,  839 

uncmic  amaurosis  with. .     839 

-  pigmentosa,  constriction  of 

field  of  vision  in. .  . .     838 
familial  character  of      .  .     838 

62 


97! 


RETINITIS   PIGMENTOSA— RHINITIS 


792 
293 


465 

63 

103 

103 

838 


840 
840 


840 

838 


Rctiyiitis  pigmentosa,  could. 

night  bliniiness  in  . .     838 

nyctalopia  in       . .  . .     841 

-  -  ophthalmoscopic    appear- 

ances in  . .         838,  841 
Retraction    of   abdomen  (and 
see  Rigidity  of  Abdomen) 
in  tuberculous  meningitis     612 
with  colic  . .  . .     134 

-  of  the  eyeball  Csee  Enoph- 

thalmos) 

-  eyelids  in  G-raves'  disease. 
REtRACTION  OF  GUMS  . 
RETRACTION      OF      HEAD, 

causes  of  .  .  641,  642,  643 

-  -  in  meningitis 

328.  359,  641,  642,  699,  709 

-  of  intercostal  spaces  in  laryn- 

geal obstruction. . 

-  ribs,  systolic 
in  adherent  pericardium 

-  -  without  adherent  pericar- 

dium 
Retrobulbar  neuritis,  affection 
of  one  eye  only    . . 

central  scotoma  from 

837,  838,  840 

occurrence  in  young  adults  838 

ophthalmoscopic  appear- 
ances may  be  normal 
with 

optic  neuritis  from 

pain    and   tenderness    in 

eye  from 

rapid  recovery  from 

sudden  blindness  from  839,  840 

onset  of  ..         '..     838 

Retroflexion    of    uterus    (see 

Uterus,  Retroflexion  of) 
Retroperitoneal    glands     fsee 
Lymphatic  Glands,  Retro- 
peritoneal) 

-  lipoma  (see  Lipoma,  Retro- 

peritoneal) 

-  tissues,  rupture  of  aneurysm 

into 

Retropharyngeal  abscess  (see 
Abscess,  Retropharyngeal) 

Retropulsion  in  paralysis  agi- 
tans 

Retroversion  and  flexion  of 
uterus  (see  Uterus,  Retro- 
version of) 

Retroverted  gravid  uterus 
(see  Uterus,  Retroverted 
Gravid) 

Rhabdomyoma  of  kidney 

Rheumatic  arthritis  (see  Arth- 
ritis. Acute  Rheumatic; 

Rheumatic  diathesis,  brachial 
neuralgia  in 

Rheumatic  myositis  diagnosed 
from  torticollis    . . 

-  tonsillitis     (see    Tonsillitis, 

Rheumatic) 
Rheumatics,    lightning    pains 

of  tabes  described  as 
Rheumatism,  acute 

-  -  albuminuria  in    . .  .  .        17 

-  -  albumosuria  in    . .  . .       20 

-  -  anaemia  in  . .  . .       38 
aortic  disease  from  233, 237,481 

-  -  arthritis  in  . .  . .     378 

-  -  bromidrosis  with  . .     714 

-  -  cerebral  embolism  from. .     138 

-  -  in  Children,  chorea  in    . .    504 

-  -  -  diagnosis  from  growing 

pains  . .        504,  507 

endocarditis  in  . .     504 

inflammations  of  fibrous 

tissues  in      . .  . .     504 

-  —  muscles  often  the  cliief 

seat  of  pain  in         . .     503 
pain  in  the  epigastrium  in485 


140 


796 


395 


167 


489 


Rheumatism,  acute,  in  children,  contd. 

sore  tliroats  in  . .     504 

chorea  in. .    156,  504,  548,  671 

contractures  following. .       167 

coronary  sclerosis  mistaken 

for         778 

delirium  of  grave  signifi- 
cance   . .  . .  . .     194 

diagnosis  from  dengue  . .     506 

endosteal  sarcoma      . .     756 

Henoch's  purpura      . .     380 

rheumatoid  arthritis  . .     378 

endocarditis  with 

103,  236,  239,  671 

eosinopliUia  after  . .     248 

epididymo-orchitis  in   517,  518 

erythema  nodosum  in    . . 

family  history  in 

fibrous  mediastinitis  in  . . 

fungating  endocarditis  in 

gall-stones  mistaken  for 

gastritis  mistaken  for     . . 

generalized  erythema  in 

history  of,  in  cerebral  em- 
bolism . .  . .        338,  563 
chorea   . .  . .        156,  548 


671 
671 
826 
314 
778 
778 
671 


mitral  stenosis 

hydrocele  in 

hyperpyrexia  in  194,  344, 

rare  in  . . 

infantilism  from . . 

inflammation  of  soft  palate, 

uvula,  and  fauces  in 

iritis  and  cyclitis  in 

joint  pains  from. . 

leucocytosis  in     . . 

lumbago  from 

menorrhagia  in    . . 

-  -  mitral  disease  from 

stenosis  from  . . 

multiple  serositis  in 

myocarditis  in     . . 

nausea  in 

night  terrors  in  . . 

nodules  of 

age  incidence  of 

of  elbows  and  scalp 

orchitis  from 

pain  in  the  back  in 

limbs  in 

muscles   in,    worse    on 

getting  warm  in  bed 

and  tenderness  in  scalp 

from  . . 

pericarditis  in     . . 

phthisis  mistaken  for 

pleurisy  in 

with  effusion  in 

prominence    of    articular 

manifestation  in  adults 

non-articular  manifesta- 
tion in  children 

restlessness  in 

scarlatinal 

scleritis  and  episcleritis  in 

simulated    by    puerperal 

fever 

pyaemia 

trichinosis 

simulating  occupation  neu- 
roses     . .  . . 

scarlet  fever    . . 

swelling  of  thyroid  gland 


320 
522 
622 
344 
215 

672 
250 
671 
400 


. .     428  I 
102,  240 
320,  773  I 
. .     123  i 
..      241 
..      671 
..     447 
.  .     452 
..     452 
..      804 
79,  517 
475,  476 
503,  504 
on 

503 


784 
671 


671 
121 


504 
622 
376 
256 

6.50 
650 
504 

178 
671 


792 

484 

784 

79 


-  tabes  mistaken  for 

-  tenderness  of  spine  from 

-  testicular  atrophy  after 

-  tonsillitis  in  239,  419,  671 

-  urate  deposit  in  . .  . .     815 

-  uretliral  discharge  due  to      206 

-  valvular     heart     disease 

from      . .  . .  . .     526 

-  various  manifestations  of     121 

-  vomiting  in         . .  . .     671 


Rheumatism,  contd. 

-  chronic,  no  cardiac  affection 

in  adults  as  a  rule  in       . .     507 

effect  of  change  of  weather 

on  the  pains  of  . .     507 

massage  and  movement 

on 507 

impairment     of     general 

health  in  . .  . .     507 
increase  of  pain  and  stiff- 
ness after  rest  in         . .     503 

pain  chiefly  in  joints  in 

some  cases       . .  . .     507 

muscles  in  some  cases    507 

less  after  movement  503,  507 

pseudo-ankylosLs  in        . .     507 

seldom  a  sequel  of  acute       507 

-  gonorrhceal    (see    Arthritis, 

Gonorrhceal) 

-  muscular  '^see  Myalgia) 
diagnosis    from    brachial 

neuralgia  . .  . .     492 

from  tetanus   .  .  .  .     162 

jiain  in  the  back  in         . .     476 

Rheumatoid  arthritis,  absence 
of  bony  outgrowths  in 
(Fiff.  108)  ..  ..379 

endocarditis  in  . .     379 

grating  in         . .  . .     379 

, suppuration  in  . .     379 

acuteness  of  first  attack . .     378 

age  incidence  of . .        378,  379 

ansmia  in  . .  . .       39 

chloasma  in         . .  . .     574 

contractures  in  . .  . .     167 

correspondence  to  StUl's 

disease  . .  . .  . .     418 

diagnosis  from  acute  rhdu- 

matism..  ..  ;.     378 

osteo-arthritis  379,  384 

disproportionately    rapid 

pulse  in  . .  . .     378 

enlarged  glands  in  . .       39 

epitrochlear  gland  in. .     379 

fixation  of  joints  in         . .     379 

freckles  in  . .  . .     378 

gradual  disappearance  of     379 

loss  of  appetite  in  . .       39 

weight  in  . .  . .       39 

muscular  atrophy  in      .  .      379 

pain  in  the  back  "from     . .     476 

parts  affected  by  . .     378 

pa.ssive    movements    and 

massage  in       . .  . .     379 

pigmentation  in  . .  39,  378 

pyrexia  in.  (Fig.  106,  p.  377) 

39,  378 

recurrence  of      . .        378,  379 

sex  incidence  of  . .  . .     378 

simulating        occupation 

neuroses  . .  . .     178 

skiagram  (Fig.  108)        . .     379 

spindle-shaped    interpha- 

langeal  joints  in  (Fig. 

107) 378 

stiff  neck  from    . .  . .     708 

sweating    of    hands    and 

feet  in 378 

temperature      curve      of 

(Fig.  106)         . .  . .     377 
ulnar  deflection  of  fingers 

in  (Fig.  108) 380 

Rhine  valley,  moUities  ossium  in  269 
Rhinitis  associated  with   cor- 
neal ulceration    . .  . .     806 

-  atrophic        . .  . .  . .     204 

anosmia  fi<om      . .  . .     668 

-  chronic,  method  of  investi- 

gating cause  of    . .  . .     204 
syphilis  causing  . .          . .     204 

-  in  cutaneous  diphtheria     . .     602 

-  foul  breath  due  to  . .  . .       99 

-  hyi^ertrophic  . .  . .     204 
loss  of  taste  due  to  . .     774 


RHINITIS— RIGIDITY    OF    SPINE 


979 


Rhinitis,  hijperlrophic,  cunCU. 

obstruction  to  nose  by  . .     668 

snorin','  due  to     . .  .  .     669 

-  impairment  of  taste  from  774,  775 

-  membranous,  not  necessarily 

diphtheritic  . .  . .     204 

-  purulent,  diphtheria  bacilli 

in  203 

micro-organisms  connected 

with 203 

-  -  from  glanders     . .        203,  204 
gouococci  causing  . .     2(J3 

-  tuberculous,  rare     . .  . .     204 
Ehinoliths,  from  rhinitis       . .     203 
Rhinophyma  . .          . .        268,  805 
Rhinorrliagia  (see  Epistaxis) 
Khinoscleroma,  age  incidence     805 

-  characters  of  . .  . .     805 

-  epithelioma  simulating      . .     805 
Rhomboid     muscles,      spinal 

nerve  root  supplying      . .     556 

nerve  supply  of . .  . .     550 

Rhonchi,  bronchitic    . .  . .     192 

-  with  bronchitis  and  emphy- 

sema        . .  . .  . .     186 

-  and  rales  in  emphysema    . .     246 
Rhubarb,  yellow  or  red  urine 

from  .  .  .  .        819,  820 

-  chrysophanic  acid  in        819,  820 

-  oxaluria  after  . .  . .     311 
Rhus     toxicodendron,       sore 

lingers  from  handling     . .     266 

causing  bullae      . .        110,  111 

Ribs,  affections  of,  tenderness 

in  the  chest  from  . .     776 

-  beaded,  in  rickets  182,  191,  695 

-  carcinoma  of  .  .  . .     776 

-  caries   of,   abscess   of  chest 

wall  from  .  .  . .     47S 
pain  in  chest  from        . .     478 

-  cartilages  eroded  by  aortic 

aneurysm  . .  . .     482 

-  cervical,    absence    of   nerve 

tenderness  in       . .  . .     492 
absolute  relief  of  paui  by 

giving  up  work  in        .  .     492 

accessory  . .         . .  . .     492 

anaesthesia     along    ulnar 

border  of  forearm  in  493,  593 

anaesthesia  from  . .     554 

analgesia  from     . .  . .     128 

atrophic  palsy  of  arm  from   554 

flexors  of  forearm  in      493 

intrinsic  hand  muscles 

from  . .  . .     493 

-  -  bilateral    . .  . .        492,  593 
brachial  neuralgia  in      . .     492 

-  -  claw-hand  from    127,  128,  493 

cyanosis  of  hands  from. .     493 

diminished  radial  pulse  from  128 

dull  boring  pain  in  arm  in     492 

effects     of     exertion     on 

symptoms  of  . .  . .     554 
frequent  absence  of  sym- 
ptoms in           . .  . .     492 

muscular  atrophy  from  74,  554 

pain  in  arms  from  128,  554,  593 

worse  in  the  evening     492 

neck  from         . .  . .     128 

radiating    along    inner 

side  of  arm  from  neck 

to  fingers  in  . .     492 

in    scapular    region    in     492 

paresis  in  arms  from  pres- 
sure due  to       . .  . .     593 
pressure  effects  due  to  fi- 
brous band  between  it 
and  first  dorsal  rib     . .     493 

pulses  unequal  in  493,  593 

relief  of  pain  on  lying  with 

hand  behind  head       . .     492 

sex  incidence  of  . .  . .     491 

simulated  by  Raynaud's 

disease  . ".         . .     493 


Hibs,  cervical,  conld. 

size,  as  seen  in  skiagram, 

no    guide    as    to   sym- 
ptomatic importance  of  493 
-  subclavian    artery   some- 
times pushed  forward  by  764 

symptoms   present   more 

frequently    in    women 

than  men         . .          . .  492 

tenderness  on  pressure  in 

posterior  triangle  in  . .  492 

vasomotor  changes  from  128 

disturbances      in     arm 

due  to           . .          . .  493 

.r-rays  in  diagnosis  of     . .  433 

-  eversion  of  lower,  in  rickets  695 

-  fractured  (see  Fracture  of  Rib) 

-  multiple     tender   syphilitic 

swellings  on         . .          . .  752 

-  new  growth  of,   tenderness 

in  the  chest  from            . .  776 

-  periostitis  of,  causes  of      . .  770 

-  post-typhoidal  periostitis  of, 

submammary  abscess  from  744 

-  rickety  changes  in  . .          . .  753 

-  systolic  retraction  of  lower, 

with  adherent  pericardium  242 

-  tuberculous  periostitis  of  . .  752 

submammary  abscess  from  744 

Rice,  beri-beri  from              75,  460 
Rice-water  stooLs  in  arsenical 

gastritis    ..          ..          ..  297 

cholera      . .          . .          . .  301 

Rickets,  association  with  mar- 
asmus       . .          . .          . .  427 

-  beaded  ribs  in  182,  191,  695 

-  bow-legs  from          .  .          .  .  212 

-  carpo-pedal  spasm  in  3,  178 

-  colonic  peristalsis  visible  in  724 

-  constipation  iu        ..          ..  143 

-  convulsions  in  169,  170,  466 

-  deep  reflexes  in       . .          . .  158 

-  deformed  chest  in  . .          . .  191 
pelvis  in  . .          . .          . .  212 

-  delayed  eruption  of  teeth  in  182 
walking  from       .  .          .  .  557 

-  diagnosis    from     achondro- 

plasia       . .          . .          . .  214 

hydrocephalus     . .          . .  557 

-  diffuse  kyphosis  in. .          . .  182 

-  enlarged  lower  end  of  radius 

in 181,  182 

ends  of  bones  in     182,  214,  695 

epiphyses  in        . .        695,  753 

-  eosinophilia  in         . .          . .  248 

-  eversion  of  lower  ribs  in     . .  695 

-  exaggerated    curve  of    long 

bones  in    . .          . .          . .  G95 

-  in  unduly  fat,  heavy  chil- 

dren          .  .          . .          .  .  427 

-  fontanelles  closed  late  in   . .  695 

-  green-stick  fractures  in      .  .  269 

-  Harrison's  sulcus  in 

170,  191,  212,  695 

-  head  rolling  in        . .          . .  782 

-  hot-cross-bun  head  in        . .  212 

-  insomnia  from          .  .          . .  357 

-  knock-knee  from     . .          . .  212 

-  kyphosLs  from         . .          . .  214 

-  laryngismus  stridulus  in    . .  466 

-  local  bulging  of  chest  in  . .  193 

-  nature  of  bone  affections  in  269 

-  neuropathic  muscular  atro- 

phy simulating   . .          .  .  158 

-  night  sweats  in        . .          . .  714 

-  nose  in          . .          . .          . .  212 

-  occipital  baldness  in           . .  782 

-  paraplegia  in  children  due  to 

556,  557 

-  pot-belly  in  . .        695,  724 

-  quadrate  head  in    . .          . .  695 

-  relation  to  infantile  scurvy  115 
pseudo-leuk.Tmia     infan- 
tum      . .          . .          42,  695 


Rickets,  contd. 

-  restlessness  in  . .  . .     782 

-  scoliosis  from  180,  181,  214 

-  secondary  lordosis  in  . .     214 

-  ."^igns  of         . .  . .  . .     170 

-  skull  changes  in      . .  . .     753 

-  spinal  caries  simulated  bj'. .     785 
curvature  in        . .  . .     212 

-  spleen  enlarged  in  . .        692,  695 
often    palpable     without 

being  enlarged  in        . .     695 

-  tenderness  of  scalp  from   780,  782 
spine  in    . .  . .  . .     785 

-  tetany  after  . .    3,  178,  802 

-  thickening  of  costo-chondral 

junctions  in  . .  . .     753 

Ricketts,  re  small-pox  and  acne 

605,  609,  834 
Rickety  dwarfism  (Fig.  63)  . .     212 
bone  bending    character- 
istic of  . .  . .  . .     214 

post-natal  origin  of        . .     214 

thorax  in  . .  . .     212 

-  rosary  . .  170,  191,  753 
Riedel's  lobe  of  liver  .  .        404,  737 

more  common  in  women       279 

confusion     with     floating 

kidney  . .  . .  . .     405 

connection   with    rest    of 

organ  occasionally  only 
peritoneal         . .  . .     404 

continuity  with  liver      .  .      737 

diagnostic  difficulties  due  to  404 

gall-stones  v.ith  . .  . .     404 

occasional  band  of  reson- 
ance   between    rest    of 
organ  and        . .          . .     405 
presence  in  young  chil- 
dren   404 

palpable  in  right  lumbar 

region   . .  . .  . .      726 

physical  signs  of . .  . .     737 

in  right  iliac  fossa  . .     737 

sharp  lower  edge  in        .  .      392 

simulating  enlarged  sail- 
bladder  278,"  279,  727 

movable  kidney        279,  727 

no  symptoms  with       279,  737 

due  to  tight  lacing        404,  405 

Rigg's  disease,  bleeding  gums 

in  (see  Pvorrhcea  Alveolaris) 
RIGIDITY   OF  ABDOMEN  ..     644 

from  appendicular  abscess     645 

appendicitis         . .  . .     736 

in  coii  bacilluria  . .  . .     646 

-  -  colic  .  .  134,  473,  645 
from    diaphragmatic 

pleurisy  .  .  .  .     645 

-  -  functional  .  .  . .      644 

from  injury  .  .  .  .     645 

in  peritonitis        134, 153, 

431,  644,  846 

pneumonia  .  .  . .     645 

tuberculous  meningitis  . .     612 

-  back  from  psoas  abscess    . .     733 
in  spinal  caries    . .  . .     181 

-  cervix,  dystocia  from         .  .      227 

-  during  convulsions  . .     169 

-  following  hemiplegia,  etc. . .     163 

-  in    hemiplegia,     prognostic 

importance  of      . .  . .     337 

-  hysterical  paralysis  398,  541,  548 

-  muscles        504 

in   disseminated  sclerosis     800 

paralysis  agitans  . .     261 

over  right   iliac  fossa  in 

appendicitis     . .  . .     135 
in  tetanus            . .        178,  463 

-  the  neck  from  cervical  caries     708 

-  rectus  muscle  in  abscess  of 

liver 409 

-  spine,   when  absent  in  dif- 

fuse kyphosis       . .  .  .     182 
in  neurasthenia    . .  . .     788 


98o 


RIGIDITY    OF    SPINE— RUB 


Rigidity  of  spine,  contd. 

Rigors,  contd. 

Pott's  disease 

131 

-  septico-pysmia 

618 

psoas  abscess 

739 

-  sick  headache 

617 

from  spinal  caries         181, 

785 

-  simulat«d     by     eclamptic 

spondylitis  deformans   . . 

787 

convulsions 

617 

-  vagina  and  perineum,  dys- 

 epilepsy    . . 

616 

tocia  due  to 

227 

hysteria    . .          . .        616, 

647 

RIGORS           

646 

uraemic  convulsions 

647 

-  in  acute  mastitis     . . 

743 

-  with  sinus  thrombosis       643 

650 

osteomyelitis       . .        6i8, 

619 

-  sraaU-pox     . .          . .         301 

647 

poliomyelitis 

617 

-  iu  subphrenic  abscess       618 

721 

-  from  antipyretic  dru^ 

618 

-  sweating  during 

646 

-  in  authras    .  . 

647 

-  in  testicular  abscess 

680 

-  appendicitis             . .        632, 

648 

-  tetanus 

647 

-  with  bacteriuria 

84 

-  thirst  during 

646 

-  in  beri-beri  . . 

647 

-  in  tonsillitis 

647 

-  biliary  colic 

135 

-  traiunatic  anuria    . . 

49 

-  bronchiectasis          . .         618, 

651 

-  tremor  from             .  .         794, 

798 

-  after  catheterization 

647 

-  in  typhus  fever 

647 

-  causes  of      . .          . .        647, 

648 

-  after  urinary  operations   . . 

49 

-  cerebral  abscess 

648 

-  in  Weil's  disease     . . 

647 

-  in  cerebrospinal  fever 

647 

-  yellow  fever             301,  372, 

647 

-  cholangitis   . .           362,  369, 

650 

K lane's  test  for  hearing 

189 

-  cholera 

647 

RINGWORM  fand  see  Tinea) 

272 

-  cholycystitis             . .        618, 

650 

-  "  black  dot  " 

274 

-  chronic  pancreatitis          135, 

292 

-  endothrix  in 

273 

-  colic  . . 

363 

-  inflammatory 

274 

-  in  diphtheria 

647 

-  kerion  in 

273 

-  dysentery 

647 

-  megaspores  in 

273 

-  empyema      . .          . .         618 

650 

-  microides  in 

273 

-  enteric  fever  (see  Typhoid 

-  mycelium  in 

272 

Fever) 

-  parasitology  of 

272 

-  erysipelas     . . 

618 

-  smooth  bald  patches  in 

274 

-  erythema  scarlatinif orme . . 

253 

-  spores  in 

272 

-  feverish  colds          . .      •   . . 

G47 

-  stumps  of  hair  in 

273 

-  fungating   endocarditis 

-  tenderness  of  scalp  from  780, 

781 

103    2?7    613.  618. 

649 

-  Tokelau  ("see  Tinea  Imbricata) 

-  with  gall-stones         280,  363 

617 

-  of  the  beard 

274 

-  gastro-intestinal  disorders 

617 

diagnosis  from  carbuncle 

274 

-  German  measles 

647 

eczematous  folliculitis 

274 

-  glanders 

647 

seborrhoea 

274 

-  gonorrhoea    . . 

650 

sycosis  vulgaris 

274 

-  gout              . .          . .        617, 

650 

syphiloderm     . . 

274 

-  hydrophobia 

647 

-  of  body,  branny  areas  in  . . 

2/5 

-  Hodgkin's  disease  . . 

649 

centrifugal  spread  in 

274 

-  influenza         . .         617,  648 

651 

concentric  rings  in 

2(5 

-  with  jaundice            321,  362 

651 

diagnosis     from     eczema 

—  leukaemia 

619 

seborrhoeicum 

275 

-  liver  abscess 

psoriasis 

275 

321,  362,  369,  108,  618 

651 

sy^jhiloderm     . . 

275 

-  lividity  in    . . 

647 

enlarged  lymph,  glands  in 

275 

-  malaria         . .          . .  35,  647 

648 

itching  in 

275 

-  Malta  fever 

647 

original  papular  lesion  of 

275 

-  measles         . .          . .        617, 

650 

scaliness  in 

274 

-  meningitis    . . 

651 

tingling  in 

275 

-  mDiary  tuberculosis 

647 

-  of  nails       . .          272,  275, 

445 

-  mumps 

647 

association    with    tricho- 

- nephritis 

647 

phytosis  of  beard  or  skin 

275 

-  with  pancreatic  calculus   . . 

135 

diagnosis  from  eczema  . . 

275 

-  paroxysmal  hEemoglobinuria 

315 

gouty  nails 

275 

-  perinephric  abscess 

618 

psoriasis 

275 

-  pernicious  anspmia 

619 

rheumatic  nails 

275 

-  phthisis        . .            617,  618 

651 

similar     condition     in 

-  plague 

647 

wasting  disorders  . . 

275 

-  pleurisy 

650 

exfoliation  in 

275 

-  pneumonia         372,  617,  618 

650 

-  parasites,  cultures  of 

273 

-  prostatic  abscess       207,  631 

64S 

-  of  scalp         . .         .  .        272 

273 

-  puerperal  fever       . .         648 

,  649 

baldness  in          . .          81, 

274 

-  pialse-rate  during   . . 

646 

condition  of  hair  m 

274 

-  pyaemia 

diagnosis  from  eczema  . . 

274 

372,  598,  647,  648,  649 

650 

favus     . . 

274 

-  pyelitis            . .         625,  648 

649 

impetigo 

274 

-  pvelonepluritis 

648 

pityriasis 

274 

-  pylephlebitis            . .  59,  362 

,  370 

psoriasis 

274 

-  pyopneumothorax 

712 

seborrhcea 

274 

-  pyrexia  iu   . . 

616 

disseminated 

274 

-  recurring,  list  of  causes  of 

648 

"  Eire   en  travers  "   in  myo- 

- in  relapsing  fever       647,  648 

,  649 

pathy  (Fig.  82)  . . 

260 

-  renal  calculus 

647 

Eising   in   the   throat   as   an 

-  replaced  by  convulsions  in 

epileptic  aura 

80 

children    . . 

646 

Eisorius,   weakness   in   myas- 

- in  sapnomia 

647 

thenia  (Fig.  81) 

260 

-  scarlet  fever            . .        647 

650 

RISUS  SARDONICUS 

651 

-  septicaemia        598,  614,  647 

648 

in  catalep.sy 

651 

Risus  sardonicus,  contd. 

hysteria    . .          . .        651,  653 

simulated  by  malingerer 

651,  652 

sclerodermia    . .          . .  653 

in  strychnine  poisoning 

463,   651,  652 

tetanus     162,  463,  651,  652,  802 

Elvers,  re  sensibility  changes  660 

EocheUe  salt  . .          . .          . .  289 

Rodent  ulcer  (Fig.  211)        . .  8ii 

age  incidence  of  . .        449,  808 

of  the  cornea  (see  ilooren's 

Xncer) 

crusts  on..          ..          ..  80S 

diagnosis  from  epithelioma  808 

lupus     . .          . .        419,  809 

syphilis,      epithelioma, 

scrofulodermia         . .  449 
of  ear,  similarity  to  epi- 
thelioma          . .          . .  469 

face,    preauricular    gland 

enlargement  from      . .  419 

nodules  of           . .          . .  419 

painlessness  of    . .          . .  SOS 

sites  of  occurrence  of   808,  812 

Eods  and  cones,  distribution  in 

retina        . .          . .          . .  835 

Eomberg's      sign,     mode     of 

eliciting    . .          . .          . .  66 

in  tabes  dorsalis             67,  665 

Eontgen  rays  (see  a--rays) 
Piosacea  (see  Acne  Eosacea) 

Eosaniltne,  pink  urine  from. .  819 

-  treatment  of  albuminuria . .  820 
Eosary,  rickety  170,  191,  753 
Eose-Bradford  kidneys  . .  14 
Eose-red    spots     in    typhoid 

fever         ..             90,  372,  610 
Eoseola  in  secondarv  syphilis 

86,  37i,  425,  672,  676 
Eosette  crystals  . .  . .  816 
Eoss,  re  somatic  pain  .  .  775 
Eothera's  test  for  acetonuria  4 
Round  ligament,  fibromyoma 
of,  diagnosis  from  hydro- 
cele of  canal  of  Nuck     .  .  711 

misplaced    ovary    . .  711 

hard    smooth    inguinal 

swelling  due  to        . .  741 

vulval  swelling  due  to  768 

lipoma    of,    diagnosis    of 

omental  hernia  from..  711 

impulse  on  coughing  in  741 

inguinal  swelling  due  to  741 

Eound-worms     (see     Ascaris 

Lumbricoides) 

Bowing,  albuminuria  after  . .  19 

-  cramp  during          . .          . .  177 

-  enlarged  heart  from           . .  224 

-  spinal  symptoms  from  . .  787 
Rub,  pericardial         . .        .  -  243 

characteristics  of            480,  481 

distinction  from  endocar- 
dial thrill          . .          .  .  790 

pleurisy             . .          . .  790 

distribution  of     . .          . .  790 

-  -  persistence  with  effusion  480 

-  peritoneal,  from  growth  in 

liver          . .          . .          . .  412 

-  peritonitic    .  .          .  .          .  .  431 

over  Uver  and  spleen  m 

general  peritonitis      . .  644 

-  pleuritic       . .           479,  481,  499 
distinction     from     endo- 
cardial thriU    . .          . .  790 

pericarditis      . .          . .  790 

not  always  audible        . .  480 

in  pneumonia      . .          . .  372 

from  pulmonary  infarction  321 

subphrenic  abscess         . .  720 

-  pleuropericardial     . .          . .  481 

alteration  with  respiration  481 

diagnosis  from  pericarditis  481 


RUB— SARCOMA 

?8l 

Rub,  pleuropericardial,  contd. 

Halicanj  ijlandi,  enlarged,  conld. 

Sarcoid,      multiple       benign, 

pain  in  chest  vvitU 

481 

lymphatic  leukaemia  . . 

31 

character  of  nodules  in. . 

451 

synchronous     with     the 

mumps . . 

674 

diagnosis  of  lupus  and 

lieart's  movements     . . 

481 

-  secretion  decreased  in  peri- 

sarcoma from 

451 

-  over  spleen,  in  perisplenitis 

499 

pheral  facial  paralysis  .  . 

537 

enlarged  lymjih  gland  m 

451 

splenic  infarct     . . 

699 

Salivation  (see  PtyalLsm) 

histological  diagnosis 

452 

Rubella  (see  German  ileaslcs) 

Sallow  complexion  (see  Com- 

 scarring  in 

452 

Rubro-spinal  tract,   intention 

plexion)    . . 

sites  of  eruptiou  in     .  . 

4.51 

tremor  from  lesion  of    . . 

800 

Salol,  black  or  brown  urine  from  820 

Sarcoma,  amemia  in              37, 

4.59 

Rumination    (see    Merycism) 

-  carboluria  from 

822 

-  caciiexia  from         .  .        459, 

461 

Runnin'^,  enlarged  heart  from 

2-14 

-  ferric    chloride   reaction    in 

-  character  of  papule  in  infil- 

Rupia in  syphilis       . .         (!53 

654 

urine  from 

196 

trations  of 

528 

Rupture  of  heart,  syphilitic. . 

241 

-  reducing  body  in  urine  due  to 

290 

-  cystic  degeneration  of 

757 

-  muscle  (see    Muscle,   Spon- 

Salpingitis,   frequent   micturi- 

- diagnosis  of  multiple  benign 

taneous  Rupture  of) 

tion  in 

483 

sarcoid  from 

452 

-  sejjment  of  aortic  valve     . . 

238 

-  haematuria  in          . .        305, 

313 

-  enlarged  liver  from . . 

55 

-  urethra 

.308 

-  pain  in  abdomen  in 

500 

-  injury  causing        . .         75G, 

803 

-  uterus  in  obstructed  labour 

229 

-  simulating   appendicitis    . . 

729 

-  kyphosis  from 

182 

-  valve     segment,      diastolic 

—  vaginal       examination       in 

-  leucocytosis  in 

400 

limit  in    . . 

106 

diagnosis  of 

500 

-  metrorrhagia  from..        433, 

434 

-  (and  sec  Hernia) 

-  myeloid,  of  tibia    . . 

756 

Rusty  sputum  (see  Sputum) 

Salplngo-oophoritls       causing 

-  oedema  of  legs  in    . .       459, 

461 

Rye,  mouldy,  ergotism  from 

287 

amenorrhoja 

24 

-  pain  in  the  leg  from 

486 

-  chronic,  diagnosis  from  un- 

- purpura  with 

596 

SABOURAUD,      re       ring- 

ruptured ectopic  gestation 

760 

-  pyrexia   in   .  .          .  .         609, 

617 

worm  parasites 

273 

-  diagnosis    of    new    growths 

-  pulsatUe  swelling  due  to    . . 

763 

-  re  tinea  umbricata 

276 

of  pelvis  from     . . 

761 

-  sunulated     by     chondroma 

Saccharomycetes    in    bladder 

-  dysmenorrhcea  from         219, 

220 

(Fi/j.  195) 

754 

with  pneumaturia 

576 

-  dyspareunia  from  . . 

221 

-  starting  as  fibrous  epulis  . . 

748 

Sacral  plexus  lesions,  talipes  in 

131 

-  fixity  of  pelvic  swelling  in 

760 

in  a  mole 

803 

muscles  innervated  by  542 

543 

-  history  of  an  acute  illness 

an  ulcer   . . 

803 

-  region,  pain  in  (see  Pam  in 

preceding.. 

760 

-  -  a  wart 

803 

the  Sacral  Region) 

-  raenorrhagia  with  .  .         420, 

760 

-  causing  swelling  in  femoral 

-  -  prurigo  ferox  of . . 

531 

-  occasional   retort   shape   of 

region        . .          . .        733 

734 

Sacralgia  (see  Backache) 

pelvic  swelling  due  to  . . 

760 

-  temperature  curve  in  (Fi/j. 

Sacro-iliac  joint,  abscess  from 

730 

-  pelvic  abscess  due  to 

760 

169)            

617 

-  -  disease,   chronic   inguinal 

pain  in     . .          . .         508 

760 

-  wasting  with 

69 

abscess  from   . . 

739 

swellmg  due  to    . .        757, 

760 

-  of  antrum  of  Highmore 

749 

sacralgia  in 

510 

-  peritoneal  irritation  in 

760 

-  bone 

755 

simulating  sciatica     . . 

74 

-  pyrexia  in    . . 

760 

cyst  formation  in 

757 

pain  and  tenderness  over, 

-  signs  of 

220 

diagnosis  from  callus     . . 

757 

in  iliac  abscess 

739 

-  sterility  due  to 

760 

central  necrosis 

751 

tuberculous  disease  of  . . 

386 

-  with  suppuration,  diagnosis 

gumma .  . 

752 

Sacrum,  abscess  of     . . 

638 

of 

760 

-  -  -  periostitis 

7-51 

-  bed-jore  over 

285 

sweating  in 

760 

-  -  eosinophilia  in     . . 

248 

-  new  growth  of           635.  f.38 

761 

wasting  in 

760 

endosteal,  absence  of  large 

-  pain  in  (see  Pain  in  Sacral 

-  uterine  congestion  in 

429 

lymph  glands  in 

756 

Region) 

discharge  with     . . 

760 

of  metastases  in 

756 

Safranln     reaction,     negative 

Salpingo-pharyngeus,     spasm 

crackling  on  pressure  in 

756 

with  alkaptonuria 

822 

of,  clicking  noises  in  the 

diagnosis  from  callus. . 

757 

-  test  for  chyluria 

126 

ear  due  to 

793 

chronic  abscess 

756 

glycosuria 

291 

Salvarsan  in  the  diagnosis  of 

osteomyelitis 

757 

Sago  spleen     . . 

696 

syphilis     . . 

814 

-  -  -  -  periosteal  sarcoma . . 

757 

Sahli's     capsules     in     testing 

Sambucus,  polyuria  after 

582 

-  -  -  -  from  rheumatism   . . 

756 

pancreatic  defects 

216 

SAND,     INTESTINAL     (Plate 

enlargement  of  bone  due 

St.  Gothard  tunnel,  ankylos- 

IX}             

652 

to 

763 

tomiasis  in  workers  in  . . 

570 

with   carcinoma  of  colon 

653 

pain  an  early  symptom 

756 

St.  Vitus's  dance  (see  Chorea) 

characters  of 

652 

sites  of  election  of  (Figs. 

Saliein,  ferric  chloride  reaction 

in  mucous  colitis 

652 

197,  198,  199) 

756 

in  urine  from 

196 

-  -  simulated  after  eating  pears 

653 

-  -  -  slow  growth  of 

756 

Salicylates,  anaemia  from         3 

",  38 

Santonin,  abnormal  colour  of 

yielding  of  swelling  to 

-  artificial,  delirium  due  to.. 

195 

urine  from            .  .          819 

820 

pressure  in  . . 

756 

-  black  urine  from     . .        820, 

823 

-  infantile  convulsions  from 

170 

expansion  of  bone  by    . . 

751 

-  bradycardia  from  . . 

98 

-  xanthopsia  from     . . 

840 

fracture  from 

269 

-  brown  urine  from  . . 

820 

Saphena  varix,    disappearance 

operation  in  diagnosis  of 

751 

-  delirium  due  to 

194 

on  lying  down     .  .         732, 

733 

from  osteitis  deformans. . 

763 

-  in  diagnosis  of  acute  rheu- 

 femoral  swelling  due  to . . 

733 

periosteal,  absence  of  in- 

matism 

375 

general  account  of 

733 

flammatory  changes  in 

756 

-  ferric    chloride  reaction    in 

impulse   on   coughing  in 

pain  in 

755 

urine  from 

196 

"732,  733, 

739 

age  incidence  of 

7.56 

-  gonococcal     arthritis      not 

reducibility  of    . .         732 

739 

commoner      situations 

benefited  by 

377 

return  after  reduction  . . 

739 

(Fig.  196)     . . 

755 

-  headache  from 

328 

simulated  by  psoas  abscess  733 

diagnosis  from  central 

-  slight   influence    in   peliosis 

femoral  hernia            733 

739 

necrosis 

763 

rlieumatica 

599 

Saponified    and    unsaponified 

chronic     abscess     of 

-  tinnitus  from 

794 

fats  in  pancreatic  disease 

116 

bone 

763 

.Salicylic  acid,  purpura  from 

596 

Sapraemia,  rigors  in  .  . 

647 

periostitis           756, 

763 

Saliva,  not  coloured  in  jaundice 

361 

SarcinjB   ventriculi  with  gas- 

endostealsarcoma    . . 

757 

-  dribbling  of,  in  bulbar  par- 

trectasis  . .          . .        713, 

845 

syphilitic  periostitis 

756 

alysis 

641 

in  gastric  carcinoma     691, 

846 

enlargement    of    veins 

-  in  uuclear  facial  paralvsis 

536 

illustrated  (Fig.  92) 

267 

over 

75G 

Salivary     calculus,     ptyalism 

in   stomach    contents   in 

-  -  -  history  of  iniui-y  in    .  . 

756 

due  to 

591 

benign  pyloric  stenosis 

hopeless  outlook  in    . . 

756 

-  glands,  enlarged  in  chloroma 

599 

134,  353, 

355 

loss  of  weight  in 

756 

982 


SA  RCOMA  —SCA  RLA  TINA 


Sarcoma  of  hone,  periosteal,  contcl. 

lymph  glands  enlarged      75G 

metastases  early  in    . .     756 

microscope  in  diagnosing  756 

operation  in  diagnosis  of  763 

rapid  growth  of  .  .      755 

the    softer,    the    more 

malignant     . .  . .     755 

popliteal  swelling  due  to  761,703 

secondary  in  lung  . .     322 

-  -  a;-rays  in  diagnosis  of  (Figs. 

196,  198,  199)  . .     751 

-  breast  746 

bloody     discharge     from 

nipple  in 


bundle  of  His 

csBcum 

cauda     equina, 

atrophy  in 
eye    . . 
groin  glands 
jaw,  character  and  diagnosis 

of 748,  756 


..     202 
98 
. .     729 
ular 

74 
279,  419 
..     739 


-  -  .T-rays  in  diagnosis  of 

-  kidney  

-  -  Clieyne-Stokes  respiration 


748 
395 


m 


124 
395 
395 


early  metastases  in 

-  -  extreme  malignancy  of, 

-  -  hsematuria  in      .  .         304,  307 
intermittent  hflnmatnria  in     395 

-  -  renal  enlargement  in      . .     395 

-  -  symptoms  of       .  .  .  .      307 

-  larynx,  hemoptysis  in      318,  325 

-  liver •''5,  413 

-  -  ascites  in. .  . .  '  55,  60 

-  -  secondary  to  eye  ,.     279 

-  -  simulating      large      gall- 

bladder . .  . .     278 

-  lung,  hai-moptysis  from      . .     317 

-  -  secondary  . .  . .     322 

-  mediastinum,    fatal    hrema- 

temesis  from        .  .  .  .      296 

simulating  phthisis        . .     296 

melanotic    . .         . .       423,  739 

of  femoral  lymphatic  gland  734 

melanuria  due  to   423,  821,  822 

-  -  primary   growth   from    a 

mole 423 

small  primary  growth  on 

toes       . .  . .  . .     423 

myeloid,  bleedmg  gums  in  SO, 


of  bone 

jaw  

ptyalism  due  to 

radius  (Fig.  197). . 

-  of  nose        

-  palate  

-  pelvis  

-  -  absence  of  expansile  pulsa- 

tion in  . .  . .  . .     741 

bruit  in     . .  . .  . .     741 

-  -  fixity  of 737 

inguinal  swelling  due  to     741 

simulating  sciatica         . .       74 

swelling     in     right     iliac 

fossa  due  to     . .  . .     737 

talipes  from         . .  . .     131 

unaltered  by  compressing 

common  iliac  artery  . .  741 
.T-rays  in  diagnosis  of    737,  741 

-  pleura,  bloodv  effusion  in  . .     118 

-  prostate        .".         ..         ..     638 

-  ribs 776 

-  skin 802 

characters  of       . .  . .     803 

-  Stomach       691 

felt  in  epigastrium         . .     723 

very  large  tumour  in     . .     691 

-  suprarenal,     secondary    de- 

posits in  cranial  bones  from  782 

-  of  testis       . .  . .         520,  766 

age  incidence  of. .         520,  766 

diagnosis  from  orchitis..     520 


Sarcoma  of  testis,  contd. 

dissemination  via  the  veins 

shorter    course    than    in 

carcinoma 

-  tibia  (Fig.  196)         754,  756, 

-  tonsils,  not  common 

sore  throat  from 

unilateral 

-  uterus,    arising    from  flbro- 

myoma 

early  age  of  some  patients 

histology  in  diagnosis  of 

pelvic  swelling  due  to    . . 

rapid  enlargement  of     . . 

simulated  by  fibromyoma 

-  vulva  

-  vertebrse 

-  a--rays  in  diagnosis  (Fig.  195, 

196,  197,  198,  199,  p.  754) 
737,  741,  748,  754,  756,  757, 
Sarcomatosis,  purpura  in 
Sartorius,  nerve  supply  of    . . 

-  spinal  nerve-root  svipplying 
Satin-wood  workers,  bullte  in 
Saturnine  encephalopathy    77, 

82,  137,  139, 

Babinski's  sign  in 

coma  in   . .  . .         137, 

dementia  and  mania  in. . 

difficulties  in  diagnosis  of 

epileptiform     convulsions 

in 
Scabies  buUfe  in         . .        654, 

-  burrows  in  . .  . .         60S, 

-  diagnosis  of  prurigo  from 

from  eczema 

small-pox 

-  eosinophilia  in 

-  extent  of  lesions  in 

-  face  rarely  affected  by 

-  fingers  affected  in266, 588, 609 

-  heterogeneity    of   lesions 

-  itching  in     . . 

-  papules  in    . . 

-  parts  affected  by    . .        609, 

-  pruritus  in  . . 

-  pustules  in  . .  601,  654,  831, 

-  vesicles  in  608,  653,  829,  831, 
SCABS 

-  in  anthrax    .  . 

-  eczema 

-  erythema 
multiforme 

-  impetigo       . .  602,  653, 

-  leprosy 

-  lupus  erythematosus 
vulgaris    . . 

-  seborrhoea    . . 

-  small-pox     . .  . .         605, 

-  sycosis  vulgaris 

-  syphilis 

-  yaws 

Scalding  pain  on  micturition 
fsee  Micturition,  Scalding) 
Scalds,  albuminuria  from 

-  buUfe  from  . . 
Scalp,  affected  by  favus 
seborrhceic  eczema 

-  cirsoid  eneurysm  of 

-  hypersesthesic    spots    over, 

in  traumatic  neurasthenia 

-  multiple  benign  sarcoid  of 

-  nerve  supply  of  (Fig.  200) 

-  cedema  of,  in  acute  nephritis 
from  tlirombosis  of  superior 

longitudinal  sinus 

-  pain  in  (see  Pain  in  Scalp) 

-  psoriasis  of  . . 

-  pustular  syphilides  of 

-  rheumatic  nodules  of       452, 

-  ringworm  of  (see  Ringworm 

of  Scalp) 

-  sebaceous  cyst  of  .  . 

-  seborrhoea  of  . .         656, 


766 
763 
672 
670 
672 

434 
430 
434 
757 
434 
434 
768 
786 


763 
596 
542 
543 
110 

173 

82 
139 
139 
139 

139 
832 
831 
532 
831 
608 
249 
447 
832 
832 
608 
654 
831 
832 
588 
832 
832 
653 
746 
653 
832 
653 
654 
654 
656 
655 
653 
655 
654 
653 
655 


657 
604 
804 


Scalp,  contd. 

-  segmental  areas  of  (Figs. 

202,  203) 

-  septic  infection  of,  preauri- 

cular gland  enlarged  in. . 

-  tender   (see    Tenderness    of 

Scalp) 

-  varicella  affecting  . . 
SCALY  ERUPTIONS  .. 

due  to  belladonna 

carbohc  acid 

eczema  655,  656,  657, 

marginatum     . . 

seborrhceicum  . . 

erythema..  ..         655, 

scarlatiforme    . . 

German  measles . . 

ichthyosis 

-  -  iodine 

keratosis  pilaris  . . 

lichen  scrofulosorum . . 

lupus  erythematosus  268, 

656,  657, 

measles 

mycosis  fungoides 

in  pemphigus  foliaceus  . . 

pityriasis  rosea 


253 
"530,  655] 


274,  655, 


447,  655,  656, 
446,  532, 


rubra 

pilaris 

prurigo 

psoriasis    . 

quinine 

scarlatma  . 

seborrho3a 

syphilis 

tinea  circinata    . . 

imbricata 

tonsurans         . .         274, 

vesicolor  276,  426, 

-  -  transition  of  papules  into 

-  -  in   urticaria 
xerodermia 

Scanning  speech  in  dissem- 
inated sclerosis    . . 

Scapula,  deformed,  in  paralysis 
of  serratus  magnus 

-  pain     under     right,     from 

gall-stones 
Scarlatina,  acute  dilatation  of 
heart  in    

-  albuminuria  in     12,  IS,  17, 

-  albumosuria  in 

-  angina  maligna  in  . . 

-  aortic  disease  after 

-  arthritis  after 

-  bald  tongue  in 

-  cancrum  oris  in 

-  cervical    adenitis,     pyrexia 

and    sore    throat    some- 
times     the     only 
ptoms  of . . 
glands  enlarged  in 

-  delirium  in . . 

-  desquamation  in    . . 
not  proof  of 

~  diagnosis  from  dengue 

from  erythema  scarlatini- 

forme     . . 

German  measles . . 

small-pox . . 

-  diazo-reaction  in    . . 

-  empyema  after 

-  endocarditis  complicating  236 

-  eosinophilia  after  . . 

-  epididymo-orcliitis  in 

-  epistaxis  in 

-  gangrene  in . . 

-  hspmoglobinuria  in.. 

-  heart  disease  from. . 

-  hyperpyrexia  in 

-  infantile   convulsions 

-  infantilism  from 

-  leucocytosis  in 

-  menorrhagia  in 


sym- 

420, 
194, 


517, 
251, 


237, 
301, 
from 


783 
419 


833 
655 
655 
655 
831 
275 
275 
656 
253 
655 
655 
655 
655 
529 

714 
655 
803 
654 
658 
658 
658 
531 
657 
655 
655 
657 
656 
274 
276 
655 
655 
528 
656 
655 

680 


135 

243 
674 
20 
674 
237 
376 
674 
282 


674 
674 
301 
674 
671 
506 

253 
418 
607 
198 
650 
239 
248 
518 
301 
282 
315 
526 
343 
170 
215 
400 
428 


SCARLA  TINA— SCROTUM 


9S3 


.Scarlatina,  contd. 

Sciatica,  contd. 

Scoliosis,  contd. 

-  naiisea     and    vomiting    at 

-  knee-jerk  not  affected  in  . . 

487 

-  due  to  rickets 

214 

onset  of   . . 

8-13 

-  lumbago  associated  with    . . 

487 

-  from  Sprengel's  shoulder  . . 

180 

-  nephritis  in..          ..        671, 

674 

-  muscular  atrophy  in          74, 

487 

-  in  .syringomyelia      128,  388, 

554 

-  nerve  deafness  after 

190 

-  need  for  caution  in  diagnosing  488 

-  torticollis 

708 

-  otitis  media  in 

674 

—  a   neuralgia    of   the   sciatic 

Scoparius,  polyuria  after     . . 

582 

-  pain  in  limbs  at  onset  o£  . . 

505 

nerve  in  some  cases 

487 

Scorbutus  (see  Scurvy) 

-  purpura  in                301,  59G, 

597 

-  a    neuritis    of    the    sciatic 

Scotoma,  central,  from  alcohol 

836 

-  pjTexia  in  . . 

674 

nerve  in  other  cases 

487 

from  atoxyl 

830 

-  rigors  with  . .          . .         047, 

650 

-  numbness  and  slight  anaes- 

 in    disseminated  sclerosis 

-  simulated    by    acute   rlieu- 

thesia  of  foot  in  . . 

487 

565, 

837 

matisni     . . 

671 

-  pain  in  the  leg  in  . . 

487 

hereditary  optic  atrophy 

837 

small-pox. . 

605 

increased  by  movements 

hippus  with 

595 

urticaria   . . 

850 

wliich  stretch  the  nerve 

487 

from  lead 

830 

-  sore  throat  in          . .        670, 

674 

-  plantar  reflex  flexor  in 

487 

-  -  migraine               . .        836, 

838 

-  spinal  artliritis  in  . . 

708 

-  rectal  or  vaginal  examina- 

 peripheral 

837 

-  spleen  enlarged  in            G92, 

698 

tion  in  all  cases  of 

487 

from  quinme 

830 

-  stiff  neck  in 

708 

-  simulated  by  carcinoma  of 

retrobulbar  neuritis      837, 

840 

-  strawberry  tongue  ui 

607 

ovary 

74 

tobacco     . .          . .        830, 

837 

-  submaxillary  lymph  glands 

rectum . . 

74 

-  general  account  of  . . 

837 

enlarged  in 

419 

uterus  . . 

71 

-  negative  or  positive 

837 

-  testicular  abscess  in 

080 

fibromyoma    of    uterus 

74 

-  paracentral 

838 

-  transverse  myelitis  due  to . . 

565 

ovarian  cyst 

74 

-  use  of  perimeter  in  mapping 

83S 

-  maligna,  hrematemesis  in  291 

301 

pelvic  gumtmata . . 

74 

-  from  retinal  haemorrhage  . . 

837 

hacmaiuria  in 

301 

inflammation  . .           74 

487 

-  ring  form  -  . . 

838 

headache  in 

301 

sarcoma 

74 

in  migraine 

837 

rapid,  weak  pulse  in 

301 

sacro-iliao  joint  disease 

72 

Scratching,  pruritus  associated 

Scarlatinal  arthritis    . . 

376 

spondylitis  deformans  . . 

787 

with          

588 

-  rheumatism 

376 

tumour  of  Cauda  equina  74 

487 

Screaming  in  hysteria 

100 

Scars,  after  burns 

709 

-  symptoms  and  test  of 

74 

-  due  to  indigestion  in  children 

130 

-  contractures  from  . . 

168 

-  tenderness      over      gluteal 

-  in  intussusception  . . 

9:: 

-  from  favus  .  .          . .         270, 

272 

region,  over  sciatic  notch 

-  rickety  children 

170 

-  healed  gumma  of  face  (Figs. 

and  down  nerve  in 

487 

Scrofula,  age  incidence  of 

808 

\Mi    1.57^ 

580 

of  sciatic  nerve  in 

384 

-  ulceration  of  the  skin  from 

80S 

-  after  herpes  zoster 

479 

-  unilateral  character  of 

488 

Scrofulodermia,  age  incidence 

603 

-  in  leprosy    . .          . .        45'), 

654 

-  a'-rays    to    exclude    organic 

-  crusting  slow  in     . . 

603 

-  lupus    erythematosus     268, 

disease  in 

488 

-  diagnosis  from  lupus        449 

603 

272,  656, 

658 

Scissor  gait      . .          . .        154 

164 

syphilitic  ulcer               449 

603 

vulgaris    . . 

448 

in  Little's  disease 

154 

-  enlarged  cervical  glands  with 

449 

-  on  lips  in  congenital  svphilis 

Scleritis,  causes  of 

256 

-  granular  scrofulous  ulcers  in 

603 

(Fig.  79).:          ..'        .. 

259 

-  conjunctivitis  distinguished 

-  large  flat  pustules  in 

603 

-  in   multiple    benign  sarcoid 

452 

from 

256 

-  lichen  scrofulosorum  with 

529 

-  neck,  from  scrofulodermia 

449 

Sclerodermia,  anidrosiswith. . 

714 

-  nodules  of    . . 

449 

-  pigmented,  in  syphilis      237 

604 

-  atrophy  of  the  skin  in 

781 

-  presence    of  other  tubercu- 

- after  small-pox 

655 

-  diagnosis  from  leucodermia 

575 

lous  signs  in 

004 

-  syphUis         ..           60 J,  709 

811 

-  ectropion  and  epiphora  from 

250 

-  scars  m  neck  in 

449 

of  palate 

237 

-  gradual  onset  of 

652 

-  small  papulo-pustnles  in  . . 

003 

-  fcxlipes  from 

132 

-  pigmentation  of  the  skin  in 

424 

-  vmdermined  edge  of  ulcer  in 

604 

-  varioloid,    after    the    small 

-  relation  to  pseudopelade  of 

-  varioloid  scars  after 

603 

papulo-pustule  of  scrofulo- 

Erocq 

782 

Scrotal  hernia  (see  Hernia) 

dermia 

603 

-  risus  sardonicus    simulated 

-  sores  (see  Sores,  Scrotal) 

-  vulval,  syphilitic    . . 

769 

by          

652 

-  swelling  (see  SweUing,  Scrotal) 

-  a--ray,  epithelioma  starting  in 

803 

-  tenderness  of  scalp  in       780, 

781 

Scrotum,  abscess  of  (see  Abscess 

, 

Schistosomiasis    ("see    Bilhar- 

-  ulceration  of  fingers  from 

266 

Scrotal) 

zia  Hfematobia) 

Sclerosis,  amyotrophic  lateral 

-  adhesion  to  tuberculous  testis 

765 

Schott's    yauheim   treatment 

(see  Amyotrophic  Lateral 

-  chancre  on  . . 

681 

in  myocardial  degeneration 

520 

Sclerosis) 

-  condylomata  on 

681 

Schoulein's  disease  (see  PeliosLs 

-  combined,     of     cord     (see 

-  epithelioma  of  (see  Carcinoma 

Kheumatica) 

Paraplegia,  Ataxic) 

of  Scrotum) 

Sciatic  nerve,  growth  of 

132 

lateral  and  posterior  (see 

-  fibro-sarcoma  of 

705 

injury  to,  talipes  from  . . 

131 

Paraplegia,  Ataxic) 

-  fistula  in  tuberculous   (and 

muscles  supplied  by 

542 

-  disseminated  (see  Dissemi- 

see Pistnla,  Scrotal) 

518 

paralysis,      causes     and 

nated    Sclerosis) 

-  injury  to,  hydrocele  from 

522 

signs  of 

542 

-  insular   (see    Sclerosis,    dis- 

- Jacquet's  erythema  of 

446 

skin  distribution  of      5-12, 

659 

seminated) 

-  mucous  tubercles  on 

081 

spinal  roots  derived  from 

542 

-  of  ovaries  (and  see  Ovary) 

508 

-  myxoma  of  . . 

805 

Sciatica,  ankle-jerk  absent  in 

487 

-  primary  lateral  (see  Lateral 

-  oedema  of,  in  acute  nephritis 

458 

-  anterior     crural     neuralgia 

Sclerosis,  Primary) 

gonorrhoeal  epididymitis 

766 

with           

488 

-  subacute  combined  (see  Para- 

- papilloma  of 

679 

-  conditions  simulating 

487 

plegia,  Ataxic) 

diagnosis  from  hernia  testis 

681 

-  diaonosis  from  osteo-arthriti? 

384 

Sclerotics  pigmented  in  ochro- 

- pruritus  of  . . 

588 

hip-joint  disease.. 

487 

nosis 

575 

-  scabies  of     . . 

447 

lumbo-sacral  spine  disease 

487 

Scoliosis    from    asymmetrical 

-  sebaceous  cyst  of    . . 

765 

new  growth  in  pelvis     . . 

487 

chest 

180 

microscope  in  diagnosing 

681 

-  -  retroversion  of  uterus  . . 

487 

-  backache  from 

475 

simulating  epithelioma 

681 

spinal  cord  lesions 

488 

-  causes  of 

180 

suppurating     . . 

681 

meningitis 

487 

-  from  cervical  caries 

708 

—  smooth  oval  swelling  in  one 

tumour  of  spinal  cord  . . 

487 

-  dwarfism  from 

214 

side  of,  in  hydrocele 

522 

-  enquiry    as    to    sphincters 

-  with  fibroid  lung   . .        193, 

246 

-  suppurating  cysts  of 

679 

before  diagnosing 

488 

-  in  Friedreich's  ataxy      104, 

559 

-  tuberculous  sinus  in          766, 

767 

-  examination    of    urine    for 

-  heart  impulse  displaced  in 

330 

-  ulcer  of  (see  Ulceration  of 

sugar  before  diagnosing 

488 

-  with  kyphosis         . .        181, 

183 

Scrotum) 

-  generalized    slight    wasting 

-  from  muscular  weakness  ISO 

214 

-  wart  of,  pre-cancerous  chan- 

of whole  hmb  in  . . 

487 

-  osteomalacia 

214 

ges  in 

079 

984 


SC  UR  V  Y— SEPTICEMIA 


Scurvy  in  adults,  rarity  of     . . 

-  albumosuria  iu 

-  anaemia  in   . .  . .  85, 

-  bleeding  from  gums  in     85, 

-  bromidrosis  with    . . 

-  bulke  in 

-  -".taneoas        haemorrhages 

round  hair  sacs  in 

-  -bility  in    . . 

-  uiagnosis  from  purpura  hie- 

morrliagia 

-  epistaxis  in  . . 

-  hsmatemesis  in      . .        394, 

-  liaematuria  in  . .        305, 

-  haemoptysis  in 

-  hapmorrhage  in 

-  infantile,  anaemia  in 

bleeding  gums  in  85, 

bone  tenderness  in 

cachexia  in 

diet  in  etiology  of 

night  sweats  in    . . 

pasry  pallor  in     . . 

profuse  perspiration  in  . . 

purpura  in  . .        596, 

spongy  gums  in. . 

-  knotty  hsemorrhagic  swell- 

ings in  calf  muscles  in     . . 

-  menorrhagia  in  428, 

-  metrorrhagia  due  to        433, 

-  nyctalopia  from 

-  photophobia  in 

-  ptyalism  due  to 

-  purpura  in  . .  85,  596, 

-  relation  to  diet  302,  599, 

-  spongy  gums  in        295,  302, 

-  stomatitis  in  . .  85, 

-  subcutaneous  indurations  in 

-  subperiosteal    haemorrhages 

in  . . 

-  symptoms  of 

-  tenderness  of  long  bones  in 

85, 
■Scurvy-rickets,  general  account 
Scybala,    abdominal     tumour 
produced  by        . .        723, 

-  in  int.Ktinal  constipation  . . 

-  mucous  coUtis 

-  palpable       . .  . .        145, 
in  left  inguinal  region     . . 

-  palpation  per  rectum 

-  simulating  appendicitis 
movable  kidney.. 

masking  tumour  in  right 

Uiac  fossa 
.Seamstresses,  actinomyees  in 

-  cramp  in 

-  sporotrichosis  of  lungs  in  . . 
Sea-sickness     . . 
.Seal-type  of  dwarf 

Season,  influence  on  pigmenta- 
tion in  xerodermia  pig- 
mentosum 

Sebaceous  cyst,  distinction 
from  fibroma  moUoscum 

lipoma 

of  external  auditory  meatus 

scrotum    . . 

simulating  epithelioma 

simulating  enlarged  thy- 
roid gland 

sit«s  of  occurrence 

tenderness    of   the    scalp 

from    inflammation    of 

of  xulTa    . . 

-  ducts,    affection    in    lupus 

erythematosus     . . 

-  glands,    affection    in    acne 

vulgaris    . . 

relation  to  lichen  scrofolo- 

somm   . . 
Seborrhoea  of  scalp,    cheilitis 

exfoliativa  with  . . 

-  st«rnal  region  affected  by. . 


599 
20 
302 
295 
714 
112 

302 

302 

302 
251 
302 
314 
318 
85 
115 
115 
115 
115 
599 
714 
599 
115 
599 
599 

599 
430 
435 
841 
574 
590 
599 
753 
599 
590 
302 

314 

44 

599 
753 

724 
141 
134 
718 
731 
635 
729 
727 

729 
705 
177 
322 

844 
214 


657 

530 

529 

403 
533 


Seborrhoeic  dermatitis,  bald- 
ness from  . .         . .       84 

corporis,  chronic  character    65S 

diagnosis  from  congenital 

syphilis..  ..  ..     447 

favus     . .  . .  . .     272 

macular  syphilide      . .     426 

532,  533 

pityriasis  rosea  . .     658 

psoriasis  . .  . .     656 

ringworm  .  .  . .     274 

rosacea. .  . .  . .     268 

distribution  of     . .  . .     656 

erfoliation    of    vermilion 

of  lips  in  . .  . .     403 
infants,  napkin-region  in- 
cidence of         . .          . .     416 

limited  distribution  of  . .     426 

occipital  glands  enlarged 

in  419 

oleosa        . .  . .  . .     656 

pruritus  in  . .  . .     588 

scales  in  . .  653,  655,  656,  657 

scalp,  face,  and  neck  affec- 
ted by  . .  . .        533,  657 

sicca  . .  . .  . .     656 

tenderness  of  scalp  from       781 

Sebum,  coloured  fsee  Ohromi- 

drosis) 
Sedatives,  constipation  relieved 

by 144 

"  See-saw  "  phenomenon,  pre- 
cordial, causes  of  . .       63 
Seidlitz  powder  in  determining 

gastric  succussion  . .     712 

"  Seizures  "  in  hysteria  .  .     506 

Segmental  areas  of  face,  defi- 
nite relation  to  individual 
teeth,  table  showing       . .     498 

head  and  neck,  maximal 

points    in   (Figs.    132- 

135) 497 

.Semen,  necessity  for  examin- 
ing in  sterility     . .  . .     707 
Semicircular   canal,  effects  of 

lesions  of  each     ..  ..     827 
haemorrhage     into,     Me- 
niere's, disease  due  to       828 
Semilunar  cartilage,  displaced     388 
Semimembranosus  bursa,  sym- 
ptoms and   signs   of  dis- 
t-ended      . .          . .  . .     762 

-  muscle,  nerve  supply  of   . .     542 
Seminal  vesicles  (see  Vesiculae 

Seminales) 
Semitendinosus,  clonus  of     . .     161 

-  nerve  supply  of        . .  .  .     542 
Senator,  re  neuromyositis      .  .      504 
Senile   changes,    cerebral  hae- 
morrhage from    . .  . .     563 

-  degeneration,  Cheyne-Stokes 

respiration  in       .  .  .  .     124 

premature  ..  ..     218 

trophic  clianges  of  naOs  in     445 

-  dementia,  amnesia  in         . .       25 

-  dyspepsia     . .  . .  . .     354 

-  gangrene  ("see  G-angrene,  Senile) 

-  intestinal   hypoplasia,    con- 

stipation due  to . .  . .     143 

-  impotence,  priapism  preced- 

ing . .  .  .  .  .      £85 

-  nocturnal  mania     . .  . .     358 

-  pruritus         . .  . .  . .      588 

-  tremor,  general  account  of       795 

-  vaginitis,  metrostaxis  from     436 
Senilism  and  infantilism  com- 
bined in  progeria  . .     218 

Senility    Cand    see    Old    Age ; 

.and  Impotence)  . .  .  .      347 

-  testicular  atrophy  in  . .       78 
Senna,  ehrysoplianic  acid  in 

819 


-  urine  pink  from 
yellow  from 


820 
819,  820 
..      819 


SENSATION.  SOME  ABNOR- 
MALITIES OF    ..          ..  659 

-  changes  in,  in  svringomyelia 

73,  388,  554,  563 

-  loss  of  (see  Anaesthesia) 

-  perversion  of,  in  chronic  al- 

coholism . .          . .          . .  172 

Sense  of  position,  impaired  in 

tabes         . .          . .          . .  493 

Sensibility,  cutaneous,  loss  of, 

mistaken  for  paralysis    . .  545 

-  deep,  meaning  of    .  .          .  .  661 

-  delayed  Ln  tabes  dorsalis    . .  665 

-  epicritic,  definition  of        . .'  661 

-  loss   of,    in   Brown-Sequard 

paralysis  .  .          .  .          .  .  540 

sciatic  nerve  paralysis    . .  542 

-  protopathic,  definition  of  . .  661 
Sensory    areas    corresponding 

to  spinal  segments  (Plate 

XI)           663 

-  disturbances,  lower  neurone 

paraplegias  causing        . .  563 

in  peripheral  neuritis     . .  75 

tabes  dorsalis      . .          . .  66 

Transverse  myelitis          . .  5C4 

-  localization  in  spinal  cord, 

diagrams      illustrating 

(Figs.  146,  147)  .  .          .  .  506 

Separation    of   epiphysis  (see 
Epiphyses,  Separation  of^ 

Sepsis,  chronic,  anaemia  in     .  .  39 

-  deep-seated,  blood  cultures 

in  detection  of     . .          . .  648 

-  post-puerperal,   foul  breath 

in 98 

-  shortness  of  breath  due  to  100 
Septic    absorption,   lymphatic 

gland  enlargement  from  410 

-  arthritis      (see       Arthritis, 

Septic) 

-  conditions,  hyperpyrexia  in  622 

-  infection  of  umbilical  cord, 

blood  per  anum  in          . .  90 

-  poisoning,     diagnosis    from 

quotidian  malaria            . .  615 

-  urethritis     (see     Urethritis, 

Septic) 

-  wounds,  gangrene  in          . .  282 
Septicemia  from  abscesses  in 

the  throat            . .          . .  614 

-  acVioluric  jaundice  in          . .  372 

-  anaemia  in   . .          . .          . .  650 

-  from  appendicitis   .  .          .  .  614 

-  cerebral  abscess       ..          ..  614 

-  debility  in   . .          . .          . .  650 

-  from  deep-seated  glandular 

suppuration         . .          . .  614 

-  diagnosis  by  blood  cultures 

598,  698 
from  typhoid  fever          . .  611 

-  dryness  of  the  mouth  in     . .  774 

-  from  empyema         .  .          .  .  614 

-  endocarditis  in        . .          . .  103 

-  foul  taste  in             . .          . .  774 

-  furred  tongue  in     . .          . .  774 

-  haemoglobinuria  in..          ..  315 

-  hyperpyrexia  in      . .          . .  343 

-  jaundice  in  . .          .  .          . .  372 

-  otitis  media  causing           .  .  614 

-  pelvic  abscess  causinr;       .  .  614 

-  pneumococcal,  meningitis  in  642 

-  purpura  in               .  .         596,  598 

-  and   pysemia,    relationships 

between    . .          . .          . .  650 

-  pvrexia  m          343,  609,  614,  650 

-  rigors  m     598,  614,  647,  648,  65fi 

-  septic  skin  rashes  in           . .  650 

-  sources  of  infection  causing  698 

-  splenic  enlargement  in    692,  698 

-  streptococcal           . .          . .  372 

-  from  suppurative  pylephle- 

bitis ..  .".  ..614 

-  sweating  in . .          . .          . .  3/5 


SEPTICO-PYMMIA—SIGNS 


985 


SeptiGO-pyeemia,  Kenoral  atcoui 

t 

Sex  iticidciicc,  conltl. 

Shock,  amid. 

of 

(i.')l» 

functional  aphonia 

538 

-  hypothermia  in 

34  G 

-  periostitis  from 

771) 

gall-bladder  disease 

500 

-  from  inversion  of  uterus    . . 

587 

-  rct'iirriiK,'  riKors  in  .  . 

(il8 

-  -  gall-stones 

135 

-  intestinal  obstruction 

153 

Septum  nasi,  (.leilectod,  iuiosmii 

-  -  gas-containing  subjihrcnic 

-  mental,  anorexia  from 

50 

from 

OliS 

abscess 

721 

-  in  paroxysmal  tachycardia 

772 

suoriiiL;  due  to     . . 

Ud'.l 

-  -  gastralgia 

485 

-  from    perforated    duodenal 

obstruction  to  nose  by 

(i(i8 

-  -  gastric  ulcer 

298 

ulcer 

484 

-  -  ulcer  of,  epistaxis  from  . . 

251 

gou  t 

381 

-  ptyalorrhcea  caused  by 

592 

-  ventriculoruni    patent    (see 

—  ha'matoporiihyriMuri:i    . . 

820 

-  severe  in  gastric  ulcer 

484 

Patent  Septum  \entricu- 

-  ~  Hanot's  cirrhosis 

410 

-  vomiting  after 

844 

lorum) 

-  -  hicmophilia           .  .         302 

599 

Shortness  of  breath  (see  Breath 

Sorositi><,  multiide  (see  Polyor- 

-  -  hysteria                . .         041 

710 

Shortness  of) 

rlioiiicnilis) 

inguinal  hernia    . . 

740 

Shoulder,    affection    by    acne 

Serous   effusion    in   cacliexia 

intermittent  hydrarthrosis 

387 

vulgaris    . . 

531 

uijuosa 

115 

-  -  locomotor  ataxia 

502 

-  -  in  osteo-arthritis  and  gout 

383 

in  diest  Csee  Chest,  Serous 

lupus  erytlicmatosus 

781 

-  drawn  down  in  fibroid  lung 

24G 

Ktfusion  in) 

-  -  maligiuuit  disease  of  tliy- 

-  high,  in  apoplectic  cases    . . 

191 

multiple    . . 

123 

roid  gland 

791 

emphysema 

191 

polyuria  in  clearing  up  of 

-  -  muco-membranous  colitis 

727 

-  fall  on,  causing  Erb's  palsy 

552 

58-J, 

581 

myxoedema 

4  GO 

-  line®  albicantes  on 

402 

-  membranes,      inllammation 

-  neurotic  pyrexia. . 

018 

-  muscles  affected  in  ITenoch's 

of  in  chronic  nephritis    . . 

13 

-  -  P.iget's  d  isease    . . 

802 

chorea  electrica  . . 

157 

leukiemia 

32 

pain    and    tenderness    in 

-  multiple  benign  sarcoid  of. . 

451 

severe  lilood  diseases.. 

122 

back 

789 

-  osteo-arthritis  of,  with  spon- 

Serratus magnus,  atrophy  of 

5fi0 

paroxysmal     ha-moglobi- 

dylitis  deformans 

787 

nerve  supjdy  of  .  . 

550 

nuria     . . 

315 

-  pain  in  (see  Pain  in  Shoulder) 

paralysis  of 

551 

-  -  -  tachycardia 

772 

-  papular  syphilides  of 

532 

spinal  nerve  root  supplying 

550 

—  peliosis  rheumatica 

GOO 

-  paralysis  of,  in  amyotrophic 

Serum  actrlutination   reaction 

pseudo-angina 

482 

lateral  sclerosis  . . 

554 

in  riyscntory 

I'JG 

pseudohypertrophic  mus- 

- rarity  of  gout  in 

383 

-  ill"  .M;ilt:i"rcvor            5(17 

012 

cular  paralysis 

560 

-  sloping,  in  phthisis . . 

191 

|iar:ity|iiioid  fever 

fill 

-  -  renal  calculus 

312 

-  tuberculous  disease  of 

385 

-  -  -  ptomaine  poisoniuj.'    .  . 

597 

rheumatoid  arthritis 

378 

-  wasting  of,  in  syringomyelia 

285 

fand  see  Wid^ilj 

splenomogalic    poly- 

Shoulder-joint,    adhesions    in. 

-  albumin 

5 

cytliremia 

581 

simulating         circumflex 

-  antimeningococcal,  in  diag- 

-  -  spondylitis  deformans   . . 

787 

nerve   paralysis  . . 

552 

nosis   and   treatment    . . 

G-13 

-  -  sterility     . . 

705 

Shoulder-shrugging  tic 

159 

-  discharge  of,  from  iiipple  . . 

202 

sulplional  poisoning 

820 

.Shrapnell's    membrane,    per- 

- globulin 

5 

-   -  syphilitic  aortic  disease. . 

237 

foration  in,  in  suppuration 

-  rashes,  anorexia  with 

597 

-  -  typhoid  spine 

787 

in  the  tympanic  attic     . . 

470 

joint  pains  with 

597 

-  -  umbilical  hernia 

524 

Shrieking  from  intestinal  colic 

472 

lassitude  associated  with 

597 

undue    abdominal    aortic 

Sick-headache,  rigors  in 

647 

muscular  pains  with  . . 

597 

pulsation 

592 

Sickness  (see  Vomiting  ;   and 

occurrence  !)  or  10  days 

-  -  Weil's  disease 

372 

Nausea)   ■ 

after  injection 

597 

-  relationships  of  gastric  and 

Siderosis  (see  Cirrhosis  of  Lung) 

pyrexia  with   . . 

597 

duodenal  ulcer    . . 

90 

Siegle's  speculum  in  Gell6's  test 

189 

purpura  with             596, 

597 

Sexual  ateleiosis 

218 

Sight,  shortness  of,  spinal  cur- 

 urticaria  from . . 

597 

-  development,  precocious  . . 

215 

vature  due  to 

183 

-  reaction,  hydatid     58,  279, 

-  disorders,    eit'ect    on    phos- 

Sights,  repulsive,  vomiting  from  844 

415,  710, 

720 

pliorus  excretion . . 

572 

Sigmoid  colon  (see  Colon,  Sig- 

 for  syphilis  (see  Wasser- 

imaginary,  in  neurasthenia 

506 

moid) 

niann's  reaction) 

-  energy,    final    outburst    of, 

Sigmoidoscopy  in  carcinoma  of 

-  transfusion,  hemoglobinuria 

causing  priapism 

585 

colon         .  .             147,  501 

735 

after          

314 

-  excesses,  effect  on   Bartho- 

 rectum 

93 

Seventh     nerve    (see     Facial 

lin's  gland 

210 

-  colitis 

501 

Nerve) 

impotence  from  . . 

347 

-  in     diagnosing      cause     of 

Sewers,  sore  throat  from 

G73 

metrorrhagia  from       433, 

435 

bearing-down  pain 

474 

Sewing  machine,  menorrliagia 

priapism  from 

586 

chronic  diarrhoea 

196 

from  using 

428 

-  feeling,  absence  of,  -sterility 

constipation     . . 

141 

-  pain  intensified  behind  eye  by 

498 

due  to      . .          . .         700, 

707 

obstruction      . .         267 

350 

Sex    incidence  of  acroparoes- 

-  intercourse,  effect  on  men- 

 pus  in  the  stools 

GOl 

thesia 

493 

struation  . . 

'13] 

-  in  dyschcKia .  . 

150 

acute  yellow  atrophy  302, 

370 

-  irritation,  epistaxis  from  . . 

251 

-  dysentery     . . 

501 

adiposis  dolorosa 

478 

Sheep,  distoma  hepaticum  in 

364 

-  malignant  peritonitis 

57 

aneurysm               538,  728, 

786 

Shell-fish  poisoning,  bulla;  from 

114 

-  rectal  examination 

635 

—  angina  pectoris   . . 

482 

colic  due  to 

130 

-  stricture  of  rectum  and  anus 

150 

anorexia  nervosa 

849 

oedema  of  face,  neck,  anil 

-  ulcerative  colitis     .  .             91 

,  92 

bath  pruritus 

588 

arms  in 

461 

Signs,  Babiuski's(see  Babinski's 

carcinoma  of  breast 

745 

Sherrington,  decerebrate  rigid- 

Sign) 

tongue 

812 

ity  of         

163 

-  Chvostek's   . . 

178 

cervical  rib 

491 

Shiga's  bacillus  in  dysentery . . 

196 

-  Corrigan's  pulse  100,  107,  233 

234 

chancre  of  tongue 

813 

Shingles  (see  Herpes  Zoster) 

-  Dalrymple's. . 

792 

-  -  cirrhosis   . . 

410 

Ships,  beri-beri  on     . .          75, 

460 

-  Dietl's  crises  (see  Dietl's  Crises) 

congenital   dislocation   of 

Shivering  (see  Rigors) 

-  Erb's             

178 

'  hip 

183 

Shock,  in  acute  pancreatitis . . 

484 

-  Flint's  bruit            108,  109, 

234 

obliteration  of  bile-ducts 

305 

-  athetosis  after 

154 

-  Friedreich's 

104 

duodenal  ulcer   . .         300, 

500 

-  constipation  from  . . 

144 

-  G-e)le's  test  for  hearing     . . 

189 

dysentery 

727 

-  delirium  due  to  severe 

195 

-  Heberden's  nodes     380,  384, 

452 

enterospasm 

473 

-  diabetes  msipidus  from 

585 

-  Hegar's  in  pregnancy 

437 

exophthalmic  goitre      772, 

792 

-  diastolic,   in  adherent  peri- 

- Hippooratic  fades."        431, 

644 

fa?cal  tumours     . . 

092 

cardium    . . 

104 

succussion 

193 

femoral  hernia     .  .          733 

740 

-  functional  dyspepsia  after 

355 

-  Hutchinson's  hot  eye 

256 

Friedreich's  ataxy 

1G4 

-  from  gangrenous  appendicitis 

481 

-  -  teeth         

259 

SIGNS— 5MA  LL-POX 


. .     350 

.  .  203 

244,  253 

427,  752 

..  228 

.  06,  67,  665 

244,  253,  792 

..  771 

3,  178 

244,  253,  792 


630 


415 
307 
575 


809 

39 

767 


173 


200 


Signs,  contd. 

-  Kernig's 

-  Koplik's  spots 

-  Moebius's 

-  Parrot's  nodes 

-  Pawlik's 

-  Eomberg's   . . 

-  Stellwag's 

-  Tache  cferebrale 

-  Trousseau's; 

-  Tou  (iraefe's 

Silica  in  intestinal  sand  . .     652 

Silicosis  (see  Cirrhosis  of  Lung) 
Silken  crepitus  in  osteo-artliritis  179 
Silver  nitrate  as  an  aid  to  cyst- 

oscopy 

copious     precipitate      of 

silver  chloride  on  adding 
to  hydatid  fluid 

-  -  irrigation  of  bladder  with 

-  -  pigmentation  of  skin  from 
in  quantitative  estimation 

of  homogentisic  acid . . 

-  -  test  for  alkaptonuria 
Singing  in  ears  (see  Tinnitus) 
Sinus  of  foot  from  mycetoma 

-  infections,  anaemia  in 

-  of  scrotum    . . 

-  suppuration,      cerebral     ab- 

scess from 

-  thrombosis  ("see  Thrombosis) 
Sinusitis,  polypi  in     . . 
Sixth  nerve  paralysis,  effects  of 
Size,  abnormal  sense  of      840,  841 
Skeleton,     dwarfism   due     to 

defects  of  the      . .  . .     212 

Skene's  tubes,  gonococci  in  . .     211 
Skiagraphy  (see  X-rays) 
Sl<in,  bleeding  nsevi  of'         . .     325 

-  boils  on,  in  ankylostomiasis    570 

-  bruising  (see  Bruising  of  Skin) 

-  capillary  pulsation  in         . .     233 

-  carcinoma  of  (see  Carcinoma 

of  the  Skin) 

-  central   scab    with   ring    of 

vesicles  on,  in  anthrax  . 

-  changes  in  Graves'  disease 
in  cretinism 

-  -  myxcedema  43, 

pseudo-elephantiasis 

myxoedema 

-  cold  and  clammy  from  in- 

ternal hfemorrhage 

-  coloration   in   carbon   mon- 

oxide poisoning  . . 
from  drugs 

-  dimpling  of,  over  carcinoma 

of  breast  . .  . .  . .     745 

-  disease,  eosinophilia  in       .  .     249 

-  distribution  of  sensory  nerves 

to  (Fig.   174)        . .  .  .      659 

-  dry   and    flushed    m   bella- 

donna poisoning  . .     195 

harsh  in  cirrhosis  of  liver     410 

pyelitis  .  .  . .      625 

shrivelled  in  carcinoma  . .     413 

-  flushed,  dry,  and  pungent  in 

lobar  pneumonia             372,  702 
SKIN,  FUNGOUS  AFFECTIONS 
OF  

-  greenish    in     acute    yellow 

atrophy     . . 

-  gumma  of     .  . 

-  lemon-yellow  colour  in  per- 

nicious anaemia  . . 

-  lesions,  pruritus  associated 

with  

in  syringomyelia 

-  loose,    dry,    caft-au-lait,    of 

congenital  syphilis 

-  loss  of  elasticity  in,  in  malig- 

nant disease 
with  emphysema 

-  mycosis  fungoides  of 


746 
261 
..  259 
259,  585 
.  .  456 
. .     259 

646 

138 
575 


270 

370 
279 

616 

588 
563 

440 

718 
186 
802 


Skin,  contd. 

-  myoma  of    . .  . .  . .     805 

-  Paget's  disease  of  . .  . .     802 

-  pale  and  sweaty  in  poisoning   195 

-  pigmentation  of  (see  Pigmen- 

tation of  Skin) 

-  sarcoma  of  . . 

-  shiny  over  affected  joint  in 

gout 

-  signs  of  jaundice  in 

-  staining  of  (see  Staining  of 

Skin) 

-  trophic    changes    in    major 

trigeminal  neuralgia 
syringomyelia . .         285, 

-  tumours  of   . . 

-  ulceration   of   (see    Ulcera- 

of  Skin) 

-  vesicles  on  (see  Vesicles) 
(and   see    Bulla,    Crusts, 

Macules,  Papules,  Pus- 
tules, Scabs,  and  Wheals) 

-  white  crystals  on,  in  uridro- 


802 


sis 


715 


-  xerodermia  pigmentosum  of 

-  yellow,  in  cretinism 
patches  on,   due  to  xan- 
thoma planum  .  .     805 

Skin-curers.  merciu-v  poisoning  in  38 
SKODAIC  RESONANCE         ..     667 

due  to  ascites      . .  . .     668 

gastric    or    colonic    tym- 
pany simulating  . .     668 
in  lung  compression 


259 


over  pleuritic  effusion   192,  667 


667 
753 
213 


749 


various  causes  of 
Skull,  bousing  of,  in  rickets  . . 

-  defects  in  anosteoplasia 

-  fractured    (see   Fracture   of 

Skull) 

-  hyperostosis  of  in  leontiasis 

ossea 

-  increase  of  size  in  acromegaly  263 

-  ivory  exostosis  of   . .  . .     754 

-  local  tenderness  of,  with  or- 

ganic intracranial  disease     327 

-  misshaped  in  rickets         212,  753 

-  multiple    tender    syphilitic 

sweUings  on         . .  . .     752 

-  natiform  in  congenital  syphilis  752 

-  rarefaction  in  rickets         . .     179 

-  secondary  growth  of,  causes  of  782 

-  tumours  of,  headache  in    . .     327 
base  near  foramen  ovale 

and  foramen  rotundum, 
trigeminal  neuralgia  in     496 
Skutch's  pelvimeter,  use  of,  in 

pregnancy  . .  . .     228 

Sleep,       average        necessary 

amounts  at  different  ages     356 

-  Babinski's  sign  during  deep       82 

-  cerebral  anaemia  in . .  ..     359 

-  cessation  of  motor  tics  during  160 

-  spasmodic  contractions  during  160 

-  influence   on  chorea  .  .      156 

hysterical  spasms  133,  166 

stridor  .  .  .  .  .  .      710 

tremors     . .  . .  . .     795 

Sleepiness  after  epileptic  con- 
vulsions   . .  . .  . .     169 

Sleeping  on  back,  priapism  from  586 

-  sickness  (see  Trypanosomiasis) 
Sleeplessness,    loss    of   weight 

due  to 848 

-  in  rickety  children  . .     170 
Sloughing  "       . .          . .  .  .      283 

-  in  erysipelas             . .          . .     740 
Slowing  of  pulse-rate . .          ..       97 
Small  intestine,  normal  situa- 
tion of 722 

-  occipital  nerve,  skin  distri- 

bution of .  .  . .  . .     059 

-  sciatic  nerve,  skm  distribu- 

tion of       . .  . .  . .     059 


833, 


604, 


Small-pox       

-  absence  of  enlarged  glands 

early  in    . . 

-  acute  hydrocele  in  . . 

-  affection  of  pharynx  in 

-  albuminuria  in       . .  17, 

-  arthritis  in  . . 

-  bleeding  gums  in    . . 

-  characters  of  the  individual 

lesion  in  diagnosis  of 

-  confluent  (Fig.  160)  605, 

-  dark  stains,  scars,  and  pits  in 

-  diagnosis  from  acne  vulgaris 

603, 

acute  eczema 

bromide  eruption 

chicken-pox 

copaiba  eruption 

erythema  multiforme 

German  measles 

impetigo  vulgaris 

iodide  eruption  . . 

measles 

purpura  simplex 

scabies 

scarlet  fever 

syphilides 

from  typhoid  fever 

-  discrete  (Fig.  160).. 

-  distribution  of  eruption  in 

(Fig.  213,  p.  833)  605,  606, 
607,   833, 

-  effects  of  exposure  in  distri- 

bution of  lesions  in 

friction  of  clothes  on  dis- 

bution  of  lesions  in     . . 

-  epistaxis  in 

-  eruption  in  bathing-drawers 

area 

-  gangrene  in . . 

-  hffimatemesis  in     . .         294, 

-  hcematuria  in  . .         301, 

-  haemoptysis  in       . .         318, 

-  haemorrhage    between     the 

pustules,  etc.,  grave  signi- 
ficance of 

into  pustules  in,  prognosis 

unaffected  in  . . 

skin  and  pustules  in  . . 

-  haemorrhages  in 

-  haemorrliagic     eruption     in 

"  bathing  drawers  area  " 
in  prodromal  stage  of  . . 
hopeless  outlook  in 

-  intense  backache   and  head- 

ache in      . . 
itcbing  in 

-  invasion   of   mucous   mem- 

brane of  air-passage=;  in. . 

-  leucocvtosis   uncommon    in 

-  melaena  in   . . 

-  menorrhagia  in 

-  modified 

-  occurrence    of    eruption    in 

mouth,  pharynx,  and 
cesophagus  in 

-  pain  in  limbs  at  onset  of    . . 

-  preliminary  roseolar  scarla- 

tiniform  rash  in  .  . 

-  prodromal     hajmorrhagic 

eruption   . . 

rashes    of,     in 

drawers  area 

-  ptyalism  in. . 

-  purpura  in 

-  pustules  in  . . 

-  Eicketcs  on 

-  rigors  in 

-  scabs  in 

-  scarring  after 

-  simulated  by  vaccinia 

-  small    shotty    pink    papule 

embedded  in  skin  in 

-  sore  throat  in  . .        67r 


bathinff- 


596, 
601,  605, 


301, 


6U3 

607 
522 
670 
20 
376 
301 

605 
606 
605 

609 
60S 
009 
834 
609 
607 
607 
607 
609 
607 
607 
608 
607 
607 
607 
606 


605 
301 

598 
282 
301 
305 
325 


598 
605 
301 


598 
598 

301 
655 

605 
400 
301 
428 
605 


673 

505 

605 

598 

447 
590 
598 
829 
605 
647 
655 
655 
834 

605 
673 


SMA  LL-POX—SPA  SMS 

987 

Small-pox,  contd. 

Soft  chancre  (see  Soft  Sores; 

Sore  throat,  amid. 

-  spleen  enlarged  in  . .        C02, 

698 

-  palate    paralysis    in    diph- 

 foul  breath  due  to 

90 

-  stomatitis  in 

590 

theria 

.559 

in  German  measles 

670 

-  swelling  of  thyroid  glaud  in 

972 

-  sores,  balanitis  from 

675 

from  gumma  of  fauces,  or 

-  symmetrical  distribution  of 

—  bubo  with 

675 

palate    . . 

670 

rash  in       

C07 

characrers  of       . .         760, 

830 

-   -  from  irritants  or  corrosives 

674 

-  ulceration  of  larynx  in 

and      condyloma     occur- 

 local  appearances  in  mild 

073 

185,  220,  318 

325 

rence  together 

769 

in  measles 

070 

-  umbilication  of  pustules  in 

655 

cure  by  antiseptics 

769 

mumps 

074 

vesicles  in 

829 

diagnosis  from  herpes  pro- 

necessity  for  examining  for 

-  vacnolation  of  papules  in  . . 

005 

gonitalis            . . 

675 

Klebs-Lofller  bacilli  in 

671 

-  vesicles  of    . . 

605 

mistaken  for  condyloma 

769 

in  peliosis  rheumatica  . . 

59& 

-  vomitiiitr  in 

301 

—  on  penis  . .          209,  674, 

675 

phlegmanous     ulceration 

-  inalisua' 

301 

commoner  sites 

675 

of  the  tonsils  . . 

670 

SMELL,  ABNORMALITIES  OF 

668 

conversion  into  chancre 

post-pharyngeal  abscess 

67a 

-  cenrre  in  uncinate  cj'rus    . . 

609 

676, 

738 

relation  of  weather  to  . . 

673 

-  loss  of,  during  ordinary  cold 

668 

diagnosis  from  chancre 

in  scarlet  fever  . .        070, 

074 

with    hysterical    heniian- 

675, 

670 

small-pox. . 

673 

ifsthesia 

666 

due  to  sexual  infection 

675 

squamou.s-ceUed  carcinoma 

-  normal,     idiosyncrasies     of 

incubation  period      675 

076 

of  palate 

670 

sense  of    . . 

008 

inguinal  glands  infected 

in  stockbrokers   . . 

070 

-  offensive,  vomiting  from  . . 

844 

from  . .          . .        675 

676 

syphilis 

-  subjective,  as  epileptic  aura 

80 

multiple            . .        675, 

076 

371,  533,  605,  615,  670 

769 

sensations  of 

069 

perforation  of  frsenum  by 

675 

from  tuberculosis  of  fauces 

670 

Smile    in    myasthenia    gravis 

rapid     destruction     of 

Vincent's  angina 

C70 

(Fig.  84,  p.  261).. 

200 

tissue  by 

675 

Sores  from  lierpes  zoster 

6.5.H 

-  transverse  type  in  myopathy 

on   scrotum 

765 

SORES,  PENILE,  causes  of  674 

,675- 

(Fig.  82) : 

200 

swelling  from  .  . 

765 

SORES,  PERINEAL   .. 

677 

Smoking,  anorexia  from 

49 

ulcers  due  to,  characters  of 

675 

various  causes  of          677, 

67& 

-  foul  taste  due  to 

774 

in  the  urethra,  account  of 

209 

SORES,  SCROTAL     .. 

679 

-  vrranular  pharyngitis  from  1170 

,673 

of  vulva    . . 

768 

causes  of  . .             679,  680 

081 

-  insomnia  from 

356 

diagnosis  from  syphili- 

 soft  (see  Soft  Sores) 

-  intermittent  claudication  from  489 

tic  condyloma 

768 

Sorrow,  loss  of  weight  due  to 

84» 

-  rolation  to  chronic  glossitis 

812 

Softening   of  bones  in  osteo- 

Sound,  in  diagnosis  of  calculus 

62* 

-  sore  throat  from 

670 

gcnesLs  imperfecta 

213 

elongated  cervix        580 

587 

Snail-track  ulcers  of  pharynx 

-  cerebral,  caases  of.. 

125 

fibromyoma      . . 

429 

in  secondary  syphilis 

672 

Cbeyne-Stokes  respuration 

hyperinvolutionof  uterus  70& 

Snake-bite,  albuminuria   after 

458 

in 

125 

-  -  -  inverted  uterus 

587 

-  gangrene  in 

282 

diabetes  insipidus  in 

585 

-  uterine,    antiseptic   precau- 

- iaundice  in  . .          . .        .362, 

374 

pseudo-bulbar     paralysis 

tions  in  passage  of 

42» 

-  purpura  from 

.596 

due  to  . . 

641 

Sound-conducting    apparatus. 

-  universal  ojdema  from     4.58 

460 

from  sinus  thrombosis  . . 

643 

deafness  due  to  defectinl89 

,190 

Sneer,  myastlienic  {Fig.  84). . 

260 

-  of  uncinate  gyrus,  anosmia 

South  America,  hydatid  disease 

.Sneezing,  epistaxis  from 

250 

from 

669 

in  . . 

720 

-  violent,   causing  subcutan- 

Solar plexus  irritation,  influence 

Spade  -  users,        Dupuytren's 

eous  emphysema 

231 

on  skin  pigmentation     . . 

574 

contracture  in     . . 

167 

Snellen's  coloured  tvpes  in  de- 

 meteorism     from     inter- 

Spasmodic     abdominal     pain 

tecting  hysterical  ambly- 

ference with    . . 

432 

(see  Colic) 

opia 

837 

Soles  of  feet,  arsenical  hyper- 

- contractions   (see    Contrac- 

Sniflint'tic 

159 

keratosis  of 

87 

tions,  ,Spasmodic) 

SNORING         ..          ..        669, 

707 

congenital  syphilitic  con- 

- dysmenorrhcea  (see  Dysmen- 

-  various  causes  of    . . 

669 

dylomata  of     . . 

446 

orrhcea,  Spasmodic") 

Snow  blindness,  conjunctivitis 

papulo-squamous  syphilo- 

-  dysyepsia  (see  Dyspepsia) 

with 

840 

derms  of 

532 

-  tics,  muscle  twitching  in  . . 

15& 

erythropsia  in 

840 

pityriasis  rubra  pilaris  of 

658 

Spasmogenic  zones  of  Ctiarcol 

7/7 

hemeralopia  in    . . 

841 

pruritus  of 

588 

Spasms  (and  see  Cramps,  Con- 

 photophobia  in  . .         574, 

840 

Soleus,  nerve  supply  of 

542 

tractions,  Contractures) 

Snuti,  anosmia  from  . . 

669 

-  pseudo-hypertrophy  of 

560 

-  of   articulatory   mu.scles   in 

-  causing  corjza 

203 

Solitary  follicles  of  intestines, 

stammering 

68& 

-  olfactory  neuritis  from 

669 

enlarged  in  IjTnphatism 

423 

-  bowel  in  carcinoma  coli    . . 

147 

Snuflles,  in  congenital  sj-philis 

Sordes,  bleeding  gums  with    8-: 

,  87 

-  carpo-pedal 

'6- 

427,  440, 

695 

-  foul  breatli  from    . . 

98 

in  association  with  laryn- 

Soap method  of  inducing  de- 

SORE    FINGER 

266 

gismus  stridulus 

466 

faecatiou  . . 

149 

SORE  THROAT  Cand  see  Pain 

infantile  tetany  . . 

466 

Soda,  sore  fingers,  washing  in 

260 

in  Xeck  ;    and  Tonsillitis) 

of  rickety  children 

178- 

Soda-water,  explosive  eructa- 

504, 670, 

673 

in  tetany. . 

802 

tion  of  gas  from. . 

639 

acute  and   fatal,  in  some 

-  clonic  in  hysteria    . . 

652 

Sodium     bicarbonate,     neces- 

cases of  scarlet  fever. . 

674 

-  of  colon,  constipation  due  to 

145 

sity   for,    in   haematopor- 

from  acute  cervical  adenitis 

-  dilator  tubfe,  clicking  noises 

phyrinuria  from  sulphonal 

820 

071 

074 

in  the  ear  due  to . . 

793. 

-  chloride,  extreme  thirst  due 

in  acute  laryngitis 

673 

-  dorsal  muscles  in  spondylitis 

to 

789 

pharyngitis 

673 

defonnans 

787 

-  nitrite  reagent 

197 

albimiinuria  in 

17 

-  face  (see  Face,  Spasm  of)  495 

537 

for  acetonuria 

4 

in  cervical  spinal  caries 

673 

—  glottis  as  an  epileptic  aura 

82^ 

-  nitroprusside  test  for  nielan- 

chicken-pox 

673 

vertigo  associated  with 

823. 

uria 

821 

chronic  pharyngitis 

673 

-  in  hydrophobia 

163 

-  phosphates,    varieties    and 

clergyman's  " 

670 

-  hysterical  facial 

537 

physiology  of 

572 

-  -  in   costcrmongers 

670 

talipes 

13.'^ 

-  salicylate,  bradycardia  from 

98 

dengue 

506 

-  of  levator  ani,  painful 

221 

nerve  deafness  from 

191 

diagnosed  by  bacteriolo- 

 palpebrae      superioris     in 

in  rheumatic  affections. . 

671 

gical  examination 

225 

exophthalmic  goitre  . . 

253. 

Cand  sse  Salicylates) 

diphtheritic                      76, 

670 

-  mobile 

1.54 

urate  crystals  in  tophi,  etc.. 

dysphagia  from  . . 

225 

-  in  occupation  neuroses 

494 

in  gout     . .            380,  382 

383 

from  follicular  tonsillitis 

670 

-  of  oesophagus          . .        225, 

841 

^88 


SPASMS— SPINAL    CORD 


Spasms,  contd. 

-  phaiynx        .  .          .  .          .  .  225 

-  post-hemiplegic       . .          .  .  157 

-  retinal     artery,      transient 

blindness  from    . .          . .  839 

-  salpingopharyngeus,  clicking 

noises  in  the  ear  due  to. .  793 

-  sphincter     ani,      dyschezia 

due  to      . .          . .          . .  150 

genito-urinary   diseases 

causing         . .          . .  150 

-  sternomastoid,  torticollis  from  708 

-  tetanus         . .          . .          . .  162 

-  tonic,    difEerentiation    from 

tetanus     . .          . .          . .  161 

-  uterine,  dystocia  due  to    . .  227 

-  of    vesical   sphincter,    after 

operations             . .          .  .  'til 

-  warning,  of  major  epilepsy  160 
Spastic   and  atrophic  paralysis 

of  arm,  mixed,  in  spinal 

cord  lesions         . .          . .  553 

-  constipation             . .          . .  144 

-  -  mucus  in  stools  in         . .  145 

-  -  pain  in      .  .          .  .          .  .  144 

-  contractures              .  .          .  .  162 

-  paralyses,  acquired            . .  155 
of  the  arm,  clinical  signs  of  546 

-  -  in      infants,      choreiform 

movements  in  156,  157 

of    one    leg,    absence    of 

atropliy  in        .  .          .  .  539 

-  -  in  Little's  disease           . .  154 
syringomyelia      . .         . .  128 

-  ijaraplegia  (see  Paraplegia, 

Spastic) 
Spasticity  (see  Gait ;  and  Para- 
plegia) 

-  in  birth  palsies       . .          . .  558 
Speaking,     influence    on    tri- 
geminal neuralgia           . .  495 

Specific  gravity  of  blood, rise  of, 
in    collapse  from  loss  of 

fluid 580 

in  diabetes  insipidus  . .  584 

as  indication  for  infusion  580 

method  of  measuring  580 

urine  (see  Urine,  Specific 

Gravity) 

Spectacles,  cure  of  headache  by  328 

Spectra,   various,   illustrated  94 
Spectroscope   in   detection   of 

haematoporphyrin            .  .  819 

-  -  hajmoglobinuria  .  .          . .  821 

-  -  methfemoglobinsemia,  etc.  187 

-  -  urobilin    . .          . .         361,  818 

-  examination     of    urine     in 

Bright's  disease  . .          . .  12 

-  test  for  blood          . .            89,  94 
Speculum  for  ear       ..        187,  190 

-  in  examination  of  the  nose  669 
in    diagnosing    cause    of 

epistaxis..            ..          ..  251 

-  in  rectal  examination         .  .  635 
SPEECH,  ABNORIVIALITIES  OF  682 

-  absence  of  in  idiocy          . .  682 

-  affected    in    nuclear    facial 

paralysis  .  .          . .          .  .  536 

hemiplegia            . .          . .  336 

-  age  of  acquirement  of       . .  682 

-  blurred,  in  general  paralysis  172 

-  centres  (Fig.  185)   . .          . .  683 
blood  supply  of   . .          . .  684 

-  cerebellar      .  .          .  .          . .  69 

-  defective,  in  acquired  infan- 

tile paralysis        . .          .  .  155 
bulbar  paralysis              . .  159 

-  -  disseminated  sclerosis    . .  174 
Little's  disease    . .          . .  154 

-  delay  in  acquiring  .  .          .  .  682 

-  -  -  association  with  destruc- 

tiveness         . .          . .  682 

dirty  habits              . .  682 

irritability    .  .          . .  682 


Speech,  contd. 

-  effect  of  word  deafness  on     684 

-  functional  disorders  of       . .     687 

-  indistinctness    of  (see   Dys- 

arthria) 

-  interference  with,  in  chorea     156 

-  interrupted      in     mercurial 

poisoning  .  .  . .      797 

-  loss  of,  from  mental  defects, 

diagnosis  from  apliasia . .     682 

-  -  after  partial  acquirement 

of,    due   to   defects    of 

hearing 682 

in  alcoholic  intoxication       682 

temporary,  in  acute  diseases  682 

-  mechanism  of  acquirement 

683,  686 

-  monotonous,  in  Friedreich's 

ataxy        . .  . .  . .     560 

in  paralysis  agitans        . .      796 

-  movements,  relation  to  pyra- 

midal lesion         . .  . .     687 

-  perverted  in  children,  idio- 

glossia  type         . .  . .     688 

-  relation  of  word  bluidness  to 

power  of  .  .  . .  .  .     685 

-  representation  in  brain     . .     687 

-  scanning,    in    disseminated 

sclerosis    . .  342,  686,  800 

-  slow,  in  myxoedema  . .     259 

paralysis  agitans  . .     259 

and    blurred    in    general 

paralysis  of  the  insane     796 
and  difficult  in  Hunting- 
ton's chorea    . .  . .     156 
jerky  in  Friedreich's  ataxy  686 

-  staccato,     in     disseminated 

sclerosis       . .         342,  686,  800 

-  tremor   of,    in    Friedreich's 

ataxy        . .  . .  . .     799 

-  uninterpretable    jargon     in 

word-deafness      . .  . .     684 

Speechlessness  in  melancholia      682 
Spermatic    cord,    absence    of 
thickening  in  gumma   of 

testis         681 

affections      of,       causing 

testicular  pain  .  .     523 

compression,     testicular 

atrophy  from  . .       78 

-  -  encysted     hydrocele     of 

(see   Hydrocele   of   the 
Cord,    Fncysted) 

-  -  inflammation  of,  second- 

ary to  urethritis  . .  523 
lipoma    of,     diagnosis    of 

omental  hernia  from  741 
impulse  on  coughing  in     741 

-  -  new  growths  of,  absence 

of  pain  in  testis  in      . .     523 

-  -  -  -  varieties  of  . .  . .  523 
thickening    of,    in    acute 

epididymo-orchitis      . .     518 

due  to  new  growth  of 

testis  . .         520,  766 

-  -  torsion  of.  association  with 

gangrene  of  testis       . .     523 

tuberculosis  of     . .  . .     523 

Spermatocele  (see  Testis,  Cysts  of) 

-  testicular  atrophy  from  .  .  78 
Spermatorrlioea  from  oxaluria  472 
Spermatozoa  in  urine,  diagnosis 

of  phosphaturia  from  . .  574 
in  oxaluria  .  .  .  .      471 

-  in  testis  cysts  . .  . .  521 
Sperm  in  in  relation  to   Char- 

cot-Leyden  crystals  . .  117 
Sphacelus  . .     "     .  .  .  .     283 

Sphenomaxillary     fossa,     tn- 

moiu-  in,  trigeminal  ncu- 

ralsia  due  to        . .  . .     496 

Sphenoidal   air-cells,  infection 

of,  headaclie  from  .  .  327 
meningitis  from          . .     642 


Sphenoidal  air-cells,  contd. 

nasal  discharge  from  204,  206 

-  sinus  dilatation,  exophthal- 

mos in      . .  . .  . .     255 

optic  neuritis  or  atrophy 

in       . .  . .  . .     255 

Sphincter  ani,  control  in  dis- 
seminated sclerosis        . .     174 

loss  of,  association  with 

exaggerated  knee-jerks  397 

- in  cerebral  diplegia       800 

with  cerebral  softening  796 

in  combined  scleroses 

of  the  cord  . .     164 
with  compression  para- 
plegia       . .         558,  786 
in  disseminated  scler- 
osis           . .         547,  800 

epilepsy        . .  160,  169 

ihac  abscess  from  508,  632 

tabes. .  . .  . .     285 

tabes  dolorosa         . .     507 

transverse  cord  lesions  164 

from  typhoid  spine       787 

uraemia  .  .  .  .        48 

-  -  spasm  of  causing  dyschezia  150 
genito-urinary  lesions  as 

&ase  of       . .  . .     150 

-  -  -  unrelaxed  in  hysteria        160 

-  vesical,  incontinence  of  urine 

from  injury  to     .  .  .  .     440 

Sphygmomanometer    in    dia- 
gnosing high-blood  pressure  526 
Spina  bifida,  paraplegia  from 

556,  557 

-  -  talipes  in..  ..  ..     131 

-  -  occulta,   pigmented  mole 

over       . .  . .  . .     557 

Spinach,  oxaluria  from  eating    471 
Spinal  alDScess  . .  . .  . .     786 

-  accessory      nerve,      bulbar 

paralysis  affecting  . .     159 

-  artery,  thrombosis  of,  caus- 

ing transverse  myelitis..     564 

-  canal,     rupture     of     aortic 

aneurysm  into     .  .  .  .     482 

-  caries  (see  Caries  of   Spine) 
~  centre  lesions,  incontinence 

of  urine  from       . .  . .     443 

-  column,    injuries    of,    inter- 

costal nerve  pain  in        . .     479 
Spinal  cord,  aneurysm  of,  para- 
lysis  of    bowel   and    tym- 
panites from        . .  . .     432 
and  brachial  plexus  par- 
alyses, differentiation  of    552 

-  -  cervical,      pressure      on, 

angesthesia  of  trunk  and   , 
legs  from  . .  . .     494 

-  -  -  -  loss     of     abdominal 

reflexes  in  . .     494 

-  -  not  coloured  in  jaundice     361 

-  -  compression,     diminislied 

power  of  micturition  in     443 

impotence  in  . .  . .     346 

diagrams  illustrating  sen- 
sory localization  in 
(Figs.  146,  147)  ..     566 

-  -  disease,  spastic  paralysis 

of  arm  from     .  .  .  .      547 
pain  in  chest  in         478,  484 

-  -  general  account  of  sensor v 

paths  in  (Fig.  177)     662,  663 

-  -  gliosis  of,  symptoms  simu- 

lating brachial  neuritis       492 

IiaBniorrliage     into     (see 

Ha3morrhage,  Spinal) 

-  -  inflammation,     pain      in 

back  in  .  .  .  .     476 

-  -  injury,  allocheiria  in      ..       21 

-  -  -  in     congenital     spastic 

paraplegia    . .  . .     131 

diagnosis  of  Krb's  and 

Duchenne's  palsies  from  552 


SPINAL    CORD— SPLEEN,    ENLARGEMENT   OF 


989 


Spinal  cord  injury,  eonhl. 

Spine,  actinomyces  of,   simu- 

Spirilla in  Vi?icent's  angina,  cuntd. 

diagnosis  of  Klumpke's 

lating  spinal  caries 

786 

-  -  laryngitis  from   . . 

670 

paralj'Sis  from     . . 

5.5.3 

-  ankylosis   of,    in    infectious 

—  pliaryngitis  from 

07U 

sciatica  from 

488 

fevers 

70S 

Spirit-druikiiiL:,  polyuria  from 

difficult  micturition  from  440 

-  aortic    aneurysm    invading. 

583 

581 

girdle  pain   at  level  of 

mistaken  for  malingering 

508 

Spirochaeta  obermeieri  in  the 

injury  in 

484 

—  ataxy    from    new    growtlis 

i)lood    in   relapsing   fever 

hemiplegia  from         34( 

,341 

affecting   . . 

68 

(Plate  XII,  p.  iVM))  373,649 

,698 

hiccough  from.. 

34.3 

-  carcinoma  of  (see  Carcinoma 

-  pallida  (Plate  Xll.  Fin.  J, 

incontinence    of    faces 

of  Spine) 

p.  690)       ..          ..86,  769 

813 

after  

348 

-  caries  of  (see  Caries  of  Spine 

) 

-  -  acute  tonsillitis  from 

670 

loss  of  sensation  below 

-  disease  ot,   abdominal  pain 

-  -  in  cerebrospinal  fluid    340 

,670 

level  of  injury 

484 

from 

473 

in  chancre     675,  678,  769 

813 

meteorism  in   .  . 

432 

ataxy  in    . . 

66 

-  -  fixing  and  staining  of    . . 

769 

muscular  atrophy  from 

72 

various  root  palsies  caused 

-  -  laryngitis  from    . . 

670 

one-sided,  causing  para- 

by         

555 

in  palatal  ulcer  . . 

041) 

lysis  of  one  leg 

.540 

-  dislocation      of,      loss      of 

pharyngi!  is  from 

67a 

paiu  in  back  in 

476 

knee-jerks  in  . . 

398 

in  syphilis 

738 

paralysis  of  bowel  in  . . 

432 

-  erosion    of    by    .Tueui-vsm 

of  liver. . 

371 

of   bowel    and    tym- 

482, 524,  728,  784 

848 

Spleen,  abscess  of       ..       014 

692 

panites  from 

432 

pain  in  testicle  from 

524 

-  "  ague-cake  " 

693 

priapism  after           585, 

586 

-  fixed  in  spondylitis  deformans  70S 

-  carcinoma  of 

692 

radicular   pain    in  arm 

-  fractured  (see  Fracture  of  Sp 

ne) 

-  dislocation  of          . .         7U0. 

737 

from  . . 

494 

-  gout  affecting 

383 

organ  lyuig  in  pelvis     .  . 

691 

spastic  paralysis  of  one 

-  hydatid  disease  of,  causing 

-  effect  of  .T-rays  on.  in  leukemia  31 

leg  after   "  . . 

540 

kyphosis  . . 

181 

SPLEEN,  ENLARGEMENT  OF 

088 

-  -  -  -  paraplegia  in 

494 

tenderness  of  spine  in 

absence  of  bowel  in  front 

talipes  after     . . 

131 

784,  785, 

780 

of           

392 

testicular  atrophy  after 

-  hyperaesthetic  spots  over,  in 

in  adhesive  pylephlebitis 

301 

li 

,  80 

traumatic   neurasthenia 

667 

Banti's  disease              694, 

696 

transverse,  acute  bedsore 

-  infective     arthritis     of,     in 

bimanual  palpation  of  . . 

689 

from . . 

286 

infectious  fevers . . 

708 

in  catarrlial  jaundice     . . 

365 

myelitis  from 

504 

-  lumbar,  suppuration  of,  swel- 

 cerebral  embolism 

138 

-  -  syphilitic   thrombosis   of, 

ling    in    right    ihac    fossa 

in  children,   due    to  con- 

primary softening  from 

432 

due  to 

737 

genital  syphilis 

695- 

transverse  myelitis  from 

-  lumbo-sacral,     disease     of. 

without  any  disease  . . 

695 

secondary  growth  com- 

diagnosis of  sciatica  from 

due  to  rickets  . . 

095^ 

pressing 

564 

pain  due  to 

487 

cirrhosl*  of  hver  42,  59.  60, 

301, 

softening,  impotence  in 

;!4(i 

.T-rays  in  diagnosis  of 

488 

302,  369,  409,  410.  695, 

090 

tumours,  allocheiria  from 

22 

-  malignant  disease  of,  com- 

 classified  list  of  causes  of 

692 

-  -  -  atrophic   palsy    of    one 

pression  of  cord  by 

561 

-  -  compression  of  the  lung  by 

067 

leg  in 

544 

paraplegia  from        561, 

786 

—  diagnosis     from     abdo- 

and  meninges,  paralysis 

rarity    of    tuberculous 

minal  ha?matoma 

692 

of  arm  from .  . 

555 

focus  with   . . 

786 

colon  tumour  .  . 

690 

diagnosis     of     sciatica 

-  ■•  -  simulating  spinal  caries 

786 

conditions  sunulating  it 

689 

from  pain  due  to  . . 

487 

tenderness  of  the  spine 

-  -  -  fa?cal   accumulation   in 

interscapular  f)ain  in 

474 

varieties  of 

786 

colon 

691 

-  -  -  knee-jerk  exaggerated  in 

474 

.r-rays  in  diagnosis  of 

787 

gastric  tumour           690 

726 

pain  in  back  in 

476 

(andsee  Carcinoma  of  Spine) 

ovarian  tumour      .    . . 

691 

umbilical  region  in  . . 

525 

-  new  growth  of,  mtercostal 

pancreatic  tumour     . . 

690 

paralysis  of  bowel  and 

nerve  pain  in 

479 

renal  tumour             391, 

392, 

tympanites  from     . . 

432 

kyphosis  in 

181 

689, 

726 

of  one  \es  from 

540 

mistaken  for  caries    . . 

564 

suprarenal  tumour    690, 

726 

SPINAL  CURVATURE 

180 

pain  in  tlie  back  hi    . . 

476 

tuberculous  peritonitis 

091 

angular,  due  to  caries    . . 

194 

in  umbilical  region  in 

525 

other  tumours 

729 

-  -  depression  of  liver  in 

405 

sacralgia  in 

510 

edge  well  defined          391, 

392 

dwarfism  from    . . 

214 

simulating  brachial  neur- 

 from  embolic  infarction 

699 

lateral,     diagnosis      from 

itis     

492 

-  -  epidemic  jaundice 

372 

caries 

477 

-  -  -  swelling   of  chest   wall 

-  -  erysipelas 

698 

pain  in  the  back  in    . . 

475 

from . . 

194 

-  -  examination  of  blood   in 

Pott's,  transverse  myelitis 

transverse  myelitis  from 

564 

diagnosis  of 

689 

in 

5G4 

.-E-rays  in  diagnosis  of. . 

525 

felt  in  left  lumbar  region 

729 

rickety 

212 

-  osteo-arthritis  of     . .         383, 

384 

-  -  fibroid  lung  and  bronchi- 

 in  syringomyelia 

554 

-  pain  and  stiffness  in  typhoid 

ectasis  from 

324 

(and  see  Kyphosis  ;    Lor- 

fever 

376 

free  downward  movement 

dosis  ;  and  Scoliosis) 

-  periostitis  of,  due  to  bacillus 

with  inspiration   of    .  . 

391 

-  meninges,    sacralgia  in  new 

typhosus  . .       ... 

787 

hi  funsating  endocarditis 

STOWth    of         ~    . . 

510 

-  rheumatoid  arthritis  of     . . 

378 

38,   76,  237,  314, 

tumour  of,  hypera?sthetic 

-  rigid  (see  Rigidity  of  Spine) 

338,  593,  598,  613, 

69» 

zone  from " 

667 

-  stiff,  from  osteo-arthritis    . . 

384 

-  -  general  congestion  of  liver 

407 

-  meningitis    (see  ileningitis. 

-  tender  (see  Tenderness  of  Spine) 

hsematemesis  hi  . .        294, 

301 

Spinal) 

-  tuberculous  disease  of   (see 

in  Hanot's  cirrhosis      369, 

410- 

-  muscles,  paralysis  of 

181 

Caries  of  Spine) 

Hodskin's  disease  42,  59, 

-  nerves,  skin  distribution  of 

659 

-  tumours  of,  paraplegia  from 

561 

64,   76,  86,  303,  366. 

-  nerve-roots,  muscles  supplied 

Spines,    local   prominence   of. 

416,  420,    617,  695, 

739 

by  individual  cervical  . . 

556 

in  Pott's  disease            134, 

474 

—     impaction  in  pelvis 

688 

-  segments,     sensory     areas 

Spinous     process,     congenital 

infantilism  with  . . 

215 

corresponding    to    (Plate 

absence  of 

785 

after  injury 

700 

-Y/)            

663 

Spirals,     Curschmann's    (see 

in   kala-azar  (Plate  XII, 

Spinati  muscles,  spmal  nerve 

Curschmann's  Spirals) 

Fig.  H,  p.  696)             34, 

693 

root  supplying     . . 

556 

Spirilla    in    Vincent's    angina 

lardaceous  disease        10, 

Spindle-shaped  interphalangeal 

(Plate  XII,  Fig.  J/,  p.  696) 

39.  197,  414, 

69ft 

joints     in     rheumatoid 

99, 

672 

-  -  leukaemia,  31.  59,  64,  76, 

arthritis  (Figs.  107,  108) 

378 

acute  tonsillitis  from     . . 

670 

302,  314,  599,  617,  607, 

693 

990 


SPLEEN,  EXLARGEMENT  OF— SPUTUM 


324 


499 

72(5 
735 
G97 
758 
095 

726 
580 
69G 


Jipleen.  enlargement  oj.  corUd. 

lung  compressed  bj 

in  Ij-mpliadenoma  (see  in 

Hodgkin's  Disease,  supra) 
IjmpliaTic  leukaemia      . .     590 

—  IvinDliOsarcoma  . .  . .     36G 

-  -  malaria     302,  303,  015,  G93,  G98 

ifalta  fever  ..  ..     50* 

mode  of  palpating        G88,  726 

-  -  notcli  on  anterior  margrin  of  392 
obstaruction     to     inferior 

vena  cava  by  . .  . .     825 
pain    in    left    hypoclion- 

drium  in  some  cases  of 
palpable  in  epigastrium 

-  —  left  hypochondrium  . . 
iliac  fossa 

-  -  in  paratyphoid  fever     . . 

pelvic  swellinsr  due  to  757, 

pernicious  amemia 

-  physical  sigrns  of         391, 

392,  C88,  689, 
vrith  i)olycytlia;mia      187, 

-  -  from  portal  obstruction 
pseudo-leakfemia  infantum 

(Fig.  2)  42,  64,  599,  694 

relapsing  fever    . .        373,  698 

relation  of  stomach  to  . .     725 

-  -  in  rickets  . .         . .  . .     695 

~  -  rub  heard  over    . .  . .     689 

simulated       by      hyper- 
nephroma        . .  . .     72G 

skodaic  resonance  due  to     GG7 

in  splenic  anaamia.  42.  64,  76, 

86,  302,  411,  .599.  694,  696 

sphenomedullarv  leukaemia 

617,  693 

sphenomegalic  cirrlioSLs369,  696 

polycythaemia  . .     693 

-  -  Still's  disease      . .  40,  418 

-  -  from  strangulation         . .     700 

thrombosis  of  portal  vein     696 

in  typhoid  fever,  90,  196, 

372,  610,  615,  697 

-  -  varicose  abdominal  veins 

from 

-  L'umma  of,  exceedingly  rare 

-  hydatid  disease  of..  "     692, 

-  infarction  of,  pain  low  do^vn 

on  left  side  of  chest  in    . . 

thrombotic,  in  leulraemia 

in  iT-mphadenoma 

splenic  enlargement  in 

-  Injury  of,  rarity  of . . 

-  -  severe  jjain  in  side  in 

-  -  splenic  enlargement  from 

-  subphrenic  abscess  from 

-  'jormal  situation  of  . .     723 

-  |;iin  and  tenderness  in,  in 

fungating    endocarditis. .     237 

-  peritonitic  rab  over         644,  699 

-  puncture  of,  in  kala-azar  34,  693 

-  rupture  of,  liaemoperitoneum 

from 

-  softness  of,  in  the  enlarge- 

ment due  to  typhoid  ferer 

-  Strangulation  of 

difficulty  of  diagnosis  of 

.spleen  enlarged  from     692,  700 

symptoms      of      "  acut-e 

abdomen  "  in  . .  . .     700 

-  swelling  in  iliac  fossa   due 

to  a  wandering  . .  . .     737 

-  tumours  of  (see  Spleen,  En- 

largement of) 
Splenic  abscess  (see  Abscess, 
Sijienic) 

-  ansmia       42,  411,  459,  694,  696 

-  -  albuminuria  in   . .  . .       17 
ascites  in..             64,  122,  411 

-  bleeding  gums  in  . .       85 
blood  changes  in  . .       64 

-  -  cirrhosis     of      liver      in 

terminal  stages  of      ..     411 


717 

697 
700 
700 


696 
411 
411 

42 
411 
411 
459 

64 
122 

76 
122 
596 

694 
694 
411 


Splenic  anxmia,  conld. 

clubbed  fingers  in 

diagnosis  from  cirrhosis  of 

liVer      ..  411,  694, 

haematemesis  in..         302, 

hemorrhages  :n  .  . 

infantile    . . 

jaundice  in 

ieucopenia  m 

rx'dema  of  legs  in 

often  really  cirrhosis 

pericarditis  in 

peripheral  neuritis  in     . . 

pleuritic  effusion  in 

purpura  in 

relation  to  splenomegalic 

cirrhosis 

severe  ansmia  in  411,  459, 

slow  course  of 

SDleen  enlarged  in  (Fig.  186, 

"  p.  694)         64,  76,  86.  302 

411,   599,  692,  694,  696 
terminal  stage  of  cirrhosis 

of  liver  known  as  Banti's 

disease  . .  . .     411 

-  artery    opened    by    gastric 

ulcer  298 

-  flexure,   carcinoma    of   (see 

Carcinoma  of  Colon  ;  and 

of  Splenic  Fle.vure) 
Splenomedullary  leukaemia  (see 

LieukeemiaJ 
Splenomegallic    cirrhosis   (see 

Cirrhosis   Splenomegallic) 

-  polycythBEmla'        ..        187, 

57S,  580,  581, 

age  and  sex  incidence  of 

cyanosis  in  184,  187, 

diagnosis  of 

polycythaemia  in 

spleen  enlarged  in         692, 

-  -  symptoms    suggestive    of 

cardiac  lesion  ia 
Splints,  bulla;  from     . . 

-  contractures  from  . . 

-  gangrene  from 

-  Hodgen's,  talipes  from 

-  miLScular  atrophy  from     . . 

-  talipes  from 

-  vesicles  from 

-  Volkmann's  contracture  from 
Splinters  in  the  rectum 
Spondylitis,  coUcky  pains  in. . 

-  deformans,  age  incidence   . . 
atrophy  of  dorsal  muscles 

with 
calcification    of    anterior 

common  ligament  iti. . 

contractures  in  . . 

fixation  of  spine  in 

after  gonorrhoea . . 

in.luenza 

kyphosis  in 

osteo-arthritis  with 

pain  in  the  chest  with    . . 

hips  and  legs  with 

sex  incidence  of . . 

simulating  lumbago 

sciatica 

spasm   of  dorsal  muscles 

with 

stiff  neck  in 

back  in 

tenderness  in   spine  from 

784,  785,  786, 

after  tonsillitis    . . 

typhoid  fever  . . 

ar-rays  in  diagnosis  of    . . 

Spondylose    rhizom61ique     of 

Marie 
Spongy    gums   (see    Bleeding 

Gums) 
Spoon-nails 
Spores  in  favus 


693 
581 
693 
693 
693 
693 

693 
110 
165 
282 
132 
72 
131 
834 
552 
635 
134 
787 


445 
270 


Spoors,  conld. 

-  of  jnicrosporon  furfur  .  .  276 
minutissimum     . .          . .  277 

-  in  ringworm  .  .  .  .  272 
Sporotrichosis  of  lung,  diagnosis 

from  phthisis                    . .  322 

haemoptysis  in   . .         317,  322 

occupation  of  patient  in  322 

-  fibroid    lung    and    bronchi- 

ectasis from         . .          . .  324 
Spotted  fever  (and  see  Menin- 
gitis, Cerebrospinal)       . .  598 
Sprains,  muscle  atrophy  from  72 

-  purpura  from          .  .         596,  597 

-  talipes  from  ..  ..  132 
■Sprengel's  shoulder  . .  . .  180 
Sprue,  diarrhoea  in     . .          . .  197 

-  fatty  stools  in         . .          .  .  265 

-  ptyalism  due  to      . .          . .  590 

-  stomatitis  in  . .  197,  D90 
Spur  of  nasal  septimi,  anosmia 

from          668 

obstruction  to  nose  by  668 

SPUTA,  varieties  and  signifi- 
cance of    . .          . .          . .  700 

Sputum,   acid-fast    bacilli    m, 

possible  fallacy  due  to  . .  701 

-  of    acute   laryngitis,    blood 

streaks  in.".          . .          . .  176 

-  anchovy-sauce-like  . .  176 
from  liver  abscess     323,  704 

-  B.  mallei  in. .          . .          . .  704 

-  black 704 

-  blood-tinged      from      new 

growth  in  lung   .  .          .  .  322 

-  bluish,     in    infection    with 

B.  pyocyaneus     . .          . .  704 

-  in  bronchiectasis      . .          99,  842 

-  bronchitis,  blood  streaks  in  176 
characters  of        . .          . .  704 

-  capsulated  diplococci  in    . .  321 

-  caseous  mass  in       . .          . .  704 

-  casts  of  bronchial  tubes  in  704 

-  Charcol>Leyden  crystals  in  117 

-  coagulation  test  for  tuber- 

culous nature  of . .          . .  704 

-  with  cough              . .          . .  175 

-  Curschmann's  spirals  in    . .  179 

-  cretaceous  pellet  in           . .  704 

-  in  diphtheria,  bronchial  casts  704 

-  distoma  pulmonale  in        . .  25 

-  dull  red  from  rupture  of  liver 

abscess  into  lung. .          . .  369 

-  elastic  fibres  in  (Fig.  187, 

p.  701)  185,288,  3i6,  317, 

319,  321,  651,  701,  703 

as     evidence     of     lung 

destruction  . .          . .  701 
in  gangrene  of  lung     99,  703 

-  in  empyema  ruptured  into 

lung           . .          . .           99,  578 

-  eosinophile  cells  in             . .  249 

-  examination  of        . .          . .  175 

in  cases  of  loss  of  weight  847 

empvema..           ..          ..  120 

-  fcetid,  "abundant  99,  651,  703 
in  bronchiectasis  193, 288, 

321,  842 


99,  28 


21,  578 
.  .  246 
88,  321 


bronchitis. 

empyema 

fibroid  lung 

gangrene  of  Itmg 

old  phthisical  vomicae 

34,  288,   651 

rupture    of   liver    abscess 

through  diaphragm     .  .     704 

-  fragment  of  new  growth  in 

322,  704 

-  ingangreneof  the  lung  99,288, 321 

-  greenish,   in   infection  with 

B.  pyocyaneus    . .  . .     704 

-  hepatic  pus  in,  from  rupture 

of    hepatic    abscess    into 
lung         176,  323,  369,  409,  704 


SPUTUM— STOMACH,   DILATED 


99  r 


''iputum,  contd. 

Staphylococcus,  contd. 

Stiffness  of  joint,  contd. 

-  iiiQuenza  bacilli  in..        321, 

702 

-  in  phthisical  sputum 

701 

from   syphilitic  synovitis 

386 

-  iji  lobar  pneumonia 

320 

-  prostatitis  due  to  . . 

83 

-  of  knee  from  osteo-arthritis 

384 

-  micrococcus  tetragenus  in 

705 

-  pyelitis  due  to 

625 

-  -  (and  see  Arthritis) 

-  microscopical  examination  of 

176 

-  in  septicEcmia 

372 

STIFF  NECK  isee  also  Pain  in 

-  naked    eye   appearance    of, 

-  simulating  gonorrliceal  ure- 

Xeck)         

707 

unreliable  in  diagnosis.. 

700 

thritis 

631 

from  acute  cervical  adenitis  674 

-  nummular    . . 

700 

-  in  sycosis  vulgaris  .  . 

602 

-  -  cerebrospinal   meningitis 

328 

-  oidium  albicans  in.. 

705 

-  tonsillitis  from 

670 

and  jaw  in  tetan-js 

162 

tropicale  in 

705 

-  ureteritis  from 

515 

metliod    of    investigating 

-  ova  of  paragonimus  Wester- 

-  uretliritis  due  to     . .          83, 

631 

nature  of 

708 

mani  in    . . 

705 

Staphyloma,  posterior 

462 

from  mumps 

674 

-  penicilium  glaucum  in 

705 

"  Starchiness "     of     face     in 

-  -  myalgia  of  neck  muscles 

507 

-  in  plittiisi.s      34,  87,  99,  185, 

288, 

pseudo-bulbar  palsy 

686 

pain  in  back  from 

477 

325,  578,  G51,  (i7-l,  700,  701 

712 

Staring     fades      of     Graves' 

in  post-basal  meningitis 

328 

absence  of  tubercle  bacilli 

704 

disease 

261 

-  -  tetiinus     . .          .  .         463 

802 

-  paeumo-bacilli  in    . . 

702 

in  paralysis  agitans 

262 

due  to  sitting  in  a  draught 

477 

-  pneumococci  in  (Plate  XII, 

Starvation,  acetonuria  in      . ._ 

4 

Stigmata,  venous,  from  cluronic 

Fig.O) 

C9C 

-  aiiicmia  in   . .          . .           37, 

459 

alcoholism 

797 

-  in  pneumonia    175,  186,  330, 

321, 

-  cachexia  from         . .        459, 

461 

Still's  disease,  (FiV/.  120) 

418 

372,  700,  701, 

702 

-  dis.ippearance  of  phosphates 

allei.-tion  of  johits  in 

418 

-  repeated  copious,  from  em- 

from urine  in 

572 

amemia  in            .  .           40, 

418 

pyema  of  lung    . . 

323 

-  glycosuria  in 

292 

-  -  corresponds      to       acute 

-  tubercle  bacilli  in  (Plate  XII, 

-  hypotliermia  due  to 

621 

rheumatoid       arthritis 

Fiij.  K,  p.  liDU)         87,  99, 

700 

-  leucopenia  in 

401 

in  adults 

418 

no  indication,  of  itself, 

-  marastmis  from 

427 

emaciation  in 

40 

of    progressive    lung 

-  a2dema  of  logs  in     . .        459, 

461 

lymph  elands  enlarged  in 

destructioa  . . 

701 

-  wastuig  from           . .          69, 

847 

40,  416 

418 

-  -  -  methods  of  concentra- 

Status epilepticus 

169 

pigmentation  of  skin  in. . 

418 

tion  of 

701 

-  lymphaticus  (see  Lymphatism) 

spleen  enlarged  in          40, 

418 

in  phthisis       . .        578, 

712 

Stays,  Riedel's  lobe  due  to  . . 

279 

Stings,  bleeding  gums  due  to 

85 

tuberculous     laryngitis 

-  spinal  curvature  due  to     . . 

214 

-  pruritus  caused  by . . 

588 

325, 

674 

Steam,  sore  throat  from 

671 

-  ve.=icles  from 

834 

and  elastic  fibres  in    . . 

185 

Stelwagon,  re  bathing  pruritus 

588 

Stinging-nettle,  wheals  from 

850 

~  viscid            ..          ..321,  372 

505 

-  re  vesicular  syphilis 

832 

Stitch,  cause  of 

478 

-  -  rusty          . .           175,  186, 

372, 

Stellwag's  sign  in  exophthalmic 

-  pain  in  chest  from 

477 

700,  701, 

702 

goitre        .  .            244,  253, 

792 

-  tenderness  in  chest  from  . . 

776 

-  Ziehl-Xeelsen     method     of 

Stenosis  (see  under  various  organs) 

Stockbrokers,  chronic  pharyn- 

staining      for       tubercle 

-  mitral  (sea  Mitral  Stenosis) 

gitis  in     . .          . .         670 

673 

bacilli  in   . . 

700 

Steppage  gait. . 

66 

Stocking  and  glove  anaesthesia 

Squamous  eruptions  (see  Scales) 

Stercobilin,       absence      from 

in     periplieral     neuritis 

Square  face  of  acromegaly  . . 

263 

fseces     with     carcinoma 

(Fig.  175) 

660 

Squint  Csee  Strabismus) 

of  pancreas 

116 

Stokers,  enlarged  heart  in 

232 

Stab,   hiemorrhage    into    cord 

-  in  gall-stone  obstruction   . . 

116 

Stokes-Adams'  disease 

172 

from 

563 

-  pancreatitis          ... 

116 

bradycardia     and     other 

-  pneumothorax  after         577, 

578 

Stercoral      ulcer      of    bowel, 

symptoms  of  . . 

97 

-  surgical  emphysema  from 

231 

acute  peritonitis  from  . . 

55 

coma  in    . . 

527 

Staccato  speech  in  disseminated 

STERILITY 

705 

convulsions  in        169,  172 

527 

sclerosis    . .          . .         3-12, 

686 

-  distinction  from  impotence 

346 

new  growths  in   . . 

98 

Staggering  (see  Gait) 

-  necessitj'     for     semen     ex- 

 sudden  halving  of  pulse- 

Staining  for  blood  films 

27 

amination  in 

705 

rate  in 

527 

-  method  for  gonococci       211, 

768 

-  due  to  oligospermia          706 

707 

Stomach,  acute  post-operative 

-  of     Skin      after     erythema 

-  salpingo-oophoritis 

760 

dilatation  of 

342 

papulatum 

531 

-  sex  incidence  of 

705 

-  atonic  dilatation  of 

354 

lichen  ruber  planus 

529 

-  from  .T-rays .  . 

80 

-  atony  of,  contramdicated  by 

pemphigus  vulgaris 

654 

Sternomastold,  .spasm  of  hjs- 

peristalsis  and  vomiting 

713 

psoriasis   . . 

657 

tprical 

166 

-  carcinoma  of  (see  Carcinoma 

sm;ill-pox 

605 

-  clonic  contractions  of 

161 

of  Stomach) 

-  -  sypli  Hides             . .         532 

604 

-  torticollis  due  to  injury  of. . 

708 

-  contents,       estimation       of 

-  Zieiil-Neelsen's  for  tubercle 

Sternum,  affection  of,  in  yaws 

449 

total  acidity  of  . . 

355 

bacilli 

700 

tenderness    of    the    chest 

examination  of  . . 

355 

Stammering 

688 

from 

776 

excess  of  mucus  in  gas- 

- bladder         

439 

-  carcinoma  of,  secondary  . . 

776 

tritis 

352 

-  in  general  paralj'sis 

688 

-  erosion  by  aneurysm        194, 

482 

microscopic  examination  of  355 

Stapedius  muscle  paralysis  . . 

536 

-  new  growth  of,   tenderness 

stagnating     in     pyloric 

hyperacusis  from 

53  7 

in  the  chest  from 

776 

obstruction 

353 

Stapes,  fixed  in  otosclerosis . . 

190 

-  periostitis  of,  causes  of 

776 

-  -  tests  for  free  HGl  in      . . 

355 

method  of  diagnosing  . . 

189 

-  swelling  on,  syphilitic 

752 

ferments  in 

355 

-  pressure  on,  vertigo  due  to 

828 

-  tenderness  of  (see  Tenderness 

organic  acids  in 

355 

Staphylococcus,  in  ascitic  fluid 

57 

of  Sternum) 

(See    also     Vomit ;     and 

-  bacteriuria  from 

83 

STERTOR        

707 

Vomiting) 

-  in  cerebrospinal  fluid 

340 

-  distbiction  from  stridor     . . 

707 

-  cough  due  to 

175 

-  circulating  blood     . . 

650 

-  during  convulsions 

169 

-  determination  of  mobility  of 

355 

-  empyema 

119 

-  in  malingerers 

173 

of  size 

355 

-  epididymo-orchitis 

518 

-  Stokes-Adams'   disease 

97 

-  dilated 

-  fungating  endocarditis 

237 

-  syncope  of  fatty  heart 

241 

acetonuria  m 

4 

-  impetigo      . .             113,  601 

602 

-  uricmic 

48 

asthenic    . . 

354 

-  laryngitis     . .            670,  673 

709 

Stiffness  of  back  from    abdo- 

 atonic,  absence  of  visible 

-  meningitis  (and  see  Menin- 

minal aneurysm.  .299,  486 

,728 

peristalsis  in    . . 

571 

gitis,  Staphylococcal)    339 

642 

in  dorsal  spinal  caries    . . 

474 

bismuth  meal  and  a;-rays 

-  in  nasal  discharge  . . 

203 

from  myalgia 

607 

in  diagnosis  of 

352 

-  normal  urethra 

82 

-  of  joint,  hysterical . . 

389 

in  carcinoma 

351 

-  pemphigus  neonatorum     111 

,113 

in    intermittent    liydrar- 

causes  of  . .          . .         352 

712 

-  pharyngitis 

670 

tlurosis  . . 

387 

characters  of  vomit 

845 

992 


STOMACH,    DILATED— STRYCHNINE  POISONING 


Stomach,  dilated,  contd. 
demonstration  of  stagna- 
tion by  treatment  iii.  .  352 

diagnosis   from   duodenal 

carcinoma         . .          . .  725 

gastroptosis  of            352,  353 

from  hour-glass  stomach  353 

of  indigestion  from     . .  352 

extreme  tliirst  due  to  . .  789 

-  -  in  gastric  carcinoma     .  .  846 

flatulence  in        . .          . .  267 

indicanuria  in      .  .          .  .  349 

large   quantities   of   fluid 

vomited  with  . .          . .  845 
limited  value  of  sucoussion 

in  indicating   . .          . .  712 

percussion  tests  for       .  .  352 

ptyalism  in          . .          . .  591 

from  pyloric  obstruction 

723,  789 

colicky  pains  of       . .  134 

pylorus  sometimes  in  right 

iliac  fossa          .  .          . .  737 

-  -  sarcinse  in  vomit  with  . .  713 

simulated  by  dilated  colon  714 

-'-  simulation  of  ascites  by  717 

-  -  succussion  sounds  in     352,  711 

-  -  tetany  after        . .  3,  178,  802 

visible  gastric  peristalsis  in  571 

vomiting  W'ith     . .        737,  843 

-  -  wasting  in            . .          . .  737 

-  disease,  constipation  in     . .  144 

-  -  of  negroes             . .          . .  115 

-  -  pain   in   temporal  region 

from      . .          . ;         . .  783 

and  tenderness  in  back 

from  (Fig.  204)        . .  788 

-  -  tenderness  in  chest  from 

77G,  779 
epigastrium  from        779,  783 

-  downward   displacement  in 

general  visceroptosis  (Fii. 

105,  p.  353)          .  .          .  .  473 

-  dry  cough  due  to   . .          . .  175 

-  flatulence     in     functional 

disorders  of         . .          . .  267 

-  flatulent  distention  of,  pain 

in  left  hypochondrium  in  499 

-  hsemorrhagic     erosions     of, 

hfematemesis  from        294,  298 

-  herniated  into   thorax        .  .  712 

-  hour-glass,      anomalies     of 

resonance  in        . .          . .  353 

diagnosis     from     gastric 

dilatation         . .          . .  353 
gastric     lavage     in     dia- 
gnosing            . .          . .  353 

paradoxical  dilatation  in  353 

symptoms  of       . .          . .  845 

vomiting  from    . .          . .  843 

-  inflation  of,  in  diagnosis  of 

pancreatic  cyst  .  .          .  .  690 

for  diagnostic  purposes 

352,  355,  690 

-  injm-ies,  liaematemesis  in  294,  299 

-  methods  of  examination  of  355 

-  motor  insufficiency  of,  evi- 

dence from   gastric   con- 
tents           844 

-  normal  emptying  time  of  . .  355 
situation  of          . .         722,  727 

-  pain  in          .  .          .  .          .  .  484 

-  reflexes,  ptyalism  from     . .  591 

-  rupture  of  aneurysm  into  140 

-  sarcoma  of  (see  Sarcoma  of 

Stomach) 

-  succussion  sounds  in  normal 

710,  711 

-  ulceration  of  (see  Gastric  Ulcer) 

-  vagus  nerve  sujiplying      . .  842 

-  a;-rays      and      bismuth     in 

demarcating         . .          . .  727 
Stomach-aclie     in      Henoch's 

purpura    . .          . .          . .  600 


Stomach-ache  and  spinal  caries 

confused  . . 
Stomacli-tube  in  diagnosis  of 

pyloric  obstruction 
Stomatitis,  aphthous 

in  childhood 

ptyalism  in 

-  bacteriology  in  diagnosis  of 


144 
815 
815 
590 
591 
86,  88 


bleeding  gums  in 

-  dysphagia  in           . .          . .  225 

-  enlargement  of  submaxillary 

lymphatic  elands  in        . .  419 

-  foul  taste  from        .  .          . .  774 
breatli  due  to      . .          . .  99 

-  impetiginous,    perleche     m 

association  with..          ..  404 

-  loss  of  taste  due  to. .          . .  774 

-  malignant     . .          . .          . .  590 

-  mercurial,  37,  295,  590,  774,  797 

-  ptyaUsm  in              . .          . .  590 

-  in  scurvy     . .          . .          . .  85 

-  sprue             . .          . .          . .  197 

-  suppurative              . .          . .  590 

-  in  syphilis     . .          . .          . .  86 

-  tuberculous,  in  phthisis     . .  591 
ptyalism  in          .  .          590,  591 

-  ulcer  of  the  tongue  with    . .  812 

-  ulcerative,  causes  of          . .  815 

-  varieties  of  . .          . .    86,  88,  590 

-  Wassermann's  reaction  in  591 
Stone  (see  Calculus) 
Stonemason's  lung     . .          . .  317 
Stools  black  after  bismuth   . .  428 

-  characters      in      pancreatic 

insufficiency         . .          . .  216 

STOOLS,  FATTY                    ..  265 

-  of  dysentery,  amcBba  coli  in  196 

-  examination  of  in  diarrhoea  196 

-  hepatic  pus  in         . .          . .  409 

-  pale,  in  obstruction  of  bile- 

ducts         ..          ..         362,  410 

-  rice-water,  in  cholera         . .  301 

-  sloughs  from  Peyer's  patches 

in  typhoid  fever  . .          . .  697 

-  trichinellfe  in,  in  trichinosis  504 

-  vibrio  of  cholera  in            . .  301 
Stoutness  in  etiology  of  gall- 
stones      . .          . .          . .  135 

STRABISMUS 709 

-  amblyopia  with       . .          .  .  836 

-  in    association   with   laryn- 

geal paralysis       .  .          . .  539 

-  without  diplopia     . .          . .  200 

-  diplopia  from           . .          . .  709 

-  in  disseminated  sclerosis   . .  838 

-  meningitis    . .  .  .350,  359,  563 

-  myasthenia  gravis              . .  687 

-  organic  cerebral  disease     . .  328 

-  due  to  syphilis        . .          . .  640 

-  tlirombosis     of     cavernoas 

sinus          .  .          . .          . .  651 

-  tuberculous  meningitis      . .  174 
Strain,  aortic  disease  due  to 

2.36,  237,  23S 

-  conjunctival  haemorrhage  from256 

-  orchitis  from            .  .          . .  79 

-  rupture  of  aortic  valve  from  106 

-  sudden      muscular,      spinal 

lesions  produced  by       . .  787 
Strangulated  hernia  (see  Hernia, 
Strangulated) 

-  fibromyomata  of  uterus     . . 

-  spleen 
Strangury   from  retention   of 

mine 
Strapping     in     distinguishing 

growth    and    gumma    of 

testis 
Stramonium    in   diagnosis   of 

asthma     .  .           .  .           .  .  582 

Straw,  actinomycosis  from  . .  87 

-  sporotrichosis  from             . .  322 
Strawberry  tongue  m  scarlet 

fever          607 


434 
700 


440 


521 


339, 


Streptococcus,  in  ascitic  fluid 

-  bacteriuria  from     .  . 

-  broncho-pneumonia 

-  in  cerebrospinal  fluid 

-  the  circulating  blood 

-  cystitis 

-  empyema 

-  epididymo-orchitis 

-  erysipelas 

-  fungating  endocarditis 

-  and  gonococci  associated  . . 

-  in  impetigo  . . 

-  laryngitis   due  to  . .      226. 

465,  466,  670, 

oedematous 

suffocative 

-  meningitis  due  to 

-  in  nasal  discharge 

-  nephritis  due  to     . . 

-  normal  urethra 

-  perleche  from 

-  pharyngitis  from    . . 

-  in  phthisical  sputum 

-  prostatitis  due  to  . . 

-  pyelitis  due  to 

-  in  septicaemia 

-  suppurative  meningitis 

-  tonsillitis 

-  ureteritis 

Streptotrichosis   of  liver 
Striations  on  lips  in  congenital 

syphilis  (Fig.  79) 
Stricture    of    cesophagus    (see 
Esophagus) 

-  of  urethra   

albuminuria  from 

associated  with  carcinoma 

bilateral  hydronephrosis  in 

bougie  in  diagnosing 

439,  440, 

and  calculus  associated 

catheter  in  diagnosing  . . 

changes  in  stream  of  urine 

from 

cystitis  from 

dribbling    of   urine   after 

cassation  of  stream  in 

-  -  endoscooe   in   diagnosing 

208,  439,  flO,  511, 

feeble  stream  of  urine  in 

forced  urination  in 

gradually  increasing  diffi- 
culty of  micturition  in 

hydronephrosis  due  to  . . 

micturition,   difficulty    in 

starting  in 

frequency  of,  in 

pain  during,  in 

in  penis  during 

nephritis  from    . . 

pyelitis  in 

pyonephrosis  from 

pyuria  due  to     .  . 

retention  of  urine  in 

from  spasm  or  congestion 

urethral  abscess  due  to. . 

calculus  behind 

fistute  from       442,  677, 

l^rethritis  from    . . 

STRIDOR         

-  distinction  from  stertor     . . 

-  in  larvngeal  obstruction 

185,  465, 

-  due  to  potassium  iodide    . . 
Strophanthus,        bradycardia 

from 
Strophulus,  papules  of 

-  severe  itching  in     . . 

-  varicella  simulating 

-  vesicles  in    . . 

-  wheals  in      . . 
Strychnine  poisoning,  absence 

of  lockjaw  in 
consciousness  retained  in 


510, 


623, 
45, 


83 
615 
340 
650 

83 
119 
518 
113 
237 
377 
601 

673 
709 
185 
642 
203 
83 
82 
403 
670 
701 


612 

670 

83 

415 

259 


510 

16 

20f) 

310 

511 
439 
439 

438 
627 


6  78 
511 
511 

511 
310 

439 
581 
441 
511 
.«! 
625 
626 
631 
440 
440 
679 
677 
678 
766 
709 
707 

462 
709 

98 
528 
850 
833 
833 
850 

463 
464 


STRYCHNINE    POISONING— SUPRARENAL    TUMOUR 


993 


Slrychnine  poisoning,  contd. 

convulsions  in      169,  170,  801 

diagnosis  by  analj'sis     464,  652 

from  hysteria     464,  652,  801 

tetanus  . .  . .       162,  802 

opistliotonos  in  . .         463,  652 

retraction  of  the  he^d  in      641 

-  risus  sardonicus  in     463, 

651,  652 
spasms  in  . .  . .     178 

-  symptoms  brought  on  by 

toucliiiiK  patient         . .     652 

-  -  trismus  late  in    . .        162,  802 
twitcliinss    and    convul- 
sions in 

from  vermin-killers 

-  priapism  caused  by 
Stuffy  rooms,  headache  from 
Stunting  in  cretinism 

-  Hanot's  cirrhosis    . . 

-  splenomegalic  cirrhosis 
Stupor  in  choliemia    . . 
Stuttering  (see  Speech,  Abnor- 
malities of) 

Stye,  conjunctivitis  due  to  . . 

Stylomastoid  foramen,  effects 
of  lesion  at 

Subclavian  artery,  abnormal 

aneurysm  of  ("see  Aneur- 
ysm, Subclavian) 

unequal  pulses  from  athe- 
roma of    . . 

Subdiaphragmatic  abcess  (see 
Abscess,  Subphrenic) 

Subinvolution  of  uterus 

-  -  menorrhagia  from 

-  -  metrostaxis  from 

uterine  congestion  in     . . 

Submammary  abscess 
Submaxillary  abscess . . 

-  lymphatic  glands  (see  Lym- 

phatic Glands,  Submaxillary) 
Subnormal  temperature        . .     345 
Subphrenic  abscess  (see   Abs- 
cess, Subphrenic) 
Subscapular    nerve,    muscles 
supplied  by 

spinal  roots  derived  from 

Subscapularis  muscle,  spinal 
nerve-root  supplying     . . 

-  -  nerve  supply  of  . . 
Subthalamic  region,  hyperpy- 
rexia from  lesions  of 

tumour  of  (see  ilid-brain. 

Tumour  of)      . .  . .     798 

Succinic  acid,  leucocytosis  from  400 
Succulent   hand    in    syringo- 
myelia     . .  . .  . .     285 

SUCCUSSION  SOUNDS  ..     710 

-  -  in  abdomen,  causes  of  . .     711 
epigastrium,     gastric 

colonic 

gastric 

limits  of  normal 

with  pneumothorax 

in  pyloric  or  duodenal  ob- 
struction 

-  thoracic 

list  of  causes  of    . . 

"  Sucking     in  "     above     the 

clavicles  in  laryngeal  or 

tracheal  obstruction  465,  642 
Sudamen,  vesicles  with  . .  714 
Sudan  m  test  for  chyluria. .  126 
Sudden    death    from    fibroid 

heart         242 

ruptured  aneurj-sm       107,  140 

Suffocative  oedema  simulated 

by  laryngeal  paralysis  . . 
Suffocation,  sense  of,  associated 

with  flushing 
Sugar  in  cerebrospinal  fluid  . . 

-  sore  fingers  from  handling 

-  in  urine  (see  Glycosuria)  _ 


802 
464 

586 
327 
258 
410 
369 
361 


256 


537 
223 


593 


429 
428 
436 
429 
744 
419 


550 
550 


556 
550 


346 


723 


352,  723 
..      710 


571 
193 
711 


539 

268 
339 

266 


Suggestion  (fear  of  pregnancy) 

causing  amenorrhoea     . .       23 

-  in  diagnosis  of  phantom  tu- 

mours        721 

-  hysteria        . .  150,  343,  527 

-  treatment     of     functional 

hiccough  . .  . .  . .     343 

paralysis  of  vocal  cords     538 

Suicide  by  phosphorus  . .     373 

-  the     result     of      extreme 

tinnitus    . .  . .  . .     793 

Sulphhoemoglobinuria  184,  187 

Sulphanilic  acid  reagent  ..  197 
Sulphates,    aromatic,    in    the 

urine         . .  . .  . .     823 

-  urinary,    ratio    of    organic 

to  inorganic         . .  . .       97 

Sulphides  formed  during  putre- 
faction     . .  . .  . .     283 

Sulphonal,  Cheyne-Stokes 

respiration  due  to  . .     125 

-  coma  due  to  . .  . .     137 

-  liasmatoporphyrinuria  due  to  820 

-  poisoning,   influence  of  sex 

on 20 

-  purpura  from  effect  of  taking  59G 
Sulphur  dioxide  causing  coryza    203 

-  granules     in     abscess     in 

actinomycosis  of  liver  . .  415 
Sulphuretted      hydrogen      in 

urine         . .  . .  . .     187 

Sulphuric      acid,      in      Ziehl- 

Xeelsen  tubercle  stain  . .  700 
Summer    season,   relation    to 

cheiropompjiolyx  . .     832 

-  severe  diarrhcea  in  infants  in  579 
Sun,  erythema  from  exposure 

to 252 

Sunstroke,  headache  in        . .     329 

-  hyperpyrexia  in      . .  . .     344 
Superciliary    ridges,    enlarge- 
ment in  acromegaly      749,  753 

Superficial  cervical  nerve,  skin 

distribution  of     . .  . .     659 

Snperinvolution  of  uterus  caus- 
ing amenorrhoea  23,  24 

Supernumerary  ribs  (see  Eib, 
Cervical) 

Superior  gluteal  nerve,  muscles 

supplied  by         . .  . .     542 

spinal  roots  derived  from  542 

-  longitudinal    sinus    tlirom- 

b'osis  (see  Thrombosis) 
convulsions  in         . .     558 

-  mesenteric  artery,  embolism 

of,     in    fungating    endo- 
carditis    . .  . .  . .     646 

-  vena  cava,  obstruction  of, 

cyanosis  from     . .  . .     184 

by   aortic   aneurysm 

(Figs.  1-2,  73)   234, 

235,  236,  826 

aneurysm     . .  . .     746 

bronchial  glands     . .     422 

bruit  with   . .  . .     236 

causes  of      . .  . .     461 

causing     oedema     of 

face,  neck  and  arms     458 

by    chronic    fibrous 

mediastinitis        . .     826 

cyanosis  from         . .     184 

in  mediastinal  fibrosis 

484,  746 

growth      . .         465,  483 

mediastinal  new  growth  826 

by  new  growth  121,188,322 

oedema  of  arms  and 

head  from  . .     826 

face,     neck       and 

arms  from       . .     461 
rupture  of  aortic  aneu- 
rysm into     . .  . .     482 
thrombosis  (see  Throm- 
bosis) 


Supinator  brevis,  nerve  supply    550 

-  jerks  exaggerated  in  upper 

neurone  lesions  . .  . .     546 

-  longus,  clonus  of    . .  . .     161 

escape  in  lead  palsy      . .       77 

nerve  supply  of  . .  . .     550 

spinal  nerve-root  supplying  556 

Suppositories  in  diagnosis  of 

nature  of  constipation  . .     142 
Suppression  of  urine  (see  Anuria) 
Suppuration  in  accessory  nasal 

sinuses,  earache  from  . .     230 

-  deep-seated,  anaemia  in     . .       39 

-  headache  in  . .  . .     328 

-  leucocytosis  due  to  614,  62J3,  899 

-  long-standing,      lardaceous 

disease  from         197,  414,  696 
causing  amenorrhoea     . .       23 

-  in  onychia   . .  . .  . .     445 

-  polymorphonuclear     leuco- 

cytosis as  evidence  of    . .     400 
Suppurative    meningitis    (see 
Jleningitis  Suppurative) 

-  otitis  media  (see  Otitis  Media) 
Supraclavicular    glands,    dia- 
gnosis of  site  of  abdominal 
growth    by    microscopic 
examination  of  . .  . .     421 

enlarged  (see  Lymphatic 

Glands,  Supraclavicular) 

-  nerve,  skin  distribution  of      659 
Supraorbital     nerve     region, 

herpetic  eruption  of       . .     807 
skin  distribution  of       . .     659 

-  neuralgia      in      iritis      and 

cycUtis      . .  . .  . .     256 

-  pain  from  eyestrain  . .     495 
Suprarenal  gland,  carcinoma  of 

(see  Carcinoma  of  Supra- 
renal) 

malignant     disease       of, 

(see     also     Suprarenal 
Tumour)  ..  ..690 

normal  situation  of       . .     722 

sarcoma     of,     secondary 

deposits  in  cranium  from  782 

-  rests     in     kidney,     hyper- 

nephroma from    . .  . .     690 

-  secretion,  effect  on  menstrua- 

tion   430 

-  tumour,  abdominal  swelling 

due  to 393 

no    Addison's   disease    if 

unilateral  . .  . .     690 

associated     with     sexual 

precocity  . .  . .     729 

diagnosis       from       renal 

tumour  . .  . .     690 

splenic  tumour  . .     690 

excessive  fatness  of  chil- 
dren from        . .  . .     454 

filling  of  loin  by  . .  . .     729 

hasmatiiria  from  involve- 
ment of  kidney  in       . .     690 

jaundice  in  . .  . .     362 

laparotomy  in  diagnosing      690 

from  renal  tumours      393 

malignant  . .  . .     690 

obesity  with        . .  . .     454 

palpable  in  epigastrium        725 

right  lumbar  region  . .     727 

'physical  signs  of. .  ..     690 

simulation    of    renal    or 

hepatic  swelling  . .     367 

premature     development 

of  genitalia  with        . .     454 

in  right  capsule,  bile-duct 

obstruction  from        . .     367 
rounded   movable   hypo- 
chondriac sweUing  due  to  393 

simulating  enlarged  spleen 

726,  729 

urinary     changes,     from 

involvement  of  kidney  in  690 

63 


994 


SUPRASCAPULAR    NERVE— SWELLING    OF    JAW 


Suprascapular  nerve,  muscles 

Swelling,  Abdominal,  contd. 

Sicelling  of  the  face,  contd. 

supplied  by     . . 

550 

in  carcinoma  of  colon      91 

499 

subjective  sensation  of  in 

paralysis  of 

551 

pancreas   . .         . .     500 

690 

trigeminal  neuralgia  . . 

495 

spinal  roots  derived  from 

550 

stomach             351,  485 

691 

vaccinia     . . 

746 

Supraspinatus,  nerve  supply  of 

550 

classified  list  of  causes  of 

715 

SWELLING,  FEMORAL 

732 

-  wasting  in  phthisis 

72 

-  -  constipation    from    pres- 

 due  to  ectopic  testis 

740 

Supratrochlear  nerve,  skin  dis- 

sure of  large    . . 

148 

-  of  foot  from  mycetoma    .  . 

809 

tribution  of 

659 

displacement    of    cardiac 

-  hyi)ochondrium,  left,  due  to 

Surgical       emphysema       (see 

impulse  by      . .         330, 

332 

splenic  enlargement 

688 

Emphysema,  Surgical) 

due  to  fifcal  accumulation 

692 

-  hypogastric,  due  to  bladder 

45 

-  kidney  (see  Nephritis,  Ascen- 

 from  intussusception 

736 

SWELLING  IN  ILIAC  FOSS/E 

ding) 

multiple,    in    tuberculous 

735, 

737 

Svi'abbing    of   tonsils    in    dia- 

peritonitis 

152 

in  psoas  or  iliac  abscess 

633 

gnosis  of  tliroat  infections 

419 

orthopnoea  from  pressure  of  465 

-  -  fossa,     left,    from     acute 

Swallowing,  difficulty  in   (see 

pancreatic  affections 

486 

diverticulitis    . . 

731 

Dysphagia; 

due  to  phantom  tumour 

761 

aneurysm  of  external 

Sweat,  bloody 

715 

-  -  pulsatile 

763 

iliac  artery 

735 

-  coloured  from  chromidrosis 

714 

pulsating   and   expansile, 

carcinoma  of  sigmoid 

735 

-  ducts    involved    in    granu- 

in abdominal  aneurysm 

486 

congenital  dilatation 

losis  rubra  nasi    . . 

714 

due  to  splenic  enlargement 

689 

of  the  colon 

735 

-  foul    smelling 

714 

-  -  -  suprarenal  tumour 

393 

-  diverticula  simulating 

-  retention,  cheiropompholyx 

tuberculous  peritonitis 

691 

carcinoma  in 

152 

due  to 

111 

tympanitic  on  percussion, 

enlarged  lymph  glands 

735 

-  urinous  odour  of     .  . 

715 

in  subphrenic  abscess 

501 

spleen  in   . . 

735 

SWEATING,      ABNORMALI- 

SWELLING,   AXILLARY     .. 

731 

kidney  palpable  in 

735 

TIES  OF 

714 

-  of  bones  in  acromegaly     . . 

753 

psoas  abscess 

733 

-  absence  of    . . 

714 

from  gout 

754 

—  -  -  ulcerative  colitis 

735 

facial  in  cervical  sympa- 

 in  leontiasis  ossea 

753 

various  tumours  felt  in 

731 

thetic  paralysis 

247 

osteitis  deformans 

753 

right,    due    to    actino- 

in  spots  of  leprosy 

424 

-  -  osteo-arthritis 

754 

myces 

736 

-  in  acute  rheumatism 

375 

pulmonary    hypertrophic 

appendicitis             729 

736 

-  bacilluria 

616 

osteo-arthropathy 

754 

broad  ligament  abscess  737 

-  colic 133, 

472 

rickets 

753 

carcinoma  of  CEecum 

-  crises  of  locomotor  ataxy . . 

562 

SWELLING  ON  A  BONE 

750 

729 

736 

-  deficiency  of,  in  myxoedema 

585 

due  to  callus 

750 

-  - pylorus 

737 

-  in  enteric  fever 

648 

carcinoma 

757 

chondroma  of  pelvis 

737 

-  extreme  thirst  after 

789 

in  chloroma 

599 

disease  of  iliuin 

730 

-  in  fungating  endocarditis  103 

237 

chondroma  (Fig.  195)     . . 

755 

enlarged  iliac  lymph- 

- Graves'  disease 

797 

clu-onic   abscess  . .        750, 

752 

atic  glands          730 

736 

-  from  hepatic  abscess 

651 

osteomyelitis   . . 

751 

extension      upwards 

-  in  Hodgkin's  disease 

649 

periostitis 

751 

of  pelvic  swelling 

737 

-  hyperidrosis,     in     arsenical 

in  congenital  syphilis   . . 

752 

hip-joint  disease 

730 

poisoning . .          . .            7C 

,  87 

exostosis  . . 

754 

mode  of  investigating 

735 

brachial  neuralgia 

491 

fibroma     . . 

755 

movable  kidney  in  . . 

729 

egg-shell    nail    associated 

gumma     . . 

752 

due  to  osteomyelitis 

with 

445 

hydatid  cj'st 

757 

of  ilium    . . 

737 

-  in  influenza 

699 

inflammatory 

750 

ovarian  cyst 

737 

-  leukJEmia 

649 

-  -  injury 

750 

pregnant  uterus 

737 

-  with  lightning  pains  of  tabes 

489 

lipoma 

755 

psoas  abscess 

730 

-  in  malaria    . .          . .           35, 

615 

mode  of  examination  in 

pyosalpinx  . . 

737 

-  malingering . . 

464 

oases  of 

750 

Kiedel's  lobe  of  liver 

737 

-  malnutrition 

714 

multiple     in     secondary 

sacro-iliac  joint  disease  730 

-  Malta  fever 

506 

syphilis 

752 

sarcomaof  pelvic  bones  737 

-  at  night     (and     see    Night 

painful  in  scurvy-rickets 

753 

in  scybala     . . 

729 

Sweating) 

714 

worse     at     night,      in 

spinal  caries 

737 

in  phthisis           . .        577, 

714 

secondary  syphilis.. 

752 

suppurating         gall- 

- pernicious  anaemia . . 

649 

due  to  sarcoma  . .        755, 

756 

bladder     . . 

737 

-  pink  tint  with 

714 

subperiosteal  extravasation 

750 

tuberculous  caecum. . 

736 

-  profuse,  constipation  due  to 

145 

-  -  tender   in  secondary   sy- 

 disease  of  ilium  . . 

773 

-  -  after  crisis  in  pneumonia 

702 

philis     . .          . .  ' 

752 

tumours     from    car- 

 in  infantile  scurvy 

115 

due  to  tuberculous  disease 

cinoma  of  colon  . . 

152 

tropical  abscess  of  liver  . . 

369 

751, 

752 

thickened      diver- 

- in  pyaemia    . .          . .        372, 

649 

periostitis 

752 

ticula    . . 

152 

-  pyonephrosis 

396 

in  tyjjhoid  fever 

752 

uterine  fibroid 

737 

-  relapsing  fever 

698 

-  in  breast      (see      Swellmg, 

various  tumours  felt 

-  rheumatoid  arthritis 

378 

Mammary) 

in  . .          . .         729, 

730 

-  in  rickets 

171 

-  in   epigastrium    in   tropical 

wandering  kidney  . . 

737 

-  during  rigors 

646 

abscess  of  liver    . . 

369 

spleen 

737 

-  in  salpingo-oophoritis 

760 

SWELLING  OF  THE  FACE  .. 

746 

-  of    ileo-costal    space    from 

-  sense  of,  in   a   dry  part,  in 

due    to    alveolar    abscess 

746 

renal  tumour 

391 

syringomyelia     . . 

664 

anthrax     . . 

746 

SWELLING,    INGUINAL    (see 

-  in  septicaemia 

375 

boil,  carbuncle,  or  suppur- 

Inguinal Swelling) 

-  with  sinus  thrombosis 

650 

ating  wound    . . 

746 

SWELLING,   INGUINO-SCRO- 

-  in  trichinosis 

504 

chancre  (Fig.  10,  p.  86)  . . 

746 

TAL  (see  Inguino-scrotal 

-  tropical  abscess  of   liver  . . 

408 

dental  caries 

746 

Swelling) 

-  urate  deposit  with . . 

815 

epithelioma 

746 

-  at  inner  side  of  orbit  from 

-  yellow  in  jaundice  . . 

361 

erysipelas  . . 

746 

ethmoidal  inflammation 

255 

Sweep's  cancer           . .         765 

803 

fibroma 

746 

SWELLING  OF  JAW,        747, 

749 

Sweets,  blue  urine  after 

823 

insect  bites 

747 

-  -  from  extension  of  cancer 

-  eosin  used  in  colouring  of 

820 

lipoma 

746 

of  tongue  or   mouth . . 

749 

-  green  urine  after    . . 

823 

mumps      . .         . . 

746 

fibroma     .  . 

748 

-  red  urine  after        . .        819 

820 

oedema  (see  CEdema  of  Face) 

due  to  fibrous  epulis     . . 

748 

SWELLING,  ABDOMINAL  .. 

715 

parotitis    . . 

746 

fracture    .  . 

747 

ascites  with  various 

59 

sebaceous  cyst     . . 

746 

hacmatoma 

747 

SWELLING    OF    JAW— SYPHILIS,     CONGENITAL 


995 


Swelling  of  jaw,  contd. 

Sycosis  vulgaris,  contd. 

Syphilis,  contd. 

injury       

747 

diagnosis  from  eczema   . . 

602 

-  aneurysm  of  heart  from    . . 

241 

otiontomata 

749 

ringworm  of  the  beard 

274 

-  angina  pectoris  from 

62 

osteoma    . . 

748 

tertiary  sypliilis 

603 

-  anosmia  from 

668 

periostitis 

747 

dropping  out  of  the  hairs  in 

602 

-  aortic  disease  from    18,  62, 

tumours    of    antrum    of 

of  face 

654 

233,  236,  237, 

238 

Ilitj'limore 

749 

leprous  nodules  simulating 

450 

-  aortitis  from           . .  38,  106, 

481 

-  -  lower        

747 

parts  affected  by 

602 

-  arthritis    in   (see   Artluritis, 

—    -  ilue    to    actinomycosis 

748 

pu.stules  in           . .        GDI, 

002 

Syphilitic) 

-  -  -  iilveolar  abscess 

747 

scabs  in    . . 

654 

-  a.scites  from. .          . .             55,  60 

omIIus  from  fracture  . . 

747 

slightness  of  itching  in  . . 

002 

-  ataxic  paraplegia  from     . . 

605 

—  -  carcinoma  fand  see  Car- 

 due  to  staphylococci 

002 

-  atheroma  from        . .        233, 

238 

cinoma  of  Jaw) 

749 

Sympathetic,  abdomuial :    in- 

- atrophic   palsy    of  one   leg 

mode  of  examination  in 

747 

fluence  on  pigmentation 

574 

from 

543 

situation  often  masked 

-  cervical  (see  Cervical  Sym- 

-  balanitis   in. . 

674 

by  superficial  swcU- 

patlietic) 

-  baldness  from         . .            8i 

,  85 

inpr     . . 

747 

Syncope  in  Addison's  disease  38 

849 

-  bleeding  gums  in    . .            85 

,  86 

-  of  joints  Cand  see  Artljriti-) 

450 

-  fatty  heirt  . . 

241 

-  of  bone,  simulating  sarcoma 

756 

-  of  legs  (see  CEdema  of  Legs) 

-  from  gastric  ulcer  bleeding 

298 

-  bronchial  stenosis  from  288, 

multiple,    red,    tender,  in 

-  local,  in  Kaynaud's  disease 

490 

324,  325, 

582 

erythema  nodosum     . . 

751 

-  in  myocardial  degeneration 

333 

-  bulke  in       . .          . .         110, 

112 

-  of    limbs,    local,    from    em- 

- thymic  infantilism  .  . 

215 

-  cachexia  from    17,  37,  114, 

bolism 

237 

Synovia!  etfusion  (see  Arthritis 

115,  347,  459,  461,  575, 

658 

-  of  lips,  due  to  mercury 

86 

and  Synovitis) 

-  and  cancer,  not  distinguished 

88 

Synovitis       from       displaced 

by  pyrexia           . .  " 

618 

-  in    lumbar   re!:;ion,    loft,    in 

semilunar  cartilage 

388 

-  cavernitis  in  penis  from     . . 

516 

splenic  enlar^oraent  . . 

688 

-  in  secondary  syphilis 

386 

-  cerebral,  coma  in      . .    136 

138 

SWELLING,  MAMMARY  (and 

-  infective,  anaemia  in 

36 

convulsions  in     . .        109, 

172 

see  Breast) 

742 

neighbouring     lymphatic 

endarteritis  from           327 

337 

-  in  the  muscles  in  trichinosis 

504 

glands  enlarged  in     418 

422 

hemianopsia  in    . . 

335 

-  nodular,  witli  varicose  veins 

450 

from  pyorrhoea  alveolaris 

87 

liemiplegia  from  . . 

337 

-  of  orbital  tissues  in  cavernous 

-  secondary   syphilis .  . 

386 

insomnia  in          . .        356, 

358 

sinus  thrombosis 

254 

(and  see  Artliritis) 

multiple     cranial     nerve 

SWELLING,  PELVIC            757 

761 

Syphilides,  circinate  tuoercular, 

paralysis  from .  . 

590 

behind  uterus  in  salpingo- 

diagnosis    from   ringworm 

ptosis  from  (Figs.  156-159) 

590 

oojilioritis 

220 

of  beard  . . 

274 

thrombosis  from    138,  173 

503 

—  ectopic  gestation. .        436, 

757 

tinea  circinata 

275 

varieties  of 

173 

nephritis  from     . . 

8 

-  combes 

533 

-  chancre  of  (see  (Chancre) 

retention  of  urine  v/ith  . . 

45 

-  distinction  from  epithelioma 

803 

-  Cheyne-Stokes     respiration 

sciatic  nerve  paralysis  from 

542 

pityriasis  rosea    . . 

658 

from 

125 

-  perinephric     (see      Kidney 

from  tinea  versicolor     . . 

276 

-  choroiditis    in,    ophthalmo- 

Enlargement) 

-  distribution  of 

533 

scopic      appearance       of 

-  in    perineum    due    to    mis- 

-  impetiginous 

604 

(Plate  VI I) 

462 

I'l.iced  te.stis 

523 

-  itching  absent  in     . . 

604 

-  chronic    hypertrophic    hse- 

SWELLING,  POPLITEAL 

-  large  acuminate,  description 

morrhagic     pachymenin- 

7G1, 762, 

763 

of  lesion  of 

604 

gitis  from 

563 

-  in  pubic  region  due  to  mis- 

 flat      pustular,     coppery 

-  condylomata  in      403,  404, 

placed  testis 

523 

areola  and  base  in 

604 

469,  654 

769 

SWELLING,  PULSATILE    763 

764 

-  miliary 

604 

soft  sore  mistaken  for   . . 

769 

in  aortic  aneurysm 

561 

-  papular         

532 

-  congenital,  adiposis  dolorosa 

of  back  in  aortic  aneurysm 

476 

diagnosis  of  lichen  scrofu- 

from 

455 

cliest  w.ill 

194 

losorum  from 

530 

arthritis  in  (and  see  Ar- 

 inguinal,  due  to  aneurysm 

varieties    of        . .         532 

533 

thritis)  .  .          .  .        260, 

386 

of  external  iliac  artery  . . 

741 

-  pigmentary,     diagnosis     of 

cirrhosis  in          . .         305 

370 

popliteal,  from  sarcoma  of 

chloasma    and    leucoder- 

condylomata  in  . .        427, 

446 

femur    . . 

762 

mia  from 

575 

convulsions  from 

170 

SWELLING,  SCROTAL        764 

767 

-  polymorphism  of    . .         533, 

607 

craniotabes  in 

782 

due  to  cysts  of  epididymis 

767 

-  pustular       . .          532,  601 

607 

deafness  in 

259 

testis  "   . . 

521 

diagnosis  from  acne 

603 

depression  of  nose  in     . . 

259 

hoematocele 

523 

small-pox 

607 

Dercum's  disease  due  to 

455 

hydrocele 

522 

preference    for    genitals, 

diagnosis  from  Jacquet's 

-  supraorbital,    from    frontal 

scalp,  and  face 

604 

infantile  erythema 

440 

sinus  inflammation 

255 

pyrexia  with 

607 

seborrhoeic  eczema 

447 

-  in  thigh  due  to  misplaced 

-  raw-ham  colour  of. .        532, 

533 

enlargement  of  head,  dia- 

testis 

523 

-  reaction  to  mercury,  arsenic. 

gnosis  of  hydrocephalus 

-  of  toe,  in  gout 

381 

and  iodides 

604 

from      . .          . .         557, 

558 

-  tongue  due  to  mercury 

86 

-  scaly              

656 

-  -  epiphysitis  in       . .         386 

752 

-  umbilical  region  from  abscess 

-  secondary  cutaneous,  coppery 

erythema  of 

253 

in  tuberculous  peritonitis 

524 

colour  of  . . 

604 

facies  m  (Figs.  78,  79)  259, 

446 

in  carcinoma  of  colon 

524 

-  small  acuminate     . . 

604 

family    history    in     dia- 

 pylorus 

524 

flat  pustular 

604 

gnosis  of 

695 

due  to  divarication  of 

raw-ham  areola  in 

604 

frontal  bosses  in  (Fig.  78) 

259 

recti  . . 

524 

-  varioliform   . . 

601 

hot-cross-bun  skull  in   752, 

782 

hernia   . . 

524 

Syphilis  (and  see  Syphilides), 

Hutchinson's     teeth     in 

sebaceoas  cyst 

524 

acetonuria  in 

4 

(Figs.  79,  80)  .  .         259, 

260 

splenic  enlargement  . . 

688 

-  acqnued,  enlarged  liver  in 

370 

hyperplastic  osteitis  in  . . 

782 

-  at      vaginal      orifice      (see 

-  albuminuria  in  13,  16, 17,  86 

,371 

infantile  convulsions  due  to  169 

Prolapse  of  Uterus) 

-  alopecia  in  . . 

450 

infantilism  in 

260 

SWELLING,  VULVAL 

768 

-  amyloid  disease  from 

197 

interstitial  keratitis  in  . . 

828 

-  -  due    to    fibromyoma    of 

-  ansemia  in   . .          . .      27,  3 

•,  38 

jaundice  in          . .         365, 

370 

vagina       . .          . .        587, 

768 

severe,  from 

459 

lardaceous  disease  from 

414 

Swimmer's  cramp 

177 

-  aneurysm  after       223,  238, 

laryngitis  in 

446 

Sycosis  vulgaris,  diagnosis  of 

602 

296,  300,  322,  368, 

lipomatosis  from 

455 

from  acne  vulgaris 

603 

483,  486,  538,  564,  728 

786 

liver  changes  in    365,  370, 

411 

996 


SYPHILIS,    CONGENITAL— SYPHILIS,    ULCERATION    IN 


Syphilis,  congenital,  contd. 

liver  enlarged  in . . 

loose,     dry,     caf6-au-lait 

skin,  of . . 
marasmus  in 

-  -  mental  deficiency  in 

napkin-region  eruptions  in 

natiform.  skull  ia 

ocular  symptoms  of 

orchitis  in 

-  -  osteo-chondritis  in 

Parrot's  nodes  in  427, 

pemphigus  from.. 

pseudo-paralysis  in       386, 

pain  slight  in  . . 

rapid  improvement  with 

mercury  in  . . 

tenderness  in  . . 

pyrexia  due  to  gumma  in 

relation     of     pseudo-leu- 

kffimia  infantum  to     43, 

-  -  sallow  complexion  in 

scars  on  lips  in  . . 

skin  eruptions  in 

snuffles  in  427,  446, 

spleen  enlarged  in  692, 

tabes  from 

tenderness  of  the  scalp  in 

tibial  deformities  in 

Wassermann's  reaction  427, 

-  -  wasting  in  .  .  .  .      370, 

-  corona  veneris  of    . . 

-  cyanosis  in  . . 

-  cyclitis  due  to 

-  danger     of     mercury       in 

nepliritis  associated  ^ith 

-  diagnosis  of . . 

-  diazo-reaction  in     . . 

-  dwarfing    of    one    or    other 

lobe  of  liver  in    . . 

-  dysphagia  from 

-  ear  affections  in     . .         469, 

-  endarteritis  from  (see  Endo- 

arteritis) 

-  enlarged  mguinal  glands  in 

738, 

-  epididymitis  in 

-  epistaxis  in 

-  esthiomfene  due  to  . . 

-  Eustachian  tube  obstruction 

in  . . 

-  eye  paralysis  from. . 

-  facial  paralvsis  from  (Figs. 

158,159)" 

-  fibroid  heart  from      62,  241, 
lung    and    bronchiectasis 

from 

-  fibrous  mediastinitis  in 

-  fingers  aifected  by  . . 

-  fissured  tongue  from 

-  gangrene  in 

-  general     paralysis     of 

insane  from 

-  giddiness  due  to 

-  gingivitis  in. . 

-  glossitis  from 

-  gumma  in  (see  Gumma) 

-  hsemoglobinuria  in 

-  herpes  progenitalis  with    . . 

-  herpetic  urethritis  in 

-  impotence  in 

-  incubation  period  of         675, 

-  infantilism  from     . . 

-  intermittent       claudication 

from 

-  iritis  in         . .  . .         256, 

-  Jacksonian  epilepsy  from. . 

-  jaundice  from  362,  366, 

-  of  law,  rarity  of     . . 

-  lardaceous  disease  from 

10,  411,  414, 

-  laryngeal  paresis  from     539, 

-  laryngitis  in  (and  see  Laryn- 

gitis, Syphilitic)  . .  86,  325, 


538, 


the 
269, 


812, 


370 

446 
427 
260 
446 
752 
259 
519 
386 
752 
111 
387 
387 

387 
387 
615 

695 
259 
259 
695 
695 
695 
489 
782 
260 
695 
427 
532 
185 
256 

590 
604 
198 

404 
224 
828 


769 
519 
250 
769 

828 
224 

589 
242 

324 
826 
266 
813 
282 


86 
813 

315 

675 
209 
347 
676 
215 

489 
450 
161 
371 
748 

696 
640 

673 


Syphilis,  contd. 

-  of  larynx,  dysphagia  in     . .  226 
hEemoptysis  in     . .          . .  318 

-  leucoplakia  from     . .        237,  813 

-  lips  affected  m          403,  404,  813 

-  and  Little's  disease           . .  154 

-  of  liver        411 

absence    of    ascites     and 

jaundice  in          . .     410,  411 

general  symptoms  in  410,  411 

ascites  with         . .  55,  60 

diagnosis  from  carcinoma 

of  liver. .          . .         411,  413 

of    catarrhal    jaundice 

from                362,  366,  371 

from  cirrhosis . .        410,  411 

hydatid  disease  of       . .  415 

enlargement  of  liver  in  . .  411 

jaundice  with  large  liver 

m           363 

lumpy  irregular  shape  of 

liver  in              . .          . .  411 

rarity  of    . .          . .          . .  410 

spirochaeta  pallida  in     . .  371 

Wassermann's  reaction  in  371 

-  loculated  hydrocele  in        . .  765 

-  lupoid  variety  of    . .          . .  449 

-  lymphatic    gland     enlarge- 

ment in       266,  416,  417, 

533,  604,  675,  738,  769 

-  macular  eruption  in  throat  425 

-  macules    in    (see    Macules, 

Syphilitic) 

-  medullary     softening      due 

to 224,  343 

-  meningeal,  headache  in     . .  327 

-  meningitis  from  (see  Menin- 

gitis, Syphilitic) 

-  mercury  in  diagnosis  of  (see 

below.  Potassium  Iodide) 

-  meteorism  in           . .          . .  432 

-  moist  anal  papules  in       . .  447 
genital  j)apules  in          . .  447 

-  of  mucous  membranes       . .  371 

-  mucous  patch  on  fauces  or 

tonsils  in  . .          . .          . .  675 

tongue  from    . .           . .  813 

-  multiple  tender  swellings  on 

bones  in   . .          . .          . .  752 

-  muscular  atrophy  in          . .  76 

-  necrosis  of  jaw  from         747,  748 
nasal  bones  from  204,  237,  252 

-  nephritis  in              . .          . .  86 

-  nerve  deafness  from         190,  828 

-  night  pains  of          . .          . .  386 

-  nodes  on  bones  in  . .          . .  752 

-  nodules  in    . .          . .          . .  449 

epididymis  in      . .          . .  519 

-  obstruction  to  nose  by      . .  668 

-  oedema  of  face,  neck,   and 

arms  from           . .          . .  458 

larynx  in  . .          . .          . .  466 

legs  in      . .          . .         459,  461 

-  onychia  in   . .          . .          . .  445 

-  orchitis  from           . .          79,  519 

-  osteocopic  pains  in             . .  503 

-  otorrhcea  in. .          . .          . .  469 

-  ozsena  from..          ..          ..  204 

-  pachymeningitis  in  paralysis 

of  upper  extremity  from  555 

-  pain    in    arm    from    aortic 

disease  due  to      . .          . .  494 

bones  in    . .          . .          . .  503 

worse  at  night  in      . .  752 

-  pains    of,     confusion    with 

osteo-arthritis      . .          . .  386 

-  pancreatitis  from    . .          . .  116 

-  papular  skin  rash  in         769,  832 

-  paraplegia  from       .  .          . .  563 

-  paralysis  of  palate  in         . .  640 

-  paroxysmal     hfemo-globin- 

uria  from             . .          . .  315 

-  perforating  ulcer  of  foot  from  809 

-  -  of  palate  from      202,  237,  640 


Syphilis,  contd. 

-  perichondritis  in      . .  . .     791 

-  perihepatitis  from  . .  . .       60 

-  perineal  sores  in     . .         677,  678 

-  periosteal  thickening  in   . .     519 

-  peripheral  neuritis  in  76,  506,  507 

-  pharyngitis  in         . .  . .       86 

-  pigmented  scars  from       237,  575 

-  potassium  iodide  and  mer- 

cury in   diagnosing,   226,   254, 

325,  449,  520,  615,  640,  658, 

674,  677,  681,  808,  814 

-  primary,  lateral  sclerosis  from  567 

-  ptyalism  in  . .  . .  . .     590 

-  pupil  reflexes  in      . .  . .     594 

-  pustules  in  . .  . .  . .     833 

association   with   cachec- 
tic state  of  health      . .     604 

-  pyrexia  in        371,  607,  609, 

614,  615,  673 

-  rarefaction  of  bones  from . .     179 

-  relation  to  soft  sore  . .     738 

-  rhinitis  from  . .  . .     204 

-  roseola  in  86,  371,  425, 

615,  672,  676 

-  rupial  crusts  in       . .         653,  654 

-  rupture  of  heart  from       238,  241 

-  salvarsan  in  diagnosis  of  . .     814 

-  scarring  of  palate  from     . .     237 

-  scleritis     and     episcleritis 

from  . .  . .  . .     256 

-  scrotal  sores  due  to  . .     679 

-  shedding  of  nails  in  . .     445 

-  simulating  asthma . .        ..    582 

carcinoma  . .        449,  618 

eczema      . .  . .  . .     533 

erythema  nodosum         . .     450 

follicular  tonsillitis         . .     672 

gout  . .  . .  . .     386 

leprosy      . .  . .  75,  4-50 

lupus         . .  . .         449,  808 

Meniere's  disease  . .     828 

perleche    . .  . .  . .     404 

psoriasis    . .  . .  . .     658 

rodent  ulcer         . .  . .     449 

rosacea      . .  . .  . .     268 

scrofulodermia    . .         449,  603 

Sycosis  vulgaris   . .  . .      603 

variceUa   . .  . .  . .     833 

yaws  . .         . .  . .     449 

-  snail-track     ulceration     of 

pharynx  in  . .  . .     672 

-  sore  throat  from      371,  425,  533, 

605,  615,  670,  672,  675,  769 

-  of  spinal  cord,  paralysis  of 

one  leg  from        . .  . .     540 

-  spmal  thrombosis  in  432,  563,  564 

-  spirochreta  pallida  in        371,  738 

-  stenosis  of  bronchus  from, 

mistaken  for  asthma     . .     582 

-  -  pharynx  from      . .  . .     225 
trachea  in            . .  . .     710 

-  Stokes-Adams'  disease  from       98 

-  stomatitis  in  . .  86,  590 

-  strabismus  due  to  . .        539,  640 

-  swelling  of  th3rroid  gland  in     792 

-  synovitis  in..  ..  ..     386 

rapid  variations  in  size  of 

joint  in 386 

tenderness  of  joint  in    . .     386 

-  tabes  dorsalis  from    489,  539,  562 

-  tenderness  of  bones  in       . .     672 
scalp  from  . .         672,  780 

-  testis    and    scrotum,    affec- 

tion of 679 

atrophy  of,  after  . .       79 

(see  Te'stis,  Syphilis  of) 

-  tinnitus  due  to        . .        794,  828 

-  tonsillitis  from    . .  563,  670 

-  transverse  myelitis  from  564,  565 

-  Ulceration  inside  cheek  from     813 

of  chin  in 603 

ear  in        . .  . .  . .     469 

-  -  face  by 808 


SYPHILIS,    ULCERATION    IN— TABES    DORSALIS 


997 


■Sypfiilis,  itlceralion,  contd. 

-  -  of  larynx  in..      1S5,  iGG,  710 


leg  from 

-  lip  from     .  . 

-  nose  in 

-  palate  in  . . 

-  rectum  in 

-  skin  in 

-  tongiie  from 

-  tonsil  from 

-  vulva  in 


•119,  811 

..     813 

. .     250 

237,  640 

. .     635 

338 

237,  812,  813 

425,  670,  813 

.  .     769 


-  unilateral  exophthalmos  from  254 

-  urethral  herpes  from         . .     209 

-  valvular  disease  of  heart  from  526 

-  vesicles  in   . .  . .  . .     832 

-  vocal-conl  paralysis  from  538,  710 
von  .faksch's  disease  due  to  42 
Wassernmnu's   reaction    in,    204, 

224,   226,   254,   279,    338,    371, 
591,  605,  658,  672,  738,  7J8,  769, 
808,  811,  814 
in  cerebrospinal  fluid  in     340 

-  wastinsT  from  . .  . .       69 

-  yaws  no  protection  from  . .     450 

-  secondary  (and  see  Syphilides^ 

-  -  cutaneous  lesions  of      604,  605 

-  -  swelling  on  skuU  in        . .     752 
f^y}>hiloderm  (see  Syphilides) 
Syringomyelia,  abnormal  sense 

of  cold  in  . .  . .  . .      664 

-  anivsthesia  in  . .         388,  664 

-  anilgesia  in..  ..  ..     665 

-  arthritis  m  . .  285,  388,  563 

similarit}'  to  osteo-arthritis  388 

tabetic  arthritis         388,  563 

-  ataxy  in       . .  . .  . .       68 

-  atrophic    paralysis    of    one 

leg  in        544 

arms  in  . .  . .     665 

-  Babinski's  sign  in   . .  82,  554 

-  brittleness  of  bones  in      . .     285 

-  bulhr  in       ..  ..        110,  112 

-  Charcot's  joints  in    285,  388,  563 

-  claw-hand  in  . .       127,  285 

-  diagnosis  from  leprosy       . .     424 

-  dissociated    anaesthesia    in 

112,  128,  285,  554,  563 

-  electrical  reactions  in        . .     554 

-  erythromelalgia  in . .  . .     490 

-  frequency  of  wounds  in     . .     388 

-  gangrene  in..  ..  ..     282 

-  glossy  skin  in  . .         . .     128 

-  glove  type  of  anaesthesia  m     664 

-  lancinating  pains  and  cramps 


128, 


-  main  succulente  in    . 

-  manual  deformity  in         . .  '  554 

-  Morvan's  disease  in  . .     563 

-  muscular  atrophy  in        73, 

285,  544,  665 

-  nystagmus  in  128,  453,  554 

-  pain  in  the  arms  in. .  . .     554 

-  painless  swelling  of  joints  in    568 

-  paralysis  of  arm  in  . .     554 

-  paraplegia  from      . .        561,  563 

-  parts  affected  by    . .  . .     664 

-  perversion  of  seasation  in        778 

-  precipitate  defecation  m..     348 

-  preservation    of    cutaneous 

sensibility  in        . .  . .       73 

-  pupil  phenomena  in  . .     128 

-  reflexes  in    . .  . .  . .     554 

-  scoliosis  in  . .  128,  388,  554 

-  sense    of    drenching    sweat 

in  part  which  is  dry  in  . .     664 

-  sensory  changes  in    73,  112,  128, 

285,  388,  554,  563,  664,  665 

-  simulating         amyotrophic 

lateral  sclerosis  . .  . .       73 

leprosy     . .  . .  . .       75 

progressive  muscular  atro- 
phy         73 

-  spastic  paralysis  of  leg  in. .     128 

-  spontaneous  fracture  in     . .     285 


Sifringomyclia,  contd. 

-  succulent  hand  in  . .         128, 

-  superficial  gangrene  in 

-  thermo-ana;sthesia   in  (Fin. 

182)  ..  ..         664, 

-  trophic  changes  in  . . 

skin,  nails  and  joints  in 

and    vasomotor    disturb- 
ances in 

-  whitlows  in . . 

Systolic    bruits    (see    Bruits, 
Cardiac) 

TABES  DOLOROSA 

chronic   general   pains  in 

the  limbs  in     . . 

-  dorsalls         .  .  262,  525, 

-  -  abdominal  colic  from     . . 

-  -  absence  of  breast  tender- 

ness in  . . 

larynx  tenderness  in  . . 

ovarian  tenderness  in . . 

testicular  tenderness  in 

tongue  tenderness  in. . 

wasting  in 

acute  cyanosis  in    ' 

allocheh'ia  hi       . .  22, 

anaesthesia  in      . .         562, 

analgesia    in    (Fig.    183, 

p.  665)        489,  493,  498, 

deep     . .  350,  662, 

anomalous  cases  of 

-  -  anosmia  from 

Ai'gyll  Robertson  pupil   in 

285,  466,  493,  498,  562,  594, 

astereognosis  in  . . 

ataxy  in         66,  277,  285, 

498,  562, 
band     type     of      hyper- 

iEsthesia  in 

bedriddenuess  from 

bladder  spasm  in 

trouble  in 

blood-pressure  in 

cardiac  crises  in  . . 

Charcot's    joint    i 

Charcot's  joint) 
chronic  general   pains  in 

limbs     . . 

colicky  pains  of . . 

constipation  m   . . 

cord  changes  in  . . 

crises  early  in 

cyTStitia  in . . 

deafness  in 

deficient     sensibility 

muscles  in 
degeneration  of  auditory 

nerve  in 

delayed  sensibility  in     . . 

diagnosis     of     peripheral 

neuritis  from  . . 
duninished  power  of  mic- 
turition in 

subcutaneous  fat  in  . . 

drooping  eyelids  in 

dull,  boring,  aching  pains 

in  legs  in  . .        489, 

erythromelalgia  in 

extsrnal   popliteal    nerve 

paralysis  in 

facies  of  (Fig.  87) 

gait  in      . .  277,  278, 

gangrene  in         . .        282, 

gastric  crises  in  350,  473, 

485,  489,  562,  665,  844, 

rise  of  blood-pressure 

350, 

simulating  dyspepsia 

violent  vomiting  in 

350, 

general  abdominal  crises  in 

girdle  pain  in       289,  484, 

high-stepping  gait  in     . . 


350, 


(see 


350, 


of 


285 
285 


665 
554 


128 
128 


66,  350 


Tabes  dorsalis,  contd. 

history  of  syphilis  in 

liypora?st.hesia  in 

-  -  hypotonia  in 

impotence  in 

individual     muscles     not 

weak  in 
intercostal  nerve  pain  in 

-  -  intestinal  crises  in 
uitolerancc    of    hot    and 

cold  water  in  . . 

knee-jerks  absent  in   285, 

350,  398,  466,  473,  562,  847 

laryngeal  crises  in  185,465,562 

diagnosis  from  result 

of     potass,    iodide 
admhiistration    . . 
from  syphilitic  ul- 
ceration of  larynx 

paralysis  associated  with   539 

lightning  pains  in  (and  see 

Lightning  Pains  in  Tabes) 
350,  489,  498,  507,  562,  664 

-  -  loss      of      control      over 

sphincters  in   . . 

convergent       pupillary 

reflex  in 

lymphocytosis  in  cerebro- 

spmal  fluid  of. .        339, 

mistaken  for  gout 

rheumatism 

niggling  pain  in  legs  in  . . 

numbness  in 

pain  in  face  in,  dull  boring 

character  of     . . 

in  the  umbilical  region 

tlie  only  complaint  in 
some  cases  of 

painful  crises  in  . . 

palpitation  m     . .        525, 

paradoxical     pupillaiy 

reflex  in 

parEesthesijB  in    . . 

paraplegia   from. . 

perforatbig  ulcer  of  foot  in 

(Fig.  207,  p.  809)  285, 

562,  809,  811 

plantar  reflex  in  . .       81 

points    for    investigation 

in  diagnosis  of 

preponderance  in  males 

ptosis  in  . . 

pupil  changes  in. . 

irregular  in 

small  in 

(and  see  Tabes   Dorsalis, 

Argj'll  Robertson  Pupil  in) 

reaction  of    degeneration 

absent  in  . .  . .     562 

rectal  crises  in     . .  . .     562 

reeling  and  staggering  in     827 

reflexes  in  81,  134,  562 

renal  crises  in      . .  . .     562 

retention  of  urine  in      . .     441 

Romberg's  sign  in  67,  665 

sallow  complexion  in     . .     262 

sense  of  position  and  move- 
ment abnormal  in     493,  665 

sensory  changes  in,  66,350, 

493,  498,  662,  664, 

665,  666,  669,  778 

shedding  of  nails  in        . .     445 

simulating  gastric  ulcer        350 

wTiter's  cramp  . .     177 

sphincter  trouble  in      441,  562 

sweating  crises  in  . .     562 

symptoms      of     syringo- 
myelia simulating       . .     563 

syphilitic     aiiection     of 

heart  in  . .  . .     527 

tenderness  m  chest  in     . .     777 

ulnar  analgesia  in  . .     493 

vertigo  due  to     . .  . .     827 

vesical  crises  in  . .  . .     563 


562 
666 
262 
346 

562 
478 
665 

665 


466 


466 


285 

594 

489 
484 
484 
489 
664 

498 


524 
664 

527 

595 
493 
562 


489 
562 
262 
262 
595 
594 


998 


TABES    DORSALIS— TENDERNESS    OF  BREAST 


Tabes  dorsalis,  contd. 

vomiting  in     350,  485,  844,  847 

AVasserniann's     reaction 

■witli 

wrinkled  forehead  in 

-  mesenterica,  with  ascites  . . 

meteorism  in 

simulation    by    anorexia 

nervosa 


489 

262 

56 

432 

850 


TACHE  CEREBRALE  ..     771 

TACHYCARDIA  ..771 

-  in  acute  yellow  atrophy  . .     370 

-  causes  of       . ,  . .  . .     772 

-  ui  diphtheritic  neuritis      . .       77 

-  exophthalmicgoitre244,  253, 

772,  792,  797,  849 

sometimes  only  evidence 

of 772 

-  mitral  stenosis        . .  61,  245 

-  otitis  media  complications         98 

-  with  parenchymatous  goitre     792 

-  paroxysmal  . .  . .     772 

-  -  palpitation  in      . .  . .     525 

-  in  pyaemia    . .  . .  . .     372 

-  pyrexial  jaundice   . .  . .     361 

-  in  tropical  abscess  of  liver       369 

-  tuberculous  meningitis       . .       98 
Tactile    vocal    fremitus    (see 

Vocal  Fremitus) 
Teenia    infection,    anoemia    in 

568,  569 

-  ecchinococcus  in  dogs        . .     719 
hydatid    disease    due    to 

bladder  sf  ase  of  .       . .     719 

-  mediocanellata  (i^/^.  150)..     568 

-  solium  (Figs.  148,  149,  152)     568 
Tailor's  cramp  . .  . .     177 

-  sporotrichosis  of  lung        . .     322 
TALIPES  130 

-  in  alcoholic  neuritis  . .     165 

-  arsenical  neuritis    . .  . .     165 

-  calcaneus,  definition  of     . .     130 
--  cavus,  definition  of  . .     133 

-  cold  and  blue  feet  m       130,  131 

-  congenital     .  .  .  .         130,  224 

-  from  contracting  scars       . .     132 

-  from  disuse..  ..  ..     165 

-  dystocia  in  etiology  of        . .     131 

-  equinus,  definition  of        . .     130 

-  from    filDrosis   and   contrac- 

ture of  calf  muscles        . .     132 

-  in  Friedreich's  ataxy   71,  164,  559 

-  hypierextended  toes  in       . .     130 

-  hysterical     .  .  .  .         132,  166 

-  from  infantile  paralysis     71,  559 

-  inflammation  of  bone        . .     132 

-  new  growths  in  pelvis      . .     131 

-  poliomyeUtis  . .  . .     165 

-  progressive  muscular  atrophy  165 

-  in  Tooth's  peroneal  atrophy 

71,  560 

-  trophic  ulcers  in     . .  . .     130 

-  valgus,  definition  of  . .     130 

-  varus,  defhiition  of  . .     130 
Tannic  acid,   dryness  of  the 

mouth  and  thirst  due  to      789 
Tapping      (see      Paracentesis 

Thoracis) 
Tape-worms  (Figs.    148,   151)    567 

-  diagnosis     of      muco-mem- 

branous  casts  from         . .      567 

-  eggs  of  (Fig.  152)    . .  . .     568 
microscopical      examina- 
tion of  ffeces  for        . .     569 

-  eosinophilia  from     249,  568,  569 

-  increased  appetite  with     . .       49 

-  infection,  chlorotic  antemia 

in 568,  570 

-  simulated  by  mucous  colitis 

134,  443,  444 
Tar  products,  bullae  in  workers 

among       .  .  .  .  .  .     110 

Tarry  stools     . .  . .  89,  316 


Tartar,  bleeding  gums  due  to  86,  87 

-  foul  breath  due  to. .  . .        99 

-  retraction  of  gums  from    . .     641 
Tartrates,    transient  polyuria 

from  drinks  containing..     581 
TASTE,  ABNORMALITIES  OF    773 

-  aura  of  epilepsy     . .  . .        80 

-  foul,  causes  of         . .  .  .      774 

-  impaired    with     peripheral 

facial  paralysis    . .        536,  537 
from    paresis    of    glosso- 
pharyngeal nerve      774,  775 

-  loss  of,  list  of  causes  of  . .  774 
with    hysterical    hemian- 

aesthesia  . .  . .     666 

-  metallic,  in  trigeminal  neu- 

ralgia        . .  . .  . .     495 

-  offensive,  vomiting  from  . .     844 

-  perverted,  list  of  causes  of      774 
Taylor,  re  splenomegalic  cir- 
rhosis         369 

Tea-drinking     by    children, 

nervous  efEects  of  . .     357 

-  excessive,  constipation  due  to  144 
pseudo-angina  in  . .     482 

-  gastritis  from  . .  . .      297 

-  insomnia  from         . .        356,  357 

-  oxaluria  from  . .  . .     471 

-  palpitation  from     . .        525,  527 

-  polyuria  from  . .  . .     581 

-  rosacea  from  . .  . .  268 
Tears,  not  coloured  in  jaundice    361 

-  explosive  bursts  of,  in  double 

hemiplajia  . .  . .     258 
paralysis  agitans         . .     262 

-  first  shed   on  seventh   day 

after  birth  . .  . .     250 

-  overflow  of  (see  Epiphora) 
Teeth  in  acromegaly  . .  . .     263 

-  affections,  neuralgia  frona       781 
locality  of  pain  and  ten- 
derness due  to  . .     783 

tenderness  of  scalp  in    . .     781 

-  caries  (see  Caries,  Dental) 

-  in  congenital  syphilis  (Figs. 

79,  80)      ..  ..         259,  260 

-  defective,     in     etiology     of 

dyspepsia  .  .  . .      354 
gastritis  from      . .  . .     352 

-  delayed  eruption  in  rickets     182 

-  displacement     of,     due     to 

fibrous  epulis       . .  . .     748 

-  grinding   during  sleep    (see 

Grindmg  of  Teeth  during 
Sleep) 

-  impacted  wisdom,  diagnosis 

of  tetanus  from  . .  . .     162 

-  pain  in,  from  glaucoma     . .     257 

-  pegged  and  notched  in  con- 

genital syphilis  (Figs.  79, 
80)  . .  .  .         259,  260 

-  relation  to  definite  segmental 

areas   in   the  face,   table 
showing    . .  . .  . .     498 

-  supijuration    in,    spreading 

neuralgia  from    . .  . .     497 

-  tumours    of    (see    Odonto- 

mata) 

-  imdue   projection   in    acro- 

megaly      263 

-  unerupted    molar,    pain    in 

the  lower  jaw  in . .  . .     501 

ar-rays  in  diagnosis         . .     501 

Teething,  insomnia  from  . .  357 
Tegmentum,  intention  tremor 

from  lesion  of     . .  . .     800 

Telangiectasis    of    cheeks    in 

chronic   alcoholism         . .       59 

-  face  in  rosacea       . .  . .     268 

-  macules  due  to       . .  . .     423 

-  multiple  hereditary  bleeding    251 

-  in  nodular  leprosy  . .  . .     450 

-  thoracic  from  emphysema       826 

-  in  xerodermia  pigmentosum     804 


Telegraphist's  cramp  177,  494 

Temperature' (and  see    Pyrexia) 

-  chart  in  Hodgkin's  disease 

(Fig.  168)  . .  . .     617 

facial  erysipelas  (Fig.  166)  614 

fungating       endocarditis 

(Fig.  164)        ..  ..     6ia 

lobar  pneumonia  (Fig.  188)  702 

Malta  fever  (Fig.  163)  . .     612 

pernicious  anaemia  (Fig. 

167)       . .  . .  . .     616 

pyaemia  (Fig.  165)  . .     SIS 

rheumatoid  arthritis  (Fig. 

106) 377 

sarcoma     of     neck     and 

mediastinum  (Fig.  169)    617 

typhoid  fever  (Fig.  162) 

611,  697 

-  in  diagnosing  early  disease     620 

-  elevation  in  health  to  102"  F. 

by  strenuous  exertion  . .     619 

-  general      observations     on 

variations  in  health  and 
diseas3      . .  . .  . .     619 

-  lowering    to    dangerous    or 

fatal  degree  from  physical 
exhaustion  . .  . .     619 

-  mechanism  of  maintenance 

of  normal  . .  . .     618 

-  pulse,    respiration   ratio    in 

normal  conditions  . .     622 

-  in  relapsing  fever  . .  . .     698 

-  subnormal 345 

-  sudden  changes  in,  menor- 

rhagia  from  . .  . .     428 

-  in  tuberculosis         . .  . .     612 

-  unexplained  oscillations   in 

chronic  disease    . .  . .     619 

Temporal  lobes,  auditorv  word 

centre  m  (Fig.  185)       ..     683 

-  muscle,  paralysis  of  . .     775 

-  region,  referred  pain  in,  in 

severe  ear  disease  . .     498 
tenderness  of       . .          . .     783 

-  segmental  area,  pain  in,  in 

iritis  and  glaucoma       . .     498 
Temporo-malar     nerve,     skin 

distribution  of     . .  . .     659 

Temporo-mandibular  joirt  ab- 
scess, occasional  discharge 
through  auditorv  meatus      470 

-  -  osteo-'arthritis  of  230,  384,  801 


earache  ia 

rheumatoid  arthritis  of . . 

Temporo-sphenoidal  lobe,  ol- 
factory aura  in  tumour  of 

Tender  spot  below  anterior 
iliac  spine  in  neuralgia 
paraesthetica 

in  neuralgia 

Tenderness,  absence  of,  in 
intermittent    hvdrarthro- 


230 
378 


80 


330 


387 


475 


133 
134 


-  importance   of,    in  relation 

to  pain 

-  of  joint  (see  Arthriti.s) 

-  abdominal,  general,  absence 

in  smiple  coUc    . . 

in  colitis 

peritonitis        . .        134,  15S 

relapsing  fever  . .     373 

tuberculous  peritonitis 

56,  719 
ulcerative  colitis  90,  92 

-  along     diaphragm     attach- 

ments, in  phrenic  neuralgia  478 

-  in   the   arm  from   brachial 

neuralgia  . .  . .     491 

-  of  bones  in  infantile  scurvy 

85,  115 

rickets       .... 

secondary  syphilis 

-  breast  in  mastitis  . . 
mastodynia 


171 
672 
743 
479 


TENDERNESS  IN    CHEST— TESTS 


999 


TENDERNESS  IN  CHEST    .. 

-  -  causes  o£ 

-  -  from  liepatic  abscess     . . 

-  beliind    ear    from    jullamcd 

mastoid  gland     . . 
lateral  sinus  thrombosis 

-  -  -  otitis  media 

-  of  ear  in  otitis  media 

-  -    otorrhoea  . . 

-  epididymis,  acute,  in  gonor- 

rliii-al  epididvniitis 
TENDERNESS     IN     EPIGAS- 
TRIUM     .. 

-  -  in  arsenic  il  poisoning   .. 
chronic  pancreatitis 

gall-bladder  disease      4SG, 

gastralgia 

-  gastric  disorders. .       779, 
ulcer  89,  298,  352, 

-  -  gastritis    . . 
lieart  disease 

-  -  liver  disease 

-  -  lung  disease 

phosphorus  poisoning    . . 

stone  in  gall-bladder     . . 

-  -  subphrenic  abscess 

--  the   eye   from   retrobulbar 
neuritis     . . 

-  of    eyebrow    from    frontal 

sinus  mflammation 

-  feet  from  cheiropompholyx 
in  erythema  keratodes    . . 

-  -  ery  tUromelalgia . . 

-  of  front  of  thigli  in  anterior 

crural  neuralgia  . . 

-  over  gall-bladder   in  carci- 

noma of  tlie  gall-bladder 

in  cholecystitis 

from  gall-stones        280, 

-  -  -  in  typlioid  fever 

-  in  gluteal  region  in  sciatica 

-  of    gums    from    abscess    of 

antrum  of  Higlmiore     . . 

-  -  septic  tooth 

-  hands  from  cheiropompholyx 

-  in  hyoid  area  in  ear  disease 

-  hypochondrlum    from  gall- 

Ijladder  disease   . . 

-  -  gastric  disorders  . . 
liver  disease 

phosphorus  poisoning    . . 

-  subpiirenic  abscess 

-  -  (and  see  Pain  in  Hypo- 

chondrium) 

-  bypogastrium  from   perfor- 

ated gastric  ulcer 

-  -  -  duodenal  ulcer 
TENDERNESS      IN       ILIAC 

FOSSA      

from  appendicitis      135, 

-  over  inflamed  frontal  sinus 

-  intercostal  space  in  pleurisy 

-  —  intercostal  neuralgia    . . 

-  of  joint  (see  Arthritis  ;  Syno- 

vitis ;   and    Joints,    AiEec- 
tions  of) 

-  over  kidney  with  bacterim-ia 
renal  calculus 

tuberculosis     . .        515, 

-  in  limbs  (see  Pain  in  Limbs, 

General ;   and   Sensation, 
Abnormalities  of) 

-  -  neuromyositis 

-  -  peripheral  neuritis 

-  over     liver    (localized)    in 

abscess  of  liver  . .        409, 

-  -  cholangitis 
cirrhosis   . . 

from  gall-stones . . 

in  general  congestion 

61,  370,  371, 
^  -  from  heart  failure  61,  370, 
suppurative  pylephlebitis 

-  in.  loins  in  pyelitis  . . 


775 
770 
779 

230 
651 
229 
230 
409 

700 

779 
92 
724 
779 
485 
783 
485 
297 
783 
779 
783 
373 
486 
720 

840 

255 
654 
451 
490 

488 

499 
499 
499 
371 

487 

502 
502 
654 
498 

779 
779 
779 
373 
720 


736 
205 
479 

478 


84 
500 
694 


504 
505 

651 
369 
368 
300 

407 
407 
649 
625 


629 
046 


Tenderness  in  loins,  conUl. 

-  in  renal  tuberculosis 
suppurative   nepliritis   . . 

-  lumbar  region  from  colitis. .  727 

-  over   McHumey's   point   in 

appendicitis         . .          . .  500 

-  over   metatarsus    in    meta- 

tarsal neuralgia  . .          . .  488 

-  in     mid-orbital     region     in 

errors  of  refraction          . .  498 

-  of   muscles   in   acute  poly- 

myositis  . .          . .          . .  504 

multiple  neuritis  489,  506,  551 

muscular  overstrain       . .  503 

myalgia    . .          . .          . .  478 

pleurodynia         . .          . .  478 

in  tetany              . .          . .  178 

-  over    musculospiral     nerve 

in  brachial  neuralgia      . .  491 

-  in  naso-labial  area  in  caries  i 

of  canine  tooth  (Fig.  132)  497 

-  In  neck,  posterior  triangle  of, 

in  cervical  rib      . .          . .  492 

in  brachial  neuralgia  491 

from  tuberculous  gland  420 

-  of  nerve  trimks  in  multiple 

neuritis     . .          . .          . .  489 

-  nerves  and  muscles,  absent 

in  tabes  dolorosa            . .  507 

-  palms  in  erythema  keratodes  451 

-  over     pancreas     in     acute 

pancreatitis          .  .          .  .  846 

-  onpercussionin  spinalcaries  181 

-  in  peripheral  neuritis        . .  661 

-  of  prostate,  acute  ..         ..  207 

-  pudic             . .          . .          . .  221 

-  per  rectum  from  obturator 

hernia       . .          . .          . .  740 

prostatitis             . .          . .  631 

rectal  abscess      . .          . .  635 

TENDERNESS  IN  SCALP    ..  780 

in  organic  cerebral  disease  328 

secondary  syphilis          . .  672 

-  over  sciatic  notch  in  sciatica  487 

-  shoulder  from    gall-bladder 

disease      . .          . .          . .  779 

liver  disease        . .          . .  779 

-  of  skull,  local,  with  organic 

intracranial  disease       327,  328 

-  soles  in  erythema  keratodes  451 
TENDERNESS  IN  SPINE  ..  784 
in  carcinoma    of    cardiac 

end  of  stomach          . .  474 

gall-stones             . .          .  .  474 

gastric  ulcer         . .          . .  474 

hydatid    disease    of    ver- 
tebra;   . .  . .         785,  786 

neurasthenia       . .          . .  788 

Pott's  disease      . .          . .  134 

psoas  abscess       . .          . .  739 

spinal  caries  134,  474,  564 

vertebral  arthritis           . .  785 

-  spleen    in   fungating    endo- 

carditis    . .          . .          . .  237 

-  spots      of,     in      trigeminal 

neuralgia  .  .           .  .          .  .  495 

-  of  Sternum  in  acute  medias- 

tinitis        . .  . .         483,  777 

from  aortic  aneurysm  . .  777 

behind,     referred     from 

oesophagus       . .          . .  779 

mediastinal  inflammation  777 

tumour              .  .          .  .  777 

-  suprapubic,  with  cystitis.  .  306 

-  in  syphilitic  pseudo-paralysis  387 

-  of  syi)hilitic  swellings  on  tibia  752 

-  of  temporal  reaion  from  dis- 

ease of  upper  bicuspids. .  783 

heart  disease    . .          . .  783 

lung  disease     . .          . .  783 

stomach  disease          . .  783 

-  of  testis       518 

exquisite    in    acute    epi- 

didymo-orchitis          . .  518 


Tenderness  of  testis,  contd. 

in  testicular  abscess      . .     680 

from  torsion        . .  . .     742 

-  over  ulnar  nerve  at  elbow 

in  brachial  neuralgia     . .     491 

-  universal    in    cerebrospinal 

meningitis  . .  . .     643 

-  uterine,  from  metritis       . .     221 

-  per    vaginara,    from    obtu- 

rator hernia         . .  . .     740 

-  vulval,  from  Bartholinitis. .     221 

caruncle    . .  . .  . .     221 

kraurosis  .  .  . .  . .     770 

-  -  leukoplakia  . .  . .     221 
Tendo-achillis  jerks  absent  in 

locomoter  ataxia  . .     562 

Tendon,  ossification  of,  simu- 
lating exostosis  . .         754,  763 
Tendon-jerks   (see  also  Knee- 
jerk  ;     Babinski's    Sign ; 
and  Ankle-jerk) 

-  exaggerated  in  amyotrophic 

lateral  sclerosis    . .  . .     554 

brachial  monoplegia        . .     546 

-^  -  in      subacute     combined 

degeneration  of  the  cord  493 

-  loss  of,  in  atrophic  paralysis 

of  arm      . .  . .  . .     549 

peripheral  neuritis  . .       66 

-  in  spastic  paralysis  of  one 

leg 539,  540 

-  unequal    and    exaggerated, 

in  hemiplegia  . .  . .     337 

-  sheaths,  gonococcal  inflam- 

mation of . .  . .  . .     376 

inflammation  in  gout     . .     382 

rheumatic  nodules  in     . .     452 

Tenesmus  in  abdominal  angina    487 

-  carcinoma  of  sigmoid  colon     731 

-  dysentery     . .  . .  90,  196,  501 

-  intussusception        . .  . .     727 

-  rectal  . .  . .  . .     473 

-  tuberculous  sigmoid  colon      731 

-  in  ulcerative  colitis  . .       91 

-  vesical,  in  acute  cystitis  . .     312 
Tenosynovitis,  crepitus  in    . .     179 

-  egg-sheU  crackling  in        . .     177 

-  simulating  occupation  neu- 

roses . .  . .         . .     178 

Tenotomy,  diplopia  after     . .     200 
Tension  of  eye  in  differentia- 
tion    of     conjunctivitis, 
iritis,  and  glaucoma       . .     257 

-  raised  in  herpes  frontalis. .     807 
Tensor  fasciae  femoris,  spinal 

nerve-root  supplying     . .     543 

nerve  supply  of  . .  . .     542 

Teres    major    and    T.   minor, 

spinal  nerve-roots  supplying  556 

nerve  supply  of       . .     550 

Terror  in  patient  after  epileptic 

convulsions  . .  . .     169 

Tertian  fever  (see  llalaria) 
Test  for  acetonuria     . .  . .         4 

-  albuminuria  . .  . .         5 

-  albumosuria  . .  20,  21 

-  alkaU,  for  alkaptonuria    . .     822 

-  for  arsenic    . .  . .  . .       92 

-  barium  chloride,  for  carbo- 

luria  823 

-  for  bile  in  stools     . .  . .     197 

-  bleaching  powder,  for  indican  821 

-  blood  in  faeces         . .  . .       89 

-  boiling,  for  albumin,  method 

of  avoiding  fallacies  of  . .     472 
phosphate  fallacy  of  . .     574 

-  bromine  water,  for  melanuria    821 

-  in    Cammidge's    pancreatic 

reaction  . .  . .     115 

-  for  carboxyhffimoglobia     . .     138 

-  caustic     soda,     for     elastic 

fibres         . .  . .  . .     701 

-  cbyluria        . .  . .  . .     126 

-  cystin  . .  . .  . .     187 


TESTS— TESTIS,    TORSION  OF 


Test,  conid. 

Testis,  eciopie,  conid. 

Testis,  contd. 

-  diacetic  acid  in  urine 

196 

in  femoral  region 

734 

-  malignant  growth  of  (and 

-  diazo-reaction 

197 

gangrene  of 

523 

see  Caroinoma  of  testis) 

520 

-  ferments  in  gastric  juice  . . 

355 

hernia  with           . .        523, 

740 

adhesion  to   skin   only 

-  ferric  chloride  for  alkapton 

822 

inflammation  of,  diagnosis 

in  late  stage  of 

520 

melannria 

821 

from  strangulated  hernia 

523 

alleged  greater  liability 

-  fluorescin,  for  corneal  ulcer- 

 in  inguinal  region 

740 

of  undescended  testis 

ation 

806 

hability  to  recurrent  trau- 

to  

523 

-  for  free  HCl 

355 

matic  inflammation   .  . 

523 

blood-stained    fluid    in 

-  Gmelin's,  for  bile  pigment 

819 

—  new  growtli  of,  diagnosis 

tunica  vaginalis  in 

520 

-  for  hearing  . . 

188 

from    hydrocele    of    a 

carcinoma  and  sarcoma 

-  Huppert's,  for  bile  pigment 

819 

hernial  sac 

742 

clinically     indistin- 

- for  indican  in  urine          348 

821 

the  tunica  vaginalis 

742 

guishable 

520 

-  iodine  for  bile  pigment 

819 

omental  hernia  . . 

743 

consistence  of  . . 

520 

-  for  lactic  acid      "  . . 

355 

pain    due    to,     diagnosis 

diagnosis  from  chronic 

-  lactose  in  urine 

290 

from  appendicitis 

740 

torsion  of  testis     521, 

766 

-  lead  in  tirine 

77 

intestinal  colic 

740 

hematocele            521, 

523 

-  liquor  potassse,  for  pus 

623 

^ at  puberty  in  . . 

523 

hydrocele       520,  521, 

522 

-  meal  in  chronic  diarrhoea. . 

196 

in  perinetun        . .         516 

740 

syphUitic  orchitis  520, 

766 

in  examination  of  disorders 

proneness     to     recurrent 

tiiberculous    testis . . 

521 

of  the  stomach 

355 

inflammation  . . 

523 

embryoma     the     com- 

 gastritis    . . 

50 

recurrent  attacks  of  pain 

monest  form  of     520, 

766 

-  for  methylene  blue  in  urine 

823 

in 

523 

enlargement  of  iliac  and 

-  nitric  acid,  for  bUe  pigment 

819 

retention  in  abdomen    . . 

523 

lumbar  glands  in    520 

766 

indican. . 

821 

inguinal  canal . . 

523 

testis  in        . .        520, 

766 

-  for  nucleoproteid   . . 

5,  6 

perineum 

533 

incorporation     of    epi- 

- Xvlander's,  efEects  in  alkap- 

situation  at  root  of  penis 

didymis  in  late  stage 

520 

T-onuria     . . 

822 

in  front  of  pubes 

523 

loss  of  testicular  sensa- 

- occult  blood           . .          94, 

197 

upper  part  of  thigh  . . 

523 

tion  in 

521 

-  ozonic  ether,  for  pus 

623 

testicular  sensation  in  the 

nodular,    irregular    tu- 

- for  pancreatic  disease 

364 

suspicions  swelling  in 

523 

mour  in 

520 

-  paralysis  of  upper  extremity 

545 

varieties  of 

523 

operation   in   diagnosis 

-  pentose  in  urine 

290 

-  embryoma  of.  age  incidence 

from  syphilitic  testis 

-  the    phenylhydrazine     and 

of    .. 

766 

or  hematocele 

766 

fermentation,     in     con- 

 the      commonest       new 

pain  in. .          . .         520, 

766 

firmation  of  glycosuria  . . 

818 

growth  of  the  testis  . . 

766 

simulation   of  fltiid   in 

-  for  phosphates,  acetic  acid 

208 

constitution  of    . . 

520 

tunica  vaginalis 

520 

-  phosphatmria           . .          . . 

574 

dissemination  via  lympha- 

 thickening  of  cord  in  520 

766 

-  psorosperms . . 

803 

tics  or  veins    . . 

766 

varieties 

766 

-  rennin 

355 

long  course  of     . . 

766 

-  misplaced  (see  Testis,  Ectopic 

) 

-  safranin,      negative      with 

metastasis  in 

766 

-  pain  in  (see  Pain  in  Testicle) 

alkaptonuria 

822 

semi-malignant  nature  of 

766 

-  painless  nodule  in,  in  tuber- 

- Sahli's,  of  pancreatic  defect 

216 

tissues  contained  in 

766 

culous  disease     . . 

680 

-  sflver  nitrate  for  alkaptonuria  822 

-  encysted  hydrocele  of 

521 

-  physiological  inequality    . . 

78 

-  soditmi    nitroprusside,    for 

-  endothelioma  of 

766 

-  reddened    soft   area   in,    in 

acetone 

4 

-  enlarged  from  abscess      518, 

680 

testicular  abscess 

518 

for  melanuria  . . 

821 

areas   of  varying   consis- 

- retained  (see  Testis,  Ectopic) 

-  for  sugar,  Tarious  . .        289, 

291 

tence  in  malignant     . . 

520 

-  sarcoma     of     (see     Testis, 

-  Tiiehnann's 

355 

due  to  chronic  torsion  521, 

766 

Malignant     Growth     of  ; 

-  urates  in  tirine 

815 

from  cyst . . 

521 

and  Sarcoma  of  Testis) 

-  urinary,  in  iodism  . . 

112 

in  epididymo-orchitis  518 

528 

-  swelling     of     (see     Testis, 

oedema 

457 

—  —  from  gumma        . .         680. 

681 

Enlarged) 

for  saturnine   encephalo- 

due  to  hematocele 

521 

-  syphilis  of,  adhesion  to  cover- 

pathv   . . 

139 

in  hydrocele 

521 

ings  in      . . 

766 

Testicular    sensation    lost    in 

rapid,  in  malignant  disease 

520 

diagnosis  of 

519 

malignant      growth      of 

syphihtie        519,  520,  681 

765 

from  new  growth 

766 

testis 

521 

-  -  tubercular  disease 

680 

tubercidous  testis      520, 

765 

syphilitic     disease     of 

-  examination  of  in  haematuria 

307 

effects    of    mercury    and 

testis 

766 

-  excision  of,  obesity  after  . . 

453 

iodides  on 

520 

in  undtecended  testis   . . 

523 

-  fibroid  syphilitic     . . 

519 

epididymis  unaffected  in 

Testis.  absces=!  of  (see  AbsceK 

-  gangrene  of . . 

523 

519,  765, 

766 

of  Testis; 

-  gonococcal  infection  of 

207 

hernia  testis  from 

766 

-  atrophT    of    (see    Atrophy 

-  in  groins  in  pseudo-herma- 

loss    of   testicular   sensa- 

Test'cular) 

phroditism 

706 

tion  in  . .          . .         765, 

766 

-  carcinoma  of  (see  Carcinoma 

-  growth  and  gumma  of,  dis- 

 nodular  affection  of  tunica 

of  Testis; 

tinguished   by  treatment 

521 

vaginalis  and  albuginea 

-  congenital  misplacement  (see 

-  gumma  of,  general  description 

in 

765 

Testis,  Ectopic) 

519,  680, 

681 

-  -  operation     in     diagnosis 

-  cyst  of.  general  account  of 

521 

diagnosis  from  testicular 

from     haematocele     or 

-  deficiency   of   deep   tender- 

abscess. . 

680 

new  growth 

766 

ness  in,  in  tabes 

562 

tuberculous  testis 

680 

-  -  potassium  iodide  in  dia- 

- ectopic          ..        ..        78 

740 

scrotal  sores  due  to       679, 

680 

gnosing..          ..         520, 

766 

acnt-e  torsion  of  . . 

523 

-  hernia   of    (see    Hernia    of 

scrotal  fistula  due  to 

679 

alleged    greater    UabUity 

Testis) 

sense    of    dragging    and 

to  malignant  disease. . 

523 

-  inflammatory  lesions  of  (see 

weight  in 

519 

attacks  of  pain  in 

740 

Epididymo-orchitis      and 

size  rarely  three  times  the 

causing  swelling  in  femora 

Orchitis) 

normal  in 

765 

region   . . 

733 

-  injury  of,  acute  epididymo- 

ulceration  from   . . 

766 

diagnosis  of 

523 

orchitis  from    . .         517, 

518 

Wassermann  reaction   in 

appendicitis  from  pain 

hsematocele  due  to 

521 

520, 

766 

due  to         ..        533 

,740 

torsion  of  testis  from    . . 

766 

-  tenderness  of  (see  Tender- 

 dullness  over 

742 

vomiting  from    . . 

844 

ness  of  Testis) 

emptiness  of  scrotum  on 

-  mal-descent  of  (see  Testis, 

-  torsion  of,  abdominal  pain  in 

742 

afiected  side   ..        523 

,740 

Ectopic) 

diagnosis  from  growth  521 

766 

TESTIS.    TORSION   OF— THROAT 


Testis,  torsion  of,  contd. 

strangulated  hernia    . . 

tuberculous  testis 

gangrene  from     . . 

great  tenderness  in 

in  Lorse-riders     . . 

-  -  inguino-scrotal    swelling 

from 
due  to  injury     . . 
-  operation  and  histology  in 
diagnosis  of     . . 

-  -  pain  in  testis  in 

-  simulation    of    intestinal 

obstruction  by 

-  swelling  due  to    . . 

testicular  abscess  from. . 

swelling  due  to  oil,  705, 

of  undescended   . . 

vomiting  in 

-  tuberculous  -  •         79, 
aching  pain  in    . . 

-  -  adhesion  to  skin . . 

afiection  of  bladder  from 

seminal    vesicles    from 

-  associated    with     tuber- 

culous spermatic  cord 

with  bladder  tuberculosis 

breaking  down  and  ulcer- 
ation of  nodules  in 

causing  ulcer   518,680,706, 

commencement  as  nodule 

in  the  epididymis     518, 

-  -  "  craggy,"    or    "  bossy," 

feel  of  nodules  in 
diagnosis  of 

-  -  -  from  chronic  torsion  . . 
gummatous  orchitis  . . 

-  -  -  malignant  growth  of  . . 

syphilitic  disease  of  520, 

testicular  abscess 

epididymis  affected  rather 

than  body  of  testis    519, 

fistula  in  scrotum  from  518, 

gradual  painless  enlarge- 
ment of  nodule  in 

hernia  testis  from         680, 

hydrocele  with    . . 

involvement  of  scrotum  in 

spermatic  cord  in 

-  nodules  In  epididymis  in 

307, 

- painless  at  first 

- tender  on  pressure  in 

in  vas  in 

-  -  -  thickening  of  vas  in  519, 

-  -  occasional     sudden     en- 

largement of  long-stand- 
ing nodule  in    . . 

-  -  onset  commonly  in  upper 

pole  of  epididymis     . . 

-  -  opsonic  index  in  diagnosing 
primary        518,  521,  080, 

-  -  prostatic  tuberculosis  with 

519, 

rectal  examination  in    . . 

relative  frequency  of 

with  renal  tuberculosis 

394, 

scrotal  fistula  due  to    518, 

sores  due  to     . .        679, 

secondary  to  other  genito- 
urinary tuberculosis  . . 

prostatic  tuberculosis 

renal  tuberculosis 

vesical  tuberculosis   . . 

-  -  sequence    of    events    in 

production    of    cystitis 
from 
slow  course  in  many  cases 

-  -  spread    of    disease    from 

epididymis  to  body  of 
testis  in 

T.     bacilli  in    discharge 

from  fistula  in 


Testis,  tuberculous,  amid. 

742 vesical  tuberculosis       513,  029 

760 vesiculiP  seminales  aflee- 

523  ted  in    . .  307,  519,  038,  767 

742 von  Pircjuefs  reaction  in 

521  "  519,  705 

-  ulceration  of,  from  involve- 
742  ment  in  scrotal  epitheli- 

766  oma  679 

-  undescended     (see    Testis, 
521  Ectopic) 

521     -  various  swellings  affecting  765,766 

Tetanic  contractions  (see  Con- 
742  tractions) 

765  Tetanus,  consciousness  retained 

680  in 464 

766  -  convulsions  in  109,  652,  801 
523 brought  on  by  touching 

742  patient 052 

394     -  definition  of  . .  . .     161 

519     -  diagnosis  from  hydrophobia     162 
705     -  -  hysteria         162,  464,  801,  802 

680 strychnine  poisoning    102,  802 

680     -  -  tetany 162 

-  drum-stick  bacilli  in  (Plate 
523  XII,  Fig.  T,  p.  696)   102, 

312  463,  652,  802 

-  duration  of..  ..  ..     652 

518  -  hyperpyrexia  in     . .  . .     343 

767  -  infection  through  wound 

652,  709,  802 
680     -  influence  of  chloroform  on      802 

-  muscular  spasms  in  . .     162 

519  -  opisthotonus  m  162,  463,  052,  802 
519     -  priapism  in..  ..  ..     580 

766     -  prognosis  of  . .  . .     802 

080     -  retraction  of  the  head  in  . .     641 
521     -  rigors  in       . .  . .  . .     647 

765     -  risus  sardonicus  in  463,  651, 

680  652,  802 

-  simulated      by      impacted 

765  wisdom  tooth      . .  . .     802 

679  -  soil  contamination  causing     802 

-  stiffness  of  muscles  in      463,  802 
680 jaw  in 162 

766  -  -  neck  in   . .  162,  652,  709 
765     -  trismus  in     162,    178,    463, 

680  "  052,  709,  801,  802 
523     -  without  external  wound  652,  802 

Tetany,  A.C.C.  >  K.C.C.    in. .     634 
680     -  accoucheur's  hand  in         . .         3 
519     -  carpo-pedal  contractions  in 
519  466,  802 

680     -  causes  and  signs  of  . .     178 

765     -  causing  convulsions  . .     109 

-  diagnosis  of  tetanus  from. .     102 

-  from  digestive  disorders     . .     178 
680     -  epidemics  of  in  young  adults     178 

-  from  food  poisoning  . .     178 

518  -  gastrectasis  . .  . .  . .     802 

519  -  infantile        . .  . .        466,  802 
765     -  after   operation  on  thyroid 

glfind         802 

078     -  in  pregnancy  . .        178,  802 

519     -  proa-nosis  in  . .  . .     802 

518      -  raritv  of  trismus  in  . .      801 

-  from'  rickets  . .        170,  802 
626     -  Trousseau's  sign  in  . .     178 

679  Tetronal,  coma  due  to  . .     137 
080     Thapsia,  sore  fingers  from    . .     266 

Thenar  muscles,  atrophy  of  . .       73 

680  -  wasting    in  Tooth's   neuro- 

518  muscular  paralysis         . .     321 

518    Thermo-anffisthesia,  definition    660 
518      -  in  lisematomyelia    .  .  . .     664 

-  from  lesion  of  the  medulla      066 

-  in  svringomyeUa  (Fig.  182, 

629  p."66.y)  563,  664,  665 

518  Thermometer  makers,  mercury 

poisoning  in        . .  . .       38 

'.  Thigh,   atropiiy  in  knee-joint 

519  I  disease      . .  . .  . .       72 

-  condyloma  of  . .  . .     769 
519  I  -  Jacquet's  erythema  of      . .     446 


Thigh,  contd. 

-  linese  albicantes  on  . .     402- 

-  lymphatic  drainage  of       . .     738 

-  muscles,  atrophy   of,   with 

hip  disease  . .         . .     183 

-  pain  in  (see  Pain  in  Thighs) 

-  pemijhigus  neonatorum  of      446 

-  scabies  of     . .  . .  . .     447 

-  seborrhceic      dermatitis     of 

infants  affecting  . .     447 

-  xerodermia  of  . .  . .  530 
Third     cervical     nerve,     skin 

distribution  of    . .  . .     659 

-  nerve    paralysis,    dilatation 

of  one  pupil  in    . .  . .     595 

ptosis  from  (Fig.  157)     590 

THIRST,  EXTREME..  ..     789 

in  diabetes  . .        292,  507 

insipidus  . .  . .     584 

phosphatic  diabtes        . .     572 

phosphorus  poisoning    .  .      373 

polsxythsemia  from      579,  580 

in  pregnancy       . .  . .     293 

-  during  rigors  . .  . .  646 
Thomas,   re   olivo-ponto-cere- 

bellar  atrophy      . .  .  .      799 

Thoma-Zeiss  and  Leitz  haemo- 

cytometers  . .  . .       27 

Thompson,  re  Brown-Sequard 

paralysis  . .  . .  . .     064 

-  re  distribution  of  sensation 

from  lesions  in  the  cord . .  662 
Thomsen's   disease,   electrical 

reactions  in        . .  . .     634 

Thoracic       aneurysm       (see 

Aneurysm) 

-  duct   obstruction,    chylous 

ascites  from  . .       58 

chyluria  in       . .  . .     126 

secondary   glands    along, 

in  abdominal  growth        421 

-  veins,  condition  of  in  new 

growth  of  lung    . .  . .     322 

-  wall  (see  Chest,  Bulging  of) 
Thorax,  extension  of  pedicu- 
losis pubis  to       . .  . .     447 

-  gas  in  (see  Pneumothorax) 

tympany  due  to . .  . .     668 

-  rickety  212 

-  secondary    deposits    in,    in 

carcinoma  of  breast  . .  743 
Thorn-apple  crystals  of  urates  815 
Threads,  prostatic      . .  . .     444 

Thread-worms  (Oxyuris)      . .     569 

-  bleeding  per  anum  from  . .       93 

-  a  cause  of  priapism  . .     585 

-  eosinophilia  with  . .  . .  249 
Thrill,  fluid,  with  ascites  . .  51 
in  ovarian  cyst    . .  . .       52 

-  hydatid         720 

in  liver      . .  . .  . .     415 

THRILLS,  PRECORDIAL,  sig- 
nificance of      . .  . .     789 

in  aortic  disease  . .  . .     233 

congenitalheart  disease  129,  244 

mitral  regurgitation       . .     238 

stenosis  . .  . .     245 

with  patent  ductus  arteri- 
osus      . .  . .  . .     184 

septum  ventriculorum       184 

pulmonary  stenosisl29, 184,  247 

Throat,  abscess,  in,  septicaemia 

from  614 

-  examination  of,  in  obscure 

P3-rexia      . .  . .  . .     620 

-  Klebs-Lofflcr  bacUlus  in    . .     641 

-  macular    eruption    on,     in 

secondary  syphilis  .  .     425 

-  reddening  of,  in  scarlet  fever 

and  erythema  scarlatini- 
forme        . .  . .  . .     253 

-  sore  (see  Sore  Tliroat) 

-  swabbings,   examination   in 

cases  of  laryngitis         . .     406 


I002 


THROBBING— TIBIA 


321,  322,  700 


Throbbing  in  aortic  disease. . 

-  sensation    in   undue    abdo- 

minal aortic  pulsation   . . 
Thrombosis,     asymmetrical 
CEdema  from       . .        455, 

-  causes  of 

-  in  childbed  . . 

-  femoral  vein  . .         186, 

-  gangrene  from 

-  infarction  from 

-  the     central    retinal     vein 

(Plate  VIII,  Fig.  0)     462, 
sudden  blindness  from 

-  cerebral       . .        . .       173, 

-  -  acquired     paralysis     of 

childhood  due  to 

aphasia  from,  acute  onset  in 

ataxy  from  . .  68, 

athetosis  in 

coma  in    . .  . .        137, 

diabetes  insipidus  in 

headache    in         327,  328, 

hemianopsia  from 

hemiplegia  from 

82,  138,  285,  337, 

after  influenza     . 

measles 

-  -  monoplegia  from 
talipes  from 

-  ui  femoral  vein 

embolism  after 

extension     to     inferior 

vena  cava    . .  61, 

-  iliac  . .  . .  . .  9, 

-  of  inferior  vena  cava  i 

-  -  -  -  albuminuria  from  9,17, 

-  ascites  from  61, 

casts  in  lurine  in 

cause  of 

hfematuria    -^ith       9, 

nephritis  simulated  by 

oedema  of  legs  from 

461, 
secondary  to  throm- 
bosis in  one  leg   61, 

simulating  peritonitis 

varicose     abdominal 

veins  from 

-  of  innominate  vein,  inflam- 

matory causes  of 

-  -  varicose  thorax  veins  from 

-  intracardiac,  embolism  from 

155,  173, 

-  intracranial  sinus,  excruci- 

ating headache  from 

hemiplegia  in  . .        337, 

from  otitis  media 

pyrexia  with    . . 

rigors  with        . .         648, 

-  cavernous,  causes  of 

dilated  frontal  veins  from 

exophthalmos  in253,  254, 

limited  eye  movements 

with  . . 

mastoid  swelling  with 

oedema  of  eyelids  from 

253, 

squint  from.     . . 

suppurative   meningitis 

from . . 

-  lateral      

bronchopneumonia  in 

clottine     of     internal 

jugular  vein  from  . . 

gangrene  of  lung  from 

oedema  over  tlie  mastoid 

bone  from    . . 

optic  neuritis  from 

from    otitis    media 

98,  123,  186, 

pain  in  the  ear  from  . . 

pulmonary      embolism 

from  . .        186, 
rigors  with      . .        648, 


826 
820 

286 

651 
338 
650 
650 
650 
253 
253 
G51 

254 

254 

651 
651 

254 
578 
321 

651 

287 

651 
051 

650 
051 

578 
650 


Thrombosis,  intracranial,  contd. 

lateral,  tachycardia  in   . .       98 

tenderness  over  mastoid 

process  from  . .     651 

superior     longitudinal, 

cerebral  softening  from  643 

coma  in   .  .         139,  643 

convulsions  in     139,  558 

diagnosis  of  ence- 
phalitis and  men- 
ingitis from     .  .      558 

-  -  -  -  -  general  head  sym- 

ptoms in  . .     558 

_  _  _  headache  in         . .     139 

infantile     diplegia 

due  to  . .  . .     556 

paraplegia  due  to  558 

cedema     of    scalp 

from       . .  . .     651 

optic  neuritis  in. .     139 

paraplegia  from  556,  643 

pyrexia  in  558,  650 

retraction  of  head  in  641 

simulating  cere- 
bellar abscess  . .     651 

-  cerebral  abscess     651 

meningitis  558, 

643,  651 

vomiting  in  139,  558,  651 

sweating  with  .  .      650 

tenderness  over  the  mas- 
toid bone  from        . .     651 

thrombosis  of  internal 

jugular  vein  from  . .     651 
vomiting  with    650,  844,  847 

-  jugular    vein    from    otitis 

media       . .  . .         123,  578 

-  -  -  secondary     to     lateral 

sinus  thrombosis     . .     651 

-  mesenteric 432 

-  -  anal  haemorrhage  in       . .       90 

-  -  constipation  with  . .     153 

-  -  heart  or  abdominal  disease 

causing. .  . .  . .     153 

-  intestinal  obstruction  from  432 

meteorism  in      . .  . .     432 

peritonitis  from  . .  . .     432 

-  of  piles  . .  . .  . .     635 

-  of  portal  vein  ("and  see  Pyle- 

phlebitis) 

ascites  in         . .  . .       58 

general  account  . .     301 

-  of  posterior  inferior  cerebral 

artery,  ataxy  from         . .     666 

cerebellar  arterv,  ataxy 

hi        . .  '.  ..        68 

dissociative  anoesthesia 

(Fig.  184)     ..  ..660 

-  pulmonary,  hfemoptysis  from   317 

-  -  infarct  of  lung  from     321,  322 

in  mitral  stenosis  .  .      320 

pleuritic  effusion  from   . .     123 

-  renal,    albuminuria    in  8,  9 

-  saphenous  . .  . .  9,  486,  825 
oedema  of  one  leg  from . .     825 

-  spinal,  paraplegia  from  .  .  563 
in  syphilis  .  .  .  .     432 

-  -  transverse  myelitis  from      564 

-  of  superior  vena  cava,  in- 

flammatory causes  of  . .  826 
oedema  of  face,  neck, 

and  arms  from  458,  401 
varicose  thoracic  veins 

from  .  .  .  .      820 

-  affecting     uncinate     gyrus, 

anosmia  from  ..  ..009 

-  venous,  infarction  of  lung  in     321 

-  in  varicose  veins     . .  . .     450 

-  white  leg  from  . .  . .  450 
Thrush,  bleeding  gums  in  86,  88 
Thumbs,     double-jointed,     in 

Mongolism  .  .  .  .      216 

Thymic  asthma  mistaken  for 

spasmodic  asthma  . .     582 


Thymus  gland  and  anaemia  . .     215 

-  enlarged,   convulsions  of 

children  with  . .  . .     169 

diagnosis  of         . .  . .     46& 

dullness  behind  sternum  in  465 

and  infantile  convulsions      170 

lymphatism  . .  .  .     423 

-  -  stridor  from         . .  . .     710 
tracheal  obstruction  from 

405,  710 
x-ray  shadow  of . .  . .     405 

-  fatal  syncope  . .  . .     215 

-  fatness  . .  . .  . .     215 

-  and  infantilism        . .  . .     215 

-  mediastinal     new     growth 

arising  from        . .  . .     826 

Thyroid  abscess  in  pyaemia  . .     792 

-  cartilage,  perichondritis  of, 

in   syphilis  .  .  .  .     791 

-  extract,   benefit    from   (see 

Thvroid  Treatment) 
THYROID        GLAND        EN- 
LARGED   

age  incidence  of        791, 

breathlessness  with   . . 

in  exophthalmic  goitre 

244,  253,  527,  772,  797, 

mistaken  for  asthma 

obstruction  to  cesopha- 

gus  by 

of  trachea  by 

veins  by 

onset  at  puberty 

palpitation  with 

paralysis  due  to 

of  vocal  cords  due  to 

parenchymatous,    anje- 

mia  with 

pressure,  effects  of 

relation  to  exophthalmic 

goitre 

slow  growth  of 

stridor  from    . . 

swellmgs  simulating  . . 

tachycardia  with 

tracheal  obstruction  from 

-  hydatid  cyst  of 

-  malignant  disease  of  (see 

Carcinoma  of   Thyroid 
Gland) 

-  -  movement    with    larynx 

on  swallowing. . 

and     ovarian     inter-rela- 
tionships 

tetany  from  removal  of  178, 

tuberculosis  of     . . 

-  infantilism  (Pig.  07) 

-  insufficiency  '   (see      Hypo- 

thyroidism ;     Cretinism  ; 
and  ilyxcedema) 

-  secretion,  effect  on  menstru- 

ation 

-  treatment,  benefit  to  myx- 

oedema  from     . . 

-  -  in  cretinism 
diagnosis      of     cretinism 

from  idiocy      . .        204, 

of  hypothyroidism 

myxcedenia  42,  259,  454, 

no     effect     on     adiposis 

dolorosa 

enuresis  cured  by 

palpitation  from  525, 

reduction  of  weight  by . . 

-  -  tachycardia  from 
Thyroidectomy,  tetany  after 

3,  178, 
Tibia,  affection  in  yaws 

-  bedsore  over 

-  deformities     in     congenital 

syphilis     . . 

-  necrosis  of,  talipes  from    . . 

-  overgrowth  after  injury    . . 

-  sarcoma  of  (J^iV- 196)  754,756, 


791 

792 
792 

849 

582 

792 
710 
793 
791 
792 
792 
538 

792 
792 

792 
791 

710 
791 
792 

405 
792 


791 
454 


792 
216 


430 

400 
216 

557 
454 
585 

455 
248 
527 
849 
773 

802 
449 

285 

260 
132 
132 
763 


TIBIA— TONGUE 


1003 


■Tibia,  contd. 

-  swelling   on,    in   secondary 

syphilis     ..          ..          ..  752 

-  tuberculous  disease  of  . .  752 
Tibial     muscle     affection     in 

infantile  paralysis         131,  132 

paralysis,  talipes  from  . .  132 

Tibialis  anticus  muscle,  spinal 

nerve  root  supplying  . .  543 
nerve  supply  of  . .          . .  512 

-  posticus,  nerve  supply  of  . .  5-12 
Tic,   convulsive,   mild    chorea 

simulating            . .          . .  156 

-  douloureux  (and  see  Trigeminal 

Xeuralgia,  Major)           . .  495 

absence    of    neurasthenia 

with 783 

pain  relieved  by  pressure  783 

and  tenderness  due  to  782 

paroxysm  brought  on  by 

I^ressure            . .          . .  783 
relation  of  ptyalorrlioea  to  592 

-  spasmodic,  a  cause  of  con- 

vulsions   . .          . .          . .  169 

-  -  muscle  twitching  in  . .  159 
Tickling,  hiccough  from  . .  342 
Tight  lacing,  furrow  on  liver 

from  . .          . .      . .          . .  405 

liver  depressed  by  404,  405 

passive     hyperoemia      of 

uterus  from      . .        428,  430 

-  -  Kiedel's  lobe  from          404,  405 

shape  of  liver  in  . .          .  .  405 

Tightness  in  chest,  from  bron- 
chitis          480 

-  -  chronic  mediastinitis      . .  484 

mediastinal  growth        . .  483 

oesophagismus      . .          . .  484 

Tilbury  Fox,  re  impetigo  con- 
tagiosa     .  .            446,  601,  654 

Tinea  Circinata  (and  see  King- 
worm  ;       and       Fungous 

.Vftections  of  Skin)         . .  274 

-  -  diagnosis    from   oircinate 

tubercular  syphiloderm  275 

macular  syphilide       . .  426 

pityriasis  rosea           .  .  658 

tinea  imbricata           . .  276 

involvement  of  lips  in    . .  403 

-  decalvans     . .          . .          . .  274 

-  imbricata,  description  of    . .  275 

diagnosis  from  ichthyosis  276 

tinea  circinata            . .  276 

parasitology  of    . .          . .  276 

-  marginata  in  bathing-draw- 

ers area    . .          . .          . .  447 

pruritus  caused  by         . .  588 

-  sycos;s  (see  Hingworni  of  the 

Beard) 

-  tonsurans  (see  Ringworm) 

scales  in  . .          . .          . .  655 

-  versicolor,      contagiousness 

low  of 276 

currant-like     masses      of 

spores  in          . .          . .  276 

description  of      . .          . .  276 

diagnosis   from  chloasma 

276,  575 

eczema   seborrhoeicum  276 

erythrasma      . .          . .  276 

leprosy. .          . .          . .  276 

pityriasis  rosea           . .  276 

syphilides         . .         276,  426 

distribution  of     . .          . .  276 

macules  in            .  .          . .  424 

microsporon  furfur  in     . .  276 

scales  in  .  .  276,  426,  655 

Tingling  in  acropanesthesia . .  493 


miliaria  rubra 
peripheral  neuritis. . 
preceding  apople.vy 
pruritus  described  as 
in  ringworm 
tabes  dorsalis 


831 
505,  661 
. .     173 


Tinkling,  metallic,  with  pneu- 
mothorax 
TINNITUS        

-  a-iisociated  with  flushing  . . 

-  epistaxis  relieving  . . 

-  good  influence  of  open  air  in 

-  increased  bj-  tobacco 

-  in  Mtnitre's  disease 

-  middle-ear  deafness 

-  nuclear  facial  paralys.'s    . . 

-  otitis  media 

-  otosclerosis  . . 

-  syphilitic  ear  disease 

-  tuberculous  otitis  media  . . 

-  varieties  of  . . 

-  from  wax  in  ears    . . 
Tiredness  at  onset  of  phthisis 
Tobacco,  amblyopia  with 
optic  disc  changes  in 

-  central  scotoma  from       836, 

-  colour  blindness  from  836, 

837, 

-  diminished  appetite  from 

-  dry  cough  from 

-  dyspepsia  from 

-  gastritis  from 

-  headache  from 

-  hemeralopia  from   . . 

-  undue  increase  of  pulse-rate 

on  exertion  from 

-  infantilism  from 

-  insomnia  from 

-  intermittent       claudication 

from 

-  loss  of  weight  due  to 

-  nerve  deafness  from 

-  palpitation  from     . .        525, 

-  pseudo-angina  in    . . 

-  retinal  cones  affected  by  . . 

-  susceptibility     of     different 

people  to 

-  tachycardia  from   . . 

-  tinnitus  increased  by 

-  tremor  from 

-  vertigo  from 

-  violent  thumpings  of  heart 

on  getting  into  bed  from 

-  vomiting  from 
Toes  in  acute  gout 

-  affected  by  scabies. . 

-  athetotic  contractions  of  . . 

-  deformity  from  boots 

-  dragging  of  in  spastic  mono- 

plegia 

-  examination  of,  in  obscure 

pyrexia     . . 

-  exostosis  of . . 

-  hyperextended,  in  paralytic 

talipes 

-  pain  in,  in  Morton's  disease 

-  in  Raynaud's  disease 
Toe-nail,  ingrowing  . . 
Tokelau  ringworm  (see  Tinea 

Imbricata) 
Toluylenediamine     poisoning, 

blood  destruction  in 

jaimdice  in 

Tomatoes,  oxaluria  from       311, 
Tongue,  affections  of  anterior 

portion,  referred  pain  in 

mental  area  in    . . 

of  dorsum,  referred  pain 

in  occipital  area  in 

-  -  -  lateral  portions,  referred 

pain  in  hyoid  area  in 
in  sprue    . . 

-  angio-neurotie  oedema  of  . . 

-  atrophy  of  . .  . .  69, 
in  bulbar  paralvs's    224, 

"  591,  641, 
myasthenia  gravis 

-  "  bald,"  in  scarlet  fever  . . 

-  not     bitten     in     hysterical 

convulsions 


Tongue,  conld. 

193 

-  biting  of,  in  epilepsy        171, 

046 

793 

convulsions 

168- 

268 

-  carcinoma  of  (see  Carcinoma 

252 

of  Tongue) 

793 

-  chancre  of,  discussed 

81.3. 

793 

-  cornet-player's  cramp  of  . . 

177 

828 

-  deep-red  colour  in  diabetes 

292- 

190 

-  deficiency  of  deep  tenderness 

536 

in  locomotor  ataxy 

562- 

470 

-  dental  ulcer  of        . .        812, 

814 

829 

-  difficulty  in  using,  a  cause 

828 

of  dysphagia 

22.> 

469 

-  dry,  from  belladonna 

77.3. 

793 

and     bromi,     in     acute 

467 

yellow  atrophy           302, 

370- 

620 

with  lardaceous  disease 

4& 

836 

pyelonephritis . . 

48 

836 

renal  tuberculosis 

48- 

837 

and  furred  in  peritonitis 

in    tropical   abscess    of 

431 

840 

liver 

369- 

49 

in  urar^mia 

45^ 

175 

-  dyspeptic  ulcer  of  . . 

812 

3.54 

-r  electrical    reactions    of,    in 

352 

bulbar  paralysis .  . 

687 

328 

-  enlargement  in  acromegaly 

26a 

841 

-  epithelioma  of  (see  Carcinoma 
of  Tongue) 

527 

-  fibrillary     contractions    of, 

215 

in  bulbar  paralysis       159, 

686- 

356 

in   disease    of    central 

nervous  system 

158- 

489 

-  fissured  in  syphilis 

813 

848 

-  furred  in  alcoholism          136, 

243. 

191 

alveolar  abscess 

747 

527 

appendicitis 

736- 

482 

foul  taste  due  to 

774 

841 

in  gastritis  ■         . .          49, 

29r 

loss  of  taste  due  to 

774 

527 

in  peritonitis 

774 

772 

pneumonia 

774 

793 

septicsemia 

774 

795 

severe  fevers 

774 

827 

tyfihoid  fever 

and    indented,    in   active 

774 

527 

congestion  of  liver     . . 

371 

843 

-  -  and  tremulous,  in  chronic 

382 

alcoholism 

59' 

832 

-  gangrene  of,  in  Raynaud's 

154 

disease 

284 

132 

-  glazed  in  pyelitis    . . 

62.5- 

-  gumma  of    .  .          .  .         279, 

814 

540 

median  position  of 

42» 

-  herpes  zoster  of 

831 

620 

-  indented  in  chronic  gastritis 

297 

754 

acromegaly 

263. 

congestion  of  liver 

371 

130 

-  leucoplakia  of  (Plate  XV) 

814 

488 

-  movements  in  chorea 

548- 

490 

-  mucous     patches      on      in 

486 

secondary  syphilis 

813 

-  paresis  of,  in  bulbar  paralysis 

641 

-  progressive  weakness  of   in 

bulbar  paralysis 

224 

374 

-  protrusion  in  cretinism 

25S 

362 

Mongolian  idiocy 

263 

471 

-  sore,  with  papular  syphilo- 

derms 

533 

in  secondary  syphilis     . . 

605- 

498 

-  strawberry    appearance    of, 
in  scarlet  fever  and  ery- 

498 

thema  scarlatiniforme   .  . 

25.3 

-  swelling  of,  due  to  mercury 

86- 

498 

-  swollen,  dysphagia  due  to 

225 

197 

-  syphilis  of  237,  279,  420,  812 

813 

457 

-  taste  nerves  of 

77.> 

>  To 

-  tremor  of 

79.5- 

alcohohc  . .   238,  243,  368 

797 

686 

cirrhosis  of  liver            368, 

410 

687 

in  general  paralysis      172, 

796 

674 

lead  poisoning    . . 

797 

paralysis  agitans 

796. 

160 

-  trichinosis  parasites  in 

801 

I004 


TONG  UE— TRICHINOSIS 


Tongue,  contd. 

Tooth's  peroneal  atrophy     .. 

71 

Training,  lack  of,  tachycardia 

-  tuberculous            . .        812 

814 

ankle-clonus  in 

560 

from 

772 

—  ulceration    of   (see    Ulcera- 

  atrophy  of  leg  muscles 

Trance,  hysterical      . .        137, 

140 

tion  of  Tongue) 

with  . . 

128 

Transfusion,    acute    nephritis 

-  unilateral  palsy  of,  absence 

Babinski's  sign  in 

81 

simulated  after  . . 

458 

of  articulatory  defect  in 

687 

claw-hand  in    . .        127 

128 

-  universal  cedema  from      458 

,460 

-  white  spots  on  in  aphthous 

commencing  in  one  leg 

545 

Transillumination   of   antrum 

stomatitis 

815 

-  -  -  diagnosis  of  transverse 

of  Highmore  {Fig.  62,  p. 

Tonic  contraction  of  uterus  . . 

229 

myelitis  from 

74 

205)            ..          ..         502 

749 

—  spasms    (see    Contractions, 

familial     character    of 

Transitional  corpuscles 

29 

Tetanic) 

{Figs.  8,  9,  p.  71)  132 

560 

Translucency    test    for    cysts 

Tonsillectomy,    death   from 

-  -  -  following      whooping- 

of  testis    . . 

521 

lymphatism  after 

423 

cough  or  measles    . . 

560 

in  hydrocele          521,  522 

741 

—  palate  paralysis  after 

640 

paralysis  of  arm  in     . . 

554 

-  of  psoas  bursa 

741 

Tonsillitis,  acute,  albuminm-ia 

paraplegia  from  557,  559 

560 

Transposition  of  great  vessels 

184 

in           . .          . .             17,  18 

plantar  reflex  in 

81 

-  liver 

404 

aortic  disease  after 

237 

reaction  of  degeneration 

-  viscera          . .          . .        184 

224 

-  -  dysphagia  witli   . . 

591 

in       ..          ..        132 

560 

Transverse  myelitis  (see  Mye- 

 earache  from 

230 

-  -  -  reflexes  in 

560 

litis,  Transverse) 

endocarditis  complicating 

239 

talipes  in             71,  132, 

560 

Traube's  space,  definition  of 

668 

enlarged  glands  from    419, 

708 

Tooth-ache,  abscess  with     . . 

747 

Trauma  (see  Injury) 

foul  breath  due  to 

99 

Tooth-brush,    bleeding    gums 

Traumatic  arthritis    . . 

375 

pains  in  the  limbs  in    503 

505 

due  to 

85 

Treadler's  cramp 

177 

in  peliosis  rheumatica   . . 

600 

-  retracted  gums  from 

641 

TREMOR         

791 

with  pharyngitis.  . 

673 

Tooth-plate  ill-fitting,  haemor- 

- in    acquired    infantile    par- 

 phlegmonous 

419 

rhage  due  to 

87 

alysis 

155 

—  -  ptyalism  with 

591 

-  obstructmg  oesophagus     . . 

222 

-  alcoholism  136,  172,  238,  258 

368 

pyrexia  in              620,  622, 

672 

-  in    oesophagus,    htemate- 

-  of  arm  (see  Arm) 

rigors  in  . . 

647 

mesis  from 

297 

-  associated  with  flushing    . . 

268 

sore  tliroat  from 

670 

opening  into  pericardium 

711 

-  causes  of      . . 

795 

spinal  arthritis  in 

708 

-  ptyalism  due  to  defective. . 

591 

-  in  congenital  diplegia  154,795,800 

spondylitis  deformans  after 

787 

Tophi  in  ear,  in  gout           381 

507 

-  differentiation  of  choreiform 

stifE  neck  from   . . 

708 

-  about  joints 

507 

movements  from 

156 

trismus  simulated  by    . . 

801 

-  sodium  urate  crystals  in 

381 

-  of  eyes  (see  Nystagmus) 

various    micro-organisms 

Torsio  testis  (see  Testis,  Tor- 

- fibrillary     in     intermittent 

causing.. 

670 

sion  of) 

claudication 

490 

-  chronic,   diphtheritic 

672 

Torticollis,  clonic  contractions 

161 

-  in  Graves'  disease   244,  253, 

syphilitic 

672 

-  contracture  in 

167 

772,  792, 

849 

-  -  from  Vincent's  angina  . . 

672 

-  description  of 

708 

-  head  (see  Head,  Tremor  of) 

-  follicular,  albuminuria  in. . 

17 

-  due  to  disuse 

163 

-  with  hysterical  chorea 

157 

constitutional  disturbances 

672 

-  hemiatrophy  of  face  with  167 

537 

-  mfluence  of  sleep  on 

795 

diphtheria  bacilli  in 

671 

-  hysterical     . . 

166 

-  intention  (see  Intention  Tremor) 

distinction     of   Vincent's 

-  due  to  injury  at  birth 

708 

-  in  Little's  disease    . . 

154 

angina  from     . . 

672 

-  retraction  of  the  head  in. . 

641 

-  mercurial      . .          . .            37,  77 

foul  breath  in     . . 

99 

-  scoliosis  in    . .            1 80,  181 

708 

-  in  occupation  cramp 

177 

high  fever  in 

672 

-  spasmodic    . . 

708 

-  paralysis  agitans     . . 

548 

leucocytosis  in    . . 

400 

Torulse  m  vomit 

134 

-  peripheral  neuritis..           77, 

285 

simulating  sjT)hilis 

672 

Trachea,    aneurysm  rupturing 

-  post-hemiplegic 

157 

sore  throat  from 

670 

into           . .            140,  318 

482 

-  rate  of  various 

795 

-  rheumatic         239,  374,  504 

671 

-  displaced  by  thyroid  gland 

792 

-  tongue  (see  Tongue,  Tremor  o 

0 

age  incidence  of            504, 

671 

-  epithelioma  of,  stridor  from 

710 

-  unilateral,  from'  tumour  of 

enlarged  submaxillary  lym- 

- irruption  of  caseating  gland 

subthalamic  region 

798 

phatic  glands  in 

419 

into 

465 

Trephining,     indications     for 

nature  of  some  cases  of . . 

374 

-  ulceration  of,  hsemoptysis  in 

318 

in  cases  of  coma . . 

137 

-  recurrent      . .          . .         121, 

671 

from    malignant    thyroid 

Treponema      pallidum      (see 

Tonsils  and  adenoids,  mouth- 

gland     .  . 

792 

Spirochfrta  Pallida) 

breatliing  causing 

672 

-  obstruction  by  aneurysm  . . 

482 

Triceps,  nerve  supply  of 

550 

-  carcinoma  of  (see  Carcinoma 

causes  of . .          . .        465, 

709 

-  pseudo-hypertrophy  of 

560 

of  Tonsils) 

diagnosis  of 

465 

-  spinal  nerve-root  supplying 

556 

—  chancre  of    . .          . .         670, 

072 

by  enlarged  thymus  gland 

710 

Trichinosis,  acute  general  pains 

-  enlarged,    association   with 

epithelioma  of  oesophagus 

710 

in  the  limbs  in    . . 

503 

adenoids  . . 

670 

intercostal  retraction  in 

465 

-  albuminuria  in 

17 

deafness  from     . . 

190 

malignant  glands  in  neck 

710 

-  blood-changes  due  to 

33 

-  -  enuresis  cured  by  removing 

248 

mediastinainewgrowth  483 

,710 

-  cachexia  in . . 

115 

insomnia  fi-om     . . 

357 

orthopncea  in 

465' 

-  diagnosis  from  acute  gastro- 

 in  lymphatism     . . 

423 

stridor  from 

709 

enteritis    . . 

504 

-  -  night  terrors  with 

448 

sucking     in     above     the 

polymyositis    . . 

504 

-  -  witli  rhinitis 

204 

clavicles  in 

465 

cholera     . . 

504 

-  -  stertor  from 

707 

syphilitic  .  . 

710 

enteric  fever 

504 

-  epithelioma   of    (see    Carci- 

 by  thyroid  tumour 

792 

rheumatism 

504 

noma  of  Tonsils) 

after  tracheotomy 

710 

-  eosinophilia  in          249,  504, 

801 

-  gumma  of,  simulating  car- 

Traclieal tugging 

222 

-  epidemic 

801 

cinoma 

672 

Tracheotomy,  haemoptysis  after 

318 

-  gastro-enteritis  from 

504 

sore  throat  from. . 

670 

-  stenosis  of  trachea  after    . . 

710 

-  high  fever  in           . .        504, 

801 

-  mucous       patch       on,      in 

-  stridor  after 

710 

-  infection  from  pork         504, 

801 

secondary  syphilis 

675 

-  surgical  emphysema  after 

231 

-  leucocytosis  in 

504 

—  sarcoma  of  (see  Sarcoma  of 

-  urgent,  from  acute  suHoca- 

-  muscles  affected  by         504, 

801 

Tongue) 

tive  oedema  of  larynx  185 

539 

-  oedema  of  face  and  eyes  in 

504 

-  syphilis  of  425,  670,  672,  675 

813 

in     bilateral     laryngeal 

-  pain    and    stiffness    in    the 

-  tuberculous 

672 

paralysis 

539 

muscles  from       . .        504, 

801 

-  ulceration  of  (see  Ulceration 

for  codema  of  larynx     . . 

673 

-  profuse  perspiration  in     . . 

504 

of  Tonsils) 

Trachoma,  corneal  ulceration  in 

807 

-  rarity  in  Great  Britain     . . 

504 

—  list    of    various    acute    and 

-  pannus    in    .  . 

807 

-  severe     constitutional     dis- 

chronic affections  of  the 

670 

-  ptosis  in 

590 

turbances  in 

801 

TRICHINOSIS— TUBERCULOSIS 


1005 


Trichinosis,  contd. 

Trismus,  contd. 

Tuberculosis,  absence  of  clinical 

-  tenderness  of  the  spine  in. . 

785 

-  tetanus         . .     162,  178,  463, 

709 

signs  for  some  time  in   . . 

610 

-  trichinella;  in  muscles  in  . . 

501 

-  various  conditions  simulating 

801 

-  acetonuria  in 

4 

—  in  stools  in 

504 

Trochanter,  great,  bedsore  over 

285 

-  albuminuria  in 

17 

-  trismus  from 

801 

Trommer's  test  for  glycosuria 

289 

-  amenorrhcEa  in 

23- 

Tricocephalus  dispar  (f  i!7.  151) 

5U9 

Trophic  changes  in  skin,  nails, 

-  anaemia  in   . .          . .  37,  450, 

616 

no  blood  changes  with  . . 

33 

and    joints    in    syringo- 

- axillary  abscess  in  . . 

731 

as  cause  of  eosinophilia. . 

219 

myelia      ..          ..        128, 

285 

-  of    bladder    (see    Cystitis, 

Trichophyton  acuminatum  . . 

272 

-  lesions  in  acquired  infantile 

Tuberculous) 

-  craterilorme 

272 

paralysis  . . 

155 

-  blood  changes  in     . . 

450- 

-  cultures,  classification 

273 

infantile  paralj'sis 

131 

-  of  breast  (see  Breast,  Tuber- 

- sulphureum 

272 

-  ulcers  in  paralytic  talipes . . 

130 

culosis  of) 

-  violaceum     . . 

272 

TrophcEdema,  hereditarj'  (see 

-  cachexia  from     17,  114,  459, 

461 

Trichopliytosis  (and  see  Ring- 

Milroy's Disease) 

-  Calmette's     reaction     for. 

worm  and  Tinea)   272,  273 

275 

Trophoneurosis,  gangrene  from 

284 

fallacies  of 

G21 

Tricuspid  area,  systolic  bruits 

-  macules  in  . . 

423 

-  cell  changes  in 

450- 

over 

106 

Tropical  abscess  of  liver  (see 

-  characteristic     temperature 

-  regurgitation,    absence    of 

Abscess,  Hepatic) 

curve  of  . . 

612 

bruit  with 

106 

-  climate,  dengue  in.. 

506 

-  in  children,  anorexia  in     . . 

50^ 

from  alcoholism . . 

243 

effect  in  producing  active 

-  chloasma  in 

574 

bruits  of  . . 

239 

congestion  of  liver     . . 

371 

-  of  colon  (see  Colon,  Tuber- 

 in  chronic  bronchitis  and 

yellow  fever  in    . . 

372 

culosis  of) 

emphysema 

246 

-  diseases,  cachexia  from    459, 

461 

-  diagnosis     from     fungating 

paiu    and    tenderness    in 

loss  of  weight  in . . 

848 

endocarditis^ 

6ia 

the  back  from . . 

789 

oedema  of  legs  in           459, 

461 

influenza . . 

Gia 

pulsation  of  liver  in     . . 

407 

severe  anaemia  from 

459 

paratyphoid  fever 

611 

secondary  to  mitral 

239 

Trousers,  ill-fitting,  a  cause  of 

yaws          

450- 

thrill  with 

791 

priapism  . . 

586 

-  empyema  resulting  from  . . 

120 

-  stenosis,  presystolic  bruit  in 

110 

Trousseau's  sign         . .            3, 

178 

-  enlarged  glands  in  groin  in 

738 

—  thrill  with 

791 

Truss,   enlarged  groin  glands 

cervical  glands  in 

421 

-  valve,    fungating    endocar- 

from 

738 

-  fatty  liver  in 

414 

ditis  of     . . 

321 

-  ill-fitting,  testicular  atrophy 

-  functional  bruits  in 

106 

Trigeminal  nerve,  tumour  of, 

from 

78 

-  general,  cerebral  type  of  . . 

69& 

neuralgic  pain  and  tender- 

Trypanosoma gambiense  (Plate 

absence  of  leucocytosis  in 

614 

ness  due  to 

783 

XII,  Fig.  G,  p.  696) "     . . 

34 

acute,  leucopenia  in 

401 

-  neuralgia    from    a    carious 

in  cerebrospinal  fluid     . . 

340 

choroid  tubercles  in 

463. 

tooth       

495 

Trypanosomiasis,  blood  change? 

diagnosis  from  bronchitis 

344 

coryza  in 

203 

in  . . 

34 

typhoid  fever  . . 

69» 

—  earache  associated  with 

230 

-  lymphocytosLs    in    cerebro- 

 frequent  origin  in  a  tuber- 

from  G-asserian    ganglion 

spinal  fluid  in 

339 

culoas  bronchial  gland 

427 

disease 

496 

-  trypanosomes  in  cerebrospina 

hyperpyrexia  in 

343 

in  glaucoma 

838 

fluid  in 

340 

purpura  in           .  .         596, 

598 

-  -  gummatous  meningitis 

496 

Tubal  abortion  (see  Abortion, 

pyrexia  with  weakness  anc 

periostitis 

496 

Tubal) 

anorexia  at  oa-set  of  . . 

612 

herpes  zoster 

496 

-  disease,  referred  pain  in  the 

rigors  in  . . 

647 

persistence  of  pain  for 

area  of  10th  dorsal  nerve  in 

509 

severe  headache  m 

699' 

months  in  some  cases 

496 

-  gestation     (see     Gestation, 

splenic  enlargement  in  692 

69^ 

iritis 

495 

Ectopic  :     and  Abortion, 

tuberculous  meningitis  a 

scars  of  old  herpes  in     . . 

496 

Tubal) 

part  of . . 

612 

from  tumours  at  base  of 

ruptured   (see    Gestation, 

-  genito-urinary,  pyrexia  in 

621 

brain 

496 

Ectopic;  and  Abortion, 

-  guinea-pig     inoculation     in 

of  5th  nerve    . .        496 

783 

Tubal; 

diagnosis  of 

71& 

—  major       . .                495 

496 

Tube-casts  (see  Casts,  Renal) 

-  haematoporphyrinuria  in  . . 

820 

aijsence  of  sensibility  in 

496 

Tubes,    distended    Fallopian, 

-  histological  diagnosis  of    . . 

814 

muscular  paresis  in 

496 

causing  dyschezia 

150 

-  iritis  and  cyclitis  in 

25& 

age  incidence  of 

495 

Tubercle  bacilli  (see  Bacillus) 

-  of  joints  (see  Arthritis.  Tuber 

cutaneous  flushing  in 

495 

Tubercles,  choroidal    (and  see 

culous ;    and    for    Tuber- 

 idiopathic,     diagnosis 

Choroid),    with    Cheyne- 

culosis  of  the  Tiscera  see 

from     symptomatic 

Stokes  respiration 

125 

under  the  different  organs. 

trigeminal  neuralgia 

496 

in  meningitis      . .        341 

699 

e.g..  Kidney ;  Liver ;  Pros- 

 lachrymation  in 

495 

ophthalmoscopic   appear- 

tate; Th3Toid  Gland,  etc.) 

photophobia  in 

495 

ance  of  (Plate  VHP)  . . 

463 

-  latent,  loss  of  weight  from 

S47 

points  in  diagnosis  of 

495 

-  unilateral  exophthalmos  due 

pleuritic  effusion  in 

121 

reflex  spasm  of  muscles 

to 254 

255 

von    Pirquet's    and    Cal- 

of affected  side  in  . . 

495 

-  (and  see  Kodules) 

mette's      reaction      in 

salivation  in    . . 

495 

Tuberculides  (see  Scrofuloder- 

diagnosing 

847 

subjective  sensation  of 

mia) 

-  leucocytosis  absent  in      620 

,699 

swelling  in  . . 

495 

Tuberculin    in     exclusion    of 

uncommon  in,  except  in 

trophic  changes  in  hair 

tuberculous  peritonitis  . . 

719 

advanced  phthisis  and 

and  skin  in  . . 

495 

-  injections     ui     diagnosing 

meningitis 

40& 

no  wasting  in  . . 

496 

chronic  abscess  of  bone 

752 

-  lichen  scrofulosorum  with . . 

52» 

Trigonal    region    of    bladder, 

Addison's  disease 

38 

-  of  Lung  (see  Phthisis ;  and 

affection  of,  causing  penile 

latent  tuberculosis     . . 

848 

Lung; 

pain 

441 

lupus  vulgaris. . 

812 

-  lymphatic     gland     enlarge- 

Trional, coma  due  to. . 

137 

tuberculosis       612,  808 

814 

ment  in  (see  Lymphatic 

Triplegia,  infantile 

155 

tuberculous  caecum 

736 

Glands) 

Triple  phosphate   crystals   in 

-  reaction     absent     in     lung 

-  marasmus  in 

427 

urine  (Fiy.  155)  . . 

573 

1           lesions     due     to     oidium 

-  milk  in  relationship  to 

84S 

TRISMUS         

801 

;           tropicale  . . 

705 

-  multiple  serositis  in 

123 

-  absent  in  hydrophobia 

162 

I eosinophilia    in    positive 

-  cedema  of  legs  in    . .        459 

,  461 

or     late     in     strychnine 

stage  of 

249 

-  onychia  in  . . 

445 

poisoning 

162 

(and   see  Calmette's   Re- 

- pancreatitis  from    . . 

116 

-  from  alveolar  abscess 

747 

action  ;    and  Yon  Pir- 

-  perforation  of  palate  in     . . 

64& 

-  in  hysteria  . . 

162 

quet's  Reaction) 

,  -  peripheral  neuritis  in 

506 

3  006 


TUBERCULOSIS— TYPHOID    FEVER 


Tuherculosis,  contd. 

Tympanites,  contd. 

Typhoid  fever,  contd. 

—  pyrexia  prolonged  iii 

609 

-  in  atonic'constipation 

143 

differential          leucocyte 

-  -  the    only    symptom    for 

-  carcinoma  of  colon . . 

367 

count  in  diagnosis  from 

weeks  in  some  cases  of 

612 

-  cirrhosis  of  liver 

410 

suppuration     . . 

402 

-  recrudescence     following 

-  diagnosis  of  ascites  from  . . 

52 

distribution  of  spots  in  . . 

607 

measles     . . 

427 

-  displacement  of  cardiac  im- 

 dryness  of  tlie  mouth  in 

774 

—  shortness  of  breath  in 

101 

pulse  by  . .          . .         330, 

332 

Eberth's  bacillus  in  fa3ces 

610 

-  simulation  by  alcoholism 

849 

-  gastric,  over  thorax 

668 

empyema  of  gall-bladder  in 

369 

anorexia  nervosa 

850 

-  in  acute  haemorrhagic  pan- 

 enlarged  mesenteric  glands 

-  of  spine  (see  Caries  of  Spine) 

creatitis    . . 

646 

in 

422 

-  testicular  atrophy  in           79 

,  80 

-  Hirschsprung's  disease     148, 

152 

epididymo-orchitis  in  517, 

518 

-  tuberculin  injection  test   of 

814 

-  loss  of  liver  dullness  from . . 

404 

epistaxis  in             90,  251, 

697 

tests  for   . . 

612 

-  orthopncea  from     . .        465, 

467 

exp.ggeration  of  knee-jerks 

—  ulceration  of  palate  in 

640 

-  palpitation  from      .  .         526, 

528 

in   convalescence   from 

397 

rectum  in 

635 

-  in  general  peritonitis 

644 

fatty  heart  following     . . 

241 

-  vertebrae  (see  Caries  of  Spine) 

-  physical  signs  of 

52 

stools  in 

265 

-  visceral,     multiple     benign 

-  in  pneumothorax    . . 

480 

fewness  of  physical  signs  m. 

697 

sarcoid  with 

452 

-  pyloric  obstruction 

134 

foul  breath  in     . . 

98 

-  von      Pirquet's     cutaneous 

-  thoracic,  due  to  stomach  or 

taste  in 

774 

reaction  for            612,  814, 

847 

colon 

668 

frontal  headache  at  onset  of  610 

-  wasting  with 

69 

Tympanum,  effect  of  nuclear 

fullness  of  abdomen  .in  . . 

90 

Tuberculous  lymphatic  glands 

facial  paralysis  on 

536 

furred  tongue  in 

774 

(see  Lymphatic  Glands) 

Type-setters,  plumbism  in   . . 

136 

gall-bladder  enlarged   in 

-  meningitis  (see  Meningitis) 

Typhlitis,  pain  in  right  iliac 

280,  281, 

371 

-  otitis     media     (see     Otitis 

fossa  from            . .        135, 

501 

gangrene  in 

282 

Media,  Tuberculous) 

Typhoid   bacilli  (see   Bacillus 

gradual  onset  with  lassi- 

- peritonitis   (see   Peritonitis, 

Typhosus) 

tude  and  anorexia  m. . 

697 

Tuberculous) 

-  carriers,  infected  bile  in    . . 

281 

hemorrhage  m,  blanching 

-  ulcer  (see  Ulceration,  Tuber- 

- fever,    absence    of    clinical 

due  to 

622 

culous) 

signs  in  some  cases  of     . . 

610 

sudden    drop    in    tem- 

Tugging,    tracheal,     due     to 

leucocytosis  in           614, 

620 

perature  from 

622 

aneurysm  . . 

222 

acute  diarrhcea  in 

196 

hfemoglobinuria  in 

315 

Tumours  (and  see  Carcinoma  ; 

dilatation  of  heart  from 

243 

headache  ui          90,  610, 

Sarcoma  ;  Swellings  ;  and 

peritonitis  from 

55 

620,  697 

699 

mider  the  various,  organs) 

-  -  agglutination  reaction  in 

lasting     several     days, 

-  pelvic  (see  Swelling.  Pelvic  ; 

(see     Typhoid     Pever, 

with  pyrexia,  at  onset 

620 

and  Pelvis,  Tumour  of) 

Widal's  Reaction  in) 

heavy  sweats  in 

648 

-  phantom     (see     Phantom 

albumosuria  in    . .            1 

-,  20 

hyperpyrexia  in. .         343, 

622 

Tumour) 

amnesia  after 

26 

-  -  hypothermia     in    conva- 

- pulsatile  (see  Swelling,  Pul- 

- -  arthritis  in 

376 

lescence  from  . . 

346 

satile) 

asymmetrical  cedema  fol- 

indicanuria  in     . . 

349 

TUMOURS  OF  THE  SKIN  .. 

802 

lo«'ing  . . 

456 

inflammation  of  bile-pas- 

- spinal  (see  Spinal  Cord  Tumom's) 

bacihi  in  blood  in 

650 

sages  by  typhoid  bacilli 

371 

Tunica     vaginalis,     various 

backache  with    . . 

787 

intestinal  bleeding  in     . . 

90 

swellings  affecting 

765 

bacteriuria  in 

83 

-  -  jaundice  in            362,  369 

371 

Tuning-fork  tests  for  hearing 

Cheyne-Stokes     respira- 

 leucocyte   count  in  diag- 

188, 

189 

tion  in. . 

125 

nosis  of  deep  suppura- 

Turkish bath,  capillary  pulsa- 

 coma  in    . . 

136 

tion  from 

401 

tion  induced  by  . . 

106 

due  to  haemorrhage  in 

140 

leucocytosis  uncommon  in 

400 

Turpentine,  anuria  from         4a 

,  48 

confinement  to  bed  at  end 

leucopenia  in        90,  196, 

-  lijematuria  from 

304 

of  first  week  m 

610 

372,  401, 

697 

—  leucooytosis  from    . . 

400 

constipation  in  .  .         610 

648 

lymphocytes  increased  in 

-  priapism  from 

586 

continued  pyrexia  in 

697 

402.  615 

697 

—  workers,  bulla?  in    . . 

110 

cramps   in 

179 

menorrhagia  in  . . 

428 

Twelfth  nerve  (see  Hypoglossal] 

cultivation     of     typhoid 

meteorism  in 

432 

Twins,  antenatal  recognition  of 

228 

bacilli  from  blood  in  . . 

610 

diagnosis  from  perfora- 

- dystocia  due  to        . .      227, 

228 

delirium  in          . .           90, 

194 

tion 

432 

Twisting  of  pedicle  of  ovarian 

diagnosis    in    absence    of 

mild     polyarticular     ar- 

cyst, pain  simulating  renal 

AVidal's  reaction  and 

thritis  as  precursor  of 

376 

colic 

392 

rasli 

611 

muscular  atrophy  in     . . 

76 

'Twitch,  muscular,  caused  by 

-  -  -  from  appendicitis,  signi- 

 necrosis  of  jaw  in 

747 

fat;gue,  etc. 

159 

ficance  of  leucopenia 

401 

nerve  deafness  after 

190 

Twitchings   before   apoplectic 

fungating    endocarditis 

-  -  oedema  of  legs  after 

459 

stroke 

157 

611, 

613 

orchitis  from       . .           79, 

765 

-  of  face  during  rigors 

646 

general  tuberculosis   . . 

699 

osteitis  of  head  and  neck  in 

376 

-  muscular,  in  meningitis    . . 

642 

influenza            610,  611, 

699 

otitis  media  in    . . 

648 

-  iu  strychnine  poisoning     . . 

802 

-  -  -  malaria .  . 

615 

pancreatitis  from 

116 

Tympanic    attic,     caries    of 

Malta  fever     . . 

612 

perforation  in      . .         648 

711 

ossicles  in  suppuration  in 

470 

paratyphoid  fever 

611 

diagnosis  from  meteor- 

 perforation  in  Shrapnell's 

pulmonary  tuberculosis 

611 

ism    . . 

432 

membrane  in  suppura- 

 pyosalpms,  significance 

severe  abdominal  pain 

tion  in. . 

470 

of  leucopenia  in 

401 

from 

622 

-  cavity,  bloody  purulent  dis- 

 septiccemia 

611 

sudden    drop    in    tem- 

charge from 

468 

small-pox 

607 

perature  from        432, 

622 

-  -  erosion  of  internal  carotid 

suppurative  pylephlebitis  614 

rise  in  pulse-rate  in 

432 

arter}-  from  clironic  sup- 

 trichinosis 

504 

periosteal  abscess  in 

752 

puration  in 

468 

tuberculous   disease   of 

nodes  in 

752 

of    lateral    sinus    from 

468 

the  kidney  . . 

612 

periostitis  in         431,  648, 

776 

opened  in  fractured  base 

467 

meningitis     611,  612, 

699 

of  rib  after 

744 

(and  see  Otitis  Media) 

tyiihus  . .           597,  610, 

698 

peripheral  neuritis  from 

76 

Tympanites   (and  see    Meteor- 

ulcerative  colitis 

91 

peritonitis  in 

648 

ism) 

431 

diarrhoea  in 

90 

pleurisy  in 

648 

-  abdominal  distention  great 

at  onset  of 

610 

pneumonia  in 

648 

from 

467 

diazo-reaction  in . . 

198 

pneumoperitoneum  in  . . 

711 

TYPHOID    FEVER— ULCERATION 


1007 


Typhoid  fever,  amid. 

Typhus  fever,  contd. 

ULCERATION  OF  THE  FOOT 

polyuria  after      . .        582, 

583 

pyrexia  over  by  twelfth  or 

(and  see  Foot,  Perforating 

primary  infectioa  of  gall- 

fourteenth  day  in  . . 

610 

Ulcer  of) 

809 

bladJer  in 

372 

prolonged  in    . .        G09, 

610 

from  diabetes  mellitus.. 

809 

pulse  in    . .           372,  Gil, 

697 

rarity  of  . .          . .        597, 

698 

general  paralysis  of  insane 

809 

pulse-rate  relatively  slow 

-  -  rash  of      . .           371,  610, 

699 

leprosy     . . 

809 

in          ..           610,  GOT, 

771 

retention  of  urine  in 

099 

locomotor  ataxy . . 

562 

pulse-t«inperature  ratio  in 

rigors  in  . .          . .        647, 

698 

-  -  perforating  (Fig.  207)    . . 

809 

372, 

697 

severe  vomiting  in 

699 

-  -  from  peripheral  neuritis 

809 

purpura  in            590,  598, 

607 

slight  leucoctyosis  in      . . 

371 

-  -  syphilis   . . 

809 

— very  rare  in     . . 

598 

splenic  enlargement  in  692 

698 

tabes  dorsalis 

809 

pus  in  stools  in    . . 

601 

sudden  onset  in  . . 

371 

-  of      frsenum      linguae      in 

-  -  pyelitis  in 

625 

termination  by  crisis 

371 

whooping-cough  . . 

814 

[•yrexia  the  earliest  sym- 

typhoid  state  in . . 

699 

-  gastric  (see  Gastric  Ulcer) 

l)tom  in  many  cases  of 

620 

Typist's  cramp            . .         177, 

494 

-  of  glans  penis  from  balanitis 

674 

-  prolonged  in 

609 

Tyrosln,  absent  from  urine  in 

-  gummatous  (Fig.  208) 

811 

-  -  rash  in     . . 

697 

phosphorus  poisoning   . . 

373 

-  of  intestine,  hsematuria  in 

rhonchi  in  chest  in 

697 

-  in    acute    yellow    atrophy 

305,  313, 

314 

-- rigors  in  (/"i?.  166)      G14, 

647, 

of  the  liver           302,  370 

843 

caecum,    surgical    emphy- 

6-18, 650,  651 ,  G98 

746 

-  relation  of  alkaptonuria  to 

822 

sema  from 

231 

indicating  compiication 

colon,  blood  per  anum  in 

92 

in       ..         ..        648, 

651 

irFFELM^\:N'yS   reagent   for 

involvement  of  bladder  in 

313 

rare  in             . .        647, 

650 

tf-stiiiL'  L'astric  acidity     .  . 

355 

pneumoperitoneum    from 

■ —  rose-red  spots  in           90, 

372, 

UL;auil;t,  tryimiiosomiasis  in 

34 

perforation  of  . . 

711 

607, 

610 

Ulceration,  "anal,  causing  spasm 

-  -  septic  arthritis  from 

375 

the  most  conclusive 

of  sphincter 

150 

or    stomach,     abdominal 

evidence  of 

610 

-  of  bladder  in  acute  cystitis 

627 

tenderness  in  . . 

134 

rupture  of  gall-bladder  in 

281 

biiharzia  infection 

630 

stricture  due  to  . . 

146 

simulated  by  pyaemia    . . 

650 

cystoscopy  in  diagnosis  of 

630 

subphrenic  abscess  due  to 

721 

sloughs      from      Peyer's 

from  cystitis        . .        629, 

630 

varieties  causing  bleeding 

90 

patches  in  the  stools  in 

697 

frequency  of  mictiirition  in 

630 

-  of  larynx,  cyanosis  from    . . 

185 

spine,  painful  and  stiff  in 

376 

hsematuria  from . . 

630 

dysphagia  due  to 

226 

snleen  soft  in 

G97 

from  injury 

629 

earache  from 

230 

■"  enlarged  in         90,  196, 

372, 

intestinal  ulceration 

633 

haemoptysis  in     . . 

318 

610,  615,  692, 

697 

malignant  disease          629 

,630 

-  -  oedema  of 

466 

spondylitis  deformans  after  787 

painful  micturition  in     . . 

630 

stridor  from 

710 

stiffness  of  hip  joint  in  . . 

376 

phosphaturia  in  . . 

630 

varieties  of          . .        226, 

710 

submammary  abscess  after 

744 

pyuria  in  .  .            623,  629 

630 

-  -  variolous   .  . 

266 

swelling  of  thyroid  gland 

rarity  of 

630 

ULCERATION  OF  THE  LEG 

810 

in 

792 

-  -  simple       . .          . .         629, 

630 

-  -  due  to  anthrax    .  . 

811 

-  -  talipes  from 

133 

surgical  emphysema  from 

231 

atheroma. . 

810 

technically  a  septicaemia 

650 

in  vesical  tuberculosis    . . 

629 

badly  united  fracture    . . 

810 

temperature  curve  of  (Fig. 

-  carcinoma  of  tonsil 

672 

—  Eazin's  disease   . . 

450 

1G2)       ..          ..        611, 

697 

ULCERATION    OF    CORNEA 

806 

bums 

810 

-  -  tenderness  of  spine  after 

784 

anterior     polar     cataract 

cold 

810 

testicular  abscess  in 

680 

from 

806 

in  diabetes  mellitus 

811 

atrophy  after 

79 

catarrhal  . . 

806 

from  diphtheria  bacilli . . 

811 

tetany  in 

178 

conjunctivitis  due  to     . . 

256 

in  elephantiasis  .  . 

810 

tinnitus  after 

794 

dendritic  . . 

807 

epitheUomatous  . . 

812 

transverse  myelitis  from 

565 

diphtheritic 

807 

from  excessive  standing 

450 

typiioid  spine  with 

787 

epiphora  from      .  . 

250 

glanders    . . 

811 

without  ulceration  of  intes- 

 with  exophthalmos 

807 

hemiplegia 

811 

tine 

372 

from  fifth  nerve  paralysis 

807 

infantile  paralysis 

811 

ulceration  of  larynx  after 

fluorescin  detection  of  . . 

806 

ochronosis    from  carbolic 

226,  318,  466, 

710 

gonococcal             255,  256, 

807 

dressings  on     . . 

822 

AVidal's  reaction   in     90, 

-  -  in  OravRs'  disease 

807 

old  age     . . 

810 

196,  372,  610,  620, 

697 

-  -  herpes  frontalis 

807 

phagedaena 

811 

-  spine,  general  account  of  376 

787 

hypopyon  from   . . 

806 

relationship  of  injury  to 

810 

—  state  in  tyjjhus  fever 

699 

iridocyclitis  from 

806 

syphilitic  . .          . .        449, 

811 

Typhus     fever,     absence     of 

iritis  from 

806 

tuberculous 

811 

sloughs  in  stools  in 

699 

irregularity  of  pupil  from 

594 

varicose,  characters  of  . . 

810 

Widal's  reaction  in    . . 

699 

lachrymation  from 

806 

in  yaws     . . 

449 

acute  dilatation  of  heart 

in      ophthalmia      neona- 

- Mooren's 

807 

from 

243 

torum   . . 

256 

-  of    the    mouth     (and    see 

onset  in 

698 

pain  in  the  eye  from 

806 

Stomatitis)          '. .          ..86,88 

coma  in    . . 

136 

panophthalmitis  from   . . 

806 

bleeding  gums  in     . .         86,  88 

cyanosis  in          . .          . . 

187 

phlyctenular 

806 

-  mucous    membranes     from 

diagnosis  from  fungating 

photophobia  from         574, 

806 

herpes 

830 

endocarditis     . .        610, 

614 

progressive  stages  in 

806 

-  multiple,      in     tuberculous 

typhoid  fever    597,  GIO, 

698 

in  trachoma 

807 

laryngitis . . 

325 

diazo-reaction  in 

198 

-  duodenum  (see  Duodenum, 

-  nose,  epistasis  in 

250 

early  prostration  in       371, 

698 

Ulcer  of) 

-  oesophagus,  surgical  emphy- 

 hyperpyrexia  in 

343 

ULCERATION  OF  THE  FACE 

sema  from 

231 

inspissation  of  blood  in. . 

187 

(and   see    Rodent  Ulcer; 

-  palate  in  syphilis    . . 

237 

jaundice  in          . .        362, 

371 

and  Carcinoma)  . .      .  . 

808 

-  penis  (see  Penis,  Ulceration  ofj 

leucocytosis  uncommon  in 

400 

-  in  fibroma  moUuscum  . . 

781 

-  peptic,  of  gums 

87 

marked  nervous  symptoms 

699 

-  of  fingers  in  diabetes 

266 

-  perforating,  distinction  from 

mulberry    and    petechial 

from  epithelioma 

266 

suppurating  com 

809 

rashes  in 

371 

frostbite    . . 

266 

originating  from  a  com 

809 

occasional    outbreaks    in 

leprosy 

266 

painlessness  of    . . 

809 

poorer   parts    of    large 

lupus  vulgaris 

266 

in  tabes    . .          . .         285, 

811 

cities     . . 

698 

in  Raynaud's  disease     . . 

266 

-  of  pharynx,  earache  from . . 

230 

purpura  in            371,  596, 

597 

scleroderma 

266 

snail-track,  in  secondary 

pyrexia  in            . .        343, 

698 

from  a--rays 

266 

syphilis 

672 

looS 


ULCER  A  TIOX—URA  TES 


Ulceration,  contd. 

Vheration,  tuberculous,  contd. 

Uncinate  gyrus,  centre  for  smell 

G69 

-  of  rectum 

473 

of  bowel,  albumosuria  in 

lesion  of,  anosmia  from . , 

669 

bearing-down  pain  in     . . 

473 

bleeding  per  anum  in 

90 

olfactoiy  atira  in  tumour  of  80 

due  to  dysentery 

635 

larynx,  cyanosis  from    . . 

185 

tumour  of,   loss  of  taste 

gummatous 

635 

nose,  epistaxis  in 

250 

due  to  . , 

774 

Imemorrliage  in  . . 

93 

from  tuberculous  cervical 

Unconsciousness    (see  Coma) 

often  impalpable 

635 

glands   . . 

420 

Unequal    pulses   (see    Pulses, 

sacralgia  from     . . 

510 

-  of  urethra,  causing  epididymo- 

Unequal) 

speculum  in  diagnosis  of 

635 

orchitis     . . 

517 

-  pupils  (see   Pupils,   Abnor- 

 surgical  emphysema  from 

231 

from  gummata    . . 

209 

malities  of) 

traumatic . . 

635 

-  vagina,  discharge  from 

210 

Urachal  cysts  , .        . .       730, 

761 

tuberculous 

635 

-  vocal    cords,    diagnosis    of 

pelvic  swelling  due  to    . . 

757 

due  to  ulcerative  colitis 

635 

laryngeal  paralysis  from 

537 

simulated    by    distended 

venerea!,  haemorrhage  in 

93 

-  vulva  due  to  epithehoma  . . 

769 

bladder 

730 

-  rodent  (see  Kodent  I'lcer) 

due  to  syphilis    . . 

769 

ovarian  cyst    . , 

730 

-  Of   scrotum   in   tuberculous 

Ulcerative  cohtis  (see  Colitis, 

tuberculous  peritonitis 

730 

testis 

60S 

Ulcerative) 

Urachus,  infiltration  by   new 

due  to  epithelioma        G79, 

765 

-  endocarditis  (see  Fimgating 

growth          . ,      . .          57, 

718 

-  -  syphiUtic  . .           680,  681, 

766 

Endocarditis) 

-  normal  condition  of 

730 

rounded  with  sliarp  edges 

-  various,  afEections  of  larmx 

situation  of 

722 

and  yellowish  base  in 

185, 

466 

-  timiour  of,  in  umbilical  region 

728 

summa 

6S1 

Ulcus  serpens  . .         . .        S06, 

807 

-  tumours  of  . . 

728 

tuberculous   518,  6S0,  766, 

767 

Ulna,  affection  in  yaws 

449 

Uramia,  absence  of  albumin- 

- septum  nasi,  epist-asis  from 

251 

Ulnar   deflection   of   hand   in 

uria  in 

350 

-  of  skin,   over  chondromat-a 

755 

rheumatoid  arthritis 

380 

—  acetonturia  in 

4 

in  epitheUoma     . . 

803 

Umit-ed  significance  of  in 

-  albuminmria  in  329,  350,  464 

647 

erythema  indurattmi  scrofu 

diagnosis 

385 

-  albuminuric  retinitis  in     . . 

350 

"losorum 

450 

in     ost-eo-arthritis     (Fig. 

-  amaurosis  in           . .        836, 

839 

glanders    . . 

603 

108,  p.  379)     . . 

385 

-  amblyopia  in 

836 

granular     scrofulous,     ia 

-  nerve,  effects  of  division  of 

-  appetite  lost  in 

350 

scrofulodermia 

603 

(Fig.  176) 

661 

-  Babinski's  sign  in  . . 

82 

-  -  from  herpes 

830 

insensitiveness  of  in  tabes 

-  bromidrosis  with    . . 

714 

iodides      in      diagn(Bing 

dorsalis 

665 

-  casts  in  urine  with . .         329, 

464 

syphilitic      ■    . . 

469 

muscles  supplied  by 

550 

-  characteristic      odour      of 

in  Jacquet's  erythema . . 

446 

skin  distribution  of 

659 

breath  in . . 

350 

leprosy                   . .  75,  450 

654 

spinal  roots  derived  from 

550 

-  Cheyne-Stokes  respiration  in 

124 

Uchen"  scrofulosorimi   as- 

tenderness  over,  in  brachial 

-  in  chronic  nephritis 

14 

sociat-ed  with  . . 

529 

neuralgia 

491 

-  coma  in       . ,      82,  136,  137, 

464 

ui  lupus  vulgaris . . 

448 

-  paralysis  (see  Paralysis,  Ulnar) 

-  contracted  pupils  in 

195 

-  -  originating  in  papules    . . 

528 

Umbilical  cord  infection,  blood 

-  convulsions  in  14,45,48,464 

647 

paia  from . . 

476 

per  anum  in 

90 

-  delirium  in  . . 

195 

rupia 

653 

short,  dystocia  due  to  . . 

227 

-  diagnosis  of  indigestion  from 

350 

sarcoma  starting  in       ..'' 

803 

-  region,     bulging     of,     by 

-  drowsiness  in 

329 

syphiUtic  endarteritis   . . 

338 

enlarged  spleen  . . 

688 

-  dyspncea  in 

329 

scarring  in 

SH 

definition  of 

722 

-  epileptiform  convulsions  ia 

iodides  in  diagnosis  of 

449 

duodenal  carcinoma  felt  in 

725 

160,  169,  172, 

647 

trophic,  in  paralytic  tahpes 

130 

organs  normally  contamed 

-  frontal  headache  in  326,  328, 

329 

tuberculous 

449 

in 

722 

-  hsematuria  in 

329 

iQ  xerodermia  pigmento- 

 in-achal  tumours  in 

728 

-  severe    haemorrhage    simu- 

sum 

804 

various   tumours   felt   in 

lating 

140 

yaws 

449 

■  t    ■    >^         ^  ^'*       727, 

728 

-  high  arterial  tension  in 

350 

-  stomach  fsee  Gastric  Ulcer) 

-  veins,  dUatation  in  cirrhosis 

-  hyperpyrexia  in 

34  i 

-  superficial     in     small     flat 

of  Uver     . . 

409 

grave  significance  of 

622 

pustular  syphiLide 

604 

UmbOication    of    growth    in 

-  hypothermia  in 

345 

-  of    t-ertiary  "  syphilis,     dia- 

liver         . .           279,  368, 

412 

-  increase  of  urea  in  cerebro- 

gnosis of  lupus  from     . . 

449 

-  papules  in  lichen  planus   . . 

530 

spinal  fluid  in      . . 

339 

-  throat  (see  Sore  Throat) 

-  pustules  in  sj-philis 

604 

-  latent 

45 

ULCERATION    OF    TONGUE 

812 

-  in  smaU-pox  eruptions      655 

829 

-  opisthotonos  in      . .        463, 

464 

-  -  in  dyspepsia 

814 

UMBILICUS,    PAIN    ROUND 

524 

-  pyelonephritis 

625 

dysphagia  due  to 

225 

-  affected  by  scabies . . 

832 

-  reaction  of  pupils  in 

839 

microscope  in  diagnosis  of 

814 

tuberculous  peritonitis 

716 

-  retinal  changes  in  . .         329 

836 

simple,  with  stomatitis.. 

812 

-  bloody  sweat  of 

715 

-  shortness  of  breath  in 

100 

in  syphihs          237    812 

,  813 

-  eczema  intertrigo  at         524 

716 

-  simulating  a  rigor  . . 

647 

tuberculous,     age     inci- 

- flatt-ened  out  from  ascites. . 

472 

-  symptoms  of 

48 

dence  of 

814 

-  secondary  growths  at     351, 

-  tremor  in     . . 

795 

rare 

814 

526,  716 

718 

-  trismus  simulated  by 

801 

simulating  epithehoma 

814 

-  hsemorrhage  from,   in  con- 

- uridrosis  in 

715 

—  —  —  —  gumma 

814 

genital     oblit-eration     of 

-  visual  defects  in     . . 

329 

in  whooping-cough    . . 

814 

bile-ducts 

365 

-  vomiting  in. .           329,  350, 

S43 

-  tonsil  in  Vincent's  angina    67C 

,672 

-  hernia  of  (see  Hernia,  Um- 

Ursemic asthma,  mistaken  for 

phlegmonous  sore  throat 

bilical) 

spasmodic  asthma 

582 

from 

670 

-  inflammation  of,  in  new-born 

715 

Urate  fallacy  in  albumin  test 

6 

sarcomatous 

672 

from  subphrenic   abscess 

716 

-  of  sodium  (see  Sodium  Urate) 

syphilitic,  sore  throat  from 

670 

-  intertrigo  of . . 

716 

in  gout     . . 

383 

tuberculous 

672 

-  lymphatic  drainage  of 

738 

Urates,  amorphous     , , 

815 

-  of  trachea,  hsemoppreis  in 

318 

-  pain  at  onset  of  intestinal 

-  cleared  by  warming 

623 

from    malignant    thvroid 

792 

coUc  at     . . 

473 

-'microscopical  appearances  of 

815 

-  tuberculous  (Fi^.  209)"     .. 

811 

-  protrusion  of,  by  ascites  . . 

50 

-.normally  white 

815 

of  bladder,  frequency  of 

-  reddening  of,  in  tuberculous 

-"simulated  by  mucus 

815 

micturition  in 

581 

peritonitis                  50,  57 

472 

phosphates          . .        623 

815 

bowel,    acute    peritonitis 

-  sebaceous  cyst  of   . . 

524 

pus 

815 

from 

55 

diagnosis    from    small 

-  tests  for 

815 

abdominal     pain     and 

irreducible  hernia  . , 

524 

-  thomapple    and    hedgehog 

t€ndemess  with 

90 

-  stretching  of  by  ascites    . . 

50 

crystals  of 

815 

URATES— URIC    ACID 


Vratef,  cnntd. 

Urethra,  coiUd. 

Urethritis,  bacteriuria  in 

-  tlioniapple  in  cirrhosis 

410 

-  carcinoma  of  (see  Carcinoma, 

-  causes  for     . . 

s,ii-r;ilj,'ia  from  excess  of 

510 

Urethral) 

-  chordee  in   . .          . .        510, 

URATES.  DEPOSIT  OF 

815 

-  caruncle     of,     dyspareunia 

-  cystitis  from           . .        627, 

after  biliary  colic 

500 

from          

221 

-  diagnosis  from  cj-stitis 

diarrhoea  . . 

815 

general  account  of 

770 

-  dyspareunia  from  . . 

iu  (Jistiiifjuishing  varieties 

-  contusion  of 

308 

-  epididymo-orchitis  from  517, 

of  heart  failure 

815 

-  discharges  from  (see  Discharge, 

-  fistula"  of  urethra  in 

—  fever 

815 

Uretliral) 

-  frequency  of  micturition  in 

with  heart  failure 

815 

-  the  u,se  of  the  endoscope  in 

208 

-  gonorrhoea    the    commonest 

in  hot  weather    . . 

815 

^  epithelioma  of  (see  Carcinoma) 

cause  of   . . 

iiulicative  of  concentrated 

-  evidence  of  bleeding  from 

305 

-  hjematuria  in          . .        304, 

urine 

815 

-  e.xamination  of,  in  obscure 

-  herpetic,    irritation    during 

lobar  pneumonia 

815 

pyrexia 

620 

micturition  in     . . 

pink  colour  of      . .        G23 

815 

-  fistuke  of  (see  Fistula?,  Urethral) 

-  history  of  infection  in 

rheumatic  fever.. 

815 

-  foreign  bodies  in     . . 

210 

-  due  to  impacted  calculus  . . 

after  much  .sweating 

815 

-  ponococci  in  female          211, 

769 

-  importance    of    uric    acid 

uroerj'thrin  in     . . 

815 

-  gumma  in    . . 

209 

crystals  in 

after  vomiting     . . 

815 

-  hard  chancre  of 

209 

-  inflammation  of  spermatic 

Urea  ui  acute  Brighfs  disease 

12 

-  herpes  of      . . 

209 

cord  in     . . 

-  cerebrospinal  lluiil.. 

339 

-  impaction  of  vesical  growth 

-  leucocytosis  in 

-  diminution  in  urine  in  acute 

in  . . 

441 

-  occasionally   due   to   septic 

yellow  atrophj-  of  liver  . . 

370 

-  injections  into,   epididyrao- 

infection   . . 

-  nitrate   fallacy   in   albumin 

orchitis  from       . .         517 

518 

-  pain  in  the  penis  in 

test           

6 

-  injury    of,     bleeding    from 

during  micturition  inSlO, 

L'reter,  calculus  in  (aec  Calculus 

external  meatus  in 

511 

-  priapism  from        ..        585, 

Ureteric; 

extravasation  of  inrine  in 

511 

-  prostatic  abscess  due  to 

-  dilatation     of,     cj-stoscopic 

from  fall  on  the  perineum 

511 

207,  511,  627, 

appearances  in    . . 

625 

faulty  passage  of  instru- 

- after  prostatectomy 

-  diseases  of,  referred  pain  in 

ments    . . 

511 

-  prostatitis  from       511,  627, 

area  of  10th  dorsal  nerve  in 

509 

fracture  of  pelvis 

511 

-  purulent  uretliral  discharge 

-  fistula  of,  causing  pneuma- 

great  care  needed  in  in- 

in . . 

turia 

576 

strumentation  in 

511 

-  pyrexia  with 

-  inUammatory  affections  of, 

-  -  haematuria  in 

304 

-  p3Tiria  due  to 

cystoscopic  appearances  in 

624 

from  kick  or  blow 

511 

-  retention  of  urine  in 

-  kinking     of,     in     movable 

pain  in  the  penis  during 

-  smarting    and    tingling     in 

kidney 

500 

micturition  in . . 

510 

terminal  urethra  at  onset 

pain    due  to,    simulating 

perineum  iu 

516 

-  suppuration     of    glandular 

biliary  colic 

500 

-  instrumentation  of,  epididy- 

follicle  in . . 

-  obstruction  of 

11 

mo-orchitis  after           517 

518 

-  testicular  abscess  due  to.. 

in  bladder  tumours 

311 

-  irrigation    of,    in    diagnosis 

-  due   to   ulceration   near   a 

—  by  calculus  (see  Calculus, 

between      anterior      and 

stricture   . . 

Ureteric) 

posterior  urethritis 

631 

-  ur-;thral  abscess  in. . 

complete,  atrophy  of  kid- 

 of  posterior  urethritis 

-  ->-  irrigation  in  diagnosis  of 

ney  due  to 

627 

028 

631 

-  chronic,     gonoccoci     often 

hydronephrosis  in 

395 

-  narrowing  of,  following  soft 

difficult  to  detect 

incomplete,  uro-  or  pyo- 

sores          

209 

when  does  infection  cease 

nephrosis  due  to 

627 

-  normal  bacteria  of . . 

82 

pyuria  due  to     . . 

-  palpation  of  lower  end  per 

-  obstruction     of,     bilateral 

-  gonorrhoeal  (see  Gonorrhoea) 

rectum           307,  .")13,  515 

594 

hydroneplirosis  m 

395 

-  gouty 

-  papilloma  of  vesical  orifice 

by  bladder  tumour 

514 

priapism  from     . .        585, 

in  papilloma  of  kidney  . . 

308 

due  to  epithelioma 

767 

pyuria  due  to     . . 

-  tuberculosis  of,  association 

-  pain  in,  with  discharsre 

441 

-  non-gonococcal,  epididymitis 

with   vesical   tuberculosis 

513 

-  palpable  tumour  of 

209 

from 

—  evstoscopic     appearances 

-  papillomata  of 

209 

due  to  instrumentation. . 

in    (Plate    V,    Fig.    D. 

-  passage  of  fieces  through,  in 

-  posterior,     diagnosis    from 

p.  308.)  . .          . .        515 

625 

carcinoma  of  rectum 

633 

chronic  cystitis  . . 

—  kidney       enlarged      and 

gas  through  (see  Pneuma- 

history  of  uretliral  infec- 

tender in 

515 

turia) 

tion  in 

pain    and    frequency     of 

-  pigmented  in  Addison's  disease  574 

urethral  irrigation  in  dia- 

micturition in 

515 

-  polypus  of,  discharge  due  to 

208 

gnosis  of 

in   penis    after    mictu- 

 sliown  by  the  endoscope 

208 

-  septic,  acute  prostatitis  and 

rition  in 

513 

-  prolapse   of   mucous   mem- 

prostatic abscess  from  . . 

—  palpation  per  rectum 

brane  simulating  uretliral 

epididymo-orchitis  in  517, 

513,  515,  C26, 

694 

caruncle    . . 

770 

due  to  infection  from  sim- 

 vaginam 

694 

vulval  swelling  due  to  . . 

768 

ple  leucorrhoea 

secondary  to  renal  tuber- 

- prostatic,  infection  in  gonor- 

- -  in  prostatic  enlargement. 

culosis  310.  312,  515,626,694 

rhoea         

518 

from  self -catheterization 

—  T.  bacilli  in  urine  in 

515 

-  rupture  of    . . 

308 

pyuria  due  to     . .        623, 

Ureteritis,  bacteriuria  in 

83 

extravasation  of  urine  in 

308 

testicular  abscess  in 

-  descending,  due  to  B.  coll 

inabiUty  to  micturate  in 

308 

-  staphylococcal 

and  to  stapli3'lococcus  . . 

515 

-  smarting    and    tingling    at 

Urethroscope  (see  Endoscope) 

frequency  of  micturition  in 

515 

end  of,  in  onset  of  acute 

Urethrotomy,   anuria  after  . . 

—  non-tuberculous,      cysto- 

urethritis.. 

511 

Uric  acid  and  calcium  oxalate. 

scopic    appearance    of 

-  soft  sores  in. . 

209 

relationships  between  471, 

ureteral  orifice  in  (Piute 

-  stricture  of  (see  Stricture  of 

cayenne  pepper   deposits 

J',  Fig.  C,  p.  .308)      . . 

515 

Urethra) 

of          

—  tuberculous 

515 

-  suppuration  round,  perineal 

the  clinker  of  metabolism 

-  pain  in  penis  after  mictu- 

sore from . . 

677 

diminution    in    urine    in 

rition  in  . .          . .        513, 

515 

-  tuberculosis  of 

210 

acute  yellow  atrophy  . . 

Urethra,  abscess  of  fsee  Abscess 

J 

-  ulceration  of,  acute  epididy- 

effect  of  biliousness  on. . 

Urethral) 

mo-orchitis  in      . .        517 

518 

deficient  exercise  on  . . 

-  nilculus   in    (see   Calculus, 

Urethral  crises  of  locomotor 

excessive  eating  on    . . 

Urettural) 

ataxy        

562 

—  excretion  in  birds 

1009 


83 
206. 
675 
631 
631 
221 
76* 
677 
631 

511 
3ia 

209 
67* 
766 

817 

523 
40O 

511 
515 
67* 
58G 

631 
767 
631 

511 
207 
630 
207 

511 

G77 
679 

766 
679 
631 

209 
209 
631 

818 
586 

62a 


76ft 

628 

62& 

62S 

515 
51S 

518 

680 
631 
68a 
631 

49 

817 

816 
817 

370 

817 
817 
817 
817 


64 


URIC   ACID— URINE 


Uric  acid,  contd. 

Urine,  abnormal  colour  of,  conta 

Urme,  changes,  contd. 

exogenous     and     endo- 

orange-yellow  from  uro- 

 myxcedema 

43 

■    genous  sources  of 

817 

bilin  . . 

818 

phosphorus  poisoning    . . 

373 

in  fevers  . . 

817 

pink,    on    addition    of 

pyelitis     . .           500,  625 

628 

gravel  from 

816 

alkali  after  drugs    . . 

819 

pyuria 

624 

in  heart  disease  . . 

817 

from      chrysoohanic 

renal  colic 

500 

leuktemia . . 

817 

acid           .  /      819 

820 

tuberculosis     . . 

626 

by  no   means   indicative 

eosin. .          . .         819, 

820 

tumour 

391 

of  gout 

816 

liiEmatoporphyrin  . . 

819 

in  the  stream 

438 

in  pernicious  anaemia     . . 

817 

haematuria   . . 

819 

due  to  vesical  calculus  . . 

512 

physiology  of  precipitation 

816 

haemoglobinuria 

819 

-  crystals  in,  in  vesical  calculus 

629 

reduction      of     Fehling's 

and  red,  from  rhubarb  820 

-  cystine  in  (see  Cystinuria) 

solution  by      . .        290, 

818 

rosaniline     . .        819, 

820 

-  deposit  ia,  in  baciUuria     . . 

615 

-  -  in  urine    . . 

290 

-  -  saatoain 

820 

of  pus  in,  in  cystitis 

628 

care   required  in  inter- 

 uroer^vthrin  . . 

818 

-  diacetic  acid  in       . .            4 

292 

pretation  of . . 

817 

port-wihe-coloured  from 

in  cyclical  vomiting  of 

—  crystals  (Fig.  212) 

816 

heematoporphyrin    . . 

819 

infants 

426 

brown  colour  of,  due  to 

red,  from  chrysophanic 

-  diminution   of  chlorides   in 

urochrome    . . 

816 

acid           . .         819 

820 

phosphorus  poisonidg    . . 

373 

glycosuria  with 

817 

eosin. . 

819 

ia  pneumonia  . . 

372 

importance  in  frequent 

haematoporphyrin  819 

820 

total  solids  in,  in  nephritis 

626 

raicturition  . . 

817 

haematuria   . . 

819 

in  pyelitis         . .  ' 

625 

urethritis 

817 

- hasmoglobinuria     314, 

819 

urea    and    uric    acid    in 

muciLs  with     . . 

816 

rosaniline 

819 

acute  yeBow  atrophy 

370 

oxalats  of  lime  with. . 

816 

smoky   tint   from   car- 

-  dribbling  of,  after  cessation 

in     relation     to     renal 

bolm-ia 

822 

of     stream     in     uretliral 

calculus      ■  .  .         817, 

818 

yellow,     from     chryso- 

stricture  . . 

511 

URIC     ACID     DEPOSIT     IN 

phanic  acid  . .      "   . . 

819 

-  dumb-bell   crystals   in  (see 

URINE 

816 

and  orange-coloured, 

Oxaluria)  (Fig.  130)       . . 

470 

Uridrosis  in  cholera    . . 

715 

pigments  producing 

818 

-  envelope    crystals    in    (see 

-  in  urffimia    . . 

715 

rhubarb 

819 

Oxaluria)  (Fig.  130) 

470 

Urinary  fistute   (see   Fistulae, 

santonin       . .        819 

820 

-  examination      in     Eright's 

Urinary) 

-  senna 

819 

disease      . .          . .      12  et 

seq. 

-  meatus,  small,  enuresis  with 

248 

-  absence  of  bile  pigment  in 

epistaxis  . . 

251 

URINE,  ABNORMAL  COLOUR 

tropical  abscess  of  liver 

369 

oxaluria    . . 

470 

OF             

818 

chlorides  in  pneumonia  186 

,321 

shortness  of  breath 

101 

black,    from    alkapton- 

- abundant    and    pale    after 

-  excessive  (see  Polyuria) 

uria  . .          . .         830 

822 

angina  pectoris  . . 

481 

-  extravasation  of,  in  injuries 

carboluria    . .         820, 

822 

-  acetone  in  (see  Acetonuria) 

of  the  urethra     . . 

511 

after  certain  drugs . . 

820 

-  agglomeration     of     oxalate 

pain  in  perineum  in 

51G 

from  choluria 

819 

crystals      indicative      of 

in  ruptured  urethra 

308 

gallic  acid    . . 

820 

oxalate  calcull^s . . 

471 

scrotal  fistula  due  to     . . 

G79 

hEematoporphyrin 

-  albumin  in  (see  Albuminuria) 

-  faeces  in  (see  Faeces  passed 

819,  820 

821 

-  albumose  in  (see  Albumosuria) 

per  Urethram) 

haematiiria   . . 

820 

-  ammonical,  source  of  error 

-  fat  in  (see  Chyluria) 

hemoglobinuria 

in  Fehling's  test. . 

290 

-  filaments   in,  "from   chronic 

314,  820 

821 

-  amphoteric  and  neutral  re- 

gonorrhcea 

207 

indicanuria  . .        820, 

821 

actions  of 

572 

-  fluorescence  in,  due  to  eosin 

820 

jaundice       . .         830 

821 

-  analysis  in  clironic  plumbism 

173 

-  fragments  of  new  growth  in 

308 

melanuria     . .        820, 

821 

-  B.  coli  in  (see  Bacteriuria) 

in  papilloma  of  bladder 

630 

methaemoglobin 

821 

-  bacteria  in  (see  Bacteriuria) 

-  gas  passed  with  (see  Pneuma- 

resorcin 

820 

-  Bence  Jones  bodies   in  (see 

turia) 

salicylates    . .        820, 

823 

Albumosuria) 

-  glycuronic  acid  in  . . 

290 

— after  salol    . . 

820 

-  bile-pigmeated    (see    Jaun- 

- gravel  in,  ia  renal  cohc 

500 

uva  ursi 

820 

dice  ;   and  Urine,  Abnor- 

- haemoglobin  in  (see  Haemo- 

blue,  from  indigo  blue 

823 

mal  Colour  of) 

globinuria) 

iadoxyl      glycuronic 

-  bilharzia   ova   in  (Fig.   13, 

-  heat  loss  due  to  evacuation 

acid 

823 

p.  93)        .  .          .  .         514, 

630 

of 

619 

methylene  blue 

823 

-  black  (see  Urine,  Abnormal 

-  hippuric  acid  in 

290 

brown,  from  alkapton- 

Colour of) 

-  hyperacidity   of,   frequency 

uria  .  .          . .         820 

822 

-  bladder    epithelium    in,    in 

of  micturition  from 

438 

carboluria    . .        820, 

822 

bacilluria.. 

615 

-  incontinence  of  (see  Inconti- 

certain  drugs 

820 

-  blood-stained  (see  Haematuria) 

neace  of  Urine  :  and  Mic- 

 gallic  acid    .  . 

820 

-  calcium  oxalate  crystals  in 

turition,  Abnormalities  of) 

hffimatoporphyrin   . . 

820 

(see  Oxaluria) 

-  increase     in     quantity     in 

hiematurLa   . . 

820 

-  Cammidge's   pancreatic  re- 

pyelitis    . . 

625 

hai-moglobinuria     31-1, 

820 

action  in  (see  Cammidge) 

of  solids   in,  in   diabetes 

584 

indioan         . .        820, 

821 

-  casts  in  (see  Albumin'oria  ; 

-  indioan  in  (see  Indicanuria) 

290 

jaundice       . .        820, 

821 

and  Casts) 

-  iodides  in     . . 

87 

Inelanuria     . .         820, 

821 

-  causes  of  turbidity . . 

82 

-  lactose  in     . . 

290 

resorcin 

820 

-  cayenne-pepper    deposit    in 

816 

-  laevulose  in  . . 

291 

salicylates     . . 

820 

-  ceils  in,  similarity  of  those 

-  lead  in         ..          . .   38,  87, 

136 

salol  

820 

derived     from     different 

-  leucin  and  tyrosin  in  acute 

uva  ursi 

820 

sources 

624 

yellow  atrophy  of  liver. . 

370 

green    

187 

-  changes  in  acute  cystitis  . . 

512 

-  lithates  in  (see  Urates) 

from  bile      . .        819, 

823 

—  associated  with  biliary  colic 

500 

-  microscopic    characters    of 

carboluria     .  . 

822 

in  carcinoma  of  liver     . . 

413 

pus  cells  in 

623 

methylene  blue 

823 

cirrhosis  of  liver . . 

410 

-  milky  (see  Chyluria) 

in  ha?maturia  . .         305, 

820 

cystic  disease  of  kidneys 

15 

physiological  causes  of  . . 

573 

hsemoglobinuria  304,  314 

819 

cystinuria 

187 

-  mucus    in    (see    Mucus    in 

in  jaundice 

360 

cystitis 

628 

Urine) 

method  of  precipitation 

820 

gastritis    .  . 

297 

-  normal  amount  passed     437, 

581 

orange-red    from    uro- 

hydatid  cyst  of  kidney  . . 

396 

in   early   tuberculosis    of 

erythrin 

881 

impacted  ureteral  calculus 

514 

kidney  . . 

310 

URINE— UTERUS 


Urine,  could. 

-  nucleo-proteiil  in  (see  Niicleo- 

proteid  in  Urine) 

-  oftonsivo  in  biicilluria        ..     015 

-  opalescence  in  pyelitis       . .     tj'_'r> 
and  turbidity  o£  in  renal 

tuberculosis      . .  . .      (J'JU 

-  overllow  incoutinence  of,  in 

retroverted  tjravid  uterus     75fl 

-  oxalate  deposit  in  . .  . .     470 

-  oxybutyric  acid  in..  -1,  2'.>'2 

-  pale  in  renal  tuberculosis  . .     02G 

-  pancreatic    reaction    in,    in 

affection  of  the  pancreas      J  86 

-  pentose  in    . .  . .  . .     290 

-  phos])hates  in  (see  Phospha- 

turia) 

-  powdered    wig    deposit    o£ 

oxalates  in  .  .  .  .      170 

-  pus  in  (see  Pyuria) 

-  reaction     of,    in     bacterial 

infections..  ..  ..       83 

-  -  lia^maturia  . .  . .      ."jO(i 
with  uric  acid  deposit  . .     81(; 

-  per  rectum,  from  ulceration 

of  new  growth     . .  . .      G.32 

-  reducing  bodies,  other  than 

glucose,  in  . .  . .     290 

-  renal  cells  in,  in  bacilluria       (ilo 

-  retention  of   (and   see  Mic- 

turition)   45,  207,  440,  631,  G99 
in  acute  prostatitis       207,  631 

-  -  with  bladder  tumour     . .     311 

causes  of  . .  . .     440 

chronic  cystitis  from    627,  628 

differentiation  from  anuria 

45,  440 

-  -  dribbling  per  urethram  in     440 

in  general  peritonitis     . .     644 

hysterical . .  . .  . .     441 

-  -  in     impacted     urethral 

calculus  . .  . .     313 

nervous  causes  of         440,  441 

after  operations. .  . .       49 

pain  and  strangury  in  . .     440 

from  paralysis  of  detrusor     443 

primary    lateral   sclerosis 

prostatic  abscess  207 

enlargement     . . 

prostatitis 

retroverted  gravid  uterus 

typhus  fever 

urethral  calculus 

stricture 

urethritis . . 

vesical  irritability 

-  scanty  and  high-coloured  in 

active  congestion  of  liver 

-  specific    gravity    in    acute 

nephritis  .  .  . .  12,  13 

chronic  nephritis        . .       15 

diabetes  insipidus       . .     584 

meUitus        . .  . .     584 

high  in  cirrhosis         . .     410 

lardaceous  disease      . .       10 

low  in  amyloid  disease     197 

in  pyelitis     . .  .  .     625 

polycystic  disease  of 

kidneys     . .  . .     396 

renal  tuberculosis  . .     626 

in  mitral  regurgitation     240 

-  spermatozoa  in,  from  bladder 

irritation  in  oxaluria      . .     4  71 

-  sjjontaneous  coagulation  in 

chyluria    . .  . .  . .      126 

-  stream    feeble    in    urethral 

stricture  . .  . .  . .     511 

-  sudden  stoppage  in  flow    . .     439 
from     impaction     of 

calculus  in  urethra     511 
witli  vesical  calculus     312 

-  sugar  in  (see  Glycosuria) 

-  sulphuretted  hydrogen  in..     187 

-  suppression  of  (see  Anuria) 


567 
G31 

440 
631 
759 
699 
313,  441 
..  440 
. .  207 
. .  443 

71 


Urine,  conltl. 

-  sweetbriar  odour  of           . .  187 

-  tests  applied  to  (see  Tests) 

-  tube-casts  in  (see  Cast,s) 

-  tubercle  baccilli  In  (and  see 

Bacillus  Tuberculosis)    . .  310 

in  renal  tuberculosis 

394,  515,  626 

vesical  tuberculosis 

312,  513,  628 

-  turbid  from  jihosphates    . .  208 
causes  of  . .          . .          . .  82 

-  twisted     stream     of,     little 

signilicance  of     . .          . .  438 

-  urates  in  (see  Urates) 

-  uric  acid  in  (see  Uric  acid) 

-  per  vaginam            . .          . .  313 
~  vesical     cellular     elements 

without  casts  in,  in  cystitis  628 

-  white  deposits  in,  oxalates  470 

-  worm-like  clots  in,  in  kidney 

tumours    .  .          . .          .  .  307 

Urobilin,   presence   in  normal 

ffeces         818 

-  spectroscopic  band  of  (Fiff. 

23)             ..              95,  361,  818 

-  traces  in  normal  urine      . .  818 
Urobllinuria,  causes  of         ..  818 

-  in  cholangitis           . .          . .  116 

-  cirrhosis  of  the  liver           . .  818 

-  colour  in       . .          . .          . .  818 

-  from     excessive      bacterial 

action  in  the  intestines..  818 

-  in  intestinal  affections       . .  818 

-  liver  diseases           . .          . .  818 
-pancreatitis..          ..          ..  116 

-  pernicious  anosmia    303,  361,  818 
Urochrome,     causing     brown 

coloration     of    uric    acid 

crystals 810 

-  normal  urine  colour  due  to  818 
Uroerythrin  in  cirrhosis  of  the 

liver          819 

-  colour  of  urate  deposit  due 

to 815,  818 

-  effect  of  alkali  on  . .          . .  818 

-  in  heart  disease      . .          . .  819 

-  high  colour  of  urine  due  to  818 

-  increased  in  hepatic  disease  819 

-  simulating  hasmaturia       . .  818 
Urotropine,     hfemoglobinuria 

from          314 

Urticaria  from    absorption  of 

fluid  from  hydatid  cyst  415 

-  affecting  fingers      . .          . .  266 

-  age  incidence  of     . .          . .  531 

-  due  to   antito.xic   sera    (see 

Serum  Rashes) 

-  bulte  in       850 

-  and  bullous  dermatoses     . .  114 

-  burning  sensation  in          . .  850 

-  desquamation  in     . .          . .  656 

-  diagnosis    from    angio-neu- 

rotio  oedema        . .          . .  746 

erythema  simplex           . .  252 

prurigo      . .          . .          . .  531 

-  distribution  of         . .          . .  531 

-  due  to  eating  fish  or  pork  746 

-  involvement  of  lips  in       . .  403 

-  itching  in      . .  531,  588,  850 

-  simulating  erysipelas         . .  850 

papular  erythema          . .  531 

prurigo  ferox       . .          . .  531 

scarlet  fever        . .          . .  850 

-  tache  C(^r(ibrale  in  . .          . .  771 

-  wheals  in      .  .          .  .          .  .  850 

-  bullosa  simulating  dermatitis 

herpetiformis       . .          . .  850 
pemphigus       . .          . .  850 

-  factitious,  htemoglobinuria  in   315 
relation  of  epidermolysis 

buhosa  to        . .        113,  114 

-  haemorrhagic,     hnemosiderin 

in  macules  following      . .  424 


Urticaria,  contd. 

-  papulosa     (sec    Strophulus) 

-  pigmentosa,  distinction  from    "■ 

xanthoma  multiplex      . .     805 

itching  in  . .  . .     805 

seu  nigricans       .  .  . .     575 

wheals  in  . .  . .     805 

Uterine    sound    (see    Sound, 

Uterine) 
Uterus,  abnormalities  causing 

amenorrhoca        . .  . .       23 

-  absence  of,  sterility  due  to 

705,  706 

-  anteversion  of  due  to  pen- 

dulous belly         . .  . .     227 

-  backward         displacement, 

bearing-down   pain   from     473 

-  bimanual   examination    for 

fibromyoma  of     . .  . .     429 

-  cachexia  from  lesions  of    . .     114 

-  carcinoma  of  (see  Carcinoma 

of  Uterus) 

-  changes  in,  in  pregnancy  . .     437 

-  chorion-epithelioma  of   (see 

Chorion-ep  ithelioma) 

-  cochleate  of  Pozzi  . .  . .     219 
sterility  due  to    . .  . .     706 

-  congenital  closure  of  cervix       705 

-  congestion  of,  absence  of  en- 

largement in        . .  . .     429 

backache  in         . .  . .     429 

causes  of  . .  . .  . .     428 

from  certain  occupations      430 

from  constipation  . .     430 

dysmenorrhoea  from      . .     219 

general     venous     back- 
pressure causing         . .     430 

leucorrhoea  in      . .  . .     429 

menorrhagia  from        428,  430 

metrorrhagia  from         . .     435 

occurrence      usually      in 

married  women  . .     429 

in  retroflexion  of  uterus       429 

sacralgia  in  . .  . .     509 

salpingo-oophoritis         . .     429 

subinvolution      . .  . .     429 

tight  lacing  .  .  .  .     430 

-  contraction    of,     spamodio 

pelvic  pain  from . .  . .     509 

diagnosis   fi-om   pains   of 

tubal  gestation  . .     509 
weak,  dystocia  from      . .     227 

-  defective    muscle    develop- 

ment of 219 

-  dilated  in  subinvolution     . .     429 

-  dilatation  and  curettage  of, 

in    diagnosing    cause    of 
metrostaxis  . .  . .     436 

-  discharge    from,    with    sal- 

pingo-oophoritis . .     760 

-  disease  of,  anfemia  in        . .       36 

causing  amenorrhcea     . .       24 

pain  in  the  back  due  to 

(Fig.  204,  p.  788)     476,  788 

lower    extremity    from     491 

referred  pain   in   area   of 

10th  dorsal  nerve  in  . .     509 

-  displaced,  causing  albuminuria  10 
forwards  by  pelvic  hrema- 

tooele 760 

nephritis  from     . .  . .         8 

sacralgia  in  . .  . .     509 

-  enlarged       429 

asymmetrically    in    fibro- 
myoma. .  . .  .  .     429 

anienorrhoea        . .  22,  23 

from  endometritis  . .     220 

pregnancy  . .  . .     350 

recognition  in  rectal  ex- 
amination        . .  . .     638 

-  fibromyoma  of   (see  Fibro- 

myoma of  Uterus) 

-  fixation  in  central  position 

by  pelvic  abscess  . .     7G0 


UTERUS— VAGUS 


Uterus,  contd. 

Uterus,  contd. 

Vagina,  contd. 

-  fixation  ia  lateral  position, 

-  rupture    of,    in    obstructed 

-  swelling   at   orifice    of   (see 

by  pelvic  cellulitis     . . 

760 

labour 

229 

Prolapse  of  Uterus) 

by  salpingo-obphoritis  . . 

220 

-  sarcoma  of  (see  Sarcoma  of 

-  various  tumours  presenting 

-  growths,    histology   in   dia- 

Uterus) 

through  the 

587 

gnosis  of     . .          . .     434, 

435 

-  small   adult   type,   sterility 

Vaginal  casts  described 

211 

metrorrhagia  from 

433 

due  to 

706 

-  discharge    (see    Discharge, 

simulating  prolapse 

587 

-  spasm  of,  dystocia  due  to 

227 

Vaginal) 

-  hoemorrhage  from,  abnormal 

-  subinvolution     of,     metro- 

- examination  in  appendicitis 

729 

(see  Menorrhagia;  Metror- 

staxis from 

436 

ascites 

717 

rhagia  ;  Metrostaxis) 

-  tuberculosis  of,  histology  in 

in    asymmetrical   cedema 

in  the  new-born  . .        435, 

436 

diagnosis  of 

434 

of  the  leg 

456 

post-climacteric  (see  Me- 

 metrorrhagia  from         433, 

435 

bearing-down  pain 

474 

trostaxis) 

-  tumours  of,  breaking-down, 

bladder  tumours 

512 

-  -  in  tubal  abortion 

760 

anaemia  in 

39 

-  -  chylm"ia    . . 

126 

rupture . . 

760 

diagnosis  from  renal  tumour  392 

dysmenorrhooa    . . 

220 

-  hom--glass           contraction. 

-  -  fluid    thrill    from    cystic 

dyspareunia 

221 

dystocia  due  to    . . 

227 

degeneration  of  fibroid 

429 

ectopic  gestation           500, 

700 

-  hyperinvolution  of,  account 

hardness  in  fibromyoma 

429 

loss  of  weight 

847 

of 

706 

histological  examination  of 

434 

obscure  pyrexia . . 

620 

amenorrhoea  with     23,  24 

706 

irregular  outline  in  fibro- 

 obturator  liernia 

740 

-   -  sterility  due  to    . .        705, 

706 

myoma  . . 

429 

ovarian  cyst 

438 

-  infantile,  sterihty  due  to    705 

706 

jaundice  in          . .        362, 

367 

tumour              .  .         367, 

691 

-  infection  of  in  puerperal  fever 

649 

-  -  metrostaxis  from 

436 

palpability  of  large  cystic 

-  inflammatory  affections  of, 

microscopic     examination 

renal  tumours  by 

393 

pain    and    tenderness    in 

of  curetting  in  diagnosis 

pelvic  abscess     . . 

760 

back  from 

789 

of  malignancy  of 

759 

cellulitis 

760 

-  inversion    of,    acute,   great 

sacralgia  in  impaction  of 

509 

growth              . .         487, 

761 

shock  in  . . 

587 

soft    or    cystic    in    some 

hasmatocele 

760 

haemorrhage  in 

587 

degenerating   fibroids 

429 

inflammation    .  . 

487 

chronic,  simulating  poly- 

 swelling  in  hypogastrium 

in  pregnancy,  method  of 

228 

poid  fibromyoma 

587 

from 

730 

-  -  pus  in  stools  from 

600 

simulating  prolapse 

587 

(and  see  Carcinoma,  Fibro- 

 pyosalpinx             632,  638, 

737 

vulval  swelling  due  to  . . 

768 

myoma) 

retroverted  gravid  uterus 

-  misplacements    of,    menor- 

-  unduly  small 

219 

438, 

758 

rhagia  in . . 

428 

Uva  ursi,  dark  urine  from     . . 

820 

salpingitis 

500 

-  muscle  deficient,  dysmenor- 

polyuria  after 

582 

sciatica     . . 

487 

rhoea  from 

2X9 

Uvula,  carcinoma  of  . .         670 

673 

for  separability  of  uterus 

relaxation  in  subinvolution 

429 

-  gumma  of    . .          . .         670, 

673 

from  pelvic  swelling  . . 

758 

-  normal  secretion  fi-om 

210 

-  pendulous,  dry  cough  with 

175 

some   causes  of  frequent 

-  pigmentation  in  lesions  of 

114 

suggested    by   cough    on 

micturition 

438 

-  polypi  of,  sterility  due  to . . 

706 

getting  in  to  bed 

176 

tuberculous  ureter       629, 

694 

-  pregnant  (see  Pregnancy) 

-  sore   throat  from  affections 

twisted  ovarian  pedicle . . 

500 

of 

070 

ureteral  calculus  impacted 

of  Uterus) 

-  tuberculosis  of 

673 

near  bladder    . . 

627 

rectocele  simulating 

587 

uterine  fibroid     . . 

438 

-  puerperal  infection  of,  septi- 

VACCINIA., swellhig  on  face 

-  growths,   metrostaxis   from 

436 

caemia  from 

698 

due  to 

746 

simulating  uterine  prolapse  587 

-  rapid  enlargement  of,  from 

-  on     face,     diagnosis     from 

-  haemorrhage     in.     new-born 

sarcoma    . . 

434 

anthrax  pustule . . 

746 

infants      .  .          . .        435, 

436 

-  retroflexion  of       . .       429, 

508 

-  papules,  vesicles  and  pustules 

-  secretions,  normal  and  ab- 

 dysmenorrhcea  from 

219 

in  . . 

834 

normal 

210 

menorrliagia  from 

428 

Vacciniform    ecthyma    of    in- 

 reaction  of 

210 

pelvic  pain  from . . 

508 

fants          

446 

-  tumour  simulating  prolapse 

uterine  congestion  in 

429 

Vagabond's  disease,  chloasma 

of   uterus . . 

587 

-  retroversion  of        429,  473, 

508 

m  . . 

574 

Vaginismus    associated    with 

diagnosis  of  sciatica  from 

Vagina,    absent,    imperforate, 

dyspareunia 

221 

pain  due  to     . . 

487 

or  stenosed          .  .    22,  23, 

705 

-  spasmodic    . . 

222 

dysmenorrhcea  from 

219 

-  affection   by   bullous   erup- 

- sterility  due  to 

706 

dyspareunia  from 

221 

tions 

88 

Vaginitis,  acute,  pain  in  peri- 

 menorrhagia  from 

428 

-  carcinoma  of  (see  Carcinoma 

neum  in   . . 

516 

pelvic  pain  from. . 

508 

of  Vagina) 

-  nature  of  discharge  due  to 

210 

recognition  of 

220 

-  closure  of,  sterility  due  to . . 

706 

-  senile  adhesive,  metrostaxis 

per  rectum 

638 

-  diphtheria  of 

211 

from 

430 

not    sufficient    cause     of 

-  distention    of,    in    amenor- 

Vagus nerve,  branches  of     . . 

174 

dysohezia 

150 

rhoea         . .          . .            22 

,  23 

inflammation  after  diph- 

 tender  prolapsed  ovaries 

by     menstrual    fluid     in 

theria    .  .          . .         772, 

773 

with 

221 

hagmatocolpos 

761 

after  influenza           772, 

773 

uterine  congestion  in     . . 

429 

-  epithelioma  of  (see  Carcinoma 

—  irritation  by  caseous  gland 

vomiting  with     . . 

844 

of  Vagina) 

772, 

773 

-  retroverted  gravid,  amenor- 

-  flbromyoma  of        . .         587, 

768 

aneurysm         .  .        482, 

772 

rhcea  with 

759 

-  growth  of,  dystocia  due  to 

227 

general  account  of     . . 

773 

bearing  down  pain  in 

473 

felt  per  rectum  . . 

638 

hiccough  in      .  .         342, 

343 

bladder  distention  in 

-  haemorrhage  from  (see  Haem- 

 by  mediastinal  fibrosis 

772 

52,  730 

758 

orrhage,  Vaginal) 

new  growth     . . 

772 

catheter  in  diasrnosis  of 

759 

-  malfornied,      dyspareunia 

tachycardia  from 

772 

chronic  cystitis  in 

628 

from 

221 

neuritis  of 

77 

difficult  micturition  from  439 

-  micturition  tlirough  fistula 

pressure  of  thyroid  gland 

frequent  micturition  in 

438 

into 

442 

tumom-  on 

792 

incontinence  of  urine  in 

759 

-  pemphigus,  etc.,  of 

114 

supplying  stomach 

842 

physical  signs  ot        758 

759 

-  rigidity  of,  dystocia  due  to 

227 

various    ways    in    which 

-  -  -  retention  of  m-ine  with 

45 

-  shortness     of,     in    pseud  o- 

related  to  cough       174, 

175 

urine  dribbling  in 

759 

hermapiiroditism 

706 

-  nuclei  degeneration,  paralysis 

vaginal  examination  in 

758 

-  stenosis  by  kraurosis        221 

770 

of  vocal  cords  due  to    . . 

538 

VALERIAN— VESICULAR    MURMUR 


1013 


Valerian,  foul  taste  from  . .  774 
Valetudinarians,  hepatoptosisin  -107 
Valvular    disease   (see    under 

Heart) 
Varicella  (see  Cliicken-pox) 
Varicocele     associated     with 

renal  tumour       ..        391,  395 

-  diagnosis  of..  ..  ..     523 

-  -  from  omental  hernia  . .  767 
omental    inguinal    hernia     741 

-  hernia  with. .  . .  . .     742 

-  impulse  on  couehini?  in    . .     523 

-  pain  in  tlie  testicle  in        . .     523 

-  reducibility  of         . .  . .     741 

-  testicular  atrophy  from      78,  79 

-  of  vulva        .  .  .  .  .  .      768 

in  association  with  preg- 
nancy   . .  . .  . .     770 

rupture  of  veins  in        . .     770 

Varicose  eczema,  hajmosideriu 

in  macules  followinp:      .  .     424 

-  veins  (see  Veins,  Varicose) 
Variola  (see  Small-pox) 
Varnish-workers,  bulliB  in     . .     110 
Vas    deferens,     infection    in 

gonorrhoea  . .  . .     518 

thickening    of    in    acute 

epididymo-orchltis      . .     518 
tuberculous,   with  tuber- 
culous bladder. .  ..     441 

in  tuberculous  testis  519, 

680,  765,  767 
Vasodilatation,    good    eilecbs 

of  in  abdominal  angina        351 
Vasomotor  affections,  ptyalor- 

rhffia  in     .  .  .  .  . .      592 

-  changes  in  arm  due  to  cer- 

vical rib    . .  . .         128,  493 
syringomyelia      . .  . .     128 

-  lesions  in  infantile  paralysis 

131,  555 

-  neuroses,  albuminuria  in  . .  16 
causing  swelling  of  hands 

or  feet  . .  . .  . .     459 

-  phenomena    in    extremities 

in  neuromyositis  . .     504 

-  system,   oedema   of   legs   in 

affections  of         . .  . .     459 

Vater,  ampuUa  of  (see  Ampulla 

of  Vater) 
Veins   on   cheeks,   dilated,    in 

cirrhosis  of  liver  . .     300 

-  of  chest,  progressive  disten- 

tion in  chronic  mediastinitis  484 

-  diastolic   collapse    of.    with 

adherent  pericardium     .  .      242 

-  dilated  abdominal,  in  portal 

obstruction      . .  . .     300 
frontal  and  orbital,  in  ca- 
vernous sinus  thrombosis  253 

mammaiy,   in  pregnancy 

and  lactation  . .  . .     743 

precordial,     in    adherent 

pericardum      . .  . .     242 

-  -  thoracic,  from  mediastinal 

growth 296 

umbilical,  in  cirrhosis    . .       .59 

-  innominate  (see  Innominate 

Veins) 

-  method     of     determining 

direction  of  flow  in       824,  825 

-  of  neck,  pulsation  in  cases  of 

pulsation  of  liver  . .     407 
in  tricuspid  regurgitation  106 

-  popliteal,  thrombosis  in     .  .     456 

-  retinal,  dilated  and  tortuous    462 

-  rupture  of,  purpura  from  596,  597 

-  thrombosed,   leucocytosis  in    400 

-  varicose,         asymmetrical 

cedema  in  .  .  .  .     456 

VEINS,  VARICOSE   ABDOM- 
INAL (Plate  XVI,  p.  824) 

9,  824 
in  ascites  . .  . .       51 


Veins,  varicose,  ahdominal,  contd. 
inferior       vena      cava 

thrombosis  . .  . .       61 

asymmetrical  oedema  in       455 

in  new  growth  of  lung      322 

superior     vena      cava 

obstruction  . .  . .     458 

-  -  on  legs 733 

-  -  nasal  mucosa,  epistaxisfrom251 

-  nodular  swellings  with . .     450 

oesophageal,    in    cirrhosis     290 

orbital,    intermittent   ex- 
ophthalmos from        .  .     255 

pain  in  the  leg  from       . .     486 

])elvic,  dystocia  due  to  . .     227 

due  to  popliteal  aneurysm    762 

relation  to  saphena  varix     733 

rupture  of  vulval  . .     768 

-  -  simulated    by    erythema 

nodosum  .  .  . .     450 

VEINS,  VARICOSE,  THORACIC 
(Fig.  73)      . .         235,  826,  827 

from  aneurysm  . .     236 

due  to  mediastinal  new 

growth  121,  343,  773 

thrombosis  m      . .  . .     456 

ulceration  of  the  leg  from     810 

Vena  cava  obstruction,  inferior 
(see  Inferior  Vena  Cava) 

superior   (see    Superior 

Vena  Cava) 
Venesection,  blood  changes  after    37 

-  coma  as  indication  for      . .     137 

-  leucocytosis  after    . .  . .     400 
Venous  congestion  of  liver  (see 

Liver,      Congestion      of. 
Venous) 

-  thrombosis  (see  Thrombosis) 
Ventilation,  headache  from  bad  328 

-  sore  throat  from  bad        . .     673 
Ventral   herniation   of   lapar- 
otomy soar,  visible  peris- 
talsis in    . .  . .  . .     570 

Ventricle  (see  HeartJ 

Veratria,  influence  on  musc-le 

tone  . .  . .        161,  163 

Vermiform  appendix,  normal 
situation  of  (and  see 
Appendicitis,  and  Abscess, 
Appendicular)     . .  . .     722 

Vermin     killers,     strychnine 

poisoning  from   .  .  .  .      464 

Vermis,  tumour  in,  effects  of 

gait  on      . .  . .  . .     643 

Veronal,  coma  due  to  . .     137 

-  poisoning,       Cheyne-Stokes 

respiration  in      . .  .       125 

-  purpura  from  . .  . .     596 
Verruca  necrogenica  . .  . .     266 

-  plana,  cliaraoter  of  papule  of     528 
distinction    from    lichen 

planus   . .  . .         . .     530 

-  vulgaris  (see  AVart) 
Vertebrae  (see  Spine) 

-  carcinoma  of  (see  Carcinoma 

of  Vertebra.') 
VERTIGO         827 

-  in  aortic  disease      . .  . .     323 

-  associated  with  flushing     . .     268 
peripheral  facial  paralysis     536 

-  in  cerebellar  lesions  . .       69 

-  cerebral  tumour  and  abscess 

330,  341 

-  epidemic  jaundice  . .  . .     372 

-  from  intracranial  gumma. .     330 

-  lesions  of  semi-circular  canal     827 

-  ilinifere's  disease   . .  . .     847 

-  in  meningitis  . .  . .     642 

-  non-obstructive  anuria      . .       46 

-  nystagmus  with     . .        453,  827 

-  objective  and  subjective  . .     827 

-  in  otitis  media        . .  . .     4  70 

-  preceding  apoplexy  . .     173 
haematemesis       . .  . .     316 


828 

48 

467 


502 
G24 


.313 
440 


Vertigo,  contd. 

-  due  to  syphilitic  ear  disease 

-  uramic 

-  from  wax  in  ears    . . 
Vesical  calculus  (see  Calculus, 

Vesical) 

-  crises  of  locomotor  ataxy  . . 

-  disease,  cy.stoscopic  appear- 

ances in   . . 
simulation  by  appendicitis    632 

-  epithelioma  (see  Carcinoma 

of  Bladder) 

-  irritability    . . 

-  sphincter    lesion?,    inconti- 

nence from  . .      ... 

-  tuberculosis    (see    Bladder, 

Tuberculosis  of  ;  and  Cys- 
titis, Tuberculous) 

-  tumours        .  .  . .  .  .     441 

-  ulceration,  pyuria  due  to  623,  629 
Vesicants,   bullae  from   appli- 
cation of  . .  . .        ]  10.  Ill 

-  causing  chloasma    . .  . .     574 

-  used  bv  malingerers         111,  112 
VESICLES        829 

-  in  acute  rheumatism         . .     375 

-  anthrax        . .  . .  . .     740 

-  cerebrospinal  meningitis  . .     643 

-  cheiropompholyx     . .  . .     654 

-  dermatitis   herpetiformis  . .     781 

-  development  into  pustule  601,602 

-  differentiation  from  papules     528 
bullae  from  . .  . .     110 

-  in  eczema    . .  . .  . .     714 

-  erythema  multiforme        . .     531 

-  herpes  frontalis       . .  . .     807 

progenitalis  . .  . .     675 

zoster         . .  .  .  .  .     479 

-  herpetic  urethritis  . .  . .     209 

-  with  hidrocystoma  714,  829 

-  Impetigo       . .  . .        602,  608 

-  from  insect  bites    . .  . .     834 

-  in  the  mouth  in  stomatitis      815 

-  napkin  region         . .  . .     446 

-  perleciic  with  . .  . .     404 

-  ring  of,  in  anthrax . .  . .     603 

-  scabies  . .  . .        60S,  654 

-  small-pox     . .  . .  . .     605 

-  syphilides     . .  . .  . .     532 

Vesico-colic  fistula     . .  . .     146 

Vesiculae     seminales,     gono- 
coccal infection  of         . .     207 

gonorrhoeal  thickening  of     638 

inflammation  of,  pain  in 

perineum  in     . .  . .     516 
pain    in   the   back    from 

diseases  of  the  . .     476 
not  palpable  per  rectum 

normally  . .  . .     638 

palpation  per  rectum 

307,  519,  638 

-  tuberculous        ..        . .    394 
association  with    other 

genito-urinary  tuber- 
culosis 307,312,513, 
519,  626,  629,  638,  694,  767 

deposits  in       . .  . .     630 

with  tuberculous  bladder  441 

testis  . .  . .     680 

nodules   felt   on  rectal 

examination  519,  638 

pain  in  perineum  in  .  .     516 

Vesicular  murmur,  absent  in 

pneumothorax     . .  . .     430 

lung  compression       . .     331 

affected  in  a  unilaterally 

enlarged  chest  . .     192 

deficient  in  bronchiectasis     703 

emphysema      . .         186,  246 

with  fibroid  lung       . .     324 

fluid  in  chest  . .  . .     193 

from  growth  of  lung  . .     322 

obstructed  bronchus  . .     296 

in  pneumothorax      193,  577 


I0I4 


VESIC  ULA  R  M  URM UR—  VOMITING 


Tesicidar  murmur,  contd. 

deficient  on  right  side  in 

large  hydatid    cyst   of 
liver      . .  . .  '       . .     415 

Yibioes  ia  purpura     . .  . .     595 

Vibrio  in  cholera       . .  . .     301 

Vicarious    menstruation    (see 

Menstruation) 
Villi,  chorionic  . .  . .     220 

Villous  carcinoma  of   bladder 
(see  Carcinoma  of  bladder) 

of  rectum,  haemorrhage  in       93 

Vincent's  angina,  bacteriologi- 
cal diagnosis  of  .  .  . .     672 
distinction     from     diph- 
theria    and     follicular 
tonsillitis          . .  . .     672 

enlargement  of  subniaxil- 

lary   lympliatio   glands 

less  common  in  . .     419 

foetor  of  breath  in  99,  672 

fusiform  bacilli  and  spirilla 

in  . .  . .        670,  672 

laryngitis  from   . .  . .     670 

pharyngitis  from  .  .      670 

prognosis  good  in  . .     672 

resistance  ito  treatment. .     672 

sore  throat  from  . .     670 

tonsillitis  from    . .         670,  672 

ulceration  of  tonsil  in  670,  672 

Violinist's  cramp        . .  . .     177 

Visceroptosis,  constipation  due 

to  (Fig.  39-)  .  .  . .     147 

-  displacement  of  kidney  in       473 

-  -  liver  in     . .  . .  . .     473 

-  -  stomach  in  . .  . .     473 

-  dull     dragging     abdominal 

pain  in     . .  . .  . .     473 

-  illustrated    .  .  . .  . .     147 

-  insufEicient    defcecation  due 

to  148 

-  profile  of  abdomen  in       . .     473 

-  a--rays    and    bismuth    meal 

in  diagnosis  of     . .         . .     473 
Visible  peristalsis  (see  Peristal- 
sis) 
VISION,  DEFECTS  OF  ..     834 

-  double  (see  Diplopia) 

-  loss  of,  in  glaucoma  . .     257 

-  normal  characters  of        834,  835 

-  peripheral    constriction    of 

field  of,  causes  of  666,  838 

-  spiral  or  concentric  limita- 

tions of  in  hysteria  . .  837 
Visual  disturbance  transitory 

in  migraine  . .  . .     329 

-  word  centre .  .  ..  ..      683 

agraphia  in  lesions  of       685 

Visuals,  definition  of .  .  ..      685 

Vitiligo,  diagnosis  of  chloasma 

from  575 

Vitreous,     hfemorrhage     into, 

erythropsia  due  to  . .  840 
sudden  blindness  from  839,  840 

-  hazy  in  glaucoma  . .          . .     838 
Vocal  cords,  ataxy  of           .  .       69 
inflammation  and  ulcera- 
tion   of,    diagnosis    of 
laryngeal          paralysis 
from 537 

paralysis  (see  Paralysis  of 

Vocal  Cord) 

fremitus  decreased  or  lost 

in  a  deformed  chest       . .     192 

in  emphysema  . .     192 

with  pneumothroas   .  .     193 

in  fibroid  lung     . .  . .     193 

tactile,  absent  in  pneumo- 
thorax . .  . .  . .     480 

decreased  in  bronchial 

obstruction  .  .         296,  322 

increased  in  emphysema    246 

fibroid  lunar. .        246,  332 

unequal  in  phthisis        . .     319 


176 
226,  673 
538,  539 
..  483 


673 


Voice,    abnormalities   of   (see 
Speech,  Abnormalities  of) 

with  cough 

in  laryngitis 

laryngeal  paralysis 

mediastinal  growth 

-  excessive    use    of,    clironic 

pharyngitis  from 

-  lost,  with  normal  cough.  In 

hysterical  aphonia      .  . 

-  monotonous     in     paralysis 

agitans      .  .  .  .  .  . 

-  nasal,  after  diphtheria  77, 181, 559 

in  myasthenia  gravis     . .     687 

with  paralysis   of  palate 

640, 

-  ready  tiring  of,  from  chronic 

pharyngitis 
myasthenia  gravis 

-  reduction     to     whisper     in 

hysterical  aphonia 

-  sounds    absent   in  bronchi- 

ectasis 

lung  compression 

deficient,  from  obstructed 

bronchus 
or   absent   in  pneumo- 
thorax 

in  fibroid  lung 

increased  in  emphysema 

-  test,  for  hearing,  whispered 
Voices,  hearing  of,  as  epileptic 

aura 
Volatile  oUs,  bullae  in  workers 

among 
Voltmann's  contracture      132, 

of  forearm  (Fig.iZ,  p.  166) 

72,  166,  552 
Volvulus,     great      abdominal 

distention  from  . . 

-  intestinal  obstruction  from 

-  pain  In  left  iliac  fossa  in    . . 

-  of  sigmoid  colon 

-  TomitincT  with 
Vomit,    absence    of   free   HCl 

in,  in  new  growth  of 
stomach  (and  see  Gastric 
Contents) 

-  black,     in      acute      yellow 

atrophy     . . 

phosphorus  poisoning     . . 

yellow  fever         . .        301 

-  hepatic  pus  m,  from  rupture 

of  liver  abscess  into 
stomach   . . 

-  sarcmfe  in,  in  new  growth  of 

stomach  (Fig.  92,  p.  267) 
VOMITING 

-  in  abdominal  angina 

-  acetonuria  in 

-  in  active  congestion  of  liver 

-  acute  encephalitis      . .     139,  547 
general  peritonitis      431 

472,  644,  718 

meningitis  . .         139,  563 

pancreatitis  292,  646,  724 

poliomyelitis        . .        128,  555 

rheumatism  .  .  .  .      671 

-  -  without  diarrhoea,  maras- 

mus from         .  .  .  .     426 
yeUow  atrophy  of  liver  302,  370 

-  in  Addison's  disease  . .       38 

-  aniemic         .  .  . .  . .       40 

-  from  appendicitis     135,  729.  736 

-  In  arsenical  poisoning  87,  92 

-  arteriosclerosis 

-  associated  with  flushing    . . 

-  with  bacteriuria 

-  in  biliary  colic 

-  from   carcinoma  of   CEECum 

colon 

duodenum 

stomach    . .    299,  357,  485,  691 

-  central  causes  of     . .         843,  844 


687 


96 


687 


703 
331 


296 


324 
246 

188 


110 
165 


152 

431 
501 
713 
153 


691 

302 
373 
373 


409 

691 
841 

351 

4 

371 


297 
328 
268 
84 
135 
729 
367 
725 


178 


350 
56 


845 


. .  737 
..  737 
. .      353 

426,  843 
4S 
841 


364 
300 

350 

341 
713 

229 
153 
846 
845 
644 
847 


Vomiting,  contd. 

-  in  cerebellar  abscess  . .     651 

-  cerebral  abscess         547,  651,  68G 

-  cerebral,  account  of  341,  847 

absence  of  nausea  in      . .     847 

tumour        173,  292,  477, 

547,  686,  782 
I  -  of  cerebral  type        328,  585. 

-  of  children,  tetany  in        . . 

-  in  chronic  intestinal  obstruc- 

tion 
peritonitis 

-  from  cohc    . .    133,  363,  500,  645 

-  collapse  after  severe  . .     346 

-  due  to  colon  inflammation       727 

-  with  constipation.  In  hyper- 

trophic   stenosis    of"   the 
pylorus 

-  copious,  from  carcinoma  of 

pylorus     . . 

in  gastTectasis 

pyloric  obstruction 

-  cyclical,  of  infants. 

-  with  cystic  kidneys 

-  definition  of  '  . . 

-  in    distoma    hepaticum    in- 

fection 

-  duodenal  ulcer 

-  early  phthisis 

-  effortless,    in    cerebral    tu- 

mour and  abscess 

-  in  excluding  gastric  atony 

-  exhaustion     of     obstructed 

labour 

-  ffficulent 

in  appendicitis    . . 

gastro-colic  fistula 

general  peritonitis 

hysteria    . . 

intestinal  obstruction  134. 

151,  431,  845,  846 
sex  incidence  of . .  . .     692 

-  of      fermenting      fluid      in 

pyloric   or   duodenal   ob- 
struction . .  . .  . .     571 

-  in  gall-stone  colic  . .  . .     363 

-  gastric  causes  of     . .  . .     843 

-  in  gastric  crises  of  tabes  350,  485 

-  from  gastric  fermentation        267 

-  -  ulcer         40,  89,  298,  352,  485 

-  gastritis        . .  . .        297,  352 
relief  of  pam  by  . .  . .     484 

-  glaucoma      .  .      "   . .         494,  838 

-  Henoch's  purpura     90,  380,  600 

-  hypothermia  after  severe. .     340 

-  hysterical,      carcinoma      of 

stomach  mistaken  for    . . 

diagnosis    of    Indigestion 

from 

-  in  influenza 

-  intestinal  obstruction    133, 

151,  153,  431.  571,  645, 
727,  733,  736,  741,  845 

peritoneal,     and     general 

visceral  causes  of 

-  Intracranial     gumma      or 

tumour     . . 

-  Intractable,  in  acute  yellow 

atrophy  of  liver  . . 

-  in  intussusception  . .        727,  736 

-  Irritant  or  corrosive  poison- 

ing   674 

-  lead  poisoning         . .  . .       77 

-  Jf^ni^re's   disease  . .  . .     828 

-  meningitis    174,    341,    350, 

359,  622,  642,  699 

-  m^aine      329,  837,  838,  840, 847 

-  morning,  in  alcoholism  238, 

243,  368,  797 
In  pregnancy       . .  . .     437 

-  neuro-muscular  mechanism  of  842 

-  non-obstructive  anuria     . .       46 

-  at  onset  of  scarlet  fever    . .     843 

-  in  otitis  media  in  children      229 


508 


350 
505 


846 
844 


336 
302 


VOMITING— WA  STING 


1015 


Vomiling,  could. 

Vulva,  conld. 

W 

asp-sting,     bleeding     gums 

-  pancreatic  lijemorrhage    292, 

046 

-  implantation  cyst  of 

768 

due  to 

86 

-  paroxysmal  in  tabetic  crfees 

350 

-  kraurosis  of   (see  Kraurosis 

Wassermann's  reaction 

37 

-  pliospliorus  poisoning 

373 

Vulvae) 

- 

-  in  ane\irysm 

786 

-  imeumonia  . . 

622 

-  cysts  affecting 

768 

- 

-  cerebrospinal  fluid 

340 

-  portal   obstruction.. 

300 

-  diabetic  eczema  starting  in 

447 

- 

-  chancre  of  the  tongue    . . 

813 

-  of  preK'tumi'y  (see  Pregnancy) 

-  elephantiasis  of 

770 

- 

-  cntineous  lesions  of  secon- 

- in  iituniaiue  iioisoning 

196 

-  endothelioma  of     . . 

768 

dary  syphilis      533,  005, 

672 

-  witli  pULTpenil  eclampsia.. 

172 

-  epithelioma  of         . .         768, 

771 

- 

-  in  diagnosis  of  syphilitic 

-  pyainii.i 

(M9 

enlarged     inguinal    gland 

pyrexia     . . 

615 

-  with  pyloric  obstruction  131, 

from 

769 

- 

-  digital  chancre    . . 

422 

:i53, 

713 

-  fibroma  of    . .          . .        768, 

771 

_ 

-  epithelioma 

813 

-  recurrent  periodical  or  cy- 

- furunculosis  of 

768 

_ 

-  general   paralysis   of   the 

clical  of  children           42G, 

843 

-  hasmatoma  of 

770 

insane  . .   139,  269,  340, 

360 

extreme  thirst  from 

789 

-  inflammatory   afTections    of 

768 

- 

-  gumma  of  bone  . . 

752 

-  in  renal  colic 

500 

-  .Tacquet's  erythema  of 

44r, 

- 

-  -  liver      . .          . .         279, 

371 

-  rickets           

171 

-  lipoma   of     . . 

768 

- 

tongue 

420 

-  severe,  in  cerebellar  abscess 

-  molluscum  fibrosum  of     . . 

771 

- 

-  lymphatic  gland  enlarge- 

or tumour 

565 

-  mucous  cyst  of 

768 

ment     . . 

417 

in  infants. . 

426 

-  neuroma  of  . . 

768 

- 

-  paralysis  of  leg  from  syph- 

 loss  of  fluid  from  tissues 

-  oedema  of     . .          . .        768, 

770 

ilitic  meningitis 

544 

due  to. . 

579 

-  pain  in  (see  Pain  in  Vulva) 

_ 

-  of  perineal  chancre 

678 

-  -  polycythasmia  in           579, 

580 

-  papilloma   of 

768 

- 

-  in  ptyalism 

591 

-  -  in  pregnancy 

579 

-  pigmentation  of,  in  Addison's 

- 

-  7tli  nerve  paralysis 

590 

typhus  fever 

699 

disease 

574 

- 

-  In  syphilis  75,  86,  204,  209, 

224, 

-  simulated  by  bronchiectasis 

842 

-  pruritus  of  . .          . .        569, 

588 

226,  254,  325,  371,417,  615, 

658, 

merycism . . 

842 

-  pseudo-elephantiasis  of     . . 

770 

675,  738,  769,  808,  811 

814 

-  with  sinus  thrombosis   139, 

-  sarcoma  of  . . 

768 

- 

contrenital        . .        427, 

695 

558,  fiSO, 

651 

-  sebaceous  cyst  of  . . 

768 

_ 

of  liver 

60 

-  strangulated  hernia 

741 

-  soft     cliancre     of,     vulval 

- 

of  jaw  . . 

748 

-  suppurative  nephritis 

646 

swflliiiL'  from 

768 

- 

testis     . . 

520 

pylephlebitis 

649 

VULVA,  SWELLING  OF 

768 

- 

-  syphilitic  arthritis 

386 

-  tenderness    in     epigastrium 

-  sypliilisfif,  siiinilating  tuber- 

- 

chancre 

675 

from 

779 

culosis 

769 

- 

on  face 

747 

-  from  torsion  of  retained  testis 

742 

-  tenderness  of  (sec  Tenderness 

_ 

endarteritis      . .         338, 

340 

--  in  trojiical  abscess  of  liver 

369 

of  Vulva) 

- 

gland  enlargement 

417 

-  ulcerative  colitis     . . 

727 

-  tertiary  syphilitic  lesions  of 

768 

- 

laryngitis 

674 

-  undue     abdominal      aortic 

-  tliread-worm  infection  of  . . 

509 

- 

testis     . . 

766 

pulsation . . 

592 

-  tuberculosis  of,  vidval  swell- 

- 

-  tabes 

489 

-  unBmia         . .             45,  329, 

350 

ing  from  . . 

768 

Wasting  in  acute  leuk.Tmia  . . 

649 

-  urate  deposit  after. . 

815 

-  ulceration  of 

769 

- 

from  anorexia  nervosa 

69 

-  in  variola     . . 

301 

-  varicocele  of,  associated  with 

_ 

carcinoma  69,  91,  93,  413,  636 

,737 

-  wasting  with 

69 

pregnancy 

770 

- 

with  cholera 

09 

-  in  whooping-cough. . 

467 

-  various  new  growths  of     . . 

768 

- 

chronic  (and  see  Cachexia) 

508 

Von   Basedow's    disease    Csee 

Vulvitis,    acute,    clinically    all 

- 

from  cirrhosis  of  liver     69, 

410 

Exophthalmic  Goitre) 

forms  more  or  less  alike 

768 

- 

diabetes        . .          . .          69, 

507 

Von  Graefe's  sign         244,  253, 

792 

-  dyspareunia  from   .  . 

221 

- 

with  diarrhoea 

69 

Von     .Taksch's     disease     ("see 

-  enuresis  with 

2d8 

- 

-  in    adults,    suspicion    of 

Pseudo-leukajmia) 

-  gonorrhoeal,  diagnosis   from. 

carcinoma  of  rectum  . . 

636 

Von  Pirquet's  reaction 

38 

simple 

768 

- 

diseases,   apparent  enlarge- 

 in    diagnosis    of    chronic 

vulval  swelling  from     . . 

768 

ment  of  liver  in  . . 

405 

abscess  of  bone 

752 

-  leukoplakic,  confusion  with 

- 

-  enophthalmos  in 

247 

—  -  latent   tuberculosis 

847 

kraurosis  vuIvee  . . 

770 

- 

-  fatty  heart  in 

241 

lupus  vulgaris 

812 

vulval  swelling  from 

768 

_ 

liver  in . . 

414 

marasmus    from    obscure 

-  simple,  diagnosis  from  gonor- 

_ 

distention  of  stomach 

737 

tuberculosis     . . 

427 

rhoeal 

768 

- 

with  dysentery 

69 

negative  in  anorexia  ner- 

- 

great,   in  cyclical  vomiting 

vosa 

850 

WADDLING     gait     in    con- 

of children 

843 

-  -  not  very  trustworthy   . . 

736 

genital  dislocation  of  hip 

277 

- 

from  hepatic  abscess 

69 

in  pleuritic  effusion 

121 

-  in  pseudol'iypertrophic  para- 

- 

in  Hodgkin's  disease 

649 

for  tuberculosis             612, 

814 

lysis  (and  see  Gait) 

277 

- 

from  malaria 

69 

tuberculous     disease     of 

Walking,  abnormalities  of    . . 

277 

- 

muscular      (see      Atrophy, 

testis     . .          . .        529 

765 

-  delayed  from  cretinism     . . 

557 

Muscular) 

-  —  peritonitis 

691 

idiocy 

557 

- 

obscure,   in  children,  prob- 

Von Recklinghausen's  disease, 

Little's  disease   . . 

154 

able     cause     tuberculous 

affection  of  scalp  in 

781 

paraplegia  in  children   556 

,557 

absorption  from  milk     . . 

427 

distinction  from  fibroma 

rickets  (and  see  Gait)  . . 

557 

- 

in  pancreatitis         . .        135 

292 

molloscum    . . 

781 

Warmth   in   bed,    increase   of 

- 

with  peritonitis 

718 

neuro-fibromata  in     . . 

781 

some  pains  by     . . 

503 

- 

in  pernicious  anromia 

649 

nodules  in 

804 

-  effect   on  pain   in  erythro- 

- 

phthisis        . .          . .        185 

319 

pigmentation  of  skin  in 

melalgia    . . 

490 

- 

with  ptomaine  poisoning  . . 

69 

781 

804 

Wart,    diagnosis   of  syphilitic 

_ 

in  renal  tuberculosis 

135 

scalp  tender  from      780 

781 

tubercle  from 

532 

- 

galpingo-oophoritis  with  sup- 

  thickening  of  nerves  in 

804 

-  epithelioma  starting  in 

803 

puration   . . 

760 

Vulva,  angioma  of     . . 

768 

-  hypertrophy  of  papules  into 

528 

- 

from  sarcoma 

69 

-  carcinoma  of  (see  Carcinoma 

-  ichthyosis  developing  into 

5.30 

- 

starvation    . . 

69 

of  Vulva) 

-  post-mortem 

266 

- 

syphilis 

69 

-  chancre  of   . . 

768 

-  sarcoma  starting  in 

803 

- 

-  congenital 

370 

-  circinate  sj'philoderm  of  . . 

532 

-  scrotal           .  .          .  .        679 

765 

- 

of     tongue     (see    Tongue, 

-  condyloma"     of,      diagnosis 

-  simulating  lichen  planus  . . 

5.30 

Atrophy  of) 

from  soft  chancre 

768 

Washerwomen,     acroparaes- 

- 

with  tro]iIcal  abscess  of  liver 

408 

-  cracked    and   fissured   from 

thesia  in  . . 

493 

- 

from     tuberculosis 

69 

leukoplakia 

221 

-  nail  staining  in 

444 

- 

ulcerative  colitis 

69 

-  dermoid  cyst  of 

768 

-  sore  fingers  of 

266 

- 

vomitmg 

60 

ioi6 


WASTING— WRIST 


Wasting,  contd. 

Werlhofs  disease        . .         596, 

600 

Wolf  bite,  hydrophobia  from 

801 

-  vomiting  and    constipation 

West  Indies,  yellow  fever  in 

372 

Wolffian  body,  retroperitoneal 

in  hypertrophic  stenosis 

WHEALS         

850 

cysts  derived  from 

725 

of  the  pylorus. . 

845 

-  in  dermatitis  herpetiformis 

831 

Wool-workers,  anthrax  in    603, 

746 

-  (and  see   Weight,    loss  of  ; 

-  lichen  planus 

832 

Word    blindness,   hemianopia 

and  ilarasrnus^ 

-  mode  of  production  of 

850 

with 

684 

Watcti  test  for  hearing 

188 

-  relation  to  erythema 

850 

inability  to  read  in 

684 

Watchmaker's  cramp . . 

177 

nodules     . ." 

850 

lesions  causing    . . 

684 

Water,    insufficient  consump- 

 papules     . . 

850 

relationship  to  defects  of 

tion  of,  as  cause  of  consti- 

- in  urticaria  . . 

252 

vision,  speech,  etc.   684, 

685 

pation 

145 

pigmentosa 

805 

varying      degrees,      and 

Water-brash  (see  Heartburn) 

-  vesicles  on  . . 

850 

difficulty  of  analysis  of 

684 

Water-drinking,  plumbism  from  3  36 

WTieezing  in  emphysema 

526 

with  word  deafness 

684 

Water-hammer  pulse  in  aortic 

Whetstone  crystals    . . 

816 

-  centre,  auditory,  importance 

regurgitation  106, 107,  233 

234 

Whip-worm  (Fig.  154) 

569 

in  acquirement  of  speecli 

683 

Watering  of  eyes  from  error  of 

Whiskers,  extension  of  pedicu- 

 lesion    of,    word    deaf- 

refraction 

328 

losis  pubis  to 

447 

ness  from     . . 

684 

Wax  in  ear,  deafne?s  from    . . 

467 

WTiisky-drinking,  polyuria  from  581 

and  visual,  situation  of 

dry  cough  from            Hi 

175 

Whispered      voice      test    for 

(Fig.  185)       . .      . . 

683 

eczema  of  external  audi- 

hearing 

188 

-  deafness  from  destruction  of 

tory  meatus  from 

468 

Whistle,     inability    to,    from 

centre 

684 

purulent  discharge  due  to 

467 

facial  paralysis    .  . 

533 

examination  of  a  case  of 

684 

tinnitus  from 

467 

in  myopathy 

260 

lesions  causing    . . 

684 

Tertigo  from       . .        467, 

828 

Wliite  corpuscles  (see  Leuco- 

 relation      to     power      of 

Waxy  renal  tube-casts 

7 

cytes) 

speech,  writing,  etc.  . . 

084 

-  sijleen  in  lardaceoas  disease 

696 

-  tongue,  or  cachexia  aquosa 

115 

WORMS,  INTESTINAL 

567 

Weakness   of    back   muscles, 

White-leg  (see  Phlegmasia  alba 

bile-duct  obstruction  from 

364 

scoliosis  from 

180 

dolens) 

causing  increased  appetite 

49 

-  in  Bright's  disease  . . 

90 

Whitlow,  a.Tillary  abscess  due  to 

731 

enuresis  with 

248 

-  carcinoma  of  colon 

91 

-  causes  of 

445 

eosinophilia  with 

249 

-  of  the  limbs  in  chronic  alco- 

- leucocytosis  in 

400 

insomnia  from     . . 

357 

holism 

797 

-  oedema   of  face,  neck,   and 

grinding  of  teeth  with . . 

293 

-  mascular,  in  general  paraly- 

arms from 

458 

infantile  convulsions  from 

170 

sis 

172 

-  painless,  in  Morvan's  disease 

285 

leucocytosis  with 

620 

paralysis  agitans 

796 

-  septicemia  from     . . 

698 

micturition  frequent  from 

438 

-  in  neurasthenia 

506 

-  with  .syringomyelia           128 

285 

night  terrors  from        3f.7 

448 

-  at  onset  of  phthisis. . 

620 

-  thrombosis  of  veins  from. . 

826 

priapism  in  infancy  from 

585 

-  progressive,  from  growth  of 

Whooping-cough        . .        400 

465 

vomiting  with     .  .         844, 

846 

lung          

322 

-  abra=ion  of  fraenum  lingua?  in 

320 

-  -  (see  also  Tape-worms,  etc.) 

in  pernicious  anasmia    . . 

30 

-  bacilli  in  sputum  in 

705 

Worry  as  cause  of  functional 

-  tremor  from 

795 

-  bronchitis  simulated  by   . . 

705 

dyspepsia 

355 

Weather,    effects    on    chronic 

-  cough  after..          ..        175, 

176 

-  constipation  due  to 

144 

rheumatic  pains . . 

507 

-  hcemoptysLS  in        . .        317, 

320 

-  ill-effect  on  neurasthenia  . . 

788 

quantity  of  urine 

581 

-  hernia  of  lung  from 

194 

-  influence      on      trigeminal 

sore  throat                    672, 

673 

-  infantile  convulsions  in     . . 

170 

neuralgia . . 

495 

-  pain   in    chest  in    phthisis 

-  leucocytosis  in 

400 

-  insomnia  from 

357 

varying  with 

480 

-  orthopncea  in 

465 

-  loss  of  weight  due  to 

848 

Weber's  test  for  hearing 

189 

-  paroxysmal  cough  in 

467 

-  malarial  relapses  due  to    . . 

36 

Weeping  (see  Epiphora) 

-  rupture  of  cortical  veins  in 

131 

-  neurasthenia  from . . 

506 

-  in  eczema    . .          . .        714, 

831 

-  subconjunctival  haemorrhage 

-  and  professional  cramp     . . 

177 

Weichselbaum,    meningococci 

in  . . 

256 

-  ptyalorrhoea  caused  by 

592 

of  (see  Meningococci) 

-  swelling  of  eyes  and  face  in 

459 

Wounds     of     the     abdomen. 

Weight  carrying,  scoliosis  from 

-  Tooth's    peroneal    atrophy 

infective  peritonitis  from 

644 

180, 

181 

developing  after             71, 

560 

-  in  the  chest,  surgical  emphy- 

- in   hypochondrium,    feeling 

-  ulceration     of    fraenum     of 

sema  from 

716 

of,  in  catarrhal  jaundice 

365 

the  tongue  from. . 

814 

-  infection  of  tetanus  tlu-ougU 

162 

-  increasing,  in  myxoedema . . 

585 

-  vomitincr  in              . .         467 

844 

-  on  the  neck,   siirgical   em- 

- lifting,  subconjunctival  hse- 

Widal's    test    in    diagnosmg 

physema  from.     . . 

716 

morrhage  from   . . 

256 

cause  of  prolonged  pyrexia 

609 

-  pneumothorax  after         577. 

578 

WEIGHT,  LOSS  OF  .. 

847 

typhoid     fever     from 

-  pyaemia  from           . .        372 

649 

-  -  from  carcinoma  147.  1.50, 

295, 

pysemia 

650 

-  septicemia  from     . . 

698 

299,  .322,  351,  718,  724,  725 

,736 

frequent  failure  of 

610 

-  of  thigh,  talipes  from 

131 

due    to    change    of    sur- 

 negative  fallacies  of 

610 

-  in  the  trachea,  surgical  em- 

roundings 

848 

-  -  in  paratyphoid  fever 

697 

physema  from     . . 

716 

Crraves'  disea.se  . .         244 

797 

positive,    not   necessarily 

Wriggling,     mild     choreiform 

Hirsciisprung's   disease . . 

718 

indicative  of  tvphoid 

611 

movements  causing 

156 

in  infants  (see  Marasmus) 

in  tynhoid  fever' 90,  196, 

Wrinkles,    diminution    of    in 

methods     of     e.xamining 

281,  327,  620,  650 

697 

facial  paralysis    .  . 

533 

in  cases  of 

847 

"Wind    (see    Flatiilence ;     and 

Wrist,  athetotic  flexion  of    . . 

154 

in  pernicious  anremia     . . 

30 

Meteorism) 

-  flexion  of,  in  brachial  mono- 

 rheumatoid  arthritis 

39 

Winged  appearance  of  scapula 

plegia 

546 

sarcoma    . . 

756 

ia    paralysis    of    serratus 

in  paralysis  from  chorea 

548 

ulcerative  colitis 

727 

magnus     . . 

551 

-  flexor     contracture     of     in 

-  sense  of,  in  gastritis 

352 

Winking,  absence  of,  in  para- 

arsenical neuritis 

105 

Weil's  disease 

372 

lysis  agitans 

2|62 

—  gonococcal  artliritis  of 

376 

albuminuria  in    . . 

17 

-  diminished,  in  Graves'  disease 

-  gout  in 

382 

jaundice  in 

362 

253, 

261 

-  h37)ertrophic     osteo-arthro- 

purpura  in 

596 

-  involuntary,   in  facial  par- 

pathy in  . . 

390 

rigors  in   . . 

647 

alysis  CFig.  139)  . .        534, 

537 

-  lichen  planus  affecting 

657 

Weir-Mitchell     treatment    in 

Winter,   bronchitis   with   em- 

- multiple  benign  sarcoid  of 

451 

functional  wasting 

850 

physema  in 

186 

-  osteo-arthritis  of    . . 

384 

Werdnig-Hoffmann     progres- 

-  cough  (see  Cough) 

-  pruritus  of  . . 

588 

si%'e  m.u.scular  atrophy  of 

Wisdom      tooth       impaction 

-  scabies  of     . .           447,  588 

832 

infants 

158 

simulating  tetanus       801, 

802 

-  tuberculous  disease  of 

385 

WRIST-DROP— ZYMOTIC    DISEASE 


1017 


Wrist-drop  from plumbisni    38, 

77,  507,  551,  798 

Wrist-jerks,  unequal  in  heuii- 

plegia        . .          . .          . .  337 

Writer's  cramp                     177,  494 

AVritiug,  difficulty  in,  in  supra- 
scapular nerve  paralysis  551 

-  effect   ol    word-deafness   or 

word-blmdness  on  power 

of 684,  C85 

Wry-neck  fsee  Torticollis) 

XASSTTHELASMA.  planum  . .  3G0 

-  tuberosum  in  jaundice      . .  360 
Xanthin     bases,     uric      acid 

derived  from       . .          . .  8J7 

-  in  urine,  reduction  by       . .  290 
Xanthoma  claaracter  of  papule  528 

-  diabeticorum           . .          . .  805 

-  macules  in  . .         . .         . .  424 

-  multiplex     . .         . .         .  -  805 

-  planum         . .          . .          . .  805 

Xanthopsia  from  amyl  nitrite  840 

-  cannabis  indica       . .          . .  840 

-  from  jaundice          . .        360,  840 

-  picric  acid    . .          . .          . .  840 

-  santonin  poisoning             . .  840 
Xerodermia,  distinction  from 

licben  scrofulosorum      . .  530 

-  papules  of    . .          . .          . .  530 

-  scales  in       . .          . .          . .  655 

-  pigmentosum,  age  incidence  804 

-  -  characters  of       . .        802,  804 

diagnosis  from  freckles..  424 

influence  of  season  on    . .  804 

-  -  macules  in           . .          . .  424 

superficial  ulcer?  in        . .  804 

telangiectases  in..          ..  804 

watery  tumours  in         . .  804 

white  atrophic  spots  in  . .  S04 

yellow  crusts  in  . .          . .  804 

Xerosis  of  the  conjunctiva  in 

keratomalacia     . .          . .  807 

X-rays  in  abdominal  aneurysm  4_86 

-  acromegaly              . .          . .  5*85 

-  acute  secondary  arthritis. .  378 

-  affections     of     antrum    of 

Highmore..         ..          ..  502 

-  aneurysm,   aortic  (Fig.   74, 

p.  236  ;  Fig.  131,  p.  483) 
107,  223,  23C,,  y22,  422, 
465,  474,  477,  483,  582,  786,  790 
of  external  iliac  arterv. .  741 

-  -  fusiform  . .          . .       "  . .  238 
popUteal  . .          . .          . .  762 

-  asthma          . .          . .          . .  582 

-  atony  of  pelvic  colon         . .  149 

-  bone  growths  or  caries       . .  270 

-  bronchial  or  mediastinal  lym- 

phatic gland  enlargement  617 

-  calculous  anuria     . .          . .  47 

-  callus            . .          . .          . .  757 

-  cardiac  displacement        . .  332 

-  cause  of  cough        . .          . .  176 
radicular   pain   in  arm . .  494 

-  cervical  caries        ..        477,  708 

-  -  rib             . .  75,  128,  493,  554 

-  chronic  abscess  of  bone     . ,  752 

-  congenital  dislocation  of  hip  183 

-  constipation  141,  142, 

144,  145,  146,  147 

-  diaphragmatic  hernia        . .  712 

-  dilatation  of  stomach        . .  352 

-  d  isease  of  lumbo-sacral  spine  488" 

-  distinguishing        empyema 

from  subplirenic   abscess 

mediastinal  growth  from 

aneurysm 

oxaluria  from  calculus  . . 

sarcomafromperiostitis  751,763 

-  -  subphrenic  abscess  from 

pyopneumothorax      . .  712 

-  duodenal  obstruction         . .  571 

-  dysphagia     .  .          .  .          . .  224 


721 


483 
311 


X-rays,  contd. 

-  egg-shell  crackling  . .        177,  179 

-  endosteal     sarcoma     (Figs. 

197,  199,  pp.  755,  756)757,  763 

-  erythema  from  exposure  to     252 

-  excluding   aortic   aneurysm     593 

-  exostosis  (Fig  194,  p.  753)       754 
of  frontal  bone    . .  . .     255 

-  foreign  bodj'  in  oesophagus     297 

-  fracture        179 

of  jaw      . .  . .  . .     747 

vertebrae  . .  . .  . .     787 

-  gastroptosis  (Fig.  105)      . .     353 

-  gout  (Fig.  113)       . .  . .     383 

-  growth  of  spine      ..  ..     182 

-  haemoptysis  ..  ..     318 

-  Hirschsprung's  disease      . .    .433 

-  hydatid    cyst  of  lung  (Fig. 

100)         323 

-  impacted  ureteral  calculus      514 

-  locating  pus  in  chest         . .     119 

-  mediastinal  growth  . .     465 

lesions       . .  . .  .  .     185 

tumour     . .  422,  474,  582 

-  mediastinitis  and  new  growth     61 

-  mottled  shadows  in  phthisis     319 

-  movable  kidney  and  renal 

calculus    . .  . .  . .     583 

-  necrosis  of  jaw       . .  . .     748 

-  odontom:it:u .  ..  ..     749 

-  (Esophageal  obstruction     . .     223 
pouch        842 

-  orbital  periostitis    . .  . .     254 

-  organic  stricture  of  intestine     146 

-  osteo-arthritis  . ,  . .     380 

-  osteosarcoma  ..  ..     179 

-  pain  in  the  arm     . .  . .     491 

-  -  back-         476 

-  -  chest         ..         ..  --     ..     479 

-  para;iysis  from  spinal  cord 

lesions       , .  . .  . .     543 

-  periosteal     sarcoma      (Fig. 

196,  p.  754)         .  .  . .      756 

-  phthisis         . .  . .        319,  736 

-  -  eAi\j(Fig.  27)     ..        120,  847 

-  pneumonia  (Fig.  99)         . .     321 

-  pneumothorjtx  480,  577,  578 

-  popliteal  swellings  . .  . .     763 

-  pyloric  obstruction'  134,  144,  571 

-  pyonephrosis  (Fig.  97,  p.  309)  396 

-  renal  calculus  fi^i^.  97,  p.  309) 

500,  626 
tuberculosis  . .  . .     626 

-  rheumatoid  arthritisfJJ'ij.llO)  380 

-  sarcoma  (Figs.  196,  197,  198) 

179,  754,  757,  763 

of  lower  jaw       . .  . .     7-18 

pelvis        . .  . .  . .     741 

-  scar,  epithelioma  starting  in    803 

-  in      sciatica      to      exclude 

organic  disease   . . 

-  sLmiinrity   of  sarcoma   and 

chondroma  under 

-  sore  fingers  from    . . 

-  spinal  caries  . .        181,  474 

-  splenomedullary     leukaemia       3L 

-  spondylitis   deformans      . .     787 

-  sterility  caused  by  . .       80 

-  in  stomach  disorders        712,  727 

-  subnhrenio   abscess        501, 

578,  720,  721 

-  talipes  . .  . .  . .     132 

-  testicular  atrophy  from      79,  80 
-■  thorax  examinations  . .       37 

in  paralysis  of  vocal  cord    538 

tumour  or  aneurysm  of  . .       75 

-  thymus  gland  enlargement    465 

-  transparency    of    bones    in 

rheumatoid  arthritis  (i^'ig'. 
110)  380 

-  tropical  abscess  of  liver    . .     409 

-  tuberculosis  of  kidney       . .     310 

-  tumour  of  pelvic  bones    737,  741 
of  spine    . .  , .  . .     525 


488 


755 


X-rays,  contd. 

-  unerupted  teeth     . .  . .     501 

-  ui-eteric  calculus  47, 135,  311,  627 

-  vesical    calculus    (Fig.    98, 

p.  312)       ..  ..  ..629 

-  visceroptosis  . .        147,  473 

YAWNING  in  test  for 
functional  and  organic 

Ijaralysis  of  arm         . .  548 

Yaws 449 

-  absence  of  giant  cells  in    . .  450 

glandular  enlargement  in  449 

heredity  in  . .  . .  450 

syphilitic  symptoms  in..  450 

-  affection    of    clavicle,    ster- 

num, ulna,  tibia,  in       . .  449 

legs,  ankles,  lips  in        . .  449 

of  metacarpal  and  meta- 
tarsal bones  in  . .  449 

-  blood  changes  in     . .  . .  450 

-  cell  changes  in        . .  . .  450 

-  diagnosis  of  lupus  from  . .  449 
of  tuberculosis  from       . .  450 

-  frambccsial  excrescences   of  449 

-  nodular  skin  changes  in    . .  449 

-  raspberry-like  granulations  in  655 

-  scabs  in        . .  . .  . .  655 

-  similarity  to  syphilis         . .  449 

-  syphilis  .no  protection  from  450 

-  ulcers  in       . .  . .  . .  449 

Yeast  cells  in  gastric  contents 

267,  353,  355,  845 

-  pneumaturia  due  to         . .     576 

-  in  sputum    . .  .  .  . .     705 

-  sugar  differentiation  by    . .     290 
Yellow  fever,   albuminuria   in 

17,  301,  373 

anuria  in  . .  . .       49 

black  vomit  in    . .        301,  373 

bleeding  gums  in  301,  373 

coma  in    . .  . .  . .     136 

constipation  in   . .  . .     372 

cyanosis  in  ..  ..187 

diagnosis        from    acute 

yellow  atrophy  372,  373 

dengue  and  malaria  . .     373 

malignant  malaria     . .     301 

falling  pulse   with  rising 

temperature  in  . .     373 

gangrene  in         . .  . .     282 

geographical   distribution     372 

-  -  headache  in         . .        301,  372 

hasmatemesis  in..         294,  301 

— '■  haematuria  in      .  .  . .     305 

haemoglobinuria  in         . .     315 

liyperpyrexia  in  . .     344 

incubation  period  of      . .     372 

inspissation  of  the  blood  in     187 

-  -  jaundice  in  301,  362,  372 

loss  of  weight  in  . .     848 

pain  in  back  and  limbs  in     372 

petechia}  in  . .  . .     301 

purpura  in  . .        373,  596 

pulse  relatively  slow  in  301,  771 

rigors  in  . .  . .         372,  647 

sudden  onset  with  rigor  in    301 

Yellow  spot,  cones  very  numer- 
ous at       . .'         . .  . .     835 

affections  of,  causing  am- 
blyopia with  nystagmus    836 

-  vision  . .  . .  . .     840 

ZIEHL-lfEELSRN  method  of 

staining  tubercle  bacilli  700 
Zimmerlin's  myopathy,  fibril- 
lary contractions  in  . .  158 
Zinc  sulphate,  vomiting  from  843 
Zona  (see  Herpes  Zoster)  . .  830 
Zygomatic  muscles,  wealmess 

of,  in  myasthenia  gravis     260 

-  process,       hyperplasia      in 

acromegaly          . .          . .     26^ 
Zymotic  diseases  Tsee  Fevers) 


5327.11 


JOHN  WRIGHX  AND  SONS   LTD.,  PRINTERS,  BRISTOL. 


